6 20 371 https://staging.drfop.org/files/original/b226593ad4d658ae5abd8ff8f834848b.pdf 36ae121273f428280cbbd01d4ed8ba0d https://staging.drfop.org/files/original/0aebfe07b23f1c1385e5e11dabd23ab4.jpg 7b1f6e7332d2d1940d9f2014e8d0a872 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_001.pdf Text Any textual data included in the document <h2>Extra-Ambulatory Activities and the Amputee</h2> <h5>Drew A. Hittenberger, CP&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Extra-ambulatory activities and their use in the treatment of amputated individuals have received considerable publicity. Initially motivated by a personal drive for physical accomplishment, many patients have discovered unsuspected levels of performance. It is this high level of performance, combined with the sense of personal accomplishment, that has captured the public's attention.</p> <p>The purpose of this article is to examine the need for physical exercise among amputees in hopes of making such activities the norm rather than the exception in rehabilitation and daily activities. To better understand the physical limitations imposed on the amputee and their effect on exercise, the following areas will be discussed:</p> <ol> <li> <p>Need for physical exercise among amputees.</p> </li> <li> <p>Areas of limitation.</p> </li> <li> <p>Factors in extra-ambulatory prosthetic design.</p> </li> </ol> <h3>Need for Physical Exercise</h3> <p>The level of physical activity a person attains naturally affects his quality of life. This motivates a general public concern for physical fitness. The physically handicapped are no exception. In fact, to the younger, more aggressive amputee, the level of physical activity he is able to exert is critical. Today, despite this need for physical exercise, figures show that most amputees become limited in their ability to participate in physical exercise programs.<a></a> This disability seems greatest for the amputee who was active prior to amputation. Whether the patient was active prior to amputation or not, the end result is the same—inactivity. As one patient put it, "There are those of us in whom the spirit of physical exertion becomes tarnished ... it no longer becomes important to be so active. The effort is too much."</p> <p>While it is natural to decrease one's level of activity after amputation, some serious questions remain. Are the members of the rehabilitation team doing all they can to maximize the patient's level of activity? if everything is being done for amputees, why do so many continue to be physically inactive? Why do so many lose their ability to participate in physical exercise and lack the basic skills for sports activities despite the need for such physical outlets?</p> <p>Most patients lose their ability to participate in physical exercise programs not only as a result of amputation, but also, and perhaps more importantly, as a result of poor post operative care.</p> <h3>Areas of Limitation</h3> <p>There are many reasons why amputees are inactive, perhaps as many reasons as there are amputees. Age, level of amputation, and general physical condition of the patient are usually considered the primary reasons why amputees are limited. But the reason amputees are inactive, in the majority of cases, is not due to a physical cause, but to a lack of information. Not many people, including the rehabilitation team, know about extra-ambulatory activities.</p> <p>To illustrate this, examine the current level of rehabilitation. Presently, rehabilitation focuses most of its attention on a basic activity (walking), and once this minimal level of activity is achieved, assistance is usually discontinued. This in effect limits the patient's functional capabilities and discourages patient participation in physical activities.</p> <p>Stating that an amputee cannot participate in extra-ambulatory activities without knowing of the possibility is like asking someone a question in French without his knowing the language, and then saying "Look, I told you he didn't know the answer." A person needs to know how to do something or have knowledge about something before he can be expected to do it. The problem then, is not lack of ability, but lack of knowledge. If it is our purpose to increase the amputee's level of activity, a considerable amount of attention needs to be directed toward extra-ambulatory activities and the communication of this information.</p> <p>A recent survey on functional capabilities<a></a> discovered that of those amputees questioned, 60% currently participate in some form of sporting activity, indicating a definite desire on behalf of the patients to participate in physical activities.</p> <p>The most common activities (<b>Table 1</b>) are swimming and fishing, and the least common, due to discomfort, are running and walking long distances. During running, a substantial amount of irritation occurs because of the impact and the rotational forces within the prosthesis, which cause tissue irritation. Despite this irritation, however, amputees continue to run because running is a prerequisite for many other physical activities. The most active patients are young individuals whose amputation resulted from either congenital deformity or trauma. Sex and length of time since amputation have little effect on the patient's ability to exercise, while age and level of amputation play a definite role in determining functional ability.2 Other factors, including pain, social embarrassment, and lack of organized training programs, must also be considered.</p> <strong>Table 1. Avocational Activities</strong><br /><img src="/files/original/0aebfe07b23f1c1385e5e11dabd23ab4.jpg" p="" />When asked about their prosthetist, 28% of the patients in the recent survey felt that their prosthetist knew about extra-ambulatory prostheses. However, of the prosthetists sampled, only 18% encouraged participation, indicating a high reluctance on the part of prosthetists. The reasons for this reluctance is not so much physical make-up, but, as stated earlier, lack of information. When making a prosthesis for extra-ambulatory activities, the prosthetist needs to have knowledge about the activity and must be able to design the prosthesis around the activity. Designing an extra-ambulatory prosthesis isn't easy. It often involves the incorporation of different materials and principals—a time consuming process. As one patient quoted his prosthetist when he was asked about extra-ambulatory prostheses, "'It is too much work and too much adjustment.'" Perhaps a reason why the level of physical activity is so low among amputees is the prosthetist's inability or unwillingness to design a prosthesis for extra-ambulatory activities. <p>Despite the reluctance on behalf of the prosthetist, 6% of the patients sampled used special equipment for sporting activities while the remaining 94% either indicated a willingness to make do with their current prosthesis or were unaware of adaptive devices available to them.</p> <p>When informed about the existence of these devices, a majority asked why they had never been told about these prostheses before, indicating a need for additional information in the areas of prosthetic design, training programs, and support organizations.</p> <p>To make a patient more comfortable with his individual situation, he can often be directed toward meeting other amputees. Through this social interaction the patient can find support by sharing similiar situations with other amputees and by finding he is not alone in confronting the problems associated with amputation. Often it is this kind of support that can make the difference between the patient being successful or unsuccessful in obtaining his maximum potential. (For a list of organizations serving physically disabled persons interested in sports and recreation, see p. 7).</p> <h3>Prosthetic Design</h3> <p>Advances in prosthetics are based on two things: 1) patients' need for improved function, and 2) technical knowledge. Based on this need for improved function, advances in prosthetic components and systems will continue to be developed. Recently, with an increase in extra-ambulatory activities, prosthetists have begun to realize the need for extra-ambulatory prostheses. Some prosthetic innovations already exist,<a></a> but additional research is needed in this area.</p> <p>The most common activities requiring prosthetic modification are swimming, running, and skiing. Since each one of these activities is different, the prosthetist must design the prosthesis specifically for that activity.</p> <p><b>Swimming</b></p> <p>Of primary importance for a swimming prosthesis are: 1) its ability to hold up under water, and 2) its ability to float. A swimming prosthesis must be made out of waterproof materials. If not, special attention must be taken to seal any material that can absorb water such as wood or leather. When wood becomes wet, it swells and causes delamination.</p> <p>Regarding the question of buoyancy, the prosthesis must be able to float, yet give little resistance to immersion. If the prosthesis is too buoyant, the patient is unable to submerge the device while swimming, which can cause the prosthesis rather than the patient's head to be above the water. To solve this problem, some prosthetists have designed prostheses that fill with water, which solves the buoyancy problem associated with the use of foams. The only problem with this design is that the water also needs to drain out fairly rapidly and if it doesn't, the prosthesis will remain full of water or leave a trail of water in its path.</p> <p><b>Running</b></p> <p>As stated earlier, running is a prerequisite for most sports activities. Due to the rotational and impact forces on the residual limb during running, a considerable amount of attention is needed in this area. Of particular importance in the design of such a prosthesis is suspension. The prosthesis must be suspended securely so as to eliminate all or as much pistoning as possible. To do this, the prosthetist can incorporate a rubber suspension sleeve or a thigh lacer with waist belt. The thigh lacer aids in medial/lateral stability, and also decreases the rotational forces on the residual limb. Therefore, if the patient is extremely active, whether he has a short residual limb or not, it is recommended that a thigh lacer be used.</p> <p>As well as tackling the problem of suspension, the prosthetist also needs to consider the matter of interface/liner materials. The liner must be able to decrease the rotational forces inside the socket so as to eliminate friction. Conventional Kemblo®, leather, and Pelite® liners have been used in the past with little success. If the patient is extremely active or has residual limb problems caused by excess rotation, a silicone or sorbathane insert should be used. To further minimize the rotation inside the socket, the prosthetist can incorporate a rotator in the prosthesis. A Greissinger foot can be used to decrease rotational capabilities, and is strongly suggested for those patients engaged in physical activities.</p> <p><b>Skiing</b></p> <p>Various types of skiing prostheses have been made. Their designs have ranged from incorporating the prosthesis directly into the ski boot, to modifying the patient's existing prosthesis. What is of primary importance in either case is that one maximizes the patient's knee flexion and aligns the prosthesis so the patient's center of gravity lies in front of the ski boot. This is the section of the ski that initiates the turn and if one does not align the prosthesis so that the patient's weight is over the front of the ski, turning will be difficult.</p> <p>Depending on the patient's level of activity, knee stability and length of residual limb, the incorporation of a thigh lacer into a ski prosthesis may or may not be needed. A turn on skis is initiated by a varus or valgus movement of the knee. If the prosthetist incorporates a thigh lacer into a ski prosthesis, he is in effect limiting knee motion and making the ski harder to turn. Therefore, if the patient can do without a thigh lacer, let him do so, because it gives him more maneuverability.</p> <p>Before designing a prosthesis for a specific activity, it is critical that the prosthetist look at the functional ability of the patient and the specific activity, and then design a prosthesis around that activity. It is only through this process that the prosthetist can develop a prosthesis that satisfies the patient's individual needs. Ultimately it is the patient's individual needs that dictate prosthetic design.</p> <h3>Conclusion</h3> <p>Despite the limited amount of technical information available on extra-ambulatory activities, they have received a considerable amount of public attention. That attention must now be directed toward decreasing the physical limitations imposed on amputees. This can only be achieved through an increase in patient/team rehabilitation communication, improved prosthetic design, and direct therapy programs. It is only by such means that amputees can experience their true physical potential.</p> <h3>Acknowledgements</h3> <p>Appreciation is expressed toward Dr. Ernest M. Burgess,<a style="text-decoration: none;">*</a> Bernice Kegel, RPT,<a style="text-decoration: none;">*</a> and the staff of the Prosthetics Research Study Center for their assistance and cooperation in the preparation of this material.</p> <p><b>References:</b></p> <ol> <li>Kegel, B.; Jeffrey C. Webster; Ernest M. Burgess, MD: Recreational Activities of Lower Extremity Amputees: A Survey. Arch. Phys. Med. Rehabil., Vol. 61, 258-264, 1980.</li> <li>Kegel, B.; Margaret L. Carpenter; Ernest M. Burgess, MD: Functional Capabilities of Lower Extremity Amputees. Arch. Phys. Med. Rehabil., Vol. 59, 109-120, 1978.</li> <li>Kegel, B. : Prostheses and assistive devices for special activities. Atlas of Limb Prosthetics, Surgical and Prosthetic Principles. American Academy of Orthopaedic Surgeons. The C.V. Mosby Company, 423-434, 1981.</li> </ol> <b>Footnote</b> Chief of Rehabilitation, Prosthetics Research Study Center, Seattle, WA<br /><br /><b>Footnote</b> Principal Investigator and Director, Prosthetics Research Study Center, Seattle, WA<br /><br /> <div style="width: 400px;"><em><b>*Drew A. Hittenberger, CP </b> Director, Research Prosthetics, Prosthetics Research Study Center, Seattle, WA<br /><br /><br /></em></div> <div style="width: 400px;"></div> Page Number(s) 1 - 4 Year 1982 Volume 6 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1982_04_001/1982_04_001-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Extra-Ambulatory Activities and the Amputee Creator An entity primarily responsible for making the resource Drew A. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_01_002.pdf Text Any textual data included in the document <h2>Historical Aspects of Powered Limb Prostheses</h2> <h5>Dudley S. Childress, Ph.D.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>People involved in work on powered limb prostheses may wonder if the history of this field is important. My answer is that one can learn a lot from history. Nevertheless, Hegel has said, "What history teaches us is that men never learned anything from it." Unfortunately, it sometimes does seem true in prosthetics that we have not always profited from past experiences. Too many aspects of the work are never published, and the multidisciplinary nature of the field produces papers in a broad spectrum of journals that are difficult to track. Books on the field are, unfortunately, not numerous.</p> <p>The brief history that follows is by no means complete, and since some of it involves years that are within readers' memories, I apologize in advance for omissions that anyone may consider significant. The history is intended to entice readers to look more deeply into historical issues. It is also intended to give some perspective on the field and to dispel notions that powered prostheses are only recent developments of "bionic man" research. Wilson<a></a> has written a brief history on external power of limb prostheses and the handbook by Spaeth<a></a> contains an introductory chapter on this subject. Brief surveys are included in papers (e.g. Childress<a></a> or Bottomley et al.<a></a>)</p> <p>Powered limbs have existed for some seventy years. This roughly corresponds with the history of powered hand tools and other powered technical devices used so widely in modern society (e.g. airplanes, automobiles, etc.). This is not surprising since technology in most fields tends to mirror the state of technology generally. The history of powered limbs is also comparable in length with the history of an identifiable field known as "limb prosthetics."</p> <p>I have chosen to consider the history of powered prostheses from a hardware viewpoint and from the viewpoint of important meetings and events. Control approaches, another viewpoint, are considered but not emphasized. Also, the perspective is from America.</p> <h3>Prologue (1915-1945)</h3> <p>The first powered prosthesis, of which I am aware, was a pneumatic hand patented in Germany in 1915.<a></a> A drawing of an early pneumatic hand is shown in <a href="/files/original/47c2da3bfe365d19dab934e665f66a7e.jpg"><b>Fig. 1</b></a>. <a href="/files/original/021188ebcef7da90fd31f98828fa6492.jpg"><b>Fig. 2</b></a> shows a drawing of what I believe to be the first electric powered hand. These drawings were published in 1919 in <i>Ersatzglieder und Arbeitshilfen</i> (Substitute Limbs and Work Aids).<a></a> This German publication illustrates the importance of history in prosthetics, containing ideas that are still being discovered today. Although the book <i>Treatise on Artificial Limbs</i> by A.A. Marks, published in 1901, does not contain anything about powered limbs, it too illustrates the importance of history in the field because many ideas put forward in it are also quite modern.</p> <strong><a href="/files/original/47c2da3bfe365d19dab934e665f66a7e.jpg">Figure 1</a>. Early compressed-gas powered hand (Perhaps the first powered prosthesis component). From Ersatzglieder under Arbeitshilfen (Limb Substitutes and Work Aids) 1919.</strong><br /><br /><strong><a href="/files/original/021188ebcef7da90fd31f98828fa6492.jpg">Figure 2.</a> Early electric hand component (Perhaps the first electric hand mechanism). From Ersatzglieder und Arbeitshilfen (Limb Substitutes and Work Aids) 1919.</strong><br /> <p>Powered limbs were probably not used to any significant extent between the World Wars, but CO₂ powered limbs were used by Weil as early as 1948.<a></a> Development work continued at Heidelberg during the 1950's under Marquardt,<a></a> and the Otto Bock Company became involved with the work about 1962. Laboratories at Munster and Hannover were also involved in this early work that led to clinical applications of gas powered prostheses. Part of Germany's prominent position in the prosthetics field can be traced to their early commitment to development work in the entire field of prosthetics.</p> <p>Kiessling<a></a> was the major U.S. investigator involved with CO₂ powered limbs. Of course, the McKibben muscle<a></a> was developed in the U.S., but has been used mainly in orthotics.</p> <p>The first, as far as we know, myoelectric prosthesis was developed during the early 40's by Reinhold Reiter, a physicist working with the Bavarian Red Cross. He published his work in 1948<a></a> but it was not widely known and myoelectric control was destined to be "rediscovered" in England, in the Soviet Union, and perhaps other places during the 1950's. Economic conditions in Germany after World War II prevented the work on myoelectric control from being continued there. <a href="/files/original/33a23ce6e5de3913d0478c534f7aba36.jpg"><b>Fig. 3</b></a> shows a picture of the first myoelectric hand prosthesis which was probably used around 1943. The system was controlled by a vacuum tube amplifier and was not portable. The hand was a modified Hüfner Hand that continued a control electro-magnet. The system was heavy, large, and not battery operated; the idea was to use it as a special prosthesis at a work station. Reiter hoped that further development could make it portable.</p> <strong><a href="/files/original/33a23ce6e5de3913d0478c534f7aba36.jpg">Figure 3.</a> Electric powered hand used by Reiter in development of first myoelectric prosthesis (Circa 1943). It consists of a Hüfner Hand in which a control magnet has been built. From Grenzgebiete der Medizin (Frontiers of Medicine) 1948.</strong><br /> <p>It is an interesting coincidence that the results of the first experiments with myoelectric control were published in 1948, the same year in which the development of the transistor was announced. Practical myoelectrically controlled prostheses required the transistor and its subsequent refinements.</p> <p>Although Reiter conceived and developed the idea of myoelectric control in the early 1940's, others had the same idea later and apparently independently. The late Professor Norbert Weiner of Massachusetts Institute of Technology is reported to have suggested the concept around 1947. Berger &amp; Huppert<a></a> presented the idea in 1952. Battye, Nightingale, and Whillis<a></a> at Guy's Hospital in London developed a myoelectric control system for a powered prosthesis in 1955 in what was for many years thought to be the first demonstration of this principle. That they were not first in no way detracts from their accomplishment. Soviet scientists were apparently the first to use transistors in a myoelectrically controlled prosthesis. The so-called Russian Hand<a></a> was the first semi-practical myo-electrical limb to be used clinically and was sold (although not widely used) on a license basis for application in Great Britain and in Canada.</p> <h3>The Early Years (1945-1967)</h3> <p>As far as the United States is concerned, the year 1945 was a turning point in prosthetics. In January 1945, military personnel, surgeons, prosthetists, and engineers met in Chicago (Thorne Hall, Northwestern University) to consider what should be done about limb prosthetics. This meeting is recognized as the beginning of the prosthetics research and development program by the U.S. government. This program ultimately resulted in the establishment of the Committee on Prosthetics Research and Development (CPRD) of the National Research Council which guided work in the field for over twenty-five years. The post-war years saw tremendous advances in limb prosthetics in general, although powered prosthesis development was slow. During the period 1946-1952, Alder-son, with the support of IBM and the Veterans Administration, developed several electric-powered limbs.<a></a> These IBM arms were impressive engineering achievements for the time, but they were somewhat difficult for amputees to use.</p> <p>The Vaduz hand, developed during the early post-war period, appears to have been a prosthesis ahead of its time and one that contained antecedents of today's electric hands. A German team headed by Dr. Edmund Wilms settled in Vaduz, Lichtenstein after World War II to continue their prosthetic hand development work. They wanted to create a hand controlled by the muscles of prehension, which would operate on a portable power source. The hand they created is shown in <a href="/files/original/603316446d9d314a4586a444cf9f0a22.jpg"><b>Fig. 4</b></a>. It has been described by Wilms.<a></a> This hand had a gear shifting mechanism to enable it to obtain high gripping force from an electric motor while also having reasonable finger velocity. This is a principle used in current Otto Bock hands. The hand used a unique controller in which a pneumatic bag inside the socket detected muscle bulge through pneumatic pressure, which in turn operated a switch-activated position servomechanism to close the voluntary-closing electric hand. This principle foreshadows the concept of extended physiological proprioception (EPP) introduced by Simpson<a></a> (<a href="/files/original/18b9b43af4d8e97b8ba3e0f2828c3ef6.jpg"><b>Fig. 5</b></a>). The complete system is shown in <a href="/files/original/105098f81ea7edb2a091dcd0415eed6a.jpg"><b>Fig. 6</b></a>.</p> <strong><a href="/files/original/603316446d9d314a4586a444cf9f0a22.jpg">Figures 4a and 4b.</a> Two views of the mechanics of the Vaduz Hand. Note position and force feedback links that connect to the inner transducer. This connects to an outer transducer (a bladder) adjacent to the residual limb in the socket. This voluntary-closing hand was activated by muscle bulge. It operated as a position servomechanism. It contained a gear shifting mechanism and a current cut-off mechanism. From Bulletin of Prosthetics Research, BPR 10-6, 1966.</strong><br /><br /><strong><a href="/files/original/18b9b43af4d8e97b8ba3e0f2828c3ef6.jpg">Figure 5.</a>&nbsp;Diagram of control circuit for Vaduz Hand. Muscle bulge compresses the outer transducer, which causes expansion of the inner transducer, moving the spindle upward. This activates the switches that close the hand. A link with the output moves the switch assembly along so that the hand stops when the link movement corresponds with spindle movement. Force feedback opens the closing limit switch at some force level when the hand meets an object. This conserves battery power. From Bulletin of Prosthetics Research, BPR 10-6, 1966.</strong><br /><br /><strong><a href="/files/original/105098f81ea7edb2a091dcd0415eed6a.jpg">Figure 6.</a> View of complete Vaduz system. Note similarity of myoelectric systems. From Bulletin of Prosthetics Research, BPR 10-6, 1966.</strong><br /> <p>Lucaccini, Kaiser &amp; Lyman<a></a> evaluated the Vaduz Hand. The center at the University of California at Los Angeles, under Lyman's direction, also evaluated the Alderson-IBM arm, the Heidelburg Pneumatic Prosthesis, and other externally powered systems, as well as conducting many control studies of their own.</p> <p>After 1953, the Vaduz Hand was marketed from Paris and consequently was sometimes called the French Hand. It apparently was difficult to keep in optimal mechanical adjustment, but it must be considered as one of the most important ancestors of today's electric hands, and a hand that contained many novel and intriguing concepts. It was available through the mid-sixties.</p> <p>The Russian Hand and Vaduz Hand were followed by an English Hand developed around 1965 by Bottomley.<a></a> This was the first myo-electrically controlled hand that exhibited proportional control (<a href="/files/original/dedd8fa68f49c7b3bcc8c3e82b8efa92.jpg"><b>Fig. 7</b></a>). This prosthesis also contained several novel features for that period of time, such as internal force and velocity feedback and a unique myoelectric signal smoothing principle called "autogenic backlash," which produced a more or less consistent direct current (DC) output from the fluctuating myoelectric signal while not sacrificing time response.</p> <strong><a href="/files/original/dedd8fa68f49c7b3bcc8c3e82b8efa92.jpg">Figure 7.</a> View of myoelectric hand developed by Bottom-ley in England. Note the two external packages on the table, battery on left and electronics on right. This was the first myoelectrically controlled hand that had proportional control. From Science Journal article by R.N. Scott, March 1966.</strong><br /> <p>The Russian Hand (<a href="/files/original/e592dc5785c3e7b7ec28c9077eaa7fef.jpg"><b>Fig. 8</b></a>), Vaduz Hand, and Bottomley Hand were single-function devices and non-adaptive. During the early 1960's Tomovic suggested an adaptive, multi-articulated hand with rudimentary sensory qualities. This resulted in the Belgrade Hand.<a></a> Although this hand was not used clinically to any great extent, it was used extensively in research laboratories and has had influence on robotic hand developments. In 1965, a Swedish research group began work on an electric hand which was adaptive and which had multiple functions (two types of grasp, wrist flexion-extension, and supination-pronation). This became known as the SVEN-Hand<a></a> (<a href="/files/original/a8cce387b55b45e6a667c49df89ae308.jpg"><b>Fig. 9</b></a>). It also has been used extensively in research, particularly regarding multi-function control<a></a> and concepts employed in it are utilized today in Swedish developments.</p> <strong><a href="/files/original/e592dc5785c3e7b7ec28c9077eaa7fef.jpg">Figure 8.</a> Photograph of Russian Hand. This was the first myoelectric hand that was transistorized and portable (Circa 1959). The external battery pack is shown in the center of the photograph. The electronic package is beneath the battery. The battery charger is at left. Note the long electrode wires and the prosthesis suspension straps. From Science Journal article by R.N. Scott, March 1966.</strong><br /><br /><strong><a href="/files/original/a8cce387b55b45e6a667c49df89ae308.jpg">Figure 9.</a> Photograph of the SVEN-Hand. This was one of the first multifunctional, adaptive, myoelectrically controlled hand prostheses.</strong><br /> <p>Congenital amputations caused by the drug Thalidomide resulted in expanded interest in powered prostheses in the 1960's. Pneumatic systems by Otto Bock (hand, hooks, wrist rotators, and elbows) were fitted successfully, particularly in Germany by Marquardt,<a></a> to many children born without limbs. However, pneumatic systems never caught on well in the U.S. probably because of difficulties with the compressed gas. Cannisters of gas were expensive and difficult to maintain and distribute in the U.S. American laws also required steel cannisters, which added to weight. Pneumatic systems have low energy storage densities and this meant that multiple cannisters were required, particularly to supply the energy needs of adult prostheses. On the other hand, these systems have actuators that are light in weight, which are easily controlled, and which have natural compliance properties that keep them from being rigid.</p> <p>Electric power can be stored more cheaply, more safely, and with greater density than gas power. Also, the control possibilities made possible by electronic circuits have given electrical systems an advantage. Unfortunately, the actuators (electric motors and gear mechanisms) tend to be heavy and may result in prostheses that are noisy and naturally non-compliant. They also have zero efficiency when activated in the stalled condition. Some of the negative aspects of electrical actuators have been overcome electronically in today's powered prostheses.</p> <p>Electro-Hydraulic systems may be used in the future because they have the potential advantage of developing high torque in small actuators. However, cost factors for the special hydraulic mechanisms needed, along with technical problems, have restricted development work in this area thus far. Early work was conducted in Canada.<a></a> The Edinburgh arm has been converted to hydraulic power at a couple of centers in the U.K.</p> <p>Research work on multifunctional limb prostheses flourished in the United Kingdom during the 1960's and early 1970's. Most notable among the developments were the Hendon Arm<a></a> and the Edinburgh Arm.<a></a> Both were pneumatic, multi-functional limbs. Simpson used a position servomechanism control principle that he called extended physiological proprioception (EPP), a principle which enables control of multiple functions without excessive mental load on the user. This control technique has been shown to be a better information link between the body and prosthesis than "velocity" controllers.<a></a></p> <p>The Edinburgh Arm, which was pneumatic, worked in spherical coordinates from the shoulder and was controlled by protraction-retraction and elevation-depression of the two shoulders. If the arm was fitted on the right side, then elevation of the right shoulder elevated the hand about the shoulder joint. Protraction of the right shoulder moved the hand more distant from the shoulder (in a radial direction). Protraction of the left shoulder moved the hand medially, and elevation of the left shoulder supinated the hand. The wrist was linked to the shoulder and elbow so as to maintain attitude of the hand during shoulder or elbow motion. This made it possible to hold a glass of water without worrying too much about spilling the contents during arm movements. Carlson<a></a> has called this kind of joint coupling, "kinematic coupling." Opening and closing the hand or terminal device of the arm was controlled by a switch through some other motion of the body. The arm was complex and difficult to keep functional on active children but the control was remarkable. Children operated its multiple functions naturally, without much training, and seemingly without too much mental load. <a href="/files/original/ca2b3ffb8c94001e703bdd917b139e04.jpg"><b>Fig. 10</b></a> shows the mechanism. Less complex (and less functional) all-electric EPP-type controllers are now under study in the U.S. and Scotland.</p> <strong><a href="/files/original/ca2b3ffb8c94001e703bdd917b139e04.jpg">Figure 10.</a> Photograph of the mechanism of the Edinburgh Arm, developed by D.C. Simpson. This CO₂-powered limb had four degrees of freedom (five if the terminal device was included) and kinematic coupling of the wrist to the elbow and the shoulder. It used spherical coordinates and was controlled by position servos that mechanically linked shoulder girdle position with prosthesis position. It is one of the most complete powered arms ever developed.</strong><br /> <p>Proceedings of meetings form an excellent historical record of powered prostheses. The first meeting of consequence in the U.S. concerning powered prostheses was held at Lake Arrowhead, California in 1960,<a></a> and was sponsored by the National Research Council. The second major meeting of this kind in the U.S. was held in Warrenton, Virginia in 1965<a></a> with considerable international input. Subsequently, the Committee on Prosthetics Research &amp; Development (CPRD) held regular meetings related to applications of external power in limb prosthetics, and the reports of these meetings form a good record of U.S. activity in this field.</p> <p>Myoelectric control received a major boost in America through a 1966 symposium in Cleveland, Ohio (Case Western Reserve University) entitled "Myoelectric Control Systems and Electromyographic Kinesiology." Bottomley demonstrated his elegant myoelectric system at that meeting. The meeting was also attended by Professor Robert N. Scott of the University of New Brunswick. Scott headed a group that developed the first myoelectric control mechanism in North America.<a></a></p> <p>A Yugoslavia-based conference, around 1963, called "External Control of Human Extremities" was followed by a similar conference in Dubrovnik, Yugoslavia and this international conference has been held there every third year since 1966. The Proceedings of the "Dubrovnik Conference," as it is often called, are a singular record of international developments in powered limb research and development since the early sixties.</p> <p>Three other symposia produced significant early publications. The symposium on "Basic Problems of Prehension, Movement and Control of Artificial Limbs"<a></a> organized in London in 1968 by the Institution of Mechanical Engineers contains a wealth of information on powered limbs. The "Dundee Conference" held in Dundee, Scotland in 1969 resulted in the book <em>Prosthetic and Orthotic Practic</em>e.<a></a> It covers prosthetics generally but has a fair amount of material on powered prostheses. Finally, the Swedish conference of 1974<a></a> produced a book that concerned early research and development work on powered prostheses and orthoses.</p> <h3>Growing Up (1967-1977)</h3> <p>I have selected the decade of 1967-1977 as one of "growing up" because 1967 is about the time it became possible to purchase a powered prosthesis commercially in the United States, and it was approximately 1977 before powered upper-limb prostheses began to take on some real clinical significance (i.e. larger numbers of clients fitted).</p> <p>The Viennatone Hand was the first commercial system available in the U.S. This hand came about as a result of Otto Bock Orthopedic Industries, a German prosthetics company, and Viennatone, an Austrian hearing aid company with expertise in electronics. Shortly thereafter, Otto Bock developed their own myoelectric system and a new hand mechanism. The Viennatone and Otto Bock Hand mechanisms (both designed by Otto Bock) have been altered somewhat through the years, but their basic appearance and design principles remain essentially unchanged.</p> <p>In the early days of myoelectric control (e.g. 1968), the battery or battery and electronics had to be worn outside the prosthesis, usually in a chest pouch, on a clip at the waist, or on a band around the humeral section of the arm. The wires and connections required by this kind of configuration led to failures due to wire breakage. There was also electrical interference on occasion. In addition, the components outside the prosthesis were a nuisance to fit and to wear.</p> <p>In 1968, I was involved in fitting a college student with one of the first self-contained and self-suspended below-elbow prostheses.<a></a> The Viennatone Hand mechanism was used in conjunction with a myoelectric controller developed at Northwestern University. Self-containment and self-suspension are standard procedures for below-elbow prostheses today.</p> <p>The Veterans Administration Prosthetics Center (VAPC) modified the Viennatone Hand mechanism and packaged it with a modified version of the electronic system developed at Northwestern. The VAPC contracted for this system to be manufactured by Fidelity Electronics, Ltd. and this system was marketed for a period of time.</p> <p>An interesting electric powered hand of this period was the hand developed at the Army Medical and Biomechanical Research Laboratory.<a></a> This hand contained a "slip detector" in the thumb. The hand would grip to about 2 Lff at the finger tips. If the object to be held started to slip, the hand would automatically increase gripping force until slippage stopped.</p> <p>Schmidl<a></a> was actively fitting many upper-limb amputees with myoelectrically controlled, powered limbs during this period and he achieved clinical significance with powered limbs well before this happened in the U.S. His center in Italy was also involved early in fittings of multifunctional limbs. Three-state controllers are used to control electric elbow, electric wrist rotator and electric hand from three muscle electrode sites. The Italian group has been at the forefront of progress in the fitting of powered limbs.</p> <p>Engineers at Temple University-Moss Rehabilitation Hospital<a></a> were probably first to attempt multi-functional control of elbow, humeral rotation, and wrist using pattern recognition techniques on myoelectric signals from multiple muscle sites of the upper arm and shoulder. They had some laboratory success. Swedish scientists<a></a> did similar work to control multiple functions of the hand (rotation, flexion-extension, and prehension).</p> <p>The New Brunswick laboratory has played an active role in developing control methods for powered limbs in North America and is well known for three-state control design and development. They have also been active in research on sensory feedback<a></a> and the University of New Brunswick sensory feedback system is the only one available today, of which I am aware. Sensory feedback was examined by many research groups during the 1970's. I reviewed some of this work in an article appearing in the <i>Annals of Biomedical Engineering</i>.<a></a></p> <p>In the late 1960's and 1970's much experimentation and development were engendered in the field of external electric power. The Japanese developed a myoelectric powered hand.<a></a> MIT scientists designed the Boston Arm,<a></a> the first myoelectrically controlled elbow. The Ontario Crippled Children's Centre (OCCC) Elbow, a switch-controlled electric elbow was also developed in the late sixties, and is still in use. A number of electric elbows, the Rancho Electric Elbow (from Rancho Los Amigos Hospital) the AMBRL Elbow (from the Army Medical and Biomechanical Research Laboratory), and the VAPC Elbow (from the VA Prosthetics Center) also made their appearance in this time period. The Boston Elbow, AMBRL Elbow, and Rancho Elbow were evaluated by the Committee on Prosthetics Research and Development (CPRD).<a></a> Subsequently, the Applied Physics Laboratory in association with Johns Hopkins University developed a powered unit<a></a> capable of pulling the cable of conventional cable-operated, body-powered prostheses. It could be controlled by other inputs, such as from skin motion sensors, which were used with several fittings for high-level arm amputees.</p> <p>The Boston Elbow was redesigned extensively to become the Liberty Mutual Powered Elbow,<a></a> available through Liberty Mutual Insurance Company. The Boston Elbow was also undoubtedly a stimulus to Jacobsen who did his graduate studies at MIT and who later developed the finely-crafted Utah Arm,<a></a> available through Motion Control, Inc. in Salt Lake City. Likewise this research at MIT influenced Hogan,<a></a> who today is developing an elbow in which elbow compliance is controlled by myoelectric signals.</p> <p>The VAPC elbow was manufactured by Fidelity Electronics and used to some extent by VA clients. It was controlled by the VAPC pull switch.</p> <p>The OCCC elbow (available through Electro-Limb in Toronto) has been a workhorse for many years. It, along with other elbows of its period, influenced Lembeck<a></a> in development of the NYU Elbow at New York University. This elbow is presently manufactured by the Hosmer Dorrance Corporation.</p> <p>The OCCC has been a leader in the fitting and development of powered limbs. It is interesting how influential children's prosthetics programs in Germany, Sweden, Britain, and Canada have been on the field of powered prostheses. This is partially the result of government sponsored research programs directed toward amputations caused by the drug Thalidomide. Besides the electric elbow, the Ontario group have made small electric hands available through Electro-Limb for many years and their new electric hand is the latest evolutionary result of their continuing development work in this area.</p> <p>Sorbye<a></a> in Sweden, pioneered the fitting of child amputees with myoelectric hands during the early 70's. His work stimulated the development of the Systemteknik Hand. His work also stimulated interest in the U.K. and an evaluation program there found myoelectric hand systems valuable for child amputees. This undoubtedly had an influence on the development of the Steeper child-sized hand.</p> <p>When Colin McLaurin was at Northwestern University in the early 1960's he developed a "feeder arm" for the Michigan Area Amputee Center (MAAC) in Grand Rapids, Michigan. It was a kinematically coupled limb, designed to enable children with bilateral amelia to eat. A single electric drive mechanism at the elbow moved the terminal device from plate to mouth in a mechanically predetermined fashion. Subsequently, McLaurin moved to OCCC and was responsible for many developments there. Later, Dr. Aitken of MAAC requested the Prosthetics Research Laboratory at Northwestern to re-design the "feeder arm." The Michigan Arm resulted, which was a simple arm with electric hook and electric elbow similar in shape and function to one of Simpson's early CO₂ powered limbs. The electric terminal device for the Michigan Arm became commercially available through Hosmer Dorrance as the Michigan Hook. This was one of the first electric hooks to become commercially available. Of course CO₂ powered hooks had been used for many years. Also, it should be noted that Bottomley<a></a> designed a unique CO₂ powered hook in the 1960's that had many merits which were never exploited.</p> <p>The Michigan Hook was a stimulus for Lembeck at New York University to develop the Prosthesis Assist Device. Like the Michigan Hook and the earlier systems at Johns Hopkins, it pulls on a cable to open a voluntary-opening hook or hand against a resisting spring (e.g. rubber band). This form of electric power utilization in prostheses lacks control sophistication but has simplicity of design and operation.</p> <p>Electric-powered prosthetic hooks have generally been thought to be desirable, particularly by Americans in the prosthetics field. During the mid-seventies, the VAPC developed an electric hook.<a></a> A few years earlier, Northwestern had introduced the synergetic prehension concept and the Synergetic Hook.<a></a> The VA purchased 12 synergetic hooks and evaluated them on VA clients. However, only recently has there been interest in commercial development of this prehension device for interchangeable use with electric hands.</p> <p>Otto Bock developed the Greifer during the late 1970's. It is a novel prehension device that is interchangeable with the Otto Bock Hand. This device is valuable for persons engaged in heavy-duty activities.</p> <p>The commitment of Otto Bock Orthopaedic Industries, Inc. to the powered limb field cannot be overlooked in any historical review. Without availability of Otto Bock hands, wrist rotators, and electronic control systems, much research work in this field would have been stymied for lack of components. Of course, without available commercial components that were backed strongly by educational programs and literature, and by repair and maintenance, it would have been impossible for practicing prosthetists to serve their clients well. Needless to say, Otto Bock, through research, production, education, and product support has made an unparalleled contribution to development for almost a quarter century.</p> <h3>The Present (1977-1984)</h3> <p>The last seven years has been a period marked not by experimental powered fittings in a small number of research centers or elite institutions, but rather by the clinical use of powered limbs by prosthetists practicing all over the country. This "coming of age" was vividly evident at the education seminar entitled, "Current Clinical Concepts of Electrically Powered Upper-Limb Prostheses" in Chicago in September, 1984 and sponsored by the American Academy of Orthotists and Prosthetists. This seminar, convened within a few hundred yards of where prosthetics research was born in the U.S., was not a seminar of researchers or a seminar directed toward particular products or particular methods; it was a seminar of clinicians involved with powered-limb fittings. Undoubtedly, this meeting was a milestone in the history of powered prostheses in this country.</p> <p>An interesting aspect about this period has been the upsurge of clinical fittings of powered prostheses and the increase of commercially available powered components. At the same time, there seems to have been some reduction of research efforts in this area. It is an area that has received considerable attention over the last twenty-five years, and perhaps research is just gathering its breath for the next important push. Whatever the situation, the clinical results show that progress has been made. That this progress has been difficult and hard won with many setbacks, is an indication of the difficulty of the problem being addressed. Indeed, adequate replacement of the human hand and arm is one of the most difficult problems facing medical technology.</p> <h3>Future Trends</h3> <p>From a technical viewpoint there will probably be movement to smaller electronic systems that have extremely low quiescent power. This will enable small power sources to be used when they are coupled with highly efficient prehension devices. Consequently, it may be possible to fit myoelectrically controlled, electrically driven prehension devices to partial hand amputees. Availability of wrist function should make this kind of fitting very effective. This new possibility with technology, coupled with the new surgical reconstruction techniques for the hand, should open up many new possibilities for rehabilitation of partial hand amputees.</p> <p>There should be an increase in reliability and serviceability of powered limb systems. They will become more modular, as well as smaller and lighter.</p> <p>Electro-mechanical components will become more efficient and will have improved dynamic performance. That is, they will be faster and more responsive to the desires of the amputee. New prehension devices, interchangeable with hands and hooks, will be developed.</p> <p>Computer-based controllers will be used in artificial arms, particularly those for multifunctional control. The Utah Arm will probably be the first commercially available arm to contain a computer-based controller.</p> <p>Prosthetists will develop better suspension techniques that minimize or eliminate harnessing in powered limb fittings. They will also, through case studies, develop fitting principles that will enable the various components to be fitted components to be fitted effectively, used appropriately in combinations, and used creatively with body-power.</p> <p>I hope that new control strategies will become available which will enable arm amputees to use multifunctional prostheses without excessive mental load. When this may happen is difficult to predict.</p> <h3>Summary</h3> <p>I have attempted to put powered limb components available today into perspective from an historical viewpoint. None of the devices used today appeared "de novo." All have been influenced by historical events and concepts, the state of technology, and prosthetics practice.</p> <p><b>References:</b></p> <ol> <li>Alderson, S.W., "The Electric Arm," <i>Human Limbs and Their Substitutes</i>, Eds. Klopsteg, P. and William, P., McGraw-Hill, 1954 (Reprinted by Hafner Press, 1969), Chapter 13.</li> <li>Almström, C, Herberts, P., and Caine, K., "Clinical Application Study of Multifunctional Prosthetic Hands," Report 2:77, Research Laboratory of Medical Electronics, Chalmers University of Technology, Göteborg, Sweden.</li> <li>Battye, C.K., Nightingale, A., and Whillis, J., "The Use of Myo-Electric Currents in the Operation of Prostheses," <i>J. Bone &amp; Joint Surg.</i>, 37B, pp. 506-510, 1955.</li> <li>Berger, N. and Huppert, C.V., "The Use of Electrical and Mechanical Muscular Forces for the Control of an Electrical Prosthesis," <i>Amer. J. Occup. Ther.</i>, 6:110-14, 1952.</li> <li>Bottomley, A., "Myo-Electric Control of Powered Prostheses," <i>J. Bone &amp; Joint Surg.</i>, 47-B(3):411, 1965.</li> <li>Bottomley, A., "Design Considerations for a Prosthetic Prehension Device," <i>Proc. of Intl. Symp. on External Control of Human Extremities</i>, Dubrovnik 1966 (Published 1967), pp. 82-84.</li> <li>Bottomley, A., Kinnier Wilson, A.B., and Nightingale, A., "Muscle Substitutes and Myo-Electric Control," <i>J. Brit. I.R.E.</i>, 26, pp. 439-448, 1963.</li> <li>Carlson, L.E., and Radcliffe, C.W., "A Multi-Mode Approach to Coordinated Prosthesis Control," <i>Proc. of 4th Intl. Symp. on External Control of Human Extremities</i>, pp. 185-186, Dubrovnik, 1972, (published 1973).</li> <li>Childress, D.S., "Closed-Loop Control in Prosthetic Systems: Historical Perspective," <i>Annals of Biomed. Engr.</i>, Vol. 9, pp. 293-303, 1980.</li> <li>Childress, D.S., "Powered Limb Prostheses: Their Clinical Significance," <i>IEEE Trans. Biomed. Engr.</i>, BME-20, No. 3, pp. 200-207, 1973.</li> <li>Childress, D.S., "An Approach to Powered Grasp," Proc. <i>4th Intl. Symp. on External Control of Human Extremities</i>," pp. 159-167, Dubrovnik, 1972 (published 1973).</li> <li>Childress, D.S., and Billock, J.N., "Self-Containment and Self-Suspension of Externally Powered Prosthesis for the Forearm," <i>Bull. Prosthetics Research</i>, BPR 10-14, pp. 4-21, 1970.</li> <li>Dahlheim, W., Pressluft hand fur kreigsbeschädigte Industriearbeiter Z. komprimierte und flüssige Gase, German Patent (1915).</li> <li>Dorcas, D.S., and Scott, R.N., "A Three-State Myoelectric Control System," <i>Med. Biol. Engr.</i>, Vol. 4, pp. 367-370, 1966.</li> <li>Doubler, J.A., and Childress, D.S., "Design and Evaluation of a Prosthesis Control System Based on the Concept of Extended Physiological Proprioception," <i>J. of Rehab. Research and Development</i>, 21:1, BPR 10-39, pp. 19-31, 1984.</li> <li>"Externally Powered Prosthetic Elbows-A Clinical Evaluation," Comm. on Prosthetics Research and Development (CPRD), Report E-4, National Academy of Sciences-National Research Council, 1970.</li> <li>Geddes, L.A., Moore, A.C., Spencer, W.A., and Hoff, H.E., "Electropneumatic Control of the McKibben Synthetic Muscle," <i>Orthopaedic &amp; Prosthetic Appliance J.</i>, 13, pp. 33-36, 1959.</li> <li>Herberts, P., Almström, C, Kadefors, R., and Lawrence, P., "Hand Prosthesis Control Via Myoelectric Patterns," <i>Acta Orthopaedica Scandinavica</i>, Vol. 44, pp. 389-409, 1973.</li> <li>Herberts, P., and Petersen, I., "Possibilities for Control of Powered Devices by Myoelectric Signals," <i>Scand. J. Rehab. Med.</i>, 2:164-170, 1970.</li> <li>Hogan, N., Mechanical Impedance Control in Assistive Devices and Manipulators," <i>Proc. of the Joint Automatic Controls Conf.</i>, San Francisco, Vol. 1, August, 1980.</li> <li>Jacobsen, S.C., Knutti, D.F., Johnson, R.T., and Sears, H.H., "Development of the Utah Arm," <i>IEEE Trans. Biomed. Engr.</i>, BME-29, No. 4, pp. 249-269, 1982.</li> <li>Kato, I., et al., "Multifunctional Myoelectric Hand Prosthesis with Pressure Sensory Feedback System-WASEDA Hand-4P," Proc. <i>3rd Intl. Symp. on External Control of Human Extremities</i>, pp. 155-170, Dubrovnik, 1969 (published 1970).</li> <li>Kessler, H.H., and Kiessling, E.A., "Pneumatic Arm Prosthesis," <i>Am. J. Nursing</i>, 65:6, 1965.</li> <li>Kobrinskii, A.E., Bolkhoivin, S.V., Voskoboini-kova, L.M., Joffe, D.M., Polyan, E.P., Slavictskü, Ya. L., Sysin, A. Ya., and Yakobsen, Ya, S., "Problems of Bioelectric Control," <i>Proc. Intl. Fed. on Automatic Control Conf.</i>, pp. 1119-22, Moscow, 1960, (Butterworth, London, 1961).</li> <li>Lembeck, W., Personal Communication, 1984.</li> <li>Lucaccini, L.F., Kaiser, P.K., and Lyman, J., "The French Electric Hand: Some Observations and Conclusions," <i>Bull. of Prosth. Research</i>, BPR 10-6, pp. 30-51, 1966.</li> <li>Mann, R.W., "Cybernetic Limb Prosthesis," A<i>nnals of Biomed. Engr.</i>, Vol. 9, pp. 1-43, 1981.</li> <li>Marguardt, E., "The Heidelberg Pneumatic Arm Prosthesis," <i>J. Bone &amp; Joint Surg.</i>, 47-B:3, pp. 425-434, 1965.</li> <li>McWilliam, R., "Design of an Experimental Arm Prosthesis: Biological Aspects," <i>The Basic Problems of Prehension, Movement and Control of Artificial Limbs</i>, The Institution of Mechanical Engineers, Proc. 1968-69, Vol. 183, Part 3J, pp. 74-81, 1969.</li> <li>Montgomery, S.R., "Design of an Experimental Arm Prosthesis: Engineering Aspects," in <i>The Basic Problems of Prehension, Movement and Control of Artificial Limbs</i>, The Institution of Mechanical Engineer, Proc. 1968-69, Vol. 183, Part 3J, pp. 68-73, 1969.</li> <li><i>Prosthetic and Orthotic Practice</i>, based on Dundee Conference of 1969, Ed. G. Murdoch, Edward Arnold Ltd., London, 1970.</li> <li>Rakic, M., "The Belgrade Hand Prosthesis," in <i>The Basic Problems of Prehension, Movement and Control Artificial Limbs</i>, The Institution of Mechanical Engineers, Proc. 1968-69, Vol. 183, Part 3J, pp. 60-67, 1969.</li> <li>Reiter, R., "Eine neue Electrokunsthand," <i>Grenzgebiete der Medizin</i>, 4:133, 1948.</li> <li>Salisbury, L.L., and Colman, A.B., "A Mechanical Hand with Automatic Proportional Control of Prehension," <i>Med. Biol. Eng.</i>, Vol. 5, pp. 505-511, 1967.</li> <li>Schlesinger, G., "Der Mechanische aufbau der kunstlichen glieder," in <i>Ersatzglieder und Arbeitshilfen</i>, Borchardt, M., et al., Eds., J. Springer, Berlin, 1919.</li> <li>Schmidl, H., "The I.N.A.I.L. Experience Fitting Upper-Limb Dysmelia Patients with Myoelectric Control," <i>Bull. of Prosthetics Research</i>, BPR 10-27, pp. 17-42, 1977.</li> <li>Scott, R.N., Brittain, R.H., Caldwell, R.R., Cameron, A.B., and Dunfield, V.A., "Sensory Feedback System Compatible with Myoelectric Control," <i>Med. &amp; Biol. Eng. &amp; Comp.</i>, Vol. 18, No. 1, pp. 65-69, 1980.</li> <li>Seamone, W., "Development and Evaluation of Externally Powered Upper-Limb Prosthesis," <i>Bull. of Prosthetics Research</i>, BPR 10-13, pp. 57-63, 1970.</li> <li>Simpson, D.C., "An Externally Powered Prosthesis for the Complete Arm," in <i>The Basic Problems of Prehension, Movement and Control of Artificial Limbs</i>, The Institution of Mechanical Engineers, Proc. 1968-69, Vol. 183, Part 3J, pp. 11-17, 1969.</li> <li>Sorbye, R., "Myoelectric Controlled Hand Prostheses in Children," Int. J. of Rehab. Research, Vol. 1, pp. 15-25, 1977.</li> <li>Spaeth, J. P., <i>Handbook of Externally Powered Prostheses for the Upper Extremity Amputation</i>, Charles C. Thomas, Springfield, 111., 1981.</li> <li>Stevenson, D.A., and Lippay, A.L., "Hydraulic Powered Arm Systems," in <i>The Basic Problems of Prehension, Movement and Control of Artificial Limbs</i>, The Institution of Mechanical Engineers, Proc. 1968-69, Vol. 183, Part 3J, pp. 37-44, 1969.</li> <li>"The Application of External Power in Prosthetics and Orthotics," Report of Conference at Lake Arrowhead, California, Publication 874, National Academy of Sciences, National Research Council, September, 1960.</li> <li>"<i>The Basic Problems of Prehension, Movement and Control of Artificial Limbs</i>," The Institution of Mechanical Engineers, Proc. 1968-69, Vol. 183, Part 3J, 1969.</li> <li>"The Control of External Power in Upper-Extremity Rehabilitation," Report of Conference held at Warrenton, Virginia, April, 1965, Publication 1352, National Academy of Sciences-National Research Council, 1966.</li> <li>"<i>The Control of Upper-Extremity Prostheses and Orthoses</i>," based on a conference held in Göteborg, Sweden, 1971, Charles C. Thomas, Springfield, Illinois, 1974.</li> <li>VAPC Research Report, Development (Components), Powered Hook developed by C. Mason, <i>Bull. of Prosthetics Research</i>, BPR 10-16, pp. 217-219, 1971.</li> <li>Williams, T.W., "Clinical Applications of the improved Boston Arm," <i>Proc. Conf. on Energy Devices in Rehab.</i>, Boston (Tufts), 1976.</li> <li>Wilms, E., "Die Technik der Vaduzer Hand," <i>Orthopädie Technik</i>, 3, 7, 1951.</li> <li>Wilson, A.B., Jr., "Externally Powered Upper Prostheses," <i>Newsletter . . . Prosthetics and Orthotics Clinic</i>, Vol. 2, No. 1, pp. -4, 1978.</li> <li>Wirta, R.W., Taylor, D.R., and Finley, F.R., "Pattern-Recognition Arm Prosthesis: A Historical Perspective-A Final Report," <i>Bull, of Prosthetics Research</i>, BPR 10-31, pp. 8-35, 1978.</li> </ol> <div style="width: 400px;"><em><b>*Dudley S. Childress, Ph.D. </b> Dudley S. Childress, Ph.D. is Director of the Prosthetics Research Laboratory and Director of the Rehabilitation Engineering Program at Northwestern University, Room 1441, 345 East Superior Street, Chicago, Illinois 60611.<br /><br /><br /></em></div> Page Number(s) 2 - 13 Year 1985 Volume 9 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 8 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-10.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 Historical Aspects of Powered Limb Prostheses Creator An entity primarily responsible for making the resource Dudley S. Childress, Ph.D. * https://staging.drfop.org/files/original/ae236bfbb39982337feabb0733c52902.pdf e72d5cf575ee14ceefaff511308e621b https://staging.drfop.org/files/original/666c4f3f407ef42ef96a9eeb30cba2cc.jpg ef072ec1bc27f9dcd672375601a67a9e https://staging.drfop.org/files/original/da001445312603a0ab4a223ff85c38d1.jpg 4f8a28f1624ff2e04786d747684a2057 https://staging.drfop.org/files/original/a32c142193dc07186843945607ee7c09.jpg 79706ff74b7376718ec3c1c01ef15ca3 https://staging.drfop.org/files/original/d6cf3cf6ad5b9329cdf3ac01b1190266.jpg f251a6a6b93993eeba8075a00dd5ac91 https://staging.drfop.org/files/original/41e3f04ea2dcb2b15a38233a0196d63c.jpg 9d90b7c57aaad093cb21238b39211ddc https://staging.drfop.org/files/original/c70f240f5eef716b30961b9ae75c899e.jpg 1e4183be00d6bedb3cc92fad6389248d https://staging.drfop.org/files/original/f4d46e9d44ec0b8a2fd85babdfade006.jpg f7682f94bed1b0ccc9e390612c5dafdf https://staging.drfop.org/files/original/d5207f95412f40949c9a0abdcc8f179f.jpg 35b4aa1ad815d9578b088cbbfd993f91 https://staging.drfop.org/files/original/dd41c84673e88dc6270e962c77261651.jpg 117eda80e9303ed50d584b0ee204d8f9 https://staging.drfop.org/files/original/4575504d9fda222439f290f7163145af.jpg 423c40aa07471e5f2cf3e718ae770e6b https://staging.drfop.org/files/original/91b675186e820e21469468d77ca70551.jpg 5afe9e85b461d2b3d97106de870921a2 https://staging.drfop.org/files/original/ac9d622bf611e960cead91b85bba30b1.jpg d785d4c25a39f7ab31ae8d5fc4053ed2 https://staging.drfop.org/files/original/554280c049e6a114db8463eaeefec20f.jpg e79e156f8cb8fe7c9dd123eec6027222 https://staging.drfop.org/files/original/c767acc60d993ecbc9a2dea3fdceafb5.jpg eaa08643ef0c977a0f9e9974a26262f3 https://staging.drfop.org/files/original/9696814c90d3a127b31bdde25d16906a.jpg 1d2ed620db67e11602f865d0cbca66a1 https://staging.drfop.org/files/original/11e6648c1da2da4e863cf22ff6b27e92.jpg 7979974fd7a2d61065ebd35791b01993 https://staging.drfop.org/files/original/0be90617be2197739e9b7215c50adcc4.jpg 761099b39d2853060144d43fd50bce9e https://staging.drfop.org/files/original/cdf2e11044f459004d4cc3bea3571520.jpg b18f89555cc3b064d9679377782bc8d8 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_02_007.pdf Text Any textual data included in the document <h2>Passive Mobilization: An Orthotist's Overview</h2> <h5>Dwain R. Faso, C.O.&nbsp;<a style="text-decoration: none;">*</a><br />Mel Stills, C.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <h3>Introduction</h3> <p>The application of passive motion in orthopedics has brought a new dimension to an old concept for the treatment of musculoskeletal problems. It is now recognized that the adverse effects of immobilization such as joint stiffness, poor articular cartilage nourishment, and collagen loss can be reversed by prolonged passive mobilization. R.B. Salter demonstrated significant results with his experimental work in the healing of osteochondral defects in rabbits subjected to continuous passive motion. R.D. Courts followed with clinical experiences of improved range of motion after total knee replacements. The indications for passive motion have since broadened to include knee ligament reconstructions, &nbsp;joint injuires, fractures, dislocations, joint sepsis, and many others.</p> <p>The orthotist is often consulted for the evaluation of passive motion devices, their set up, adaptation, and implementation with fracture orthotics, external fixation, and traction. This article will provide an overview of passive mobilization as a supplement to the practitioner's database and present a variety of clinical situations encountered in the Dallas area at a large trauma and reconstruction center.</p> <h3>Background</h3> <p>For centuries, the clinician has vacillated between the uses and benefits of rest versus motion in the management of various disorders and injuries involving body joints. Rest or motion have been the most prescribed forms of non-operative treatment, yet the controversy of indication, duration, and value of each is far from being resolved.</p> <p>In the teaching of Hippocrates, the injured body was to be at 'rest and lie up.' His use of splints in musculoskeletal injuries assured rest. With the impregnation of bandages with plaster of Paris in 1852 by Flemish surgeon Antonius Mathijsen, immobilization took on a new form. The use of plaster casts in treating trauma and injury unquestionably assured the concept of immobilization by orthopedic surgeons for the next 130 years with little examination of the potential damage to articular tissue. Additional support of the rest concept was led by the British surgeon Hugh Owen Thomas. His doctrine of rest was to be complete, prolonged, uninterrupted, and enforced. This was accomplished through the use of splints of his own design, many of which are still in use today with minor modifications. Thomas' immobilization techniques routinely included uninjured joints above and below the fracture site.</p> <p>The mobilization concept found its roots in the Aristotelian teaching that movement is life. In the late 1900's, a school of mobilization took on a significant form through its advocate, Dr. Lucas-Champonniere. This French surgeon supported the use of massage and motion as a means of preventing muscle atrophy and joint contracture during the management of fractures and joint injuries. He believed that motion helped to relieve pain rather than to aggravate it. The use of balanced skeletal traction for fractures involving joint surfaces, initiated by Professor George Perkins, emphasized active motion in the realignment of fragments and prevention of stiffness.</p> <p>In the 1950's, the 'movement is life' principle found a resurgence under the guidance of the Association for Osteosynthesis (AO). They coined the term "fracture disease" for the chronic edema, joint stiffness, muscle atrophy, and disuse osteoporosis found in the treatment of fractures with immobilization. The AO group's technique of open reduction, rigid internal fixation with compression, and no casting encouraged early mobilization and provided a significant aggressive treatment. Apley, Dehane, and more recently Mooney and Sarmiento advocated the closed functional treatment of fractures through the use of cast bracing. Although these two methods vary, both preserve joint motion and encourage early function.</p> <h3>Continuous Passive Motion</h3> <p>The human body has evolved and developed into an organism that needs to move in order to maintain optimum efficiency. When the body is immobilized, the overall physical fitness declines rapidly: the heart rate decreases, and cardiac output no longer rises sufficiently during even mild activity; the upright position is poorly tolerated; the nervous system response slows; calcium is released by the immobilized skeleton and is excreted in urine, reflecting the extent of bone loss; muscle atrophy occurs with the reduction of fiber size, thereby resulting in the decline of tensile strength and energy absorption capacity; and the immobile body loses three percent of its original strength per day in a linear fashion for the first seven days, after which little strength is lost.</p> <p>The joints of the body are especially susceptible to immobilization. The articular cartilage layers depend on synovial fluid for nutrition. Motion makes for constant interchange of fluid between the layers of articular cartilage and synovial fluid. Joint motion causes alternating cartilage compression and distension. The absence of these pressure fluctuations causes a stagnation of intercellular fluid and a decrease in nutrition.</p> <p>Surprisingly, the adverse effects of immobilization on the human body generated little interest for evaluation. In the 1960's, Salter began investigation on the effects of immobilization versus mobilization on articular tissue in rabbits. His studies produced significant laboratory evidence that continuous passive motion offered startling benefits in the articular repair process in knee joint injuries compared to the routine care of immobilization. Salter's conclusions for his first 12 years of experimentation are:</p> <ul> <li> <p>Continuous passive motion (CPM) is well tolerated and seems to be relatively painless.</p> </li> <li> <p>CPM has a significant stimulation effect on the healing of articular tissue, including cartilage, tendons, and ligaments.</p> </li> <li> <p>CPM prevents adhesions and joint stiffness.</p> </li> <li> <p>CPM does not interfere with the healing of incisions over the moving joint.</p> </li> <li> <p>The principle of rest for healing tissue is incorrect.</p> </li> </ul> <p>Evidence for the clinical effectiveness of continuous passive motion on the process of healing is both subjective and objective. In various studies, Dr. Richard Courts demonstrated that there is a reduction in postoperative pain and an increase in post total knee joint range following the use of continuous passive motion for several weeks. The decrease in pain experienced may be caused from the rhythmic joint movement providing competitive interference to retard the pain-spasm reflex and alleviate pain at the source. The increase in range of joint motion reported may be due to the improved orientation and strength of collagen fibers formed, preventing adhesions which would limit range without disturbing or causing damage to adjacent uninvolved normal structures.</p> <p>Clinically, Salter has indicated CPM use immediately postoperatively for the management of open reduction internal fixation (ORIF) of the ankle, knee, hip, and elbow with usage ranging from one to three weeks. Decreases in wound edema, joint effusions, pain medications, and an increase in patient comfort and shorter hospital stays are documented as compared to non-CPM patients. Schnebel and Evans found that while active flexion is acquired earlier in CPM patients, there was no statistical difference in active flexion in late motion studies between CPM and non-CPM total knee arthroplasty patients.</p> <h3>Design</h3> <p>Continuous passive motion machines can be categorized into three groups by design: mattress-mounted, bed frame mounted, and single joint units. Clinical use of continuous passive motion has primarily been utilized for mobilization about the knee and hip joint due to the mechanical design of the majority of motion devices, i.e. the mattress-mounted units. These machines are similar in that the patient lies supine with thigh and calf held in the unit, and the knee and hip are mobilized simultaneously. (In these units the patient is unable to move about in the bed or make significant posture changes.) Ankle movement may also be provided. Some mattress-mounted machines and their suppliers are:</p> <blockquote> <p>Autoflex, <i>Chattanooga Corp</i>.<br />CAPE System, <i>Zimmer</i><br />CK-7 Passive Motion Knee Exerciser, <i>OEC</i><br />Danni-Flex, <i>Danniger Medical Technology</i><br />Kinetec Passive Leg Exerciser, <i>Richards</i><br />Powerflex 3000, <i>Biodynamic Technologies of Florida</i><br />Stryker Leg Exerciser, <i>Stryker</i><br />Sutter CPM 2000, <i>Sutter Biomedical</i></p> </blockquote> <p>The bed frame mounted units attach to standard overhead Bulkin frames and provide the versatility for mobilizing multiple joints. These systems are:</p> <blockquote> <p>CPM K-10, <i>Sutter Biomedical</i><br />Passive Mobilizer, 3D Orthopedic Inc.</p> </blockquote> <p>Single joint units address specific joints of the body only. These are:</p> <blockquote> <p>Miami Ankle Motion Machine, <i>Zoya Orthopaedic</i><br />Kinetec Elbow Exerciser, <i>Richards</i><br />CPM-5000, <i>Sutter Biomedical</i><br />CPM Mobilimbs L1-A, <i>Toronto Medical Corp.</i></p> </blockquote> <p>Functional features of all systems vary from: microswitching to torque sensing, mechanical range setting to computer programmed, 110 volt to battery operated, patient-controlled cycles to programmed cycles, and one speed to variable speeds. Yet all systems have been developed more from subjective than objective data. The questions of how much force, optimum speeds, duration of cycle, direction of pull/push/lift to the joint, control of joint motion, or should the joint be loaded or unloaded need to be addressed in order to quantify CPM and avoid the potential dangers of this modality.</p> <p>Dangers exist when these systems are utilized by those unfamiliar with mechanical systems and/or the expectant results they are trying to obtain. The level of knowledge required varies, i.e. the mattress-mounted units are limited in application and therefore are relatively simple. The multiple joint systems would require more expertise because of the increased options of use, the mechanical advantages gained with the use of pulleys and springs, and the variations of movements occurring about the anatomic joints. These systems tend to be more cost-effective since their various uses can be applied to a greater patient population.</p> <h3>Two Year Experience</h3> <p>In our experience at a major trauma hospital, the need for versatility, ease of use, and reliability were of utmost importance. We utilized five machine designs over a two year period: Sutter K-10, CPM Mobilimb L1-A, Richards Passive Leg Exerciser, 3D Passive Mobilizer, and a home-grown unit. All systems functioned very reliably. The Mobilimb unit had a rechargeable battery powered system which, for our use, proved to be the least practical.</p> <p>The mattress mounted units were limited to mobilizing knees and hips, especially in cases of joint replacement. The trays to these units were cumbersome to housekeeping. The staff would take the tray off the bed to change linens, causing frequent malalignments when setting it back on the bed, usually due to fear of reapplying and/or the lack of understanding how the system functioned. Patient comfort was a major concern. If the patient was not comfortable in the system due to the physical design of the system or improper positioning in the unit, the staff would turn off the machine, thereby reaping no benefits. The tray would not fit properly if the patient was above or below the average height of five foot ten inches. These systems did not provide a recorder to document how long the patient had the system on or how many cycles the limb experienced.</p> <p>Lack of full extension and flexion became another concern in our use of any of the units utilizing the tray that the leg simply laid in. Although the tray would indicate full extension, the leg would still be flexed, and usually abducted and externally rotated (<a href="/files/original/666c4f3f407ef42ef96a9eeb30cba2cc.jpg"><b>Fig. 1</b></a>).</p> <p>Because of these reasons and the need to be able to utilize traction, cast braces, and rehabilitative orthotics with passive motion, we began using a homegrown version utilizing the Sutter K-10 without the mattress mounted tray. Through the use of dynamic suspension, we could achieve full extension with the assistance of gravity, mobilize a patient in traction, maintain abduction and adduction, and set up bilateral limbs with only one machine. This variation enabled the patient to move about in bed and provided easier bed pan use and overall more comfort. It won favor with our ancillary staff because there was nothing in their way to be moved or replaced (<a href="/files/original/da001445312603a0ab4a223ff85c38d1.jpg"><b>Fig. 2</b></a>). In March 1984, we began using the Passive Mobilizer by 3 D Orthopedic Inc. This system had incorporated many of the features of our homegrown unit with some significant improvements. The system provides a linear pull rather than the rotating arc of the Sutter K-10 so that flexion and extension limits are more easily controlled and eliminates the potential hazard of the rotating arm (<a href="/files/original/a32c142193dc07186843945607ee7c09.jpg"><b>Fig. 3</b></a>). Also, the unit includes a cycle counter to document how many cycles the patient has experienced. These two additional features were found to be very useful in our practice.</p> <strong><a href="/files/original/da001445312603a0ab4a223ff85c38d1.jpg">Figure 2.</a> Home grown unit using Sutter K-10 motor and control system.</strong><br /><br /><strong><a href="/files/original/a32c142193dc07186843945607ee7c09.jpg">Figure 3.</a> Patient with a right acetabular fracture with 30 lbs. of tibial traction in continuous passive motion (3D Passive Mobilizer). Hip flexed 0-90° and kept abducted.</strong><br /> <p>The use of passive mobilization should begin as soon as possible. The earlier the application, the better the results that can be anticipated. In the case of elective procedures, such as total joint replacements, the passive mobilization system should be set-up before surgery to familiarize the patient with the machine and its operation. At our center, the majority of the cases are trauma related and of a fracture variety. Patients are placed in passive motion postoperatively in the O.R., recovery room, or when transferred to the orthopedic floor. The unit is set to allow 30-40° of motion initially post-op with the rapid increase of range of motion to tolerance.</p> <p>In this two year experience, we have had 168 cases involving the use of continuous passive motion. These are broken down into three major categories:</p> <dl> <dt></dt> </dl> <p>Articular Fractures</p> <p>Knee—79<br />Hip—17<br />Elbow—4<br />Ankle—3</p> <p>Joint Replacement</p> <p>Knee—14<br />Hip (Cup)—8</p> <p>Other Knee Problems</p> <p>Sepsis—20<br />Lig. Repair—12<br />Edema Control&nbsp;6</p> <p>Continuous passive motion was also applied to mobilize the cervical spine (in halter traction post soft tissue trauma), the shoulder (post manipulation or rotator cuff repair), and the lumbar spine (post laminectomy or decompression). These were not listed because the applications are still under evaluation.</p> <p>Our goal in utilizing the modality of continuous passive motion is full range of motion. Initially we target for 0-40° of motion the first day, cycling the limb approximately one complete cycle per minute. Increase in ROM is aggressively addressed daily to pain tolerance. Since time minimums in CPM have not yet been established, patients are kept in passive motion except during meals, physical therapy, or bathroom use.</p> <p>The goal established for ROM of the knee and hip is 90+°. It was felt that if the joint could go through a passive 0-90 +° range pain free, and prior to discharge 0-90+° active range, that normal knee and hip motion could be achieved on an out-patient basis with aggressive physical therapy. Many factors influenced the outcome. Patient compliance and willingness to participate in this treatment plan is a major factor. Competent application and training in the use of continuous passive motion is also critical to the outcome.</p> <h3>Cases</h3> <p><i>Case 1</i></p> <p>A twenty-nine year old male sustained a high caliber gunshot wound to the left knee (<a href="/files/original/d6cf3cf6ad5b9329cdf3ac01b1190266.jpg"><b>Fig. 4</b></a>), traversing the lateral femoral condyle through the joint space and through the lateral tibial plateau. Open reduction internal fixation (ORIF) and ligamentous repairs were made. Postoperatively, the patient was placed in a standard cast brace due to the inability to provide adequate medial-lateral stability of the knee surgically (<a href="/files/original/41e3f04ea2dcb2b15a38233a0196d63c.jpg"><b>Fig. 5</b></a>). The cast brace was attached to a continuous passive motion dynamic suspension system to restore and maintain motion (<a href="/files/original/c70f240f5eef716b30961b9ae75c899e.jpg"><b>Fig. 6</b></a>). At the time of the initial cast bracing, the patient had considerable soft tissue edema about the knee. The use of passive motion quickly reduced that swelling to the point where the cast brace provided little support. After one week, the cast brace was reapplied with the addition of a varus producing strap (<a href="/files/original/f4d46e9d44ec0b8a2fd85babdfade006.jpg"><b>Fig. 7</b></a>) and the patient began ambulation training and was discharged. (If atrophy or swelling should continue, the varus producing strap can be easily adjusted to maintain force on the knee and another cast change would not be required).</p> <p><i>Case 2</i></p> <p>A twenty-five year old female sustained a fracture dislocation of the left knee (<a href="/files/original/d5207f95412f40949c9a0abdcc8f179f.jpg"><b>Fig. 8</b></a>). The fracture and ligaments were internally fixed, and the patient was placed in a continuous passive motion dynamic suspension system utilizing a Mobilizing Brace (3 D) and a bootie (<a href="/files/original/dd41c84673e88dc6270e962c77261651.jpg"><b>Fig. 9</b></a>). The patient achieved 0-90° of motion in two days and was maintained in passive motion for five days until she could achieve the same range of motion actively without excessive pain. The patient was then cast braced for increased medial-lateral stability, received gait training, and was discharged from the hospital.</p> <p><i>Case 3</i></p> <p>A nineteen year old male sustained a distal fracture with a split condylar fracture to the right leg (<a href="/files/original/4575504d9fda222439f290f7163145af.jpg"><b>Fig. 10</b></a>) and a lateral condyle fracture on the contralateral side (<a href="/files/original/91b675186e820e21469468d77ca70551.jpg"><b>Fig. 11</b></a>). Fractures were stabilized, but were not internally fixed at time of admission because of emergency vascular repairs being required. Three days post injury, the patient underwent ORIF of his fractures (<a href="/files/original/ac9d622bf611e960cead91b85bba30b1.jpg"><b>Fig. 12</b></a> and <a href="/files/original/554280c049e6a114db8463eaeefec20f.jpg"><b>Fig. 13</b></a>). The right leg was placed in a free knee Mobilizing Brace and the left leg was placed in the rehabilitative free knee orthosis. A continuous passive motion dynamic suspension system was placed on the lower right extremity (<a href="/files/original/c767acc60d993ecbc9a2dea3fdceafb5.jpg"><b>Fig. 14</b></a>). The lower left extremity had normal pain free motion following surgery. The patient was kept in passive motion for five days and achieved 0-100° of pain free motion. A cast brace was applied on the right extremity; the patient received gait training and was discharged.</p> <p><i>Case 4</i></p> <p>An eighteen year old male sustained bilateral femur fractures and bilateral patella fractures. The patient underwent bilateral closed inter-medullary (IM) rodding of the femur and the patellas underwent bilateral ORIF (<a href="/files/original/9696814c90d3a127b31bdde25d16906a.jpg"><b>Fig. 15</b></a> and <a href="/files/original/11e6648c1da2da4e863cf22ff6b27e92.jpg"><b>Fig. 16</b></a>). The patient was placed in a free knee Mobilizing Brace on the left leg and attached to a continuous passive motion dynamic suspension system immediately postoperatively. The right leg was maintained in a straight position and in a denotation boot to prevent the fractured femur from spinning on the IM rod. In two days, the left knee had 0-90° of pain free passive motion. Active motion on the right lower extremity was limited to 0-15° of motion. At that time, the patient's right leg was placed in a free knee Mobilizing Brace and bilateral passive motion began (<a href="/files/original/0be90617be2197739e9b7215c50adcc4.jpg"><b>Fig. 17</b></a>). Right leg motion progressed to 0-90° passive motion in four days, while the left leg was maintained in the 0-90° range. (This passive motion device, providing bilateral application from one power source, can be adjusted for varying degrees of motion independent of each other by varying the tension on the attachment lines.) Ambulation training began utilizing the bilateral Mobilizing Braces with drop locks in position (<a href="/files/original/cdf2e11044f459004d4cc3bea3571520.jpg"><b>Fig. 18</b></a>). The patient was fully ambulatory with this system, achieved full range of active motion in ten days, and was discharged. Passive motion was maintained for a longer period than normal due to the degree of articular damage to the patellas.</p> <h3>Summary</h3> <p>Passive range of motion has proven itself as a useful treatment modality for increasing or maintaining range of motion of the hip, knee, ankle, shoulder, and elbow. Clinically, we have observed improved wound healing and reduction of edema. Septic joints that are or have been opened and drained appear to clean up sooner than joints treated with only incision and drainage (I &amp; D) and daily whirlpool. Patients are comfortable with reduced requests for pain medications. Patients also seem happier and this may be due to the fact that something is being done to help them get better on a continuous basis. Therapy time can now be devoted to improving muscle control and independent activity levels rather than painful ROM exercises.</p> <p>Of the 168 cases presented in this paper, all but two patients did or would have benefited from passive mobilization. The degree of success depended to a large extent on patient compliance. All patients who cooperated with this treatment modality improved their motion and reduced their hospitalization with two exceptions.</p> <p>One patient had undergone total knee replacement and was placed in CPM in the recovery room. Approximately 20° of motion was achieved initially. All attempts to increase her motion failed in that the 3D device would stall at a given point and reverse itself. The referring physician was contacted in order to report the difficulties. It was learned that the patient, some 40 years earlier, had undergone a spontaneous hip fusion probably due to infection. Conventional CPM can not be utilized for ROM of the knee if the hip is immobilized.</p> <p>The second failure was with a young sickle cell disease patient also having severe sepsis of the knee. All attempts of passive mobilization were painful and limited to less than 30° of flexion. The patient underwent arthrodesis of the knee and was later discharged with granulating wounds.</p> <p>Patients with fractures involving articular surfaces of the knee have done well with 0-90° of pain free active motion obtained in generally less than ten days. Depending on the degree of internal fixation or patient compliance, a cast brace was applied prior to discharge. As stated earlier, cast bracing and passive mobilization is a common treatment modality.</p> <p><b>References:</b></p> <ol> <li>Burks. R.. Daniel. D,. and Losse. G.. "The effect of continuous passive motion on anterior cruciate ligament reconstruction stability." <i>Amer. J. Sports Med.</i>, 212:323, 1984.</li> <li>Coutts, R.D., Toth C., and Kaita J.H., "The role of continuous passive motion in the rehabilitation of the total knee patient." <i>Total knee arthroplasty-a comprehensive approach</i>. Hungerford D. ed.. Baltimore: Williams &amp; Wilkins, pp. 126-32. 1983.</li> <li>Dehne. E., Torp, R.P., "Treatment of joint injuries by immediate mobilization," <i>Clin. Orthop.</i> 77:218, 1971.</li> <li>Frank, C., Akeson, W.H., Woo, S.L.Y., Amiel, D., and Courts. R., "Physiology and therapeutic value of passive joint motion." <i>Clin. Orthop.</i>, 100:113-125, 1984.</li> <li>Korcok, M., "Motion, not immobility, advocated for healing of synovial joints," <i>J.A.M.A.</i>, 246:2005, 1981.</li> <li>Lynch, J.A., et al., "Continuous passive motion: A prophylaxis for deep venous thrombosis following total knee replacement," Scientific paper 143, AAOS 51st. meeting, 1984.</li> <li>Muller, "Influence of Training and of Inactivity on Muscle Strength." <i>Arch. Phys. Med. Rehab.</i>, 51:449, 1970.</li> <li>Mooney, V., and Ferguson, A.B., "The influence of immobilization and motion on the formation of fibrocarti-lage in the repair granuloma after joint resection in the rabbit." <i>J. Bone Joint Surg.</i>, 48A:1145, 1966.</li> <li>O'Driscoll, S.W., Kumar, A., and Salter, R.B., "The effect of continuous passive motion on the clearance of a hemarthrosis from a synovial joint: An experimental investigation in the rabbit," <i>Clin. Orthop.</i>, 176:305-11, 1983.</li> <li>Perry, C.R., Evans, L.G., Rice, S., Fogarty, J., and Burdge, R.E., "A new surgical approach to fractures of the lateral tibial plateau," <i>J. Bone J. Surg</i>., 66A:1236, 1984.</li> <li>Richardson, W.J., and Garrett, W.E., Jr., "Clinical use of continuous passive motion," <i>Contemp. Orthop.</i>, 10:75-79, 1985.</li> <li>Salter, R.B.: Presidential address, Canadian Orthopaedic Association, Halifax, N.S. <i>J. Bone Joint Surg.</i> 64B:251, 1982.</li> <li>Salter, R.B., and Hamilton, H.W., "Clinical application of basic research on continuous passive motion for disorders and injuries of synovial joints: A preliminary report of a feasibility study," <i>J. Orthop. Research</i>, 1:325-342, 1984.</li> <li>Schebel, B.E., and Evans, J.P. "The use of continuous passive motion in the rehabilitation of total knee artho-plasty," Scientific poster, AAOS 52nd meeting, 1985.</li> <li>Steinberg, F.U., <i>The Immobilized Patient</i>, New York, Plenum, 1980.</li> <li>Strang, E.L., and Johns, J.L., "Nursing care of the patient treated with continuous passive motion following total knee arthoplasty," <i>Orthop. Nursing</i>, 3:27-32, 1984.</li> </ol> <em><b>*Mel Stills, C.O. </b> Mel Stills, CO., Instructor, Orthopedics, South Western Medical School, 5323 Harry Hines Boulevard, Dallas, Texas 75235.</em><br /><br /><em><b>*Dwain R. Faso, C.O. </b> Dwain R. Faso, CO., Manager, Research and Development, 3D Orthopedics, 11126 Shady Trail, Dallas, Texas 75229.<br /><br /><br /></em> Page Number(s) 7 - 19 Year 1985 Volume 9 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_02_007/1985_02_007-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Passive Mobilization: An Orthotist's Overview Creator An entity primarily responsible for making the resource Dwain R. Faso, C.O. * Mel Stills, C.O. * https://staging.drfop.org/files/original/5a4fc207f88a465ad37dcf6b41150096.pdf 479c711e6dc5b0867b71528e3903ffe9 https://staging.drfop.org/files/original/d9ff1b62874d00a6e00a0d672fb43173.jpg 0e51c21a9139763ce305a13968b0cec8 https://staging.drfop.org/files/original/470d0172053dbf6511badf4a238ae5be.jpg 15352b6afae30f74a1a8e9f9ad3f67b6 https://staging.drfop.org/files/original/407855162477bbeecc14efd62661a52c.jpg 724072469eb262d7f443f6bfd29433f7 https://staging.drfop.org/files/original/ea665054cf74df0afd40296eaa419d88.jpg 18d5adb11fc47556e504851627efe5d5 https://staging.drfop.org/files/original/115a307852ee295ff5a6479530d3b830.jpg 57a34343d50ccf4fd7303046f6a9bdcc https://staging.drfop.org/files/original/e9eb5b5f48d616e1dd25a731a081527f.jpg f8fd1d577ec78d9e1f12a765caf2a199 https://staging.drfop.org/files/original/f751c384bf9fac833690768a5251a514.jpg 0f1756a2ea50caf1741b0411c7bdf878 https://staging.drfop.org/files/original/00a80e563c204095cf4122ec59ed733c.jpg 129961f2dc91933885eded5d7c503983 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_02_008.pdf Year 1954 Volume 1 Issue 2 Page Number(s) 8 - 19 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_02_008.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_02_008.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>Contributions of the Lower-Extremity Prosthetics Program</h2> <h5>Edmond M. Wagner, M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>When, in 1945, the National Research Council launched its program for improvement of artificial legs, the original concept was that the major portion of the work would in all probability consist simply of devising mechanically improved artificial knees, ankles, and feet and of applying new materials to existing designs. But it soon became apparent that, if any appreciable success were to be had, the scope of the work would have to be broadened considerably. For new items that were designed failed Lo satisfy the amputee, and there were insufficient fundamental data on which to base improvements. Such information as was available on the mechanics of the lower extremity was either incomplete or else not presented in such form as to be useful to designers.</p> <p>The character of the fit was shortly found to be a matter of paramount importance in determining the success or failure of a given device. But fitting itself was based largely on the personal experience of individual fitters, and there were in existence no formalized standards or rules for guidance in obtaining proper fit. Moreover, the results of testing of devices were too often based on the impressions of only a few amputees and casual observers, either or both generally not qualified to express a competent opinion. There was not even general agreement on some of the principles involved in the surgery of amputations. Before any real progress could be made, information had to be secured in all these fields and coordinated with data from others.</p> <p>The task of obtaining the required information was assigned by the National Academy of Sciences to a number of subcontractors. At the outset, basic research on problems concerned in lower extremities, including studies on surgery, pain,<a></a> and fitting,<a></a> was placed with the University of California at Berkeley.<a></a> To assist designers and fitters, and to provide a record of the devices and techniques being used in the limb industry, a review of prior art was carried out at Northwestern University,<a></a> and the Surgeon General of the Army sent to Europe a commission<a></a> to study and report on the prosthetics art as practiced in various other countries. Solutions attempted in the past for many problems in leg design are cataloged and described in the Northwestern report<a></a> and in the report of the European commission .<a></a> Development of devices was undertaken by Goodyear Tire and Rubber Company;<a></a> Vickers, Inc.,<a></a> Detroit; C. C. Bradley and Son;<a></a> Catranis, Inc.;<a></a> Adel Precision Products;<a></a> A. J. Hosmer Corporation;<a></a> Northrop Aircraft;<a></a> the U.S. Naval Hospital at Oakland, California;<a></a> National Research and Manufacturing Company;<a></a> the Aero-Medical Laboratory of the U.S. Air Force, Wright-Patterson Air Force Base; the Army Prosthetics Research Laboratory, Walter Reed Army Medical Center; and the University of California at Berkeley . <a></a> Later in the program, the Denver Research Institute<a></a> of the University of Denver carried out an investigation of below-knee prostheses, some additional basic data have been supplied by New York University<a></a> and by the Prosthetic Testing and Development Laboratory of the Veterans Administration in New York City, and another commission<a></a> was sent to Europe to observe progress abroad after 1945. Testing and evaluation of devices has been developed and carried out at New York University,<a></a> and the Orthopedic Appliance and Limb Manufacturers Association has cooperated in general program guidance.</p> <h3>Development of Basic Data</h3> <p>Because prior to 1945 little study had been conducted on the characterislics of human locomotion, because of the complexity of the problem, and because of its highly specialized nature, it was necessary first to devise special equipment for collecting information which, ultimately, would lead to determination of the mechanical and physiological changes occurring during various activities of the lower extremity. A number of pieces of unusual apparatus, such as force plates, a glass walkway (<b>Fig. 1</b> and <b>Fig. 2</b>), and special photographic equipment were designed,<a></a> and from the data collected using this equipment it was possible to determine such factors as the forces and moments in human and artificial legs and the roles played by major muscle groups under a series of conditions. From such findings it has been possible to describe fully the phenomenon of human locomotion and thus to establish a set of realistic criteria for the design and evaluation of artificial-leg components. Aside from applicability to the field of prosthetics, the data collected are useful also to designers of leg braces and to the medical profession in the treatment of pathological gait.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The University of California glass walkway. With this device, motion pictures taken from a single camera yield sufficient information to determine relative motions of various segments of the body during level walking. Subject shown here is wearing an above-knee experimental 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. Normal subject prepared for participation in studies using the University of California glass walkway. Some targets are mounted on levers to amplify motions otherwise of small magnitude. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The major portion of this work was performed at the University of California, Berkeley, and many of the results have been documented in reports and in the journal literature. Of the many reports issued, most, such as those of Cunningham<a></a>, of Bresler and Berry<a></a> and of Radcliffe,<a></a> generally cover a single phase of the subject.</p> <h3>Creation of Design Objectives</h3> <p>From study of the basic data, and from careful review of current practices, it has been possible to set up a listing of design objectives for leg prostheses, it being understood that above all the prosthesis must satisfy the amputee. Arranged in generally decreasing order of importance, these requirements are as follows:</p> <ol> <li>Security from fall.</li><li>Minimum consumption of energy in normal walking</li><li>Appearance of the walking pattern to compare favorably with that of a normal person.<br /> a. Smooth swing phase, including deceleration of the prosthesis at the end of extension, control of heel rise at the end of flexion, and deceleration of the prosthesis just prior to heel contact.<br /> b. Smooth stancephase, includingattainmentof full extension without final snapping action.<br /> c. Ability to change gait to maintain smooth, normal-appearing gait.</li><li>Ability to extend the leg under load at any time.</li><li>Proper phasing of the locking action, if used, with all portions of the stance and swing phases.</li><li>Performance of incidental operations—such as going up and down stairs and ramps, turning, and sitting down—with reasonable ease and smoothness.</li></ol> <p>A listing of the features desired of leg prostheses at three functional levels (<b>Table 1</b>) has finally evolved.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Improvement of Fitting and Alignment</h3> <p>As a result of the early attempts to improve existing knee-brake devices, it was found that fitting and alignment were together often more of a determining factor in amputee acceptance than was the performance of the device itself. In the two trips to Europe,<a></a> various techniques and several mechanical aids for obtaining greater uniformity in fitting were observed. These techniques and devices have been analyzed, and from the resulting knowledge, together with information from the basic studies, improved methods of fitting and aligning above- and below-knee legs have been formulated. All of these observations have been published in a report of the University of California at Berkeley .<a></a></p> <p>In order to make these principles of fitting and alignment easier to apply, an adjustable leg (page 23) for above- and below-knee prostheses, with provisions for individual adjustment of major elements, was designed by the project at Berkeley and turned over to the limb industry. This leg, once adjusted, can be worn by an amputee for periods of a few days to determine if the fitting is satisfactory. To transfer to the permanent prosthesis the measurements thus determined by the adjustable leg, there has been designed a fixture which holds the elements of the prosthesis in position while they are being assembled with the predetermined alignment. With these two devices, which are now available commercially, fittings become quite exact. The ease with which minor adjustments can be made in the adjustable leg makes it possible to try variations in fitting which, previously, were avoided because of the time and expense involved. Moreover, the adjust- able leg has the psychological advantage of demonstrating to the amputee that the fit of the device he is obtaining is the optimum for him.</p> <h3>Methods Of Suspension</h3> <p>A major factor involved in fitting of both above- and below-knee legs is the socket. On the first trip to Europe,<a></a> a number of exceptionally well-fitted suction sockets (page 29) were observed in Germany. This type of suspension had been tried previously in the United States<a></a> and in England with poor results. The successful cases seen in Germany in 1946, however, prompted another trial of the technique in the United States. A thorough study of the shape of the socket and other features involved in fitting of suction sockets was undertaken at the University of California at Berkeley.<a></a> As a result of the successful conclusion of this work, the suction socket has since been widely applied by the United States limb industry and has been accepted by the Veterans Administration as an improved method of fitting prostheses for above-knee amputees where there are no contraindications. The knowledge gained in perfecting the technique of suction-socket fitting and in determining the optimum shape of the suction socket has contributed to improvement in the fitting of other sockets. Development work is now proceeding on suction sockets for below-knee amputees.</p> <p>In addition to the work on suction sockets, a "soft" socket for below-knee amputees, consisting of a thin, resilient pad under a conventional leather or plastic socket lining in a plastic or wooden socket, has reached the testing stage at New York University.</p> <h3>Schools for Prosthetists and Surgeons</h3> <p>Since the suction socket was as much a technique as a device, it was determined that, if the suction socket was to be as successful in general practice as it had been in the development period under the supervision of the University of California, the technique had to be taught to limbfitters throughout the United States. Accordingly, plans were laid for a series of schools to be held in various cities in the United States. A course of instruction was laid out, and under the auspices of the Veterans Administration, with the assistance of the Orthopedic Appliance and Limb Manufacturers Association, a series of schools was held throughout the country. The Veterans Administration, by requiring that fitters and surgeons have certificates from one of these schools before suction sockets could be provided beneficiaries, ensured that the best practices were provided. Establishment of these schools was an important advance, for it provided a mechanism for bringing to the commercial limb industry and medical pro- fession the new techniques and ideas developed. Their success has led to expansion of the principles of the clinic-team approach for handling both upper- and lower-extremity cases.</p> <p>In connection with the suction-socket schools, manuals were issued on how to fit suction sockets. They constituted the first attempt to present, in a manner that would be useful to the limbfitter, data developed in the program. Their success has led to the issuance of manuals on other subjects.</p> <h3>Amputation Surgery</h3> <p>In the early investigations, it became apparent that relative difficulty of fitting rather than surgical considerations often dictated the site of amputation. This circumstance led to a study of the sites of election and to a consideration of whether some changes might not be advisable. Studies have since clearly shown that the longer the stump the more function and control can be obtained-a matter that has not always been fully appreciated. In the above-knee amputee, the increased length of stump is particularly important, since it is one of the governing factors in obtaining stability of the prosthesis in abduction. In the above-knee amputation, it has also been found advantageous to tie the muscles together across the bottom of the stump or otherwise to attach muscles to the bone to aid in obtaining stability in abduction. These new concepts are leading to a revision of amputation practices. There will, no doubt, be other such advances in amputation surgery as more is learned about body mechanics.</p> <h3>Pain Studies</h3> <p>Pain, both phantom and real, has always been a troublesome problem in amputee management. In order to obtain a clearer understanding of and possible solutions to the pain syndrome, a project was instituted at the University of California. Although practical applications of methods to alleviate pain and eliminate phantom pain have been meager to date, the mechanism of pain radiation has been elucidated, and the results<a></a> form the basis for future work in this field.</p> <h3>New Devices</h3> <p>One of the most important parts of the lower-extremity program is the development of new devices. Consequently, device development has been one of the major efforts. In the early stages of the program especially, there was an urgent demand from new Service-connected amputees for improved devices. At the time, the data from the basic studies at the University of California were not available. But because of the urgent demand, a program for invention and development of devices was undertaken simultaneously with the program for developing basic data. While most of these devices were unsuccessful, the time, money, and effort expended developing them were not entirely wasted. For in trying these devices, much needed information was developed, and the need for long-range research on several items of a basic nature was pointed out. As the data were collected at the University of California, devices were pro- duced incorporating features which seemed desirable.</p> <p>A great deal of effort was expended in attempting to perfect a knee lock for above-knee amputees. But most of these designs were abandoned for one reason or another after a few models had been made and tried on amputees. The particular difficulty in obtaining smooth and reliable action in a knee lock was found to reside in the method of control. In addition to knee locks, considerable effort has been expended on coordinated motion between the knee and ankle, toe pickup, transverse rotation in the leg, and control of the swing phase. Numerous devices incorporating such features have been made. Both mechanical and hydraulic devices, with varying degrees of complexity, have been tried.</p> <p>Of all the knee locks tried to date, only two, the Stewart-Vickers (<b>Fig. 3</b>) and the Henschke-Mauch (<b>Fig. 4</b>), appear to have reached the point of having commercial possibilities. More recently, however, there have been indications that proper swing-phase control, coupled with alignment stability or limited stability over the first few degrees of flexion, are all that the average above-knee amputee may need. The more or less elaborate knee locks might therefore be indicated for special cases, for older persons, or for those who prefer "the best" and can afford it. Both Stewart and Henschke-Mauch have swing-phase control devices incorporated in their designs, and both have under test legs in which only the swing phase is controlled.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Schematic diagram of the Stewart-Vickers hydraulic leg incorporating knee lock, swing-phase control, and coordinated motion between ankle, shank, and thigh. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Schematic diagram of the Henschke-Mauch hydraulic leg incorporating knee lock and swing-phase control. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Another lower-extremity device now under test is the University of California four-bar-linkage or polycentric knee (<b>Fig. 5</b>). The four-bar-linkage knee is not a new idea, but the UC version has been so designed that the toggle action existing in prior designs to provide extreme stability as the knee approaches full extension has been eliminated. Instead, it depends for its stability on alignment in fitting. It has the advantage, like many other four-bar linkages, of providing at the start of flexion a pivot point about 6 in. above the actual knee joint-a feature which provides a very favorable mechanical advantage for the amputee to start the leg to flex.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Schematic diagram of the University of California four-bar-linkage (polycentric) knee showing change in center of rotation of shank as knee is flexed. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the UC leg the swing phase is controlled by a radial-vane type of damping device in which hydraulic fluid passes from one side of the vane to the other through suitable needle valves. Hence this device is responsive to gait change and limits excessive heel rise as cadence is increased.</p> <p>The limbshop at the U.S. Naval Hospital, Oakland, California, has developed and had accepted by ACAL a complete above-knee leg featuring a very simple mechanical device for controlling the swing phase in connection with a more or less conventional knee bolt (<b>Fig. 6</b>). This type of swing-phase control is not nearly so responsive to gait change as are the hydraulic units, but it marks a definite advance in the design of artificial knees. Also featured in the Navy leg are a plastic shank and the so-called "Navy functional ankle." The latter (<b>Fig. 7</b>) uses a rubber block with different degrees of hardness at front and rear to provide for plantar flexion and dorsiflexion and at the same time to permit some rotation about the vertical axis of the leg. It is anticipated that the Navy above-knee leg will be available commercially early this summer.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. U.S. Navy variable-friction knee. As flexion takes place, projection <i>A </i>of the knee block rotates until it contacts lever arm C, which induces additional friction about the knee bolt to limit heel rise. As extension occurs, projection <i>B' </i>rotates to contact lever arm <i>D, </i>which induces additional friction to decelerate the shank (terminal deceleration). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. U.S. Navy functional ankle. Single cable extends through rubber block of different degrees of stiffness at front and back. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To summarize the work done on new devices for lower extremities, there is now available a large store of information on devices which have been tried and found lacking in one respect or another. With what is now known about performance desired in above-and below-knee legs, it is possible that a review of past developments, coupled with some changes based on present knowledge, may lead to the development of more acceptable leg prostheses. At this time, however, only the Navy functional ankle and the swing-phase control have been accepted as completed devices. Others appear very close to acceptance.</p> <h3>Testing and Evaluation</h3> <p>Throughout the early stages, the development of new devices in the lower-extremity program was retarded by the lack of techniques and organization for objective testing and evaluation. Until the data on the mechanics of walking had been developed, it was almost impossible to set up means for objective evaluation because no satisfactory standards of comparison were available. In addition to this lack of standards, it became apparent early in the program that some means had to be established for testing, under a controlled set of conditions, the devices which appeared ready for production. A testing laboratory at New York University was therefore set up. With its entry into the program, there was obtained a much better evaluation of the desirability of the devices proposed and a much better idea of their mechanical performance . <a></a> It was soon found that most of the devices submitted had minor mechanical shortcomings, and as a result many devices which two or three years ago appeared almost ready for release are only now approaching that point. The field-testing procedure has avoided premature release of several supposedly completed items and has indicated the need for more information on several basic points. It has thus proven to be a very valuable step in the development program, and the information gained in the field tests has fully justified the time and cost of field-testing.</p> <h3>Clinical Program</h3> <p>When the program for development of new devices had reached a certain stage, it became apparent that, if there could be instituted a clinical program to try devices on various amputees under as nearly identical conditions as possible, progress would be much more rapid. Information was also needed to confirm conclusions about the suitability of certain devices for various sites of amputations and for various physical and mental characteristics of the amputee and to determine new types of devices which might be needed under certain sets of conditions. Among others, such questions as the need for, or suitability of, a knee lock, or whether limited stability coupled with swing-phase control would be better, needed investigation and decision.</p> <p>A clinical study was therefore set up under the direction of the University of California at the U.S. Naval Hospital, Oakland, with certain facilities provided by the Surgeon General of the Navy. It is expected that, by providing a complete staff of surgeons, prosthetists, physiotherapists, engineers, and research workers, with the opportunity for controlled fitting and follow-up of patients, rapid progress will be made in improving fitting and alignment techniques, in surgical procedures, and in the development of improved devices.</p> <h3>Development Program</h3> <p>Since the establishment of the lower-extremity clinic, a development group, staffed with people skilled in lower-extremity prosthetic art, including representatives from the industry, has been established. This group has headquarters at the U.S. Naval Hospital at Oakland, California, in close proximity to the clinic. It is expected that they will complete the development of some of the devices partially completed in the past and develop new devices, possibly combining or utilizing some of the ideas and data resulting from development work on these new devices. It is expected that this group will bring the program for new devices somewhere near its required level within the next two years.</p> <h3>Conclusion</h3> <p>Because the improvement of leg prostheses has required research and investigation in many fields, and because of the broad scope of much of the work, its full usefulness will not be realized until some time in the future. Time and study are required to analyze the data and to apply the results of such analyses. Nevertheless, the basic data developed under the ACAL program have already been useful, not only in the design of above- and below-knee prostheses but also in the design of leg braces, and they have proved extremely helpful in the diagnosis of pathological gait. Among the developments of more or less immediate practical applicability are the new techniques introduced for fitting and aligning above- and below-knee prostheses. Devices to facilitate adjustments in fitting so that optimum results can be attained quickly have been developed and introduced to the industry, as has also the equipment for transferring the dimensions determined for the prosthesis.</p> <p>As a result of efforts of ACAL, the suction socket for the above-knee amputee has come into general use in the United States. In addition, the principles developed in the suction-socket program have helped to improve techniques used with other types of sockets, thus contributing generally to the well-being of the leg amputee. Experience gained in the suction-socket program has led either directly or indirectly to the development of the clinic-team concept which is proving so useful in the management of amputees of all types.</p> <p>Certain changes in the surgical procedures of amputation have been suggested, especially in regard to the so-called "sites of election" and to stabilization of the above-knee stump in adduction. Study of the nature and propagation of pain in stumps has yielded results which should be the basis for future advances in treatment and prevention of pain arising from amputation.</p> <p>Outgrowths of the lower-extremity clinical study may be expected to confirm, apply, and develop further the principles of fitting and alignment, to advance further the use of the suction socket, to improve the fitting of conventional above- and below-knee sockets and the "soft" socket for below-knee amputations, and to develop prostheses for other types of amputations. With the above-knee clinic established, the work in surgery, prescription, fitting, and training of the amputee is likely to advance even more rapidly than has been the case in the past.</p> <p>The development of devices with increased function, reliable enough and with benefit enough to the amputee to justify the increased complexity and cost, has proven difficult.</p> <p>Many devices have been built, tested, and found wanting in one detail or another mechanically or else have proven too costly to be practical at the present time. Although thus far only two devices, the Navy variable-friction knee and the Navy functional ankle, have been accepted by ACAL and made ready for distribution, several experimental ones appear to be almost ready for general use. The groundwork in the field of lower-extremity prosthetics has been laid. By 1956 we should see the appearance of many more, and more practical, accomplishments resulting from the preceding eight years of pioneering work.</p> <p><b>References:</b></p> <ol> <li>Adel Precision Products Corp., Burbank, Calif.,ubcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>The development of a hydraulically operated artificial leg for above knee amputations, </i>1947.</li> <li>Bradley, C. C, and Son, Inc., and Catranis, Inc.,yracuse, N. Y., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Artificial limb development for above-knee amputees including mechanical and hydraulic knee locks; suction socket and suction socket controls; knee lock controls operated by hip motion, stump muscles and fool position; toe pick up and foot providing lateral, plantar and dorsal flexion, </i>1947.</li> <li>Bresler, B., and F. R. Berry, <i>Energy characteristicsof normal and prosthetic ankle joints, </i>University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950.</li> <li>Catranis, Inc., Syracuse, N. Y., Subcontractor'sinal Report to the Advisory Committee on Artificial Limbs, National Research Council, in preparation, 1954.</li> <li>Cunningham, D. M., <i>Components of floor reactionsduring walking, </i>University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, November 1950.</li> <li>Denver Research Institute, University of Denver,enver, Colo., Subcontractor's Final Report to the Advisory Committee on Artificial Limbs, National Research Council, <i>A program for the improvement of the below-knee prosthesis with emphasis on problems of the joint, </i>August 1953.</li> <li>Eberhart, Howard D., Verne T. Inman, and Borisresler, <i>The principal elements in human locomotion, </i>Chapter 15 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Eberhart, Howard D., and Jim C. McKennon, <i>Suc-tion-sockei suspension of the above-knee prosthesis, </i>Chapter 20 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954. 9. Feinstein, Bertram, James C. Luce, and John N. K. Langton, <i>The influence of phantom limbs, </i>Chapter 4 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, in press 1954.</li> <li>Goodyear Tire and Rubber Company, Akron, Ohio,ubcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], <i>The development of a fool prosthesis incorporating a metal structure and a bonded rubber to metal ankle joint, </i>1947.</li> <li>Hosmer Corp., A. J , Santa Monica, Calif., Sub-ontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Hydraulic weight bearing knee lock for knee disarticulation amputations, etc., </i>1947.</li> <li>National Research and Manufacturing Company,an Diego, Calif , Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], <i>An investigation of low pressure laminates for prosthetic devices; design and fabrication of above-knee and below-knee artificial legs; preparation of a production survey for manufacture of artificial plastic legs, </i>1947.</li> <li>New York University, Prosthetic Devices Study, Report to the Advisory Committee on Artificial Limbs, National Research Council, <i>The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, </i>March 1953.</li> <li>Northrop Aircraft, Inc., Hawthorne, Calif , Subcon-ractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>A report on prosthesis development, </i>1947.</li> <li>Northwestern Technological Institute, Evanston,11., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, </i>1947.</li> <li>Parmelee, Dubois D., U. S. Patent 37,637, February, 1863, and reissue patents 1,907 and 1,908, March 4, 1865.</li> <li>Radcliffe, C. W., <i>Information useful in the design ofdamping mechanisms for artificial knee joints, </i>University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950.</li> <li>Radcliffe, C. W., <i>Use of the adjustable knee and align-ment jig for the alignment of above-knee prostheses, </i>University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951.</li> <li>Saunders, J. B., V. T. Inman, and H. D. Eberhart, <i>The major determinants in normal and pathological gait, </i>J. Bone and JointSurg., <b>36A </b>(3):543 (1953).</li> <li>Stewart, John H. F., U. S. Patent 2,478,721, August 9, 1949.</li> <li>United States Naval Hospital (Amputation Cen-er), Oakland, Calif., <i>Construction, filling and alignment manual for the U.S. Navy soft socket below knee prosthesis, </i>printer's date 9-29-53.</li> <li>University of California (Berkeley), Prostheticevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Fundamental studies of human locomotion and other information relating to design of artificial limbs, </i>1947. Two volumes.</li> <li>University of California (Berkeley), Prosthetic</li> <li>Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, <i>Summary of European observa-tions, summer, 1949 </i>[by H. D. Eberhart <i>el al.], </i>October 1949.</li> <li>University of California (Berkeley), Prostheticevices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, <i>The suction socket above-knee artificial leg, </i>3rd edition, April 1949.</li> <li>University of California (Berkeley), Prostheticevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Studies relating to pain in the amputee, </i>June 1952.</li> <li>War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, <i>Report on European observations, </i>Washington, 1946.</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>13.</b> </td><td class="clsTextSmall">Northrop Aircraft, Inc., Hawthorne, Calif , Subcon-ractor's Final Report to the Committee on Artificial Limbs, National Research Council, A report on prosthesis development, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Goodyear Tire and Rubber Company, Akron, Ohio,ubcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], The development of a fool prosthesis incorporating a metal structure and a bonded rubber to metal ankle joint, 1947.</td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prostheticevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Eberhart, Howard D., and Jim C. McKennon, Suc-tion-sockei suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954. 9. Feinstein, Bertram, James C. Luce, and John N. K. Langton, The influence of phantom limbs, Chapter 4 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prostheticevices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Information useful in the design ofdamping mechanisms for artificial knee joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, Report on European observations, Washington, 1946.</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>18.</b> </td><td class="clsTextSmall">Saunders, J. B., V. T. Inman, and H. D. Eberhart, The major determinants in normal and pathological gait, J. Bone and JointSurg., 36A (3):543 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Summary of European observa-tions, summer, 1949 [by H. D. Eberhart el al.], October 1949.</td></tr><tr><td class="clsTextSmall"><b> 26.</b> </td><td class="clsTextSmall">War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, Report on European observations, Washington, 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Radcliffe, C. W., Use of the adjustable knee and align-ment jig for the alignment of above-knee prostheses, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951.</td></tr></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">Bresler, B., and F. R. Berry, Energy characteristicsof normal and prosthetic ankle joints, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, April 1950.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Cunningham, D. M., Components of floor reactionsduring walking, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, November 1950.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Stewart, John H. F., U. S. Patent 2,478,721, August 9, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Eberhart, Howard D., Verne T. Inman, and Borisresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, in press 1954.</td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Northrop Aircraft, Inc., Hawthorne, Calif , Subcon-ractor's Final Report to the Committee on Artificial Limbs, National Research Council, A report on prosthesis development, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, Summary of European observa-tions, summer, 1949 [by H. D. Eberhart el al.], October 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Northrop Aircraft, Inc., Hawthorne, Calif , Subcon-ractor's Final Report to the Committee on Artificial Limbs, National Research Council, A report on prosthesis development, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Denver Research Institute, University of Denver,enver, Colo., Subcontractor's Final Report to the Advisory Committee on Artificial Limbs, National Research Council, A program for the improvement of the below-knee prosthesis with emphasis on problems of the joint, August 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study, Report to the Advisory Committee on Artificial Limbs, National Research Council, The functional and psychological suitability of an experimental hydraulic prosthesis for above-the-knee amputees, March 1953.</td></tr></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>21.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prostheticevices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Northwestern Technological Institute, Evanston,11., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">National Research and Manufacturing Company,an Diego, Calif , Subcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], An investigation of low pressure laminates for prosthetic devices; design and fabrication of above-knee and below-knee artificial legs; preparation of a production survey for manufacture of artificial plastic legs, 1947.</td></tr></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">Adel Precision Products Corp., Burbank, Calif.,ubcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, The development of a hydraulically operated artificial leg for above knee amputations, 1947.</td></tr></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">Catranis, Inc., Syracuse, N. Y., Subcontractor'sinal Report to the Advisory Committee on Artificial Limbs, National Research Council, in preparation, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Bradley, C. C, and Son, Inc., and Catranis, Inc.,yracuse, N. Y., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Artificial limb development for above-knee amputees including mechanical and hydraulic knee locks; suction socket and suction socket controls; knee lock controls operated by hip motion, stump muscles and fool position; toe pick up and foot providing lateral, plantar and dorsal flexion, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">United States Naval Hospital (Amputation Cen-er), Oakland, Calif., Construction, filling and alignment manual for the U.S. Navy soft socket below knee prosthesis, printer's date 9-29-53.</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">Hosmer Corp., A. J , Santa Monica, Calif., Sub-ontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Hydraulic weight bearing knee lock for knee disarticulation amputations, etc., 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, Report on European observations, Washington, 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Parmelee, Dubois D., U. S. Patent 37,637, February, 1863, and reissue patents 1,907 and 1,908, March 4, 1865.</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>26.</b> </td><td class="clsTextSmall">War Department, Office of the Surgeon General,ommission on Amputations and Prostheses, Report on European observations, Washington, 1946.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Parmelee, Dubois D., U. S. Patent 37,637, February, 1863, and reissue patents 1,907 and 1,908, March 4, 1865.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prosthetic</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>18.</b> </td><td class="clsTextSmall">Saunders, J. B., V. T. Inman, and H. D. Eberhart, The major determinants in normal and pathological gait, J. Bone and JointSurg., 36A (3):543 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Goodyear Tire and Rubber Company, Akron, Ohio,ubcontractor's Final Report [to the Committee on Artificial Limbs, National Research Council], The development of a fool prosthesis incorporating a metal structure and a bonded rubber to metal ankle joint, 1947.</td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">University of California (Berkeley), Prostheticevices Research Project, and UC Medical School (San Francisco), Progress Report [to the] Advisory Committee on Artificial Limbs, National Research Council, Studies relating to pain in the amputee, June 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Edmond M. Wagner, M.E. </b></td></tr><tr><td class="clsTextSmall">Consulting engineer, 930 Rosalind Road, San Marino, California; member, Lower-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-2.jpg Figure 2 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-3.jpg Figure 3 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-4.jpg Figure 4 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-5.jpg Figure 5 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-6.jpg Figure 6 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-7.jpg Figure 7 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-8.jpg Figure 8 http://www.oandplibrary.org/al/images/1954_02_008/May-1954OCRBatch1-9.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Contributions of the Lower-Extremity Prosthetics Program Creator An entity primarily responsible for making the resource Edmond M. Wagner, M.E. * https://staging.drfop.org/files/original/fc94390daaecbf5fe0e515d25844a562.pdf addcea0ef5d054afe2d97b8b2ed7d402 https://staging.drfop.org/files/original/b63e79eeb63c71071d4e658053cf7453.jpg 7033f3a9ae76997cae29ba015bdf6e1a https://staging.drfop.org/files/original/c916255036e94916ce3f90294984788f.jpg ed7c60521a368679fe0866091d1ba7c5 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_01_017.pdf Year 1968 Volume 12 Issue 1 Page Number(s) 17 - 19 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1968_01_017.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_01_017.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>Immediate Postsurgical Prosthetics Fitting of a Bilateral, Below-Elbow Amputee, a Report</h2> <h5>Edward Loughlin, M.D. <a style="text-decoration:none;">*</a><br />James W. Stanford, III, C.P. <a style="text-decoration:none;">*</a><br />Marcus Phelps, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>The application of immediate postsurgical prosthetics fitting procedures in the management of lower-extremity amputees has been reported as providing a number of advantages, notably control of postsurgical edema, a marked reduction in pain, and a material reduction of the period of hospitalization. <a></a></p> <p>Although somewhat different considerations are involved in upper-extremity cases, immediate postsurgical prosthetics fitting of upper-extremity amputees is a logical progression in the application of these procedures. Upper-extremity amputations are considerably less frequent and are usually in a younger age group. Adequate wound healing is usually not a problem, local factors being the most important determinant. Still the application of a rigid dressing is a sound surgical concept.</p> <p>Unilateral amputees have a high rejection rate for actual use of their prostheses. It is believed that immediate postsurgical fitting of prostheses to upper-extremity amputees permits rehabilitation from the earliest possible moment and, hopefully, a higher acceptance rate. As used in this report, the term "immediate fitting" means the application of a rigid surgical dressing with terminal device at the time of surgery or in the immediate postoperative period. This is in contrast with "early fitting," which is applied at some time after the removal of sutures.</p> <p>During the past two years, the authors have had the opportunity to apply immediate prosthetics fittings to three patients, with four upper-extremity amputations. The case reported here is that of a bilateral, below-elbow amputee.</p> <h3>Case History</h3> <p>LMW, a 26-year-old employee of an electric power company, sustained electrical burns of both upper extremities on March 7, 1967, the result of receiving 19,000 volts of current through both wrists. One month later he was seen in the hospital by a consulting group (general surgeon, plastic surgeon, and orthopaedic surgeon) for consideration of possible reconstructive measures. It was the consensus of the group that no useful hand or part thereof could be salvaged (<b>Fig. 1</b>). As a result, on April 17, 1967, bilateral midforearm amputations were carried out. At the time of surgery extensive muscle necrosis was found-as expected- proximal to the apparent skin defect. This required loose closure of the amputations. Drains were placed in the wounds and compression dressings were applied. On April 20, 1967, the patient was returned to the operating room so that the wounds could be viewed, and they appeared to be clean. At this time rigid surgical dressings with terminal devices and harnessing were applied. From that time on, a marked improvement in the emotional status of the patient was noted (<b>Fig. 2</b>). The patient wore his temporary prostheses until May 26, 1967, when he was fitted with permanent prostheses. The patient made an excellent recovery, returning to full-time work in November 1967.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Neither the left nor the right hand was considered salvageable. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. From the time of the application of the rigid dressings and temporary prostheses, there was an upturn in the patient's emotional status. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Application of Temporary Prostheses</h3> <p>Some details in the application of the rigid dressings and temporary prostheses may be of interest.</p> <p>Autoclaved lamb's wool was applied over the suture lines, and Orion Spandex socks were then rolled into place and held under tension.</p> <p>To satisfy two somewhat conflicting considerations-that is, to ensure that the rigid surgical dressing would not be displaced when the patient flexed and extended his elbows, and to avoid immobilization of the elbow joint with plaster-Ace bandages were applied about 3 in. below the elbow and continued proximally to encase the elbow joint. Elastic plaster bandages were then applied, and the Ace bandages were incorporated into the plaster wrap. The plaster wrap extended to a point just below the condyles of the joint. Thus the rigid dressing was held in contact, and at the same time limited movement was permitted to the joint.</p> <p>Steel straps attached to WE-500 wrist units were then applied to the rigid dressing with regular plaster for reinforcement.</p> <p>A retainer plate riveted to an anchor plate was attached to the socket for cable attachment.</p> <p>A standard bilateral ring harness with plastic triceps pad and flexible leather hinges completed the setup.</p> <p>Two 5XA hooks were applied with one rubber band each.</p> <p>On April 25, 1967, sufficient atrophy had occurred to warrant new rigid dressings. The foregoing procedure was repeated. At this time, extra rubber bands were added to the terminal devices, and the patient demonstrated proficiency at a number of activities.</p> <p>On May 9, 1967, the second cast change was made, and a wrist-flexion unit was applied to the right side. Again, more rubber bands were applied.</p> <h3>Permanent Prostheses</h3> <p>"Definite prostheses" were prescribed for the patient on May 18, 1967. The prostheses were fabricated and subsequently fitted on May 26, 1967. The prescription included:</p> <ul> <li>Bilateral below-elbow plastic prostheses.</li> <li>Double-wall sockets.</li> <li>Flexible joints.</li> <li>5XA hooks.</li> <li>Dorrance No. 4 hands.</li> <li>Two wrist-flexion units.</li> <li>One driving ring.</li> <li>One button hook.</li> </ul> <p><b>References:</b></p> <ol> <li>Berlemont, M., <i>Notre experience de V appareillage precoce des ampules des membres inferieurs aux Etablissements Helio-Marins de Berck</i>, Annales de Medecine Physique, Tome IV, No. 4, Oct.-Nov.-Dec. 1961.</li> <li>Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., <i>Management of lower-extremity amputees using immediate postsurgical fitting techniques</i>, Prosthetic and Sensory Aids Service, U.S. Veterans Administration, 1967.</li> <li>Weiss, Marian, <i>Neurological implications of fitting artificial limbs immediately after amputation surgery</i>, Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</li> <li>Wilson, A. Bennett, Jr., <i>New concepts in the management of lower-extremity amputees</i>, Artif. Limbs, Spring 1967, pp. 47-50.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Berlemont, M., Notre experience de V appareillage precoce des ampules des membres inferieurs aux Etablissements Helio-Marins de Berck, Annales de Medecine Physique, Tome IV, No. 4, Oct.-Nov.-Dec. 1961.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Burgess, Ernest M., Joseph E. Traub, and A. Bennett Wilson, Jr., Management of lower-extremity amputees using immediate postsurgical fitting techniques, Prosthetic and Sensory Aids Service, U.S. Veterans Administration, 1967.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Weiss, Marian, Neurological implications of fitting artificial limbs immediately after amputation surgery, Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., New concepts in the management of lower-extremity amputees, Artif. Limbs, Spring 1967, pp. 47-50.</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>Marcus Phelps, C.P. </b></td></tr><tr><td class="clsTextSmall">J. E. Hanger, Inc., of Georgia, 947 Juniper St., N.E., Atlanta, Ga. 30309.</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>James W. Stanford, III, C.P. </b></td></tr><tr><td class="clsTextSmall">J. E. Hanger, Inc., of Georgia, 947 Juniper St., N.E., Atlanta, Ga. 30309.</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>Edward Loughlin, M.D. </b></td></tr><tr><td class="clsTextSmall">Peachtree Orthopaedic Clinic, Atlanta, Ga. 30301</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1968_01_017/spring68c-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1968_01_017/spring68c-02.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Immediate Postsurgical Prosthetics Fitting of a Bilateral, Below-Elbow Amputee, a Report Creator An entity primarily responsible for making the resource Edward Loughlin, M.D. * James W. Stanford, III, C.P. * Marcus Phelps, C.P. * https://staging.drfop.org/files/original/c14dfe270bafb90a2b20c29025446a0e.pdf ea4783b10f5c3a4d12c12442901d6cfc https://staging.drfop.org/files/original/e1c5e0817e16709456d081f6f415e65f.jpeg 25f2e057c93d0e69803ff76ac02699cb https://staging.drfop.org/files/original/b41bc35c2793e59d83d08621281b2157.jpg d5bfa6e4244d4b75c3af3ee1a2a68fca https://staging.drfop.org/files/original/38a21614eba81d206bc337aeb5d6e7fd.jpg b15d554896978844d9a1ee39e912bc50 https://staging.drfop.org/files/original/ab1b7ad80230fb3c67ffc6ab3131818b.jpg 382f8f76e28b2dde663fe0ef853f6e34 https://staging.drfop.org/files/original/4b05615aa03be409c03076b58f01516d.jpg d8571f4ee65ef85e91ebdfa64c11a806 https://staging.drfop.org/files/original/d44602f704718bd80028a10a39ab8557.jpg e1ed3363899743fe273d87b37d17f806 https://staging.drfop.org/files/original/aaeef9fb5c5bb12a4dd59e22be53a3c9.jpg 0f490c5304c88163f508047e5ba454cb https://staging.drfop.org/files/original/e0754e5e8e0d5cf1482166067833d458.jpg a89802e08f0b5c0fc15a0c44adff5e94 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_001.pdf Text Any textual data included in the document <h2>Scoliosis: Orthotic Management Concepts</h2> <h5>Edward P. Van Hanswyk, CO.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The orthotic management of idiopathic scoliosis (<a href="/files/original/e1c5e0817e16709456d081f6f415e65f.jpeg"><b>Fig. 1</b></a>) over the years has employed a number of different orthotic systems. Included among them have been the Milwaukee and modified cervico-thoracolumbosacral orthoses (C.T.L.S.O.) as well as various prefabricated, modular, and custom fabricated thoracolumbosacral orthoses (T.L.S.O.).</p> <p>The prescription of any of the systems is dependent upon a number of variables, including the level and degree of curvature, the degree of rotation, the age and physical condition of the patient, and the degree of patient cooperation expected.</p> <p>No matter which system is selected, and no matter which set or combination of variables is present, there exists a number of orthotic management principles for consideration. The purpose of this paper is to outline these principles and theories, the similarities and differences presented by scoliosis, and orthotic management systems employed.</p> <p>In order to present these relationships, a number of somewhat original, and perhaps not so original, orthotic management concepts and theories are discussed. The theories include: 1. the reasons for reducing lumbar lordosis; 2. the idea and employment of a "righting reflex," both sagittal and coronal; 3. the concept of "costal distraction"; 4. the importance of axial alignment; and 5. a theory concerning the deviations of scoliosis, the creation of forces, and the force systems necessary for their control and correction.</p> <h3>Lumbar Lordosis</h3> <p>Historically, there has been an emphasis over the years on the reduction of lumbar lordosis (<a href="/files/original/b41bc35c2793e59d83d08621281b2157.jpg"><b>Fig. 2</b></a>) in the orthotic management of the spine, especially in the orthotic management of scoliosis with the C.T.L.S.O. and the T.L.S.O., for a number of reasons.</p> <ol> <li> <p>In the orthotic management of a lumbar or thoraco-lumbar scoliosis, flexion of the lumbar spine has a positive effect on scoliosis. The distraction that occurs between the thoracic spine and sacrum reduces lumbar scoliosis. The reasons presented for this "correction" include the release of the hip flexors and resultant pelvic tilt, and the stretch of the posterior longitudinal ligaments; the net result being an improvement of the lumbar scoliosis.</p> </li> <li> <p>When managing a lumbar curve in an orthosis with a corrective force from the posterior lateral direction in an attempt to reduce scoliosis and vertebral rotation by compressing of muscle bulge, it is necessary to provide an anterior counter-force to prevent an increase in lordosis.</p> </li> <li> <p>Recognizing that the thoracic and lumbar spine are interrelated, efforts to control lordosis with encasement and stabilization of the pelvis produce an opportunity for leverage and corrective forces, both inductive and direct, to be applied to the thoracic spine.</p> </li> </ol> <h3>"Righting Reflex"</h3> <p>The "righting reflex" (<a href="/files/original/38a21614eba81d206bc337aeb5d6e7fd.jpg"><b>Fig. 3</b></a>) is an example of an inductive force. When producing flexion of the lumbar spine, the kyphotic posture of the thoracic spine accentuates a forward flexion of the shoulder and head. The body's natural tendency to right itself over the center of gravity produces an extension or reduction in thoracic kyphosis. This sagittal plane reflex can be utilized in the orthotic management of Scheurmann's kyphosis and idiopathic scoliosis.</p> <p>Another "righting reflex" force developed is in the coronal plane. In double curves, thoracic and thoracolumbar, when the lumbar curve is reduced, causing a lateral shift of the head and shoulders, the body's natural tendency to right itself results in a reduction in thoracic scoliosis as well.</p> <p>In the orthotic management of scoliosis in a C.T.L.S.O., the "righting reflexes" can be planned as an adjunct to the direct counter-lateral and anti-rotational forces of the thoracic pad.</p> <p>In a T.L.S.O., this inductive extension is aided by a fulcrum created by the superior trim line of the orthosis. In theory, even though the length of the lever arm superior to the apex of the thoracic curve does not appear adequate for a significant force to be applied, the planned instigation of "righting reflex" forces is used to augment a lesser, direct force.</p> <h3>Axial Alignment</h3> <p>The encasement and stabilization of the pelvis provides the counter-force and leverage for direct force application to the thorax as well.</p> <p>Because of the rotational component present in scoliosis, axial alignment of the body, rib cage and pelvis is necessary. The direct force created by symmetric alignment of the pelvic and thoracic surfaces of the orthosis results in a direct anti-rotational corrective force. This is particularly applicable in the orthotic management of a thoracic curve in a T.L.S.O. Since the rotational component present in scoliosis is one variable that may preclude the use of a T.L.S.O., management of rotation in this system can be viewed as critical.</p> <h3>"Costal Distraction"</h3> <p>Another direct force advantage created by the encasement of the pelvis is "distraction." Stabilization of the pelvis and the "total contact" encasement of the lower rib cage in a T.L.S.O. produces an opportunity to maximize the distance between the pelvis and the rib cage, resulting in a distraction of the lumbar spine. The flattened abdominal surface induces lumbar flexion and also increases the intra-abdominal pressures, augmenting this force. The resultant costal-pelvis distraction is another planned, direct force in the orthotic management of lumbar scoliosis in a T.L.S.O.</p> <h3>Orthotic Management Goals</h3> <p>The concepts and theories presented might now be viewed in relation to orthotic management goals relative to scoliosis, specifically the evaluation of the various scoliosis deviations and the corrective forces available in the orthotic management system employed.</p> <p>In the normal spine, the muscles act antagonistically on either side to maintain a straight, neutral spine. The spine, rib cage, and pelvis are symmetrically related and supported by the musculature.</p> <p>In the scoliotic spine, as the vertebrae rotate and move laterally, the muscles lose their lever-arm advantage, and the spine, rib cage, and pelvis lose their symmetry. The orthotic management goals then become:</p> <ol> <li> <p>repositioning of the vertebrae, not only by direct forces, but also by inductive reflex forces.</p> </li> <li> <p>re-establishment of muscle levers and re-establishment of symmetry of the rib cage and between the rib cage and pelvis.</p> </li> </ol> <h3>Thoracic Scoliosis (Two Deviations)</h3> <p>In identifying the orthotic system to be used, the differences in scoliosis deviations should be recognized.</p> <p>Thoracic scoliosis (<a href="/files/original/ab1b7ad80230fb3c67ffc6ab3131818b.jpg"><b>Fig. 4a</b></a>) is seen as a two-deviational deformity, 1. a lateral deviation, the curve, 2. a rotational deviation, the rib prominence. Theoretically a three-directional force system is necessary for management of these deviations. The choice of C.T.L.S.O. or T.L.S.O. force systems depends, of course, on the variables outlined previously.</p> <p>In the three-directional force system C.T.L.S.O. (<a href="/files/original/4b05615aa03be409c03076b58f01516d.jpg"><b>Fig. 4b</b></a>), the forces include, 1. the counter-lateral force of the thoracic pad, 2. the anti-rotational force of the thoracic pad, and 3. the distractive force of the pelvic base opposed by the occipital portion of the neck ring.</p> <p>Certain thoracic curves can be managed also in a T.L.S.O. system: The two-deviational deformity of thoracic scoliosis managed with the lateral and anti-rotational force of the axially aligned surfaces of the orthosis, augmented by the righting reflex inductive forces, coronal and sagittal.</p> <h3>Lumbar Scoliosis (Three Deviations)</h3> <p>Thoraco-lumbar and lumbar curves (<a href="/files/original/d44602f704718bd80028a10a39ab8557.jpg"><b>Fig. 5</b></a>) are seen as a three-deviational deformity (<a href="/files/original/aaeef9fb5c5bb12a4dd59e22be53a3c9.jpg"><b>Fig. 6</b></a>). In addition to the lateral and rotational deviations there is usually a tendency toward lordosis. The asymmetry and loss of muscle levers and the shape of the lumbar vertebrae allow hyper-extension which contributes to a third deviation. It becomes necessary to incorporate a four-vector force system to manage this three-deviational deformity.</p> <p>The four-vector force system T.L.S.O. (<a href="/files/original/e0754e5e8e0d5cf1482166067833d458.jpg"><b>Fig. 7</b></a>) contains: 1. anti-lordotic, 2. lateral, 3. anti-rotational, and 4. costal distraction forces, all described earlier.</p> <p>In summary, understanding of the concepts and theories presented is necessary to provide the orthotic management system reflecting the re-positioning and forces required for appropriate correction.</p> <p><b>References:</b></p> <ol> <li>Van Hanswyk, Edward P., Hansen, Yuan, and Eckhardt, Wayne, A., "Orthotic Management of Thoraco-Lumbar Spine Fractures with a 'Total-Contact' TLSO," <i>Orthotics and Prosthetics Journal</i>, Vol. 33, No. 3, pp 10-19, September, 1979.</li> <li>Van Hanswyk , Edward P. and Bunnell, William P., "The Orthotic Management of Lumbar Lordosis and the Relationship to the Treatment of Thoraco-Lumbar Scoliosis and Juvenile Kyphosis," <i>Orthotics and Prosthetics Journal</i>, Vol. 32, No. 2, pp 27-34, June, 1978.</li> </ol> <div style="width: 400px;"><em><b>*Edward P. Van Hanswyk, CO. </b> Instructor, Department of Orthopedic Surgery, University Medical Center, SUNY, Syracuse, New York.</em></div> Page Number(s) 1 - 4 Year 1981 Volume 5 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-7.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 8 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-8.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 Scoliosis: Orthotic Management Concepts Creator An entity primarily responsible for making the resource Edward P. Van Hanswyk, CO. * https://staging.drfop.org/files/original/e71416996352556efb023812c4eedec5.pdf 25ebf46eaf69e9b152e2c190d46f2a77 https://staging.drfop.org/files/original/b6c5c1116f50d1110f991f8a6c0e582b.jpg 53141fda199ab171208acf35d095a73d https://staging.drfop.org/files/original/42e04c9ddf407f09592f368dc9ff1c12.jpg 651ea138a11022d6edf8e33366739adf https://staging.drfop.org/files/original/bcdce6329da04a8a8f4710fbe3957aec.jpg 227b1bc4f43139dc742e5cfc3434f264 https://staging.drfop.org/files/original/061a0c8f6051439279c49121003e4252.jpg e92f1b105cd71be2e26422d8ed541101 https://staging.drfop.org/files/original/220a179b1734ff365426e6b757fbf1a4.jpg 106d747231911de3f7ab6a749818955f https://staging.drfop.org/files/original/a030df8afdd8d496ea38ff35eb10a376.jpg 099981a8288aa53e4f8ab7a1afcf3ec3 https://staging.drfop.org/files/original/06b6efdef352c9a36c19e593016d0058.jpg 5cf35916d68ebab5f2fa7015770d5ec5 https://staging.drfop.org/files/original/e33abac33eb28c4425dc5ba7d3d9829f.jpg bbf0ffd1753ca99e90634ba88f777e5b https://staging.drfop.org/files/original/741aaf7774c9fb485c220490dfa15d66.jpg 104b74ab4ce49065ab443a4973decc68 https://staging.drfop.org/files/original/c7f5624a84623a65da53be9b14b7ad50.jpg 0d835a39d62f5c64705c7b7f85ff2696 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_01_004.pdf Year 1958 Volume 5 Issue 1 Page Number(s) 4 - 56 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1958_01_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_01_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Studies of the Upper Extremity Amputee. I. Design and Scope.</h2> <h5>Edward Peizer, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Man's increasing dominion over his natural environment has been ascribed to three specific characteristics a highly developed brain, binocular vision, and an apposable thumb. Although not particularly specialized from a biological viewpoint, these three attributes have enabled him to adapt to a varied physical environment and, perhaps more important, to alter the physical environment to suit his needs. Loss of any one of them deprives him of fundamental human capacities and seriously inhibits his ability to compete, to interact, and to manipulate the objective world around him. Impaired brain function is usually irreversible, and in the case of vision loss heroic measures are often required to obtain even a modicum of functional restitution. But the situation is somewhat different today with respect to the loss of an upper extremity. New concepts and developments in the field of limb prosthetics have increased the potentialities of arm amputees. Not all the problems are solved. Far from it. But systematic and concerted efforts in medicine and engineering are being applied toward reducing the limitations attendant upon the loss of an arm. It is perhaps ironic that historically these constructive efforts have been stimulated by the destructive forces of war.</p> <h3>Historical Development</h3> <p>In the aftermath of World War II, a grateful nation spared no effort to alleviate the condition of those who had been wounded or maimed in its defense. Among its many other services, the Veterans Administration undertook the task of providing prosthetic and rehabilitation services to all veteran amputees. In pursuit of this goal, it soon became clear that existing artificial limbs fell far short of meeting the needs and expectations of their users. Perhaps because of the greater dependence of the leg amputee upon adequate service, and because of the consequent emphasis on attention to his problems, the major needs were found among upper extremity amputees. Arm prostheses were found to be heavy, uncosmetic and unsanitary, and possessed of very limited function (<b>Fig. 1</b>) and (<b>Fig. 2</b>). Too often they were relegated to the closet. Generally accepted standards of prosthetic quality were lacking. Better materials, improved design, new prosthetic components, and improved fitting and fabrication techniques were clearly required.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Typical below-elbow prosthesis, vintage World War II. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Typical above-elbow prosthesis, vintage World War II. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Not generally recognized was the need for highly individualized training to develop proficiency in the use of an artificial arm so that vocational and other skills could be acquired. Without a common ground of experience, the physician rarely took part in the prescription and fitting of prostheses. Thus, even the most skilled prosthetist, faced with the task of providing his patient with a well fitting, comfortable, and highly functional prosthesis, sometimes found himself in the unfamiliar role of psychologist, therapist, and/or vocational counselor. In short, sound, complete, systematic rehabilitation programs for amputees were lacking. Officials of the Army, the Navy, and the Veterans Administration wasted little time in hand wringing. Authority was soon forthcoming, and funds were made available for a broad attack on these problems. The resources of science, applied during the war years to destruction and demoralization, were now directed toward the restoration of human loss and the enrichment of human life. The first step was the establishment, in 1945, of the Committee on Prosthetic Devices of the National Academy of Sciences National Research Council, which later became the Advisory Committee on Artificial Limbs and which is today the Prosthetics Research Board. This led to the inception of the Artificial Limb Program and to the establishment of research projects for the scientific study of the problems involved. At the University of California at Los Angeles fundamental studies were undertaken of the biomechanical principle involved in normal prehension and of the problems of using artificial arms. At the same time, the industrial laboratories of Northrop Aircraft, as well as the Army Prosthetics Research Laboratory, were creating new materials, new devices, and new fabrication techniques, while New York University was assigned the task of evaluating these developments. The scientific facilities of both industry and government were thus employed to reduce the problem through efforts in basic and applied research.</p> <p>The earliest results indicated that solving the problems and fulfilling the needs of the upper extremity amputee was a task vastly greater than that of improving the mechanical aspects of fitting and fabricating prostheses. The finest artificial limb is of little value without training in its use. Further, the loss of a limb was seen to create important disturbances in the personality as a result of functional loss and distortion of the self concept. The amputee entertains doubts as to how he will appear to and be accepted by his family and friends. He wonders, often with misgivings, about his economic potential. He has what appear to him to be insuperable problems, and he needs help in restoring his self confidence as well as his lost function. In order to meet these amputee needs, a complete and rational system of rehabilitation programming was required, and since 1945 considerable progress has been made in developing such an approach to this problem.</p> <p>After several years of organized effort, a great deal of research information became the basis for an all around approach to the treatment of upper extremity amputees. Through the development of models, the testing of hypotheses, and the experimental treatment of a number of arm amputees of all types, it became possible to indicate with some confidence how certain types of patients should be fitted, how their arms should be constructed, and how they should be trained to use them. As an added result, it is becoming a commonplace that all the amputee's needs cannot be served by a single individual, regardless of his professional status or training. With recognition of individual needs and the variety of amputee problems, it became clear that successful rehabilitation of these patients demanded the highly qualified and specialized services of a number of disciplines. Prosthetists, therapists, and physicians each have vital contributions in this enterprise, as may also nurses, social workers, vocational counselors, and psychologists. The modern concept then became the "team approach," the team consisting minimally of the doctor, the prosthetist, and the trainer and including such other specialists as each case required.</p> <p>In order to evaluate these findings, a series of studies, which came to be known as the "NYU Field Studies," was conceived in 1951 at the Prosthetic Devices Study at New York University.</p> <h3>Goals of the Upper Extremity Field Studies</h3> <p>The NYU Field Studies of upper extremity prosthetics developed as the logical consequence of two main preconditions the laboratory research program and the prosthetics education program. As for the first, out of the laboratories had come a whole series of new devices which, on the basis of preliminary testing on relatively small groups, gave promise of being significantly improved components. Before some of them could be considered "proved" items of a prosthetic armamentarium, more definitive testing on broader, more representative samples under varying conditions seemed essential. But more than gadget testing was involved. New fabrication techniques employing plastics had also been developed, and although arms made according to these procedures seemed superior to older types, it remained to be seen if the procedures could be mastered by limbmakers all over the country and economically and conveniently applied to the production of all types of artificial arms.</p> <p>The second factor to be considered in planning the studies was the matter of broad and speedy dissemination of the new knowledge and skills. It was clear that the new procedures could not be evaluated in clinics whose personnel were not completely familiar with their use. Moreover, considerable urgency prevailed about making new developments and improvements available to all amputees as soon as possible. To fulfill this requirement, a prosthetics education program was organized to train clinic team personnel. But it was generally observed that additional assistance was required in significant numbers of clinics before they could begin to process patients effectively.</p> <p>For all of these reasons, the NYU Field Studies were designed in 1953 with three main objectives in view:</p> <ol> <li><i>To evaluate the utility and acceptability of specific prosthetic materials, components, and treatment procedures</i>. In order to appraise the usefulness of prostheses provided amputees by the program, and in order to gauge the reactions of the patients to the new arms, a comprehensive evaluation procedure was to be developed. The comfort and appearance of a prosthesis and the confidence it inspires in its user are as important in prosthetic service as are structural and mechanical adequacy. Each of these areas was explored.</li><li>To provide direction for future research in relation to practical field needs. Field study operations should provide access to large representative samples of upper extremity amputees. Clinical contact with these patients would furnish a means for determining existing prosthetic problems and, even more important, for evaluating the importance of these problems to amputees themselves. With this information available to the developmental laboratories through a feedback arrangement, their efforts could be directed toward the problems of most immediacy and importance.</li><li>To extend the educational process by rendering administrative and technical assistance to newly organized prosthetics clinics. Shortly after graduation from the prosthetics courses at the University of California at Los Angeles, potential clinic teams were to be visited by NYU representatives, the purpose being to encourage and aid in the establishment of a clinic procedure along the lines taught in the courses. The expeditious organization of a clinic served two functions amputees would have early access to modern treatment, and a clinic treating patients according to these procedures was a potential participant in the field studies and a source of research data.</li></ol> <p>Before these concepts could be tested in the crucible of clinic practice throughout the nation, several preliminary steps were necessary. First, meaningful and reliable methods had to be found for evaluating the effect of prosthetic treatment procedures. Second, a number of clinics had to be organized to participate in the studies if valid inferences about the general utility of the experimental procedures were to be drawn. Third, training in the new prosthetic techniques and procedures had to be given to those who dealt directly with amputees. Actually, all three of these steps were undertaken at approximately the same time.</p> <h4>Inauguration of the Upper Extremity Field Studies</h4> <p>The staff of the Prosthetic Devices Study of New York University had been engaged in developing on a generally theoretical basis a philosophy and methodology for evaluating the status of arm amputees. The problem was approached directly, attempts being made to determine the most important outcomes in prosthetic restoration and to measure the extent to which the newer management procedures provided them. Accordingly, procedures and instruments were devised for determining the extent of residual function and the degree of adjustment to physical disability (<b>Fig. 3</b>). The status of the patient after treatment could thus be compared with his pretreatment condition as a basis for evaluation. But before these instruments could be applied on a broad scale it was necessary to test their reliability and administrative feasibility as well as to refine the procedures for their application. For this purpose, a preliminary "pilot" study was planned, and Chicago was selected as the test site.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Calibrated grid for measuring the arm movements required to perform certain common activities. Use of top and side mirrors provides information in three dimensions simultaneously. Clocks record time data. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Chicago "Pilot" Study</h4> <p>The pilot study carried out in 1952 called for a small number of surgeons, therapists, and prosthetists from the Chicago area to attend a special four week course of instruction in upper extremity prosthetics at the University of California at Los Angeles in order to familiarize the participants with the devices, fabrication techniques, and clinical procedures to be evaluated.<a></a> Upon their return to Chicago, they were joined by representatives of NYU's Prosthetic Devices Study, and the pilot study was launched.</p> <p>This field trial of research instruments and procedures involved the screening of a number of amputees in the Chicago area and the selection of a group for treatment in the Veterans Administration clinic. To enable the clinic properly to prescribe the new prosthesis, each of the selected subjects was given a comprehensive evaluation prior to other treatment. In addition, research evaluations were conducted by NYU representatives to provide baseline data against which the effects of the rehabilitation procedures could be evaluated. The new arm for each participant was then prescribed in accordance with the prescription procedure taught in the UCLA course and was to be fabricated precisely as prescribed and according to the mechanical and cosmetic standards formulated. When the arm was complete, it was brought to the clinic for a checkout which consisted of a detailed examination by the clinic staff to assure themselves of the adequacy of the product. If revisions were required, they were made before the patient was given the arm; if none were needed, the clinic prescribed appropriate training treatments to be administered by the therapist.</p> <p>After training was completed, the amputee was again seen by the clinic team; if the arm were still satisfactory and maximum results had been achieved through training, the patient was to wear the arm routinely in daily living. At the end of a two month period of daily wear, the subjects were re evaluated in a manner similar to the pretreatment evaluation.</p> <p>As a result of the Chicago study, valuable experience was gained in the processing of patients. Research techniques were refined, clinic procedures were crystallized, methods for administering questionnaires and for taking measurements were standardized, and instruments were revised and augmented. With the end of the pilot phase, expansion of the upper extremity field studies to national proportions began, an expansion made possible by the participation in the program of a number of widely distributed private clinics as well as Veterans Administration clinics.</p> <h4>Organization Of Participating Clinic</h4> <p>The unprecedented nature of the projected field studies made the selection of a number of clinics a formidable task. It was first necessary to locate interested and qualified clinic personnel. Then it was necessary to orient them as to the nature of the program as well as to the need for special training. Steps for integrating the clinics into the field program required explanation, and specific operating procedures had to be worked out with individual groups. This task was undertaken by the Director of the Prosthetic Devices Study, Dr. Sidney Fishman.</p> <p>After completion of the pilot study in Chicago early in 1953, and continuously for two years thereafter, Dr. Fishman and Dr. Miles H. Anderson, the Director of the Prosthetics Education Project at UCLA, visited many large population centers throughout the country in order to meet with medical and paramedical personnel interested in the treatment of arm amputees. On the basis of expressions of interest, and of an appraisal of the available facilities and potential case loads, a number of clinical facilities were invited to participate. During these discussions, research procedures were described, expected outcomes were explained, and the roles of the clini members and of the NYU research workers were defined. Arrangements were made for members of each clinic staff to attend the courses in upper extremity prosthetics at UCLA (see below).</p> <p>It was quickly realized that financial problems would be encountered both by private clinics and by participating limbshops. In the former, the newer training procedures called for increased services of therapists and doctors. In the latter, the employment of newer fabrication and fitting techniques required an initial investment on the part of the prosthe tists in components, equipment, and materials. In addition, the checkout of an arm by the clinic team often resulted in revisions adding to initial fabrication costs. For these reasons, certain fiscal arrangements were indicated. Monies were made available to clinic teams to pay the training fees for amputee cases participating in the work. In order to spur the fabrication of the new type arms and to permit participation in the program by the prosthe tists, arrangements were made to purchase five experimental limbs from each shop participating in the studies. As a result of these efforts, 75 clinics representing 30 states and the District of Columbia (<b>Fig. 4</b>) participated in the field program. Each treatment center was directed and staffed by graduates of special upper extremity prosthetics training courses. Of the total number of clinics involved, 28 were Veterans Administration installations and 47 were other public and private institutions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Location of the participating clinics See facing page. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Prosthetics Education Program</h4> <p>The new knowledge and techniques, organized into courses of instruction and revised after the pilot school, were offered in a series of 12 schools (<b>Fig. 5</b>) conducted at UCLA, the chief purpose being to familiarize doctors, therapists, and prosthetists with the new developments and to encourage the team approach to the prosthetic rehabilitation of the upper extremity amputee. It thus became possible to teach to those with primary interest new concepts for the management of upper extremity cases.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Students and instructors of one of the 13 courses in upper-extremity prosthetics offered at the University of California at Los Angeles. This particular course was held in the autumn of 1954. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In effecting the transfer of information and skill to the primary amputee treatment grou consisting of the doctor, the therapist, and the prosthetist, academic tradition was broken. It seemed plain that if the "team approach" were to be taught, the members of the team should go to school together. Accordingly, in a unique educational enterprise, orthopedic surgeons, specialists in physical medicine, physical and occupational therapists, and prosthetics craftsmen became classmates. The six week course offered at UCLA began with a three week session of instruction for prosthetists only. During this portion of the course, prosthetists were exposed to a highly concentrated educational dose of prosthetic design and construction principles, plastics technology, anatomy, and kinesiology. Then they tested their knowledge by fitting patients under the direct supervision of their instructors.</p> <p>In the fourth week, the prosthetists were joined by the therapists. This group began with a concentrated portion of mechanics, biomechanics, and the characteristics of a wide variety of both newly developed and the older prosthetic components. Under the supervision of the instructors, they also received experience in training the patients previously fitted by the prosthetist students.</p> <p>At the beginning of the sixth week, the prosthetists and therapists were joined by the physicians and surgeons, who were given several days in which to review and digest the course materials. Practice clinic teams, consisting of the doctor as clinic chief and of at least one therapist and one prosthetist, were then organized. The entire class then proceeded to operate as clinic teams until graduation, whereupon each of the individuals returned home, a potential participant in the soon to follow upper extremity field studies. The new knowledge and skills were broadly disseminated by these educational efforts, but their utility and effectiveness on patients could not be clearly seen until large numbers of varying types of patients had been treated and evaluated.</p> <p>The Prosthetic Devices Study, charged with the responsibility for following up the program concepts, designed studies to evaluate the modern treatment methods. The central questions to be answered were deceptively simple: Are upper extremity amputees better served by means of the program procedures? In what specific areas can improvement, detriment, or indifference be found?</p> <h4>Areas of Research</h4> <p>In relatively unexplored fields, the formulation of meaningful research questions is often laborious, unsure, and time consuming. Merely selecting the most scientifically promising problems from the many questions which arise is in itself an important research task. Many possible approaches to the field must be evaluated, and those selected for study must give promise of becoming part of and contributing to the solution of larger problem areas. The research plan developed at the Prosthetic Devices Study to achieve the objectives of the field study program evolved in this way. It provided for three major interrelated study areas to be exploited concurrently.</p> <p>The first of these, a census of amputees, called for interviewing large numbers of upper extremity amputees in order to begin the organization of a broader body of knowledge concerning them and to provide a large population from which to select a sample for more detailed study. This was the "Survey Phase." Secondly, a segment of this population was selected for clinic treatment by means of the rehabilitation procedures under study. These efforts of the field operations, referred to as the "Clinical Studies," were designed to provide information about the feasibility of clinic procedures and prosthetic fabrication methods. The third study area provided for the pre and post treatment evaluation of a portion of the sample selected for clinic treatment. This approach, called "Evaluation Studies," was intended to elicit more detailed information about a smaller number of amputees than was possible in the survey and to provide a basis for evaluation of the methods and materials employed in the treatment procedure.</p> <p>In its final form, the research plan provided for trips by NYU field representatives to attend the monthly meetings of each participating clinic. Consequently, a given member of the staff would be in the field approximately two weeks out of each month, and a routine field trip often took him to five or six cities, where he would visit perhaps six or eight clinics and observe 20 to 30 amputees under treatment. With 75 participating clinics to serve, a field staff of 10 representatives directed by two field supervisors was organized. Since clinic meeting dates and times were quite firmly fixed, and since the time required to be spent with each subject varied from fifteen minutes to four hours, depending upon the stage of treatment, the trips required considerable planning. To minimize loss of time, schedules were arranged by correspondence, and confirmed when possible, before each trip. Despite the difficulty of control, the attrition rate when the studies ended was low. Some what less than 10 percent of those initially selected failed to complete the full treatment course and follow up studies.</p> <p>The NYU representative served two main functions: he established liaison among the treatment centers in the field and between them and New York University, which resulted in interchange of information and coordination of effort, and he was responsible for the collection of the research information. These data were gathered in the field by means of interviews, questionnaires, tests, and measurements.</p> <h4>Survey Studies</h4> <p>Each arm amputee referred to a participating clinic was considered a prospective research subject, and each was given a screening interview, the purpose being to obtain pertinent information concerning the patient, his prosthesis, and his needs and aspirations. Initially, clinics screened only those amputees who were immediately in need of treatment. The information thus gleaned contributed to the survey to be made of the status of upper extremity amputees in the United States and was also useful in the selection of subjects for more detailed study. On the basis of the screening data, two classes of subjects were selected. One group was to be treated only in the clinic by the prescribed procedures. The other, in addition to the clinic treatment, was to undergo a detailed pretreat ment evaluation and a similar post treatment procedure.</p> <p>At the screening interview, the purposes and general procedures of the program were explained to the prospective participant, and information of an administrative and medical nature was collected. The common vital statistics dealing with age, height, weight, and marital and occupational status were recorded. In addition, the date, cause, and site of amputation were obtained, and the length, range of motion, shape, and condition of the stump were described. Detailed descriptions were compiled of prostheses worn by candidates, and their quality and the subjects' ability to use them were evaluated. The data contributed by each amputee were recorded on forms developed for this purpose (Appendices IA and IB).</p> <p>The selection of amputees to be processed at the first and subsequent prescription meetings was made at the Prosthetic Devices Study on the bases of available information and the sampling requirements of the study. Factors taken into account in the selection of the subjects included type of amputation, general health and physical condition of stump, and motivation of patient (his interest and willingness to participate). The entire census included 1630 male upper extremity amputees, of whom 826 were below elbow cases, 668 had amputations above the elbow, 89 had disarticulations at the shoulder, and 47 were bilateral amputees of all types. The findings arising from these survey studies are described in the article by Berger.</p> <h4>Clinical Studies</h4> <p>The idea of the clinic team was the key concept of the newly developed management procedures. The clinic was viewed as a means and a method for focusing the special skills of all the necessary medical and ancillary specialists on the specific problems of providing the amputee with the best possible replacement for the lost member. The primary service group consisted of physicians and surgeons, therapists, and prosthetists. Other specialists, such as administrative personnel, vocational rehabilitation counselors, social service workers, or psychologists, were added according to the special needs of individual cases. The fundamental nature of the clinic was emphasized by the requirement that each of the basic members be present before an "official" meeting of the clinic could be opened. It was at these clinic meetings that the treatment concepts to be evaluated were applied. There were six basic steps in the clinic procedure prescription, preprosthetic treatment, fabrication of the prosthesis, initial checkout, training, and final checkout. Of these, three prescription, initial checkout, and final checkout required meetings of the full clinic team.</p> <h5><i>Prescription</i></h5> <p>Prescription, during these studies, called for the selection of specific components from an armamentarium of tentatively approved devices for assembly into an individual prescribed prosthesis. Most of these components were designed for specific types of cases or uses and were to be prescribed in accordance with their design purposes. The final prescription was to be the concensus of the clinic members as to the most applicable components in each case. In practice, however, the medical, surgical, and physical therapy needs of each patient were considered, as were also personal and vocational indications for specific components and materials. Required was a written prescription specifying every component to be used, and all deviations from standard applications were avoided unless expressly written into the prescription. To standardize the type and quality of the information collected at these meetings, the prescription form in Appendix IIA was developed. This procedure not only was the first treatment step but it also permitted the collection of research data describing the specific devices fitted to the subjects. On the basis of subsequent acceptability and utility to the amputees, inferences could be drawn as to the worth of these components.</p> <h5><i>Preprosthetic Treatment</i></h5> <p>As part of the prescription process, the patient was examined for conditions which might produce difficulty in wearing or using an artificial arm. Particular efforts were made to institute treatment prior to fitting a limb and thereby to avoid the influence of these factors upon the acceptance and use of the prosthesis. Medical and surgical problems involving disease, infection, inflammation, redundancies, bone overgrowth, neuromata, and plastic alterations were referred to the physician for treatment. Muscular weakness and limitations in joint mobility considered amenable to treatment were referred to the therapist.</p> <h5><i>Fabrication of the Prosthesis</i></h5> <p>When the prescription was completed, instructions were given to one of the attending prosthetists to fabricate the arm. With strict adherence to the details of the prescription, the limbmaker produced the arm by use of the techniques of fitting taught by the program. He was encouraged to inspect the completed arm by means of a checklist embodying the structural, functional, and cosmetic standard that his product would have to meet at the next clinic meeting.</p> <h5><i>Initial Checkout</i></h5> <p>When the arm had been fabricated, it was brought to the clinic prior to being worn by the subject. At this clinic meeting, called "initial checkout," the standards developed in the program were applied. The initial checkout included an objective and subjective appraisal to see that the device fulfilled the prescription requirements and that it met established standards of fit, comfort, function, and appearance (<b>Fig. 6</b>). The information thus obtained described the ranges of motion available with the arm, the forces required to operate it, and stability, fit, comfort, and weight. In addition, some 30 items dealing with details of fabrication, appearance, color, specific components, and general quality were checked. These standards were considered to represent minimal levels of prosthetic adequacy. All the appropriate measurements and checks were recorded on a form similar to that shown in Appendix IIB.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. A typical clinic meeting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>These data were used to control the quality of the arms in order to permit valid generalizations about their worth. In addition, when compared with the outcomes of the treatment procedure, these data provided the basis for evaluation of the standards themselves.</p> <p>The checkout was performed at a regular meeting of all members of the clinic. If the arm failed checkout, it was referred to the prosthetist for appropriate revisions (<b>Fig. 7</b>). Consequently, it was sometimes necessary for the subject to appear at the clinic more than the minimum of three times. If the prosthesis met all the requirements, the amputee was permitted to wear the arm regularly and was scheduled for training by the therapist, the next step in the clinic procedure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Checkout. Final harness adjustments are made on a new arm prosthesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Training</i></h5> <p>The training given to each subject by the therapist was organized in two parts controls training and use training.</p> <p><i>Controls Training.</i> In the preliminary step, the objective was to familiarize the amputee with the mechanics of his appliance and to develop his ability to control its movements.</p> <p>First he was taught to operate the arm freely so as to learn by kinesthetic reaction the motions and forces required to control it. Then various objects with abstract forms and of varying consistencies were introduced t develop prehension skill. When, in the opinion of both therapist and amputee, these control motions were adequately developed, the next training phase began.</p> <p><i>Use Training.</i> Once the basic operating techniques were learned, they were applied to performing the practical activities of daily living, including self help, home tasks, and vocational and social activities (<b>Fig. 8</b>). The training objectives were now to give the amputee confidence in his ability to use the arm by exploring a variety of activities and to achieve proficiency in performing them. In this connection, it was necessary to recognize that the prosthesis cannot replace the lost member and that at best it becomes an auxiliary of the remaining arm.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Use training. The therapist explains how to approach, grasp, and manipulate a variety of common objects. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>By application of this fairly standardized sequence of activities, it was possible to collect research information relating to achievement levels and to the number of hours of training required to achieve satisfactory performance. When the amputee seemed capable of satisfactory performance with his prosthesis, the therapist arranged for him to reappear at the clinic for a final checkout.</p> <h5><i>Final Checkout</i></h5> <p>The final checkout concluded the process of providing the amputee with an arm. In a fashion similar to the pretraining initial checkout, it was conducted at a regular meeting of the clinic, all members present. The purpose at this time was threefold to recheck the mechanical and functional adequacy of the arm after use in training, to assure the clinic that satisfactory proficiency levels had been attained, and to be sure that nothing further in the way of service could be offered the patient if the first two conditions were met.</p> <p>The objective and subjective appraisal was again accomplished by means of the standardized checkout procedure (Appendix IIB). The arm was carefully inspected for signs of wear, and evidence was presented that the amputee was adequately trained. If the condition of the arm and proficiency of the subject in its use were deemed satisfactory, he was discharged with instructions to use the arm in accordance with his daily needs.</p> <h5><i>Recapitulation</i></h5> <p>Altogether, the group treated in the clinics included 378 below elbow, 321 above elbow, 46 shoulder disarticulation, and 24 bilateral amputees. Of the total of 769, 410 received no further treatment, while 359 were extensively studied prior to and after completion of the treatment procedures.</p> <p>The complete procedures employed in these studies are rather too complex for convenient presentation here in more than outline form. The full description and explanation of the most recent modification of these procedures is the subject of short term courses of instruction currently being offered at the University of California at Los Angeles and at New York University. The manuals used in these courses<a></a> contain detailed descriptions of the procedures and may be referred to for further information.</p> <p>The results of these clinic studies are presented in the article by Springer.</p> <h4>Evaluation Studies</h4> <p>The prosthesis for an upper extremity amputee is a necessarily limited means of providing those motions lost through amputation prehension, pronation supination, wrist flexion extension, and, in the case of the above elbow amputee, the additional function of flexion extension of the forearm. The chief goals of the evaluation procedures were to determine the extent to which a prosthesis provided functional as well as cosmetic replacement. A corollary purpose was to discover additional parameters of prosthetic utility and acceptability by increasing our knowledge of why an amputee accepts and uses more readily and efficiently one prosthesis in preference to another.</p> <p>The extent to which prosthetic restoration is successful is dependent upon what each subject brings to the appliance in terms of physical and mental characteristics and on what the appliance brings to him in terms of functional capabilities and qualities of comfort and cos mesis. Evaluation procedures were, therefore, aimed at the analysis and understanding of both the human and the mechanical variables that are involved in the successful use of an arm prosthesis. Although the potential significance of the pre injury personality was recognized, it was not investigated because of the difficulty of obtaining such information in a field study of this nature.</p> <p>Some of the significant evaluation factors lent themselves to objective measurement; others, of a more personal and subjective nature, could be obtained only from the amputee himself. For this reason, the evaluation procedures and instruments were designed to collect both objective measurements and more subjective data dealing with the reactions and responses of the amputee.</p> <p>In this connection, the measurement rationale underlying the collection of data should be understood. Quantitative data are convenient for systematic analysis. But quantification can be meaningful only within well developed and clearly defined evaluation areas. The appraisal, for example, of certain functional characteristics of an arm lends itself readily to objective or quantitative measurement, since the problem area is defined by the extent to which the prosthesis replaces certain lost motions. The problem here is clear; the ranges of motion and the forces applied can actually be measured. In much the same way, an evaluation of performance may be made by scoring such objective aspects as speed, errors, and even some types of quality. On the other hand, in dealing with those effects of treatment procedures relating to feelings, attitudes, emotions, comfort, and fit, the parameters to be measured are not at all clear. For this reason, in such obscurely defined areas qualitative data deriving from interviews and from both structured and unstructured responses of the subject tend to be more valuable in outlining and clarifying the areas of study. Once this is done, the particular factors may become amenable to quantitative measurement.</p> <p>Actually, only three possible sources of data were available objective measurements describing events, the expert opinions and judg ments of qualified observers, and the reactions of the subjects. Each of these sources was exploited. Specific mechanical and biomechani cal factors were measured by objective methods. Prosthetic quality and proficiency in performance with an arm were appraised by trained observers whose reliability was periodically checked and re established. Finally, the amputee himself provided information relating to his reactions to the arm, its quality, and its usefulness to him. Within two broa categories, the human and the mechanical, the following were studied:</p> <h5><i>Biomechanical Data</i></h5> <ol> <li>The strength and ranges of motion of the arm and shoulder girdle and the general physical condition of the amputee.</li><li>The ranges of motion permitted by the prosthesis, its efficiency, and the forces required to operate it.</li></ol> <h5><i>Performance Pattern</i></h5> <ol> <li>Proficiency in accomplishing the basic activities of prehension, transportation, and release in various planes and at different levels.</li><li>Quality of performance of practical daily life activities.</li><li>The range of activities in which prostheses are used and the extent of their importance.</li></ol> <h5><i>Amputee Reactions</i></h5> <ol> <li>Importance and extent of use of prostheses in daily living.</li><li>Reactions to treatment procedures.</li><li>Appraisal of prostheses and components.</li></ol> <h5><i>Psychological Reactions</i></h5> <ol> <li>Personal meanings of amputation and prosthetic restitution.</li><li>Social consequences of loss of limb and of prosthetic replacement.</li></ol> <h5><i>Biomechanical Data</i></h5> <p>It is reasonable to assume that an upper extremity prosthesis which affords the amputee a greater range of motion and which requires a minimal amount of energy or force for operation will be a more desirable appliance. While much more information is necessary before final judgment can be made, comparative data on these factors formed one of the bases for the evaluation of arm prostheses. This kind of data was obtained through direct measurement using such instruments as rulers, spring scales, and goniometers. They were used to measure pinch force between hook or hand fingers; efficiency of force transmission through the cable system; ranges of pronation, supination, and forearm flexion; socket displacement under axial load; and weight of the prosthesis. In the case of the above elbow amputee, additional information was collected on force input required to flex the forearm, angular deflection of the humerus needed to produce given ranges of forearm flexion, and ranges of motion at the shoulder. These measures were recorded on th instrument shown in Appendix IIIA. The outcome of these evaluations will be presented in an article in the next issue of Artificial Limbs (Autumn 1958; Vol. 5, No. 2).</p> <h5><i>Performance Patterns</i></h5> <p>The performance of the subjects in standardized, specially designed activities was observed and analyzed. This procedure was employed to provide information concerning the effectiveness and appearance of the performance patterns. Two approaches to the evaluation of performance were taken. Both abstract and practical function were evaluated. In the former, the ability accurately to grasp, transport, and release objects of varying sizes, shapes, weights, and consistencies was graded (<b>Fig. 9</b>). In the evaluation of practical function, amputees were graded on their performance of meaningful daily life activities (<b>Fig. 10</b>). Proficiency scores and time and motion data were recorded on the forms appearing in Appendix IIIB, while activities were tabulated as shown in Appendix IIIC.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Evaluation of abstract function. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Evaluation of practical function. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Amputee Reactions</i></h5> <p><em>Analysis of Importance and Extent of Use of Prosthesis in Daily Living.</em> In an attempt to appraise the importance of the prosthesis to the amputee, and to determine some of the specific ways in which prostheses were used, the interview technique was utilized. The subjects were asked if they used their prostheses in specific activity areas, including work, home tasks, social life, dressing, and eating. If thei response was positive in any area, they were asked to specify the particular use they made of the arm. They also were asked to rate the importance they placed on their prostheses in each of the activity areas.</p> <p>The extent to which a subject used his prosthesis to accomplish the tasks of daily life seemed to be a significant factor in appraising the degree of functional restoration afforded by the prosthesis. For this reason information was gathered about the frequency with which the prosthesis was used in ordinary two handed activities. In order to make this more meaningful, additional information was collected concerning the frequency with which each activity was encountered in the course of the daily life of the particular amputee. Additional information about common activities which were not done and the reasons therefor also was gathered.</p> <p>The following key questions were used:</p> <ol> <li>How often does the occasion arise for the amputee to perform each of a number of typical two handed activities?</li><li>How often does the amputee use his prosthesis in performing each activity?</li><li>If the need for an activity arises more often than the prosthesis is used in accomplishing the task, why does the amputee not use his prosthesis?</li><li>What is the relative importance of each of a number of activities?</li></ol> <p>These evaluations were made by means of the instrument shown in Appendix IIIC. The results of this study will appear in an article in the next issue of Artificial Limbs (Autumn 1958; Vol. 5, No. 2).</p> <p><em>Reactions to Amputation and Prosthetic Experience.</em> The subjective reaction of an amputee to his prosthesis was deemed an important factor in its evaluation. Apart from his feelings about the characteristics of the prosthesis, his experiences in securing it and wearing it are also contributing factors in his acceptance or rejection of the arm, and information in this regard may be important to an understanding of his status. This type of information was obtained through the use of interviews and questionnaires. By these means, data were gathered relating to:</p> <ol> <li>Time lapse between amputation and first prosthesis.</li><li>Preprosthetic physical therapy.</li><li>Procedures in prosthetic prescription.</li><li>Services of prosthetist.</li><li>Procedures in initial checkout of prosthesis.</li><li>Training in the use of the prosthesis.</li></ol> <p>The article by Springer describes the findings of this study.</p> <p><em>Amputees' Appraisal of Prosthesis and Components.</em> An evaluation of the prescribed components was an essential aspect of the studies. An armamentarium had been developed, and components had been prescribed on the basis of their design features. In order to appraise the relative value of these components, the amputees were asked to comment on specific characteristics of all the components of their prostheses and to describe the suitability or inconvenience of any device with which they were familiar. The following information was elicited:</p> <ol> <li>The extent of his acquaintance with prosthetic components.</li><li>His appraisal of certain specific characteristics of each device with which he was familiar.</li><li>His expression of the suitability of prosthetic components for activities.</li><li>A comparison of currently and previously worn prostheses.</li></ol> <p>These opinions and experiences were recorded as shown in Appendix HID. The results and significance of this study will appear in an article in the next issue of Artificial Limbs (Autumn 1958; Vol. 5, No. 2).</p> <h5><i>Psychological Reactions</i></h5> <p>It is frequently observed that some amputees fail to wear or use a prosthesis which seems to be well fitted and functional. Others, with properly prescribed and well fitted arms, and even those with inadequate prostheses, accept and use them extensively. These reactions were attributed to the varying, highly personal meanings of amputation and prosthetic restoration. For this reason, a psychological analysis by means of interviews and questionnaires was undertaken to explore the significance of these factors.</p> <p>The instruments used included a 57 item multiple choice questionnaire (Appendix HIE) developed by the Prosthetic Devices Study. Completed by the subject in the presence of an NYU representative, it was designed to provide information about the feelings and behavior of amputees relative to amputation and prosthetic restoration. The following reactions were elicited: feelings of functional adequacy, acceptance of loss, sensitivity about disability, ability to cope with social situations, feelings of independence, and attitudes toward prostheses.</p> <p>Another questionnaire (Appendix IIIF) contained nine open end questions. This provided an opportunity for the subject to express his feelings about the effects of his condition and treatment upon his personality and social activities. It supplemented the more highly structured 57 item questionnaire (Appendix IIIE).</p> <p>The third instrument (Appendix IIIG) was a novel (experimental) application of a projective device. It consisted of nine cartoons depicting common social situations in which the fact of amputation might lead to awkwardness or embarrassment. It permitted the amputee to select one of a number of possible responses to each potentially embarrassing situation. By his reaction, the patient was expected to express his feelings of independence, the degree to which he faced reality, hi acceptance of the amputation, and his sense of security. Each response represented a gradation of possible reactions to each situation.</p> <p>A fourth questionnaire (Appendix IIIH) was employed specifically to elicit information from subjects who had never previously worn prostheses. It consisted of 15 multiple choice questions relating to the amputee's knowledge of prosthetic components and his expectations regarding the functional, cosmetic, and comfort qualities of artificial arms. A series of open end questions was included to determine opinions of prosthetic usefulness and difficulties of prosthetic wear.</p> <p>Upon execution of these procedures, the evaluation of an amputee was complete, but the entire process was performed twice. The first appraisal, conducted by the NYU representative prior to the prescription meeting, provided a detailed description of the pre treatment condition of the patient with respect to his physical condition, functional capacity, experience as an amputee, quality and usefulness of his prosthesis, and his emotional reaction to disability. Approximately three months after a satisfactory final checkout, or six to nine months after fitting, the previously evaluated subjects were again processed for a post treatment evaluation, the procedures followed being essentially the same as in the pretreatment evaluation. The instruments used are given in Appendices IIIE, IIIF, IIIG, and IIIH.</p> <p>These data are analyzed and discussed in an article to appear in the next issue of Artificial Limbs (Autumn 1958; Vol. 5, No. 2).</p> <h3>Summary</h3> <p>Some of the problems involved in prosthetic service to amputees just after World War II, and the steps taken by governmental and private organizations toward their solution, have been described in this section. The development of the Artificial Limb Program has been traced briefly from its inception throug the initial studies in which problems were isolated and new methods and materials to solve them were developed. The dissemination of new knowledge through the organization of a prosthetics education program has been discussed, and the design and scope of the studies undertaken to evaluate the new developments have been described. "Survey Studies" were carried out to increase the available knowledge about amputees in this country. "Clinical Studies" were pursued to evaluate the effect of the newly developed treatment methods. And "Evaluation Studies" of the changes in amputees' conditions brought about by these treatments were planned and executed.</p> <p>The evaluation instruments and techniques have been described briefly in this section in the interest of presenting a clear overview of the whole process. A total of 359 amputees were studied by means of these procedures. This group contained 168 below elbow, 158 above elbow, 23 shoulder disarticulation, and 10 bilateral amputees.</p> <p>The upper extremity field studies represented a pioneering effort to apply special skills to special problems in a broad, only partially understood field. A multiplicity of interests, unique requirements, and a paucity of previous research combined to broaden the scope of the studies. The methods and instruments employed are considered a first step toward the establishment of more precise and valid methods for evaluating the condition of those with physical impairment. But despite the broadness of the field and the research requirements, service to the amputee was always a paramount consideration.</p> <p><b>References:</b></p> <ol> <li> Universeity of California (Los Angeles), Department of Engineering, <i>Manual of upper extremity prsthetics</i>, 2nd ed., W. R. Santschi and Marian Winston, eds., in press 1958. A preprint was used. </li> <li>New York University, Prosthetics Education Project, Post-Graduate Medical School, Prosthetic clinic procedures, 1956. Chapter I.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall"> Universeity of California (Los Angeles), Department of Engineering, Manual of upper extremity prsthetics, 2nd ed., W. R. Santschi and Marian Winston, eds., in press 1958. A preprint was used. </td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">New York University, Prosthetics Education Project, Post-Graduate Medical School, Prosthetic clinic procedures, 1956. Chapter I.</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"> Universeity of California (Los Angeles), Department of Engineering, Manual of upper extremity prsthetics, 2nd ed., W. R. Santschi and Marian Winston, eds., in press 1958. A preprint was used. </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>Edward Peizer, Ph.D. </b></td></tr><tr><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, 2nd ed., W. R. Santschi and Marian P. Winston, eds., in press 1958. A preprint was used.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1958_01_004/tmp4F8-10.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 Studies of the Upper Extremity Amputee. I. Design and Scope. Creator An entity primarily responsible for making the resource Edward Peizer, Ph.D. * https://staging.drfop.org/files/original/b25b9a939b4d5c4ae9c2f2acedbd696c.pdf b30d583cd18be4ab29c7f0440219cbfc https://staging.drfop.org/files/original/085e246a53c62b03b6a70a4a5358313e.jpg 7e93897e87d2197f2f94cc38f6151bab https://staging.drfop.org/files/original/bf1d9342409ad283c4fc51fe85e5c428.jpg 8f49557f305b3f91b7b067d1d2fb37d8 https://staging.drfop.org/files/original/2401bf3d7149007a01025885d08d12ae.jpg c566cc861e0b9018fe1dc2d38a6f166f https://staging.drfop.org/files/original/c726ce3e24b0aade2c6e4dafa6f1bc65.jpg b0f4603259af940f59a613343b3209e6 https://staging.drfop.org/files/original/521e1b62356225f950ec5636d3aa0e99.jpg dba0a9cfe630f9f2342e23e916484200 https://staging.drfop.org/files/original/253df5a8e8ea95d454b65a3804d794f2.jpg bb1cae0e839a9c04e07cecb7754caece https://staging.drfop.org/files/original/e5705786f693a02943d04c1e21474ff9.jpg 36fc5cade6ee7836f0dad674628a3d63 https://staging.drfop.org/files/original/c93272788dcc12626615e966d1932254.jpg 43b0d4a687d08e1b229d409a604aeb7a DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_02_043.pdf Year 1963 Volume 7 Issue 2 Page Number(s) 43 - 49 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_02_043.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_02_043.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>Socket Flexion and Gait of an Above-Knee, Bilateral Amputee</h2> <h5>Edward Peizer, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>Many factors affect the gait of an above-knee, bilateral amputee as he walks on his prostheses. Among the factors are his general health and strength, the length and condition of his stumps, the alignment of his prostheses, his comfort, and the type of knee units employed.</p> <p>While some of these factors are difficult to observe accurately, others lend themselves to objective measurement and evaluation by means of current bioengineering techniques. Not long ago, the Bioengineering Laboratory of the Veterans Administration Prosthetics Center had occasion to evaluate the gait of an above-knee, bilateral amputee, and in the course of the evaluation developed records that show graphically the "before" and "after" effect of increased hip flexion of about 10 deg. in both sockets.</p> <h3>Background</h3> <p>An above-knee, bilateral, 26-year-old, male amputee veteran, who was fitted with two suction sockets and two Hydra-Cadence knee units, was referred to the Bioengineering Laboratory for gait evaluation. The amputations resulted from an automobile accident; the patient was a vigorous young man in good health, with well-muscled, strong stumps. He weighed 158 lb. with prostheses, stood 5 ft. 8 in., had 12-in. stumps, and had worn constant-friction knee units for two years. In May 1962, he was fitted with one Hydra-Cadence unit, and approximately three months later was fitted with a second Hydra-Cadence unit.</p> <p>After he had worn both units for three or four months, evaluation indicated that, although he managed two suction sockets adequately, the two Hydra-Cadence units produced a jerkiness in his gait which was tentatively attributed to the higher energy requirements of the hydraulic units.</p> <p>The clinic team recommended that both Hydra-Cadence units be replaced with constant-friction units and requested the Bioengineering Laboratory to obtain photographic records of his performance on the Hydra-Cadence units for subsequent comparison with records to be obtained of his performance on the constant-friction units.</p> <p>On May 15, 1963, the amputee appeared at the Bioengineering Laboratory for evaluation. Preliminary examination of the prostheses indicated only marginal-if not inadequate- initial hip flexion. Observation of the subject's gait tended to confirm this impression; he seemed exceptionally "stable" and found it necessary to jerk his knee forward to initiate the swing phase. This produced a marked lurching pattern in his gait.</p> <p>The Bioengineering Laboratory recommended realignment of the prostheses, with particular emphasis on increasing initial hip flexion as a step which might improve function and obviate the necessity for refitting with constant-friction knee units. The clinic team concurred. A biomechanical analysis of the amputee's performance with his unaltered prostheses was conducted at the Laboratory on May 15. On May 24, 1963, after the amputee's prostheses were realigned by procedures which did not involve refabrication of the sockets, his performance was re-evaluated.</p> <h3>Procedures</h3> <p>The purpose of the two biomechanical evaluations was to identify changes in the gait pattern of the amputee which might have occurred as a result of changing the attitude of both sockets so as to increase initial hip flexion (<b>Fig. 1</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Socket realignment to provide 10 deg. of initial hip flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Because of the length of the amputee's stumps (12 in.) and the need to maintain cosmetic acceptability, the maximum increase of hip flexion possible was from 0 deg. to 10 deg. This change in attitude was intended to increase the amputee's functional range in hip extension and thereby improve his control of knee stability during stance, with potential effects upon his speed of walking, his stride length, the smoothness of the path followed by his center of gravity, the application of his body weight to the floor, the characteristics of his push-off, and his knee flexion at toe-off. Since the change was simply an increase of flexion, and only in one plane, it was accomplished without the use of the VAPC adjustable coupling.<a></a></p> <p>Although the amputee normally walked with the aid of canes, he did not use them during the two evaluations.</p> <p>For each evaluation, the amputee walked along a level walkway, first in one direction and then in the other, thus making two transits of the walkway on each occasion. Run No. 1 and run No. 3 were made on May 15; run No. 4 and run No. 5 on May 24. Because of equipment failure on run No. 2, no data are shown for that run.</p> <p>He was targeted with reflective tape at the head, elbow, hip, knee, ankle, and shoe for photography from the side by an interrupted-light camera during the transits. Also, as he proceeded along the walkway, he stepped on a set of force plates (thus providing a measure of the application of his body weight to the floor). Simultaneously, the tachograph (<b>Fig. 2</b>) measured and recorded his acceleration and velocity. Descriptions of these procedures and devices appeared in Artificial Limbs in 1954.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Schematic diagram of the tachograph, a system for recording linear velocity. The subject wears a lightweight belt, to which is attached a fine cable that turns the rotor of a direct-current generator. Voltage produced by the generator is proportional to the velocity of the subject. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Results</h3> <h4>Average Velocity</h4> <p>Average velocities, determined by integrating the tachograph curves, are given below in fiftieths of an inch of galvanometer deflection. An increase in velocity may reflect easier initiation of swing phase, an increased push-off force, or greater stride length. <b>(Table 1)</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It can be noted that the patient's velocity was greater after realignment of his prostheses-substantially higher in run No. 4, and moderately higher in run No. 5. In <b>Fig. 3</b>, the velocity curves prior to realignment fall below the zero velocity level, indicating backward movement. In order to initiate the swing phase, it was necessary for the patient to incline his torso forward, with a consequent rearward thrust of the pelvis. The tachograph recorded this rearward thrust as a backward movement.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Tachograph recordings. Run No. 1 and run No. 3 were recorded on May 15, 1963, prior to realignment of prostheses; run No. 4 and run No. 5 on May 24, 1963, after realignment. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Average Stride Length</h4> <p>Stride length is the distance between consecutive heel contacts by the same leg. In this case, increased stride length may be regarded as a result of greater control and strength in hip extension, increased push-off force, and easier initiation of the swing phase.</p> <p><b>Average Stride Length</b></p> <blockquote><p>Prior to Realignment of Prostheses: 17.0 in.<br />After Realignment of Prostheses: 19.4 in.</p> </blockquote> <h4>Smoothness Of Gait</h4> <p>In addition to measuring velocity, the tacho-gram reflected other elements of the gait pattern. Thus the smoother wave forms recorded after realignment of the prostheses (<b>Fig. 3</b>) indicate less lurching and jerkiness in the gait pattern.</p> <h4>Anteroposterior And Vertical Displacements</h4> <p>No significant differences were observed in the displacement of the head, elbow, hip, and knee after realignment of the sockets. However, the ankle displacement curve (<b>Fig. 4</b>) indicated a more rhythmic oscillation of greater amplitude after the realignment. This motion reflects more normal timing and range of knee flexion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Pathways of targeted points on the amputee during ambulation, as determined by interrupted-light photography. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Knee Flexion</h4> <p>Knee flexion at toe-off and during the swing phase prior to realignment of the sockets was variable and at times very limited. After realignment of the sockets, the extent of knee flexion at toe-off and during the swing phase was more consistent and generally of more normal magnitude. <b>(Table 2)</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Floor Reaction Forces</h4> <p>In view of the variability of the patient's performance on the four runs, vertical load and fore-and-aft shear forces do not show consistent differences. Nevertheless, reference to <b>Fig. 5</b> indicates that:</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Force-plate data. Vertical forces applied by the subject to the force plate during the stance phase are shown in the upper curves. Less time was required to apply the full body weight to the prosthesis after realignment. Fore-and-aft shear forces shown in the lower curves indicate the pattern of push-off and toe-off. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The patient applied his full body weight to the prostheses faster after the sockets were realigned. <b>(Table 3)</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Full body weight was applied to the prostheses in a smoother, less jerky fashion, as indicated by a diminution of the oscillations in the patterns representing performance after realignment.</p> <p>The smaller amplitude of the oscillations in the vertical load curves after realignment indicates decreased lurching in the stance phase and perhaps a smoother initiation of the swing phase on the contralateral side.</p> <p>The fore-and-aft shear load curves indicate greater horizontal forces after push-off with the realigned sockets. Moreover, the increased magnitude of the aft shear loads after toe-off before realignment indicates a greater degree of toe drag.</p> <h4>Motion-Picture Analysis</h4> <p>Motion pictures were made of the patient prior to and after realignment of the sockets. Analysis of the gait patterns indicated the following positive changes:</p> <ul> <li>Somewhat less anteroposterior pelvic lurch.</li> <li>More symmetrical arm swing.</li> <li>Somewhat longer step length.</li> <li>Narrower walking base.</li> <li>Easier initiation of the swing phase with increased hip flexion.</li> </ul> <p>Analysis of the motion pictures did not bring out any significant improvement in stability. However, this may have been masked by the obviously improved mobility.</p> <h3>Summary</h3> <p>The performance of an above-knee, bilateral amputee in level walking with two suction sockets and two Hydra-Cadence knee units was compared before and after increasing initial hip flexion approximately 10 deg. Before realignment, he had worn the assembly three or four months. However, the second evaluation was conducted on the same day as the realignment; consequently, the comparison does not represent a reliable index to the significance of the change. The observations disclose only immediate reactions; another evaluation after at least three months of wear should provide a more conclusive analysis.</p> <p>In general, the patient's performance revealed marked variations from run to run, making it difficult to select a truly representative performance for each test condition. For this reason, "before" and "after" data describing performance during the runs have been presented.</p> <p>The increased initial hip flexion was undertaken to increase the amputee's range and strength in hip extension. Analysis of the data disclosed mild improvements in:</p> <ul> <li>Stability.</li> <li>Velocity and stride length.</li> <li>Smoothness of gait pattern.</li> <li>Initiating the swing phase by increased push-off forces.</li> </ul> <p>The only significant change which could be identified in the symmetry of the motions of body segments was a more normal ankle displacement, reflecting improved knee flexion in the swing phase.</p> <p>A follow-up inquiry on August 20, 1963, disclosed that the patient, who was employed in a summer camp, was wearing his prostheses daily. Because of the hilly terrain where he was working, he was using two crutches rather than the two canes previously used. Despite his comments that the limbs were heavy and he wanted to have the socket fit re-checked, he regularly wore the prostheses from 8:00 a.m. to 11:00 p.m. daily and did considerable walking.</p> <p>This experience illustrates a tendency toward excessive concern for stability when fitting and aligning prostheses for above-knee, bilateral amputees, thereby imposing needless functional limitation.</p> <p>In this particular case, more than 10 deg. of initial hip flexion could have been tolerated without significant loss of stability. However, even the increase of 10 deg., the maximum in view of stump length and cosmetic requirements, had several beneficial effects on the patient's performance.</p> <p><b>References:</b></p> <ol> <li>Contini, Renato, <i>Prosthetics research and the engineering profession</i>, Artificial Limbs, September 1954, p. 47.</li> <li>Staros, Anthony, <i>Dynamic alignment of artificial legs with the adjustable coupling</i>, Artificial Limbs, Spring 1963, p. 31.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Contini, Renato, Prosthetics research and the engineering profession, Artificial Limbs, September 1954, p. 47.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Staros, Anthony, Dynamic alignment of artificial legs with the adjustable coupling, Artificial Limbs, Spring 1963, p. 31.</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>Edward Peizer, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Bioengineering Laboratory, 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_02_043/1963-Autumn-51.jpg Figure 2 http://www.oandplibrary.org/al/images/1963_02_043/1963-Autumn-53.jpg Figure 3 http://www.oandplibrary.org/al/images/1963_02_043/1963-Autumn-52.jpg Figure 4 http://www.oandplibrary.org/al/images/1963_02_043/1963-Autumn-56.jpg Figure 5 http://www.oandplibrary.org/al/images/1963_02_043/1963-Autumn-57.jpg Figure 6 http://www.oandplibrary.org/al/images/1963_02_043/1963-Autumn-54.jpg Figure 7 http://www.oandplibrary.org/al/images/1963_02_043/1963-Autumn-58.jpg Figure 8 http://www.oandplibrary.org/al/images/1963_02_043/1963-Autumn-55.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 Socket Flexion and Gait of an Above-Knee, Bilateral Amputee Creator An entity primarily responsible for making the resource Edward Peizer, Ph.D. * https://staging.drfop.org/files/original/c737cb139033e8c4e783bb778fe2e303.pdf afba2b2f06d76842bef498473100a1b1 https://staging.drfop.org/files/original/53a89d8480ff368ebfc6962ec042be72.jpg b2d8f26b2c1cafd28d9b7ad03029a668 https://staging.drfop.org/files/original/2ef1058566b5da2b2e748d2d399df4c3.jpg a8237eb97aeffbee15ffa247a537a667 https://staging.drfop.org/files/original/0e0af5faf2d7d019ccf6efbf80ecc4e4.jpg 81b5c27b0158cb11f17f9b3811ec9ac7 https://staging.drfop.org/files/original/9fae0d917cf822fda036ea66b7f8ff35.jpg 39a6b402d16ad8e2ef8e5667351eef50 https://staging.drfop.org/files/original/fda55ff8d76b3af1f4afc1d3a8cc3787.jpg a25e75a93fc30ecdd9c8b6975d942de6 https://staging.drfop.org/files/original/635c07500a4b3f511b40baacfd0ec89f.jpg adb8ecb8590d21be56e26f5405cf8bf4 https://staging.drfop.org/files/original/881b402166909b183a592b5b932f5677.jpg 7a3a00e45dd8702373b17959937a5126 https://staging.drfop.org/files/original/867e91a41092a8cb68da465cd4034cf0.jpg da1b4fa8505ac79518e6226d88cac8c5 https://staging.drfop.org/files/original/05fd05eb81ff45ee5e7dcdccc396ce52.jpg dc75320f708c13452a69fae429e97894 https://staging.drfop.org/files/original/e6f7b2da3a4fadbf8a3a527edd3b5316.jpg 374c020c738c1a7a0b67d6f9b7e5072f https://staging.drfop.org/files/original/b0841997a49c9c7aab4eec937823c93b.jpg af43b44b1a7974fa376e7e9cc4272e4a https://staging.drfop.org/files/original/3ecc27bcefe23c8876046fa46a244a58.jpg 0cc9e916aae2a19c818aa922e2e9dd6d https://staging.drfop.org/files/original/3f61c1ac694eecb5767bc99734eebdca.jpg 84b791ff84fc7c8e0ba091dd088d83ad https://staging.drfop.org/files/original/6c08a4ed2a642bee3bf78630fcb66ac5.jpg 4dd94891a6ce8096342cf7ecff639b6e https://staging.drfop.org/files/original/b3b7237e745179d1ea21a21d0e3d3ecc.jpg d402232aa9be558b350be8c78a1075dc https://staging.drfop.org/files/original/b8ba70d807eb81df01ce717eb7db28ef.jpg cc62f2333467e76a57f6725f0c159351 https://staging.drfop.org/files/original/9cb3b4e808194b8ed3234d51106c404f.jpg 74505ee95ad7d6144a9d5ef5dff2fc5f https://staging.drfop.org/files/original/67170ee9e96df59048a0de1aa68a16c4.jpg ced97b253b8926ea606e2d78a8c894ab https://staging.drfop.org/files/original/8d01098d0675e6e9c890d0e24af2e450.jpg c3cd02b27f4bda7a2e64bc3d1b4b3807 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_02_004.pdf Year 1958 Volume 5 Issue 2 Page Number(s) 4 - 30 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1958_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_02_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Studies of the Upper-Extremity Amputee V. The Armamentarium</h2> <h5>Edward R. Ford, CP. <a style="text-decoration:none;">*</a><br />Earl A. Lewis, M.A., R.P.T. <a style="text-decoration:none;">*</a><br /></h5> <p>One of the most interesting aspects of the evaluation procedures is concerned with comparisons between the prosthetic equipment worn by the participating amputees prior to the NYU Field Studies and that later provided as part of the studies. Some amputees entering the program were found to be wearing modern arms based on the latest components and materials and constructed according to the latest methods of fabrication. Others had outmoded and sometimes outworn prostheses. And a third group either had never worn prostheses before or else were not wearing a prosthesis at the time the program began. Accordingly, the data gathered were not only on the new program prostheses but also on the old arms previously worn, if any, and hence the present analysis deals not only with the effects of program arms but also to a considerable extent with comparisons between the old and the new prostheses.<a style="text-decoration:none;">*</a> Of the 1630 arm amputees involved in the NYU Field Program, 359 were available for comprehensive investigation throughout the period covered by the evaluation studies. Of the 359, which together form the basis for this discussion, 168 were below-elbow amputees, 158 were above-elbow amputees, 23 had shoulder disarticulations, and 10 were bilaterals. Those who had prior experience with prostheses were used to form the comparative analysis of old vs. new.</p> <p>Although the subjects making up the group were generally available for intensive study, it was not possible to obtain from every amputee an answer to every question. In other instances, the investigators received multiple responses to questions. Moreover, certain areas of investigation called for responses in relation to the number of components involved, in which case the number of responses varied with the bilateral group and with those patients who utilized more than one terminal device. Although the reflection of these factors in the data causes some inconsistency in numbers of replies, it does not reduce the over-all value of the results.</p> <p>For purposes of identification, all prostheses worn by the amputees prior to inception of the NYU Field Studies are here referred to as "old prostheses" or "preprogram arms," although in a few cases they were rather new and reflected some of the latest techniques and components. All prostheses fitted during the course of the research studies are identified as "program" or "new" prostheses, although some of the components and techniques had for some time enjoyed either limited or general use in the prosthetics field. While the "old prostheses" represent an admixture of various techniques and components, some old, some new, the "program prostheses" represent the best of the old plus the latest innovations in the field of limb prosthetics at the time.</p> <p>In passing, it should perhaps be noted that the data concerned were for the most part gathered on program prostheses fabricated shortly after the prosthetists' completion of the prosthetics courses at the University of California at Los Angeles. The skills and experience available for handling the latest components, materials, and techniques were therefore somewhat limited during the early days. As experience and attendant skills increased, the quality of the prostheses improved. No apology for the program treatment procedures and prostheses (which, as will be seen, were clearly superior to preprogram efforts), this circumstance indicates that expansion of present gains can be expected as prosthetists and prosthetics clinics continue to accumulate experience with latest procedures.</p> <h3>Terminal Devices</h3> <p>The artificial hand or hook is generally considered to be the most important single component of an artificial arm. A major functional purpose of all other components of the upper-extremity prosthesis is to make it possible for the terminal device to be positioned and the function of grasp to be utilized. Moreover, the hook or hand is important from the standpoint of aesthetics, since it is exposed to view almost constantly and is a matter of curiosity to all who recognize it as a prosthetic device. Today's prosthetic armamentarium presents a choice, from a selection of hooks and hands, of terminal devices most likely to meet the wearer's needs. Within this framework are devices which operate on the voluntary-opening or the voluntary-closing principle<a></a>. Available hands are either essentially cosmetic or else are designed to provide prehension as well as cosmesis<a></a>. Either type permits the functions of pushing, pulling, and holding down objects.</p> <p>Were any one of these devices completely satisfactory, it would enjoy exclusive use by all wearers of arm prostheses. Since such is not the case, amputees frequently interchange two or more terminal devices, say a hand and a hook, and some even interchange two hooks of different shapes and operational characteristics. In any event, many factors influence the selection of terminal devices<a></a>, so that what- ever is chosen usually represents a compromise based upon consideration of the psychological, environmental, and biomechanical circumstances of the individual amputee.</p> <h4>The APRL Hand and Glove</h4> <p>One of the most widely publicized developments in the Artificial Limb Program has been the APRL voluntary-closing terminal devices—the APRL hook and the APRL hand with its companion glove of plasticized polyvinyl chloride<a></a>. Prior studies<a></a> had established the usefulness of these devices, and the Upper-Extremity Field Studies presented a unique opportunity to introduce these items into many more clinics over the country and to obtain additional information concerning the value of the devices to amputees. The APRL hand was therefore prescribed in almost all research cases where a prosthetic hand was indicated (285 out of 291). Four patients expressed strong desires to continue with voluntary-opening hands, while two others elected to continue with passive, cosmetic hands.</p> <p>Tests showed that grasp forces available with the APRL hand, in which grasping force is related directly to the force that can be exerted by the wearer, were much higher than those to be had with other types of functional hands. Almost all wearers of the APRL hand (89 percent) could exceed 20 lb., a force not uncommon in the palmar prehension of non-amputees <a></a>. Voluntary-opening mechanical hands, in which the force is limited to that available from springs or rubber bands, showed a maximum prehension force of 5 lb.</p> <p>When these tests were completed, the subjects were questioned regarding their reactions toward the APRL hand in the areas of usefulness, appearance, ease of operation, and weight.</p> <h5><i>Usefulness</i></h5> <p>Most of the amputees considered the APRL hand to be a useful device or at least one of limited use. Less than 12 percent considered the hand to be of no use. But the pattern of responses clearly indicates that the hand becomes less useful to the wearer as the level of amputa- lion becomes higher, presumably owing to the increased difficulty of using a prosthesis with decreasing stump lengths.</p> <p>The ability to control grasp and to maintain it (by automatic locking) was well received by 50 percent of the amputees for whom APRL hands had been prescribed, and increased function over a wide range of activities elicited important voluntary comments from another 27 percent. The choice of using either the large or the small finger opening prompted positive comments by 11 percent of the sample. When comparisons were made of the amputee reactions to usefulness, the APRL hand was rated considerably higher than other types of hands previously worn. <b>Fig. 1</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5><i>Appearance</i></h5> <p>Noted was an exceptionally high degree of amputee satisfaction with the appearance of the APRL hand. As might have been expected, level of amputation did not seem to influence the wearers' reactions in this area. More than 90 percent of all the amputees felt the APRL hand and glove to be either "very satisfactory" or "satisfactory" in appearance. In no other component of the prosthesis do we have such a large number of amputees exhibiting this degree of positive response.</p> <p>The size of the APRL hand was felt by 6 percent of the wearers to be a problem. Discoloration and difficulty in keeping the glove clean elicited negative comments from 12 percent of the subjects. Poor wear characteristics of the glove (abrasion, tearing, rubbing through) elicited negative comments from 9 percent of the sample. When amputee reactions to the appearance of the AFRL hand were compared with the corresponding reactions to the appearance of other hands previously worn, the results were very favorable toward the APRL device.</p> <h5><i>Ease of Operation</i></h5> <p>Almost 72 percent of the amputees for whom an APRL hand had been prescribed felt that it was easy to operate, another 26 percent considered it somewhat difficult to operate, and less than 3 percent found it very difficult to operate. Below-elbow amputees experienced the least difficulty in hand operation. As expected, fewer found the APRL hand "easy" to operate as the level of amputation became more proximal. <b>Fig. 2</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Some of the amputees had worn other "functional" hands prior to the APRL device. When they compared ease of operation of their old prosthetic hand with that of the APRL hand, the APRL model was preferred. It is interesting to note that the shoulder-disarticulation and above-elbow cases exhibited dramatic changes in their reactions to use of functional hands, a fact which would suggest that the APRL hand has much greater applicability than the older hands. For one thing, in the dual-control system<a></a> the cable-excursion requirements are lower for voluntary-closing devices than for voluntary-opening devices, and this circumstance exerts an important influence on the use of above-elbow and shoulder-disarticulation prostheses. Apparently the additional control motions needed for operation of voluntary-closing devices did not constitute an objection insofar as ease of operation was concerned.</p> <h5><i>Weight</i></h5> <p>Judging from amputee opinions relating to the weight of the APRL hand (15 oz. with glove), the below-elbow group found the weight more satisfactory than did any other. In view of the greater residual anatomy in the below-elbow case, this result is generally understandable even though the short below-elbow case, without assistive forearm lift<a></a> is at a disadvantage. It is significant to note that 42 percent of all amputees for whom a hand had been prescribed felt that the APRL hand was somewhat heavy or very heavy, an indication that further improvements, aimed at weight reduction, are needed. Nevertheless, amputees who had worn other hands considered the APRL hand lighter. All in all, the wearers' reactions consistently favored the APRL hand.</p> <h5><i>Discussion</i></h5> <p>It should be understood that amputee reactions toward the APRL hand were of special interest to the research program. Consequently, many such hands were prescribed not for specific vocational or avocational reasons, nor because of patient interest, but to observe the effects upon a rather large number of amputees who had no specific objections to being fitted on a trial basis. Many confirmed hook wearers were therefore included in the group fitted with APRL hands.</p> <p>The data show that mass fitting (285) of the APRL hand caused an additional 27 percent of the patients to wear hands on a more or less regular basis. Very few amputees expressed serious over-all negative feelings toward the APRL hand and glove.<a style="text-decoration:none;">*</a> Apparently, however, 25 percent of the patients for whom APRL hands had been prescribed wore them less than one day a week. Some, after a brief experience with the hand, declined to wear it at all and preferred to return to exclusive use of a hook. Since this response cannot be related to any specific dislike for the APRL hand and glove, it appears to relate more to a basic preference for a hook.</p> <p>A number of improvements in the APRL hand were suggested during interviews with the amputees. One was that a range of sizes would be most welcome since the one size available at the time was often either larger or smaller than the corresponding normal hand. Amputees with large hands seemed to feel that the APRL hand and glove were too small and effeminate. Another, cited especially by those with the higher levels of amputation, concerned the need for reducing the weight of the APRL hand. Other proposed improvements related to appearance and durability (especially of the glove) and to the complexity of function arising from the double control motion required for locking and unlocking.</p> <p>In brief, the APRL hand, with its two-position prehension range, its voluntary-closing self-locking mechanism, and its cosmetic glove, showed superior grasp forces and was considered to be more useful, easier to operate, and much better in appearance than other mechanical hands. Although the wearers indicated that weight reduction in the APRL hand would be welcomed, the existing hand was considered more satisfactory than other mechanical hands. Despite these positive findings, it was apparent that design changes directed toward weight reduction, improved durability in the cosmetic glove, establishment of a range of sizes, and simplification of operating requirements would improve the device significantly.</p> <h4>Rubber-Band-Loaded Hooks</h4> <p>The type of hook which, historically, is the standard in the prosthetics field, and the one to which all other designs are compared, is the steel or aluminum voluntary-opening split hook in which the fingers rotate about a single pivot and are held in the closed position by the contraction of rubber bands that stretch during opening<a></a>. Addition of more and more rubber bands increases the maximum available finger forces at the expense of added work in opening.</p> <p>Many variations in finger shape are to be had. Some fingers are lined with rubber to reduce slippage, others are unlined. In the studies concerned, prescription of rubber-band-loaded hooks was often on the basis of previous amputee experience. Sometimes clinical judgment favored them, especially for use with bilaterals, because of the simplicity of operation as compared with voluntary-closing, self-locking terminal devices which, although superior in grasp forces, demand additional control motions, a requirement generally considered to be a shortcoming. In tests involving 68 of these simple hooks as worn by amputee subjects, it was found that the rubber bands had been selected to yield prehension forces ranging from 1 lb. to 14 lb. (average, 4.3 lb.), depending on individual preference.</p> <p>With regard to usefulness, appearance, ease of operation, and weight, amputee reactions to rubber-band-loaded hooks are rather consistent regardless of level of amputation. Although in general there is a high degree of acceptance, 21 percent of the below-elbow amputees and 8 percent of the above-elbow cases indicated that rubber-band-loaded hooks are of limited use only. Thus again improvement is needed. The subjects themselves suggested more durable rubber inserts for the fingers, elimination of rubber bands, and reduction in the conspicu-ousness of the hook without reducing its functional value. <b>Fig. 3</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Sierra Two-load Hook</h4> <p>A relatively new design for voluntary-opening hooks, which traditionally have used rubber bands for closing, is the Sierra two-load hook featuring a spring to close the fingers<a></a>. Heavy or light closing forces are selected by positioning a small mechanical switch located on the post provided for attachment of the control cable. The case which houses the operating mechanism is made of aluminum, and the hook fingers, also of aluminum, are lyre-shaped and lined with neoprene for increased security of grasp.</p> <p>The novel design of the two-load hook, with its simplicity of operation (voluntary-opening) and choice of two grasp forces, interested both clinics and amputees. Consequently, 64 of these devices were prescribed in the study. Data taken on 51 subjects show that pinch forces averaged 3.4 lb. for the light-load setting of the mechanism, 6.6 lb. for the heavy loading.<a style="text-decoration:none;">*</a> <b>Fig. 4</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Amputee reactions to the two-load hook were generally positive insofar as usefulness, ease of operation, weight, and, to a lesser extent, appearance were concerned. As with rubber-band-loaded hooks, there were indications of need for improvement, for 13 percent of the below-elbow amputees and 12 percent of the above-elbow cases indicated that the two-load hook was of limited use only. That 12 percent of the above-elbow amputees felt the device somewhat difficult to operate is a finding hard to interpret, unless perhaps these particular subjects had been accustomed to extremely light loadings on hooks operated by rubber bands.</p> <p>In general, there was a favorable reaction toward the availability of two levels of grasp force from which to select. Although apparently the light load was used most often, the wearers found that the heavier loading was sometimes very desirable. The indications were that a desirable improvement could be effected if the ranges of prehension force could be made adjustable by the wearer (perhaps by use of a simple tool). When amputee comments were compared (two-load hook versus rubber-band-operated hooks worn previously), there was no clear-cut preference for either type, although the two-load fared slightly better in all areas except appearance. <b>Fig. 5</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>APRL Hook</h4> <p>The APRL hook is, like the APRL hand, a voluntary-closing, automatic-locking terminal device<a></a>. The body and fingers are of aluminum to keep weight within reasonable limits, the fingers being lyre-shaped and lined with neoprene to increase the security of grasp. Opening ranges of approximately 1-1/2-in. or 3 in. are selected by manipulation of a small switch protruding from the hook case. The control cable attaches to a lever arm projecting from the side of the housing for the mechanism. As with the APRL hand, prior studies<a></a> had established the general acceptability of the hook, and the NYU Field Studies presented a unique opportunity to gain additional insight into its application and to introduce it into more climes throughout the country.</p> <p>The basis for prescription was to furnish the APRL hook in a majority of cases where a hook was required. The only exceptions were those cases where a clear contraindication was apparent (for example, in cases of patient refusal to wear any type of hook, or to change from some other type to the APRL hook, or where occupational requirements demanded extremely rugged construction, or where the subject was interested in trying the Sierra two-load hook). Consequently, rather large numbers of amputees in the study were equipped with the APRL hook.</p> <p>The data obtained with 228 hooks were similar to those obtained with the APRL hand when it was compared to voluntary-opening hands. Grasp forces were found to be considerably higher with the APRL hook than with voluntary-opening hooks. Eighty-nine percent of the wearers could exert forces over 9 lb., 54 percent over 20 lb.</p> <p>Although amputee reactions to the APRL hook were generally positive, the present design evidently leaves much to be desired in the area of appearance and, to a lesser degree, in the area of usefulness. In interviews, the amputees mentioned:</p> <ol> <li>The possibility of reducing length and bulk by incorporating the terminal-device mechanism in the forearm.</li><li>Dissatisfaction with the reliability of operation (locking after closing), although some wearers were generally aware that the fault might lie with themselves in not permitting the mechanism to alternate.</li><li>Backlash, which in varying degrees caused some wearers distress.</li><li>The potential advantages (aesthetic as well as functional) of having the hook "thumb" as well as the moving finger on the medial aspect. At present, when the "thumb" is on the medial side the moving finger is on the lateral side and opens away from the wearer's body. If the wearer wants the moving finger to open toward him, the "thumb" is placed on the lateral side.</li></ol> <p>Some interesting points are observed when we compare the responses to the APRL hook with those to the APRL hand. Since in general hooks are conceded to be more functional than artificial hands, it comes as no surprise that in the area of usefulness the APRL hook rated higher than did the hand. As regards appearance, reactions were much more favorable to the hand than to the hook, but, in the case of the latter, amputation level had no apparent effect on amputee feelings. In any event, a significant number of patients found both hand and hook unsatisfactory in appearance. <b>Fig. 6</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>More than 80 percent of the amputees wearing the APRL hook indicated that it was easy to operate regardless of amputation level. Conversely, responses by wearers of the APRL hand indicated that operation became somewhat more difficult at the higher levels of limb loss. By far the majority of wearers registered satisfaction with the weight of the hook (8-1/4-oz.), whereas the weight of the gloved hand (15 oz.) was less well received. The higher the level of amputation the more critical weight became. Next to be considered are the reactions voiced in regard to the usefulness, appearance, ease of operation, and weight of rubber-band-loaded hooks (voluntary-opening) worn prior to the studies and of the APRL hook (voluntary-closing) supplied during treatment. The below-elbow and shoulder-disarticulation wearers considered the rubber-band and APRL hooks approximately equal in usefulness, while the above-elbow wearers felt the APRL hook to be somewhat more useful. As for appearance, about 70 percent of the subjects found both APRL and rubber-band hooks generally "satisfactory." Whereas 15 percent indicated dissatisfaction, the remaining 15 percent said that in appearance both hooks were "very satisfactory." When ease of operation was considered, the below-elbow and above-elbow wearers favored the APRL hook slightly, although both hooks were rated highly with regard to operating characteristics.</p> <p>The wearers of shoulder-disarticulation prostheses showed a distinct preference for the APRL hook with respect to ease of operation, probably because of the ease with which closure can be effected and because of the low excursion requirements peculiar to voluntary-closing terminal devices. This finding may indicate that rather light prehension forces are used by most wearers of shoulder prostheses, for were this not the case they would react against the difficulty of reopening the hook. There is no indication from the data that the additional control motions required for use of the APRL hook made hook operation less "easy." <b>Fig. 7</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Hook weight appeared to present no major problem regardless of level of amputation. Although the 8-1/4 oz. APRL hook was generally considered by the wearers to be more satisfactory than the Dorrance No. 555 (3 oz.), the Dorrance No. 5 (7 oz.), or the Dorrance No. 7 (8-3/4 oz.), the responses may have been influenced by the use of a new prosthesis, which very often was better fitted, more comfortable, and more efficient than the old arm with the rubber-band hook.</p> <p>It is apparent from the foregoing discussion that functional, split hooks were rather highly valued regardless of type. In all cases, usefulness, ease of operation, and weight were apparently quite acceptable to almost all wearers. Only in the area of appearance did a significant number of subjects indicate dissatisfaction, and even then most of the amputees accepted prevailing appearance.</p> <p>The amputees who used rubber-band-closing hooks prior to the study and changed over to the APRL hook during the study were in an excellent position to compare terminal devices. The below-elbow amputees felt that the APRL hooks and those of the rubber-band type were approximately equal in usefulness, the responses favoring the APRL hook slightly. The above-elbow cases seemed to favor the APRL hook rather strongly, the responses indicating an attitude considerably more positive toward the usefulness of the new hooks. The shoulder-disarticulation cases seemed to favor the rubber-band hooks slightly with respect to usefulness, but the smallness of the sample (13 patients) prohibits drawing any conclusions in favor of either type of hook for this special group.</p> <p>In sum, it appears that the rubber-band and the APRL types are about equal in usefulness, the data favoring slightly the APRL design. No clear-cut advantage in the use of one over the other is evident from amputee reactions. In all probability, personal preference based on past experience, influence of the clinic team, or other intangibles are contributing factors. The entire area affecting the choice of terminal devices is one that should be given additional study.</p> <h3>Wrist Units</h3> <p>Prosthetic wrist units are designed to facilitate attachment of the hand or hook to the forearm and to permit pronation-supination of the terminal device<a></a>. The most common type (screw-in type) bears a female thread such as to accept the terminal-device stud, and a rubber washer and retaining plate are used to control the tendency toward excessive loosening or tightening when the terminal device is rotated. A newer type of wrist unit, intended to provide not only for easy rotation but also for easier interchange of terminal devices, incorporates a control button which, when depressed, frees the hand or hook for rotation. Further depression of the control button permits removal of the terminal device from the wrist unit, the need for unscrewing being thus eliminated. In still another wrist, also designed for quick interchange of terminal devices, the turn of a knurled ring releases the hand or hook for rotation or removal. <b>Fig. 8</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the NYU Field Studies, prescription of wrist units favored the button- or ring-operated wrist (plug-in type) wherever more than one terminal device was to be used. When a single terminal device was prescribed, the screw-in type was generally favored, since then interchange was not a major consideration. Plug-in wrists fitted to 266 research patients and screw-in types fitted to 93 were followed over an average wear period of six to nine months, and amputee reactions were obtained concerning two aspects of wrist function-attachment and removal of the terminal device, and pronation-supination to achieve acceptable attitudes of approach. Of the 359 amputees wearing program arms, those equipped with plug-in units were slightly more satisfied with the attachment function than were those who wore screw-in wrists. Pronation-supination was fairly satisfactory with both types.</p> <p>Despite the general amputee acceptance of both types of wrist, however, there was also evidence of substantial dissatisfaction. Interviews with the amputees and observation of their performance revealed that a simpler and faster method of exchanging terminal devices was required, as were also improvements in the cable connections, which were then cumbersome and difficult to manipulate with one hand. Evidently, improved rotation mechanisms were needed to permit easy correction of terminal-device attitude for best angle of approach.</p> <p>When specific wrist features (ease of operation, usefulness, weight, and appearance) were explored (page 16), the wearers were even more positively inclined toward the plug-in wrist unit. The reactions of 138 amputees who had screw-in wrists on their old arms and plug-in wrists on their program arms show that, insofar as exchanging terminal devices was concerned, the plug-in wrists were favored by a greater percentage of the below-elbow wearers than were the screw-in wrists. The opinions of the above-elbow amputees showed only a slight trend in favor of the plug-in wrists. Because only a small number of shoulder-disarticulation cases changed to plug-in wrists, their reactions were not recorded. The responses of 107 amputees who had used screw-in wrists on their old arms and plug-in wrists on the program arms showed that the plug-in type of wrist was considered by below-elbow wearers to be easier to rotate than was the screw-in type.</p> <p>Opinions concerning the locking function of wrist units are of interest since only the plug-in type locks the hook or hand in its selected attitude, the screw-in type depending upon friction to maintain terminal-device orientation. In 106 cases, both below-elbow and above-elbow wearers considered the plug-in type of wrist (with its ability to permit rotation of the terminal device as well as to lock it) somewhat more useful than the screw-in, nonlocking type.</p> <p>In the areas of weight and appearance, the plug-in type was again, and somewhat surprisingly, favored over the simpler, screw-in unit. Despite the fact that the plug-in wrist is actually heavier than the screw-in type, amputees favor it. Apparently the "halo effect" of the new prosthesis with its generally superior comfort, appearance, and efficiency may be responsible for the positive responses in the areas of wrist weight, wrist appearance, and ease of wrist rotation.</p> <p>In summary, the plug-in type of wrist was favored slightly over the screw-in type, first because of the relative ease with which terminal devices could be exchanged and second because the hand or hook could be locked in any desired attitude of pronation-supination. Below-elbow amputees seemed to favor the plug-in type more than did the above-elbow group, an understandable result when it is considered that below-elbow wearers are generally more active with their prostheses and more inclined to exchange terminal devices than is the case with above-elbow amputees. In any event, it was apparent from observations and from amputee remarks that improved cable attachments were needed to facilitate ease of connecting and disconnecting hands or hooks. Despite the fact that some below-elbow wearers considered rotation of terminal devices easier with plug-in wrists, observation leaves little doubt but that the screw-in type is superior in rotation features. It seems clear that attitudes toward the rotational qualities as well as toward the weight and appearance of the plug-in wrist were positively affected by concomitant reactions toward superior locking and attachment qualities. <b>Fig. 9</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Elbow Joints for Below-Elbow Prostheses</h3> <p>Almost all below-elbow prostheses are suspended from cuffs fitted above the bony prominences of the elbow joint. The cuff and prosthetic forearm are connected by means of mechanical elbow joints, some of which (rigid hinges) are designed to permit flexion and extension only, others (flexible hinges) permitting also pronation and supination.<a></a> Metal hinged joints are generally used for shorter stumps where stability against inadvertent rotation is a major requirement. Flexible leather, steel-cable, or fabric-type joints are generally used in prostheses for longer stumps where residual, natural forearm rotation can be utilized. Short stumps typically have limited purchase in the prosthesis and therefore require a snug, high-fitting socket in order to obtain forearm stability<a></a>. But the high-fitting socket often restricts the wearer's range of flexion owing to crowding of flesh as the forearm is raised. Special joints, known as "step-up" joints<a></a>, are designed to relieve this condition and to produce an increased range of flexion. Since in such a case the range of motion increases at the expense of lifting power, it is sometimes necessary to use an assistive forearm lift similar to that commonly used with above-elbow prostheses <a></a>. Whenever the very short below-elbow stump is un-suited for lifting the prosthetic forearm, it is fitted with locking joints actuated either by movement of the stump or by a cable control similar to that used for the above-elbow case.<a></a></p> <p>Evaluated comprehensively with both old and new prostheses were 136 unilateral below-elbow amputees, the elbow components of the prostheses being as follows: <b>Fig. 10</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The data show that in general the new arms permitted a greater range of forearm flexion than did the preprogram arms, partly no doubt because of an increased use of step-up joints in the new prostheses and partly because of improved socket shaping to avoid restriction of flexion through crowding of flesh at the brim of the socket. <b>Fig. 11</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Before the advent of the Upper-Extremity Field Studies, use of flexible elbow joints had been reserved almost entirely for patients with wrist disarticulations or long below-elbow stumps. Of all the amputees in the group investigated, only 17 had had flexible joints in their preprogram arms, and of these only one had a stump shorter than 6-1/2 inches. Moreover, the available stump rotation was rather good, only one having less than 20 deg. of pronation-supination. Experience indicated that even still shorter stumps might retain slight but useful rotation and that patient comfort might be increased and clothing damage decreased with use of flexible hinges. Consequently, during the program many stumps within the group of 136 amputees (74 arms) were fitted with flexible joints even though the rotation possibilities were knowingly limited (22 cases with residual stump rotation of less than 20 deg., 13 patients with stumps shorter than 6-1/2 in.).</p> <p>As expected, the average rotation range for the entire group with the new prostheses decreased as compared with the average rotation range of the 17 who had been provided with flexible hinges on their old arms. But it must be pointed out that many more amputees now had not only the facility of active pronation-supination but also the greater comfort and reduced clothing damage inherent in the use of flexible joints. The 16 amputees who used flexible hinges on both old and new arms exhibited the same range of pronation-supination with the two prostheses. <b>Fig. 12</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The reactions of the below-elbow subjects to the various elbow joints evaluated during the study were in general very positive in the areas of usefulness, ease of operation, and weight but a great deal poorer in the area of appearance. Although the step-up and stump-actuated joints were unacceptable to a few amputees, negative generalizations are impossible because the size of the sample was too limited (24 step-up joints, 7 locking joints). And indeed these components must be widely acceptable, judging from the overwhelming percentages of positive responses. The negative comments made by wearers of step-up joints indicate an inability to stabilize the forearm sufficiently to obtain effective use of the terminal device. The development of locking step-up joints has been suggested as a means of stabilizing the prosthetic forearm for amputees with short or very short stumps.</p> <p>The principal findings with regard to elbow joints for below-elbow prostheses center around a shift toward increased use of flexible hinges and a corresponding decrease in the number of rigid joints used.<a style="text-decoration:none;">*</a> Of special interest is the finding that stumps shorter than 6-1/2 in. should also be considered for flexible elbow joints. Although the shorter stumps can be expected to provide only minimal pronation-supination, even slight gains in rotation are important for hand and hook positioning. There was no reported instance of socket instability on the shorter stumps fitted with flexible joints on program arms, and the gains in patient comfort and in reduction of clothing damage lead to the conclusion that use of any joint other than flexible should be advocated only after serious consideration of the specific needs of the individual patient. Although the sample using step-up or locking joints was small, and although it is apparent that the joints were generally satisfactory, development of a step-up joint capable of locking the prosthesis in flexion seems quite desirable, since stabilization of the forearm for effective terminal-device operation or for lifting objects appeared to be difficult with the step-up joints used both before and during the study.</p> <h3>Elbow Joints for Above-Elbow and Shoulder-Disarticulation Prostheses</h3> <p>Positioning of the prosthetic forearm and terminal device of a modern above-elbow or shoulder-disarticulation prosthesis in the flexion-extension plane requires that the elbow be unlocked. Locking of the elbow permits control-cable forces to by-pass the forearm lift and to act upon the terminal device.<a style="text-decoration:none;">*</a> Rotation of the prosthesis about the humeral axis to facilitate mediolateral positioning of the forearm is accomplished by means of a turntable incorporated in the elbow and controlled by a friction element which resists free movement.<a></a> In general, about 2 lb. of force and half an inch of cable travel are needed to lock present mechanical elbows, about 5 lb. to unlock. But the exact figures vary slightly from elbow to elbow and from manufacturer to manufacturer. Program arms fitted during the early phases of the study were built around Sierra Model C elbows<a></a>, which had unlocking forces (6.3 lb.) and excursion requirements (9/16-in.) slightly higher than those of the Hosmer E-400 units (4.0 lb. and 1/2 in.), which in turn became available to the clinics later in the study and which were identical in operating principle. Besides this, the Hosmer E-400<a></a> was at the time a new component, clinics were therefore particularly interested in its application, and consequently it was prescribed almost routinely during the latter part of the program. Of the 170 internal elbows fitted and evaluated during the study, 110 were Sierra Model C's, 42 were Hosmer E-400's, and 18 were Hosmer E-300's (an earlier elbow incorporating a locking mechanism of quite different design, now discontinued). External elbow locks<a></a>, intended for amputees with long humeral stumps or with elbow disarticulations, were used in 11 cases.</p> <p>Above-elbow and elbow-disarticulation amputees achieve elbow locking and unlocking by a combined extension-abduction of the humeral stump, a motion which exerts pull upon a control cable attached between the elbow and the shoulder harness.<a></a> Alternate pulls on the elbow-lock control cable result in locking and unlocking or vice versa. Shoulder-disarticulation amputees usually control the elbow lock by elevating the shoulder on the side of the amputation, thus exerting pull on a control cable attached between elbow lock and waistband. <a></a> </p> <p>All of the elbow-disarticulation, above-elbow, and shoulder-disarticulation prostheses provided in the program were equipped with locking elbows of the alternating type. Of the 181 cases (170 internal locking, 11 external locking) available for study, 76 had had prior experience with prostheses incorporating the older manual locks, and 18 had worn arms without locking elbows. Fifty-two had previously used alternating elbows of the type used in the program arms. In 35 cases, either the patient had not previously worn an arm or else the type of elbow was unknown.</p> <h4>Internal-locking Elbows</h4> <p>The data show that a considerable number (36 out of 101) of the preprogram arms provided little or no initial elbow flexion, owing chiefly, no doubt, to fabrication technique and workmanship rather than to the nature of the elbow units themselves. Program arms tended to group around the standard of 10-15 deg. of initial flexion, a feature that tends to make initiation of forearm lift less difficult. Moreover, forearm flexion was restricted in the old arms, less than a third of them being capable mechanically of approaching 135 deg. of flexion. In general, program arms could be flexed to much greater extent, almost two thirds of the subjects reaching or surpassing 135 deg.</p> <p>As for other deficiencies in the new arms, 35 cases exhibited serious impairment of elbow-lock operation, primarily because of harnessing inadequacies. A considerably larger number of prostheses showed less than optimal elbow function, mostly because of poor arrangement of the elbow control cable and the front support strap. In 12 cases, malfunction of the elbow mechanism was apparent, and 37 of the new prostheses required adjustment for insufficient initial elbow flexion. Thirteen arms required attention to correct friction characteristics in the elbow turntables.</p> <p>Generally, then, more careful attention to adjustments and to harnessing detail for elbow-lock operation was obviously required. Direct amputee reactions to the cable-controlled, internally locking elbows were quite favorable, only 4 of the 170 wearers experiencing negative feelings when all aspects of elbow use were considered. Of the few negative comments made (25), the majority related to lack of dependability in elbow operation, probably because of such factors as careless harnessing or inadequate training in the required operational pattern. As might have been expected, the cases with the shorter stumps found operation of the lock more difficult than did those with the longer stumps. Except where the fitting of the short-above-elbow patient was expertly done, the shoulder-disarticulation cases had less difficulty in elbow locking and unlocking by means of shoulder elevation than did the short-above-elbow cases using the same control motion.</p> <h4>External-locking Elbows</h4> <p>External-locking elbow joints are sometimes used for elbow disarticulations and for very long above-elbow cases<a></a>. Although in the study 11 elbow-disarticulation amputees were fitted with external joints, only 8 had had experience with internal-locking elbows on their old arms. From the viewpoint of usefulness, they favored the internal mechanism slightly, perhaps because of the rotation turntable and because of the greater number of available locking positions in the internal elbows. As for appearance, the arms fabricated with outside-locking elbows seemed to be more acceptable than those constructed with internal units because, while the outside-locking units protrude on the medial aspect of the arm, internal units may be fitted to elbow disarticulations and to very long above-elbow cases only by lowering the elbow center abnormally.</p> <p>Ease of operation gave rise to some differences in amputee reactions toward internal as compared with external elbows. Since the forces and control motions are essentially identical in the two types, the discrepancies probably relate more to the nature of the harnessing or to the skill of the patient than to the particular characteristics of the elbows themselves.</p> <p>As one might have anticipated, amputee reactions to weight favored the outside-locking units, which are somewhat lighter than the internal elbows. <b>Fig. 13</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Summary</h4> <p>To summarize, only 29 percent of the 181 amputees studied were known to have worn on their preprogram arms locking elbows of the alternating type. In the studies, all unilateral above-elbow patients were fitted with the more modern locking units, thus freeing the normal arm from the responsibility of operating a manual lock for the amputated side. Program arms had greater ranges of forearm flexion and were adjusted to provide greater initial flexion so as to make it easier for the patient to lift the forearm. But elbow-lock operation with the new arms was often impaired by poor harnessing arrangements that required correction. While in general the amputees were quite favorably disposed toward the cable-controlled, locking elbows, infrequent negative complaints of lack of dependability related to inadequacies in harnessing and to poor operational patterns on the part of some wearers. A limited number of amputees fitted with external-locking joints provided sufficient positive evidence to ensure the future of these components in the array of items available for long-above-elbow or elbow-disarticulation patients.</p> <h3>Harnessing</h3> <p>If the upper-extremity prosthesis is to be of functional use to the amputee, two basic needs must be met. A suitable attachment of the prosthesis to the body must be made, and power must be provided for operating and controlling the limb. Although the socket is made to conform to the stump, it tends to become displaced, especially during lifting. The prosthesis is therefore suspended from the shoulder by means of a harness which keeps the socket in close contact with the stump and resists any tendency for the prosthesis to shift out of position. Usually the same harness serves as the force-transmitting medium between body sources of power and the cable system of the prosthesis<a></a>. For both above- and below-elbow amputees, two basic types of harness are in common use today-the figure-eight harness and the chest-strap harness <a></a>. Commonly, the chest-strap design is applied in the shoul-der-disarticulation case too <a></a>.</p> <p>Of all artificial arms, the unilateral below-elbow prosthesis is perhaps the simplest to suspend and to power. In the figure-eight method, suspension is obtained by a loop of 1-in. fabric tape passing under the axilla on the sound side and over the shoulder on the amputated side, the front end of the tape being attached to a biceps cuff (which in turn supports the elbow joints connecting to the prosthetic forearm), the other end (the back) to the control cable for the terminal device. Forward rotation of the arm upon the shoulder on the amputated side causes forces to be applied to the cable and gives the excursion necessary to operate the hook or hand. In the chest-strap method, suspension of the biceps cuff is achieved through use of adjustable leather or fabric straps attached to the anterior and posterior aspects of a leather shoulder saddle, and the control cable is attached to an adjustable fabric tape sewn to the chest strap in the region of the seventh cervical vertebra. Although the figure-eight type of harness is used almost universally for the unilateral below-elbow prosthesis, it is considered by some that the chest-strap type, with its broader weight distribution over the shoulder, is indicated for amputees anticipating extremely heavy-duty services or for those who cannot tolerate the axilla pressures typical of the figure-eight loop <a></a>.</p> <p>For the unilateral above-elbow prosthesis, the figure-eight and the chest-strap harnesses enjoy in general a more equal popularity. Program arms tended strongly, however, toward the simpler figure eight, in which the fabric tape loops over the sound shoulder, under the axilla on the sound side, and then over the shoulder on the amputated side <a></a>. It is generally conceded that the above-elbow chest-strap harness, which uses a leather or fabric saddle to reduce the unit pressure on the shoulder, is preferred whenever the patient anticipates activities involving heavy lifting or when he cannot tolerate the axilla pressure characteristic of the figure-eight harness <a></a>.</p> <p>For the unilateral shoulder-disarticulation or forequarter amputation, the most common harness in use today is that of the chest-strap type, elbow locking and unlocking being achieved by elevation of the shoulder on the amputated side. A fabric tape extends from the elbow-lock control cable and attaches to another surrounding the waist. Scapular abduction gives power and excursion for forearm lift or, when the elbow is locked, for terminal-device operation <a></a>.</p> <p>In the evaluation studies, harnesses were individually prescribed according to type and made in accordance with the latest techniques. But because the harness is always a custom-made item fitted by the prosthetist according to the requirements of the individual patient, there were introduced a number of variables involving such intangibles as skill and judgment. Although in program prostheses each harness had to meet certain requirements designed to ensure proper suspension and adequate power and excursion, it was apparent almost from the beginning that serious harnessing problems existed. About 45 percent of all arms showed harness deficiencies at checkout. The above-elbow prostheses were notably troublesome, 375 harnessing faults showing up on the 303 arms going through checkout. The below-elbow prostheses, though considerably simpler, were also a source of difficulty, 150 harnessing faults being discerned on 361 below-elbow patients. The shoulder-disarticulation group of 53 patients had 39 harnessing faults. <b>Table 1</b>, <b>Table 2</b>, and <b>Table 3</b> reflect the types of harnessing faults found at clinical checkout of the program arms.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It should be pointed out that the prostheses were rated at checkout according to criteria evolving from material presented at the prosthetics courses offered as part of the program. Accordingly, any deviations from the accepted harnessing practices taught in the courses were considered "faults." But it was recognized that arm harnessing is an individualized procedure and that therefore certain faults might be less critical than others depending upon the amount of deviation from the standard, the physique of the patient, his threshold of tolerance for discomfort, and other intangible considerations. Consequently, it should be made clear that recognition of a fault did not necessarily mean the prosthesis was unusable but, more often than not, that the limb simply was not operating at a peak level of performance and/or comfort. Fortunately, the problems encountered with the harnesses at checkout were markedly reduced as the prosthetists gained experience. Strict adherence to the checkout standards, along with increased understanding and skill, served to ensure that each arm wearer was ultimately harnessed so that he could use the prosthesis in a functional manner. After checkout (and prosthetic corrections, when indicated), the amputees embarked upon a long-term period of wearing the new prosthesis.</p> <p>Amputee reactions to the new arm harnesses were checked with regard to comfort, appearance, and fit as these matters affected the function of the prosthesis. Generally, the wearers' reactions were quite favorable, and it was apparent that the subjects generally had a higher regard for the new harnesses than they had for the old (<b>Table 4</b>). Although program harnesses scored highly with all amputee groups, the above-elbow amputees consistently rated their harnesses slightly lower than did the below-elbow or shoulder-disarticulation groups, probably because the above-elbow figure-eight harness is more com- plex and in comparison with below-elbow harnesses somewhat more snug-fitting.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Interviews with the amputees disclosed that most participants who had worn prostheses prior to the studies felt that the new harnesses were much better than the old ones. Particular comments evidenced satisfaction with reduction in amount of harness needed to obtain satisfactory prosthetic function with the new arms. Some wearers commented upon possible areas of improvement, a response which almost always involved the desire to be burdened with no more harness than necessary to control the arm. A number of subjects indicated discomfort at the axilla, and problems relating to shift of the harness out of place were not uncommon. Although difficulty in operating the elbow lock was corrected in most cases, some wearers felt that other means should be sought for control of elbow lock.</p> <h3>Power-Transmission Systems</h3> <p>To achieve functional use of a prosthesis, the amputee must be able to avail himself of residual sources of body power. Flexion, extension, and abduction of the arm, extension of the forearm, shoulder elevation, scapular abduction, and chest expansion are the most common power sources harnessed by the prosthetist to provide movement of the artificial arm.<a></a> Transmission of the forces thus generated is accomplished by the use of Bowden cables connecting the points of force generation (harness components) and the points of force application (forearm or terminal device). In the below-elbow prosthesis, forward movement of the shoulder on the sound side, flexion of the arm on the amputated side, singly or in combination, exerts against the harness system a force that is transmitted for operation of the terminal device, the forearm being lifted by the stump. Above-elbow and shoulder prostheses utilize the same type of power-transmission system, except that with arms of this type the cable is used also to lift the prosthetic forearm whenever the elbow is unlocked (dual control). <b>Fig. 14</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Prior to the Upper-Extremity Field Studies, many arm amputees had been using Bowden cable for power transmission. Others used steel cable without housing, nylon cord, leather or rawhide thongs, and other miscellany, as shown in <b>Table 5</b>. But all program arms were equipped with Bowden cable and subjected to checkout procedures to ensure that minimum standards of power-transmission efficiency (below-elbow prostheses, 70 percent; above-elbow and shoulder-disarticu-lation prostheses, 50 percent) were met. When checked, the program arms showed for every amputation level substantial increases in efficiency over the standards shown by the power-transmission systems of the corresponding old prostheses. Indeed, the new arms exceeded the minimum efficiency standards with such regularity that raising of the standards is now indicated.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Full opening and closing of the terminal device was possible for an increased number of amputees through use of the new arms. When function of the terminal device was tested at each of four operating positions (at full extension, at 90 deg. of flexion, at waist, and at mouth), the results showed a marked increase in opening range for each amputee type at all four positions.</p> <p>Doubtless this improvement was due to the use of better harness and belter-fitting sockets, with better transmission of force and excursion through the cabling system, if not to application of the voluntary-closing terminal devices, which inherently use less excursion than do the voluntary-opening hooks that predominated in the old prostheses. <b>Fig. 15</b>, <b>Fig. 16</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Initial checkout of all patients provided with program arms revealed some problems in application of the Bowden cable (<b>Table 6</b>). faulty placement of retainers, improper cable lengths, and poor. soldering of connections were the main sources of trouble. Of course some of the arms had more than one fault, whereas about half of the 790 arms fitted and checked out in the study had no faults at all in the transmission system.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Those in the study who had used power-transmission systems in both old and new arms (285) generally found the Howden-cable system easy to use, acceptable in noise level and in appearance, kind to clothing, and free of excessive maintenance requirements. Of these amputees, 201 responded to questions intended to elicit preference either for their old or for their new cable systems. Only 10 of the 201 in the group preferred their old power-transmission systems, 103 preferred the new. Yet 88 had no preference, which indicates that a significant number of preprogram arms had the advantage of an adequate power-transmission system.</p> <p>Suggestions for improvement indicated that the amputees would have liked to have seen the cables concealed within the prosthesis, although the existing appearance was not considered unsatisfactory. Easier and quieter operation might also constitute an improvement, although here again there appears to have been no major criticism. <b>Fig. 17</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Complete Prosthesis</h3> <p>Thus far we have considered only the individual elements of the prosthesis. A matter of equal importance, however, is the consideration of the prosthetic appliance in its entirety and of the effects of clinical treatment and training with the prosthesis. Although the data presented here concern the below-elbow, above-elbow, and shoulder-disarticulation cases only, findings from the 10 bilateral amputees who were available for evaluation may also be considered indicative of probable trends. The responses of the small bilateral group, consistently positive toward the new program arms, were substantially in agreement with the responses from the other amputees. Although most wearers considered their new arms to be useful, the desire for further improvement was reflected in the significant percentage of wearers who considered the arms to be of limited use only. When the amputees compared the general usefulness of the old prostheses with the general usefulness of the new arms, the new arm was preferred. The greatest improvement showed up in the shoulder-disarticulation and above-elbow groups. When all amputation levels were considered together, only 59 percent of the wearers felt that the old prosthesis was "useful." With the new arms, the figure went up to 79 percent. While nearly 5 percent of the wearers felt the old arm to be of no use, less than 1 percent reacted in this manner to the new arms.</p> <p>Perhaps the most meaningful gains in function were made in the area of harnessing and in routine use of locking elbow joints for above-elbow and shoulder-disarticulation cases. Although harnessing problems existed initially with program arms, the checkout procedures brought the difficulties to light so that suitable improvements could be made. Certainly arm harnessing was a major problem prior to the Field Studies also, as indicated by the fact that the new harnesses were preferred over the old by a ratio of five to one (<b>Table 4</b>). Locking elbow units, which stabilize the forearm and terminal device for above-elbow and shoulder amputees, are obviously superior to nonlocking elbows from a functional standpoint. For without elbow lock, prehension is handicapped, pushing and pulling with flexed elbow are seriously impaired, and carrying with flexed elbow (as in carrying a coat over the arm) is so difficult as to be impractical. Although manual elbow-locking mechanisms are effective, the newer elbows, operated through the harness system, free the sound hand for more important services. But it must be remembered that all these gains, which now bring prostheses for all types of arm amputation to a relatively high level of usefulness, depend upon a number of factors, including prescription of suitable components, quality of design and construction, and training in prosthesis use, all of which doubtless contributed to the positive attitudes displayed by the test wearers.</p> <p>The appearance of the new plastic-laminate arms was accepted in a perfunctory way only, most of the arms being considered "satisfactory." When 266 amputee responses were compared (appearance of new arm vs. that of old arm), it was evident that positive changes in reaction had taken place. In general the amputees favored the newer arms. It is in the area of appearance alone that the responses indicate serious reservations in acceptance of any artificial arm, old or new. Since under certain social conditions amputees might well be inclined to limit their activities rather than bring attention to the fact that an artificial arm is being worn, sensitivity toward appearance is extremely important. Even the best arm prostheses available today fall far short of being cosmetically adequate and cannot hope really to satisfy either wearers or observers. <b>Fig. 18</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Ease of operation of the new prostheses apparently left something to be desired for a substantial number of the amputees, especially those of the above-elbow and shoulder-dis-articulation types. Simpler elbow-lock operation and reduction in the difficulties of terminal-device positioning (perhaps by providing more mobility at the wrist) were mentioned as important areas requiring improvement. When the amputees compared old and new prostheses with respect to ease of operation, the new arms nevertheless proved superior. Many amputees (59 percent) felt that operation of their old prostheses was "easy." But when later they were asked to comment on the ease of operation of their new arms, 84 percent replied that operation was "easy." Slightly over 7 percent of the wearers felt that operation was "very difficult" with the old arms, whereas less than 1 percent felt that way about the new arms. Although again these important gains were most prevalent among the shoulder-disarticulation and above-elbow cases, significant improvements were noticed among the below-elbow amputees also. <b>Fig. 19</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although to date very little attention has been given to study of its significance, the weight of the prosthesis has always occasioned a great deal of interest. Generally speaking, the practice has been to keep weight at a minimum, since amputee weight tolerance has not as yet been determined specifically. The data indicate that the below-elbow arms furnished in the program were slightly lighter than the corresponding preprogram arms (1.8 lb. compared with 2.1 lb.). Above-elbow prostheses weighed an average of 2 3/4 lb., there being no significant differences between the old and the new. The average weight of the new shoulder-disarticulation arms was about 3 1/2 lb., about 1/2 lb. heavier than preprogram types. Amputees at all levels generally felt that the total weight of the new prosthesis was satisfactory, although there were some indications that further weight reduction would be welcomed. About 7 percent of the subjects felt that the prostheses were somewhat heavy, less than 2 percent that they were very heavy. But 33 percent of the wearers considered the new prostheses more acceptable in terms of weight than the old arms, even though only slight differences in actual weight were noted. Such reactions are thought to be related to increased function, improved comfort, better fit, and/or improved weight distribution in the new arms. <b>Fig. 20</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>When comparisons were made between amputee reactions to the old and to the new arms, the data for all levels of amputation clearly favored the newer, program-type, plastic-laminate prostheses. Such endorsement by wearers reflects not only the superior construction and the improved mechanical components incorporated into the newer prostheses but also the values of the patient-management procedures advocated by the program-prescription of carefully selected arm components, checkout to ensure basic adequacy of the fitting, and finally proper training in the use of the prosthesis.</p> <p><b>References:</b></p> <ol> <li>Alldredge, Rufus H., and Eugene F. Murphy,<i>Prosthetics research and the amputation surgeon</i>, Artificial Limbs, 1(3): 4 (September 1954).</li> <li>Fishman, Sidney, and Norman Berger, <i>The choice of terminal devices</i>, Artificial Limbs, 2(2): 66 (May 1955)</li> <li>Fletcher, Maurice J., <i>New developments in hands and hooks</i>, Chapter 8 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Fletcher, Maurice J., <i>The upper-extremity prosthetics armamentarium</i>, Artificial Limbs, 1(1): 15 (January 1954).</li> <li>Fletcher, Maurice J., and A. Bennett Wilson, Jr., <i>New developments in artificial arms</i>, Chapter 10 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Fletcher, Maurice J., and Fred Leonard, <i>The Principles of artificial-hand design</i>, Artificial Limbs, 2(2): 78 (May 1955).</li> <li>Leonard, Fred, and Clare L. Milton, Jr., <i>Cosmetic gloves</i>, Chapter 9 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>New York University, Prosthetic Devices Study,Report No. 115.09 [to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Field test of the APRL hook</i>, April 1950.</li> <li>New York University, Prosthetic Devices Study,Report No. 115.12 [to the] Advisory Committee on Artificial Limbs, National Research Council, <i>Field test of the APRL hand and glove</i>, April 1951.</li> <li>Pursley, Robert J., <i>Harness patterns for upper-extremity prostheses</i>, Artificial Limbs, 2(3): 26 (September 1955)</li> <li>Taylor, Craig L., <i>The biomechanics of the normal and of the amputated upper extremity</i>, Chapter 7 in Klopsteg and Wilson's <i>Human limbs and their substitutes</i>, McGraw-Hill, New York, 1954.</li> <li>Taylor, Craig L., <i>The biomechanics of control in upper-extremity prostheses</i>, Artificial Limbs, 2(3): 4 (September 1955).</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, Artificial Limbs, 2(3): 4 (September 1955).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, Artificial Limbs, 2(3): 4 (September 1955).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 1954).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of control in upper-extremity prostheses, Artificial Limbs, 2(3): 4 (September 1955).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 1954).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, 1(1): 15 (January 1954).</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and A. Bennett Wilson, Jr., New developments in artificial arms, Chapter 10 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, 1(1): 15 (January 1954).</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and A. Bennett Wilson, Jr., New developments in artificial arms, Chapter 10 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and A. Bennett Wilson, Jr., New developments in artificial arms, Chapter 10 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Dual control. See Pursley 10 or Taylor 11.</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">See Artificial Limbs, Spring 1958, p. 77.</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">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 1954).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 1954).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 1954).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 1954).</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, 1(1): 15 (January 1954).</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., The upper-extremity prosthetics armamentarium, Artificial Limbs, 1(1): 15 (January 1954).</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and A. Bennett Wilson, Jr., New developments in artificial arms, Chapter 10 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study,Report No. 115.09 [to the] Advisory Committee on Artificial Limbs, National Research Council, Field test of the APRL hook, April 1950.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The prehension forces of the two-load hook are predetermined at time of manufacture and are not readily adjustable as are those in the simpler hooks, where rubber bands can be added or removed.</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">Fishman, Sidney, and Norman Berger, The choice of terminal devices, Artificial Limbs, 2(2): 66 (May 1955)</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Norman Berger, The choice of terminal devices, Artificial Limbs, 2(2): 66 (May 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Less than 3 percent had over-all negative reactions to the hand; 6 percent had over-all negative reactions to the glove.</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">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3): 4 (September 1954).</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness patterns for upper-extremity prostheses, Artificial Limbs, 2(3): 26 (September 1955)</td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study,Report No. 115.09 [to the] Advisory Committee on Artificial Limbs, National Research Council, Field test of the APRL hook, April 1950.</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study,Report No. 115.12 [to the] Advisory Committee on Artificial Limbs, National Research Council, Field test of the APRL hand and glove, April 1951.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and Fred Leonard, The Principles of artificial-hand design, Artificial Limbs, 2(2): 78 (May 1955).</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Leonard, Fred, and Clare L. Milton, Jr., Cosmetic gloves, Chapter 9 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Norman Berger, The choice of terminal devices, Artificial Limbs, 2(2): 66 (May 1955)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and Fred Leonard, The Principles of artificial-hand design, Artificial Limbs, 2(2): 78 (May 1955).</td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Leonard, Fred, and Clare L. Milton, Jr., Cosmetic gloves, Chapter 9 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., New developments in hands and hooks, Chapter 8 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The data reported here were all recorded on forms similar to those shown in Appendices IIB, IIIA, and HID of the issue of Artificial Limbs for Spring 1958 (pp. 25-28, 29-31, and 40-45).</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>Earl A. Lewis, M.A., R.P.T. </b></td></tr><tr><td class="clsTextSmall">Field Supervisor, Prosthetic Devices Study, Research Division, College of Engineering, New York University; formerly Field Representative, PDS, NYU.</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>Edward R. Ford, CP. </b></td></tr><tr><td class="clsTextSmall">Director, Prosthetics Laboratory, Orthopedic Aids, Inc., Garden City Medical Center, Garden City, N. Y., and Consultant, Prosthetic Devices Study, Research Division, College of Engineering, New York University; formerly Project Coordinator, PDS, NYU.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1958_02_004/1958-Autumn-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 Studies of the Upper-Extremity Amputee V. The Armamentarium Creator An entity primarily responsible for making the resource Edward R. Ford, CP. * Earl A. Lewis, M.A., R.P.T. * https://staging.drfop.org/files/original/465b011652d5a340194157a65a7ec6cc.pdf 058afa0a050515ba9cadcbbbe5bbdcbc https://staging.drfop.org/files/original/1117b4f8d56a347cb37a8fec48fb1ba1.jpg fb35416caeea9a249029aa892a41fa14 https://staging.drfop.org/files/original/f48d51f3218c758f4338e50f0b689234.jpg fabaf7cea0b1796ff8316615aabb3e95 https://staging.drfop.org/files/original/812c173d343ffad067c6c208af011518.jpg e1dad0e0174b7d66a96d04ede66f5469 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 http://www.oandplibrary.org/cpo/pdf/1984_04_024.pdf Text Any textual data included in the document <h2>Rochester Parapodium</h2> <h5>Edwin Kinnen, Ph.D.&nbsp;<a style="text-decoration: none;">*</a><br />Martha Gram, P.T.&nbsp;<a style="text-decoration: none;">*</a><br />Kenneth V. Jackman, Ph.D.&nbsp;<a style="text-decoration: none;">*</a><br />Franklin V. Peale, M.D., P.C.&nbsp;<a style="text-decoration: none;">*</a><br />P.W. Haake, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Gerald A. Tindali, C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />James A. Brown, O.P.A.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The Biomechanics Team at the University of Rochester Medical Center has been developing and testing design modifications to the Toronto parapodium since 1975. Early in 1983, these design modifications had stabilized, and prototypes of the new design were offered to medical centers and orthopedic laboratories in the United States and Canada. The Rochester parapodium has now been fitted to over 80 young children of ages 17 months to 14 years. Most of these children have flaccid paralysis due to spina bifida or spinal injury from L5 to T12.</p> <p>The Rochester parapodium differs from the Toronto design in the hip and knee hinge and locking mechanisms. The hip joints unlock together with a single lever release and lock automatically on extension. The hip joints unlock with a forward motion and have no lateral projections, which allows ease in releasing hip lock in a confined space such as a wheelchair. The knee joints also unlock independent of the hip joints with a second single lever release and lock automatically on extension with the aid of an extension assist bar.</p> <p><b><a href="/files/original/1117b4f8d56a347cb37a8fec48fb1ba1.jpg">Figure 1</a>: The hip joints unlock independent of the knee joints.</b></p> <p>Without lateral projections, rolling is easier for the child who applies the orthosis sitting or in the supine position on floor, then rolls to prone position in order to elevate to a standing posture. This separated locking and unlocking action has simplified many everyday activities for the paraplegic child.</p> <p>With increased control, the child can become independent in sitting and standing from a chair with arms. He can also bend over to pick up objects from the floor with hips flexed and knees locked. These are important functions for a preschooler exploring his or her surroundings and participating in peer group activities.</p> <p><b><a href="/files/original/f48d51f3218c758f4338e50f0b689234.jpg">Figure 2</a>: Both joints unlock with a pull of a lanyard.</b></p> <p>Previously, children wearing the parapodium had to get up from a prone position on the floor by pulling to standing with fully extended knee and hip joints. Now a child can use jackknife-like movements to stand. These movements appear to require much less energy and open the activity to children with higher levels of paralysis.</p> <p>The lateral supports have also been redesigned for the Rochester parapodium, using bar stock instead of tubular sections. These flat lateral supports facilitate rolling, a very important movement for a child who is independent in dressing and changing positions. The new side bar design, a more rigid construction, also improves the child's momentum during swivel walking. With polypropylene added to the bottom of the base, many children can learn to swivel-walk at functional speeds, with hands free.</p> <p><b><a href="/files/original/812c173d343ffad067c6c208af011518.jpg">Figure 3</a>: A child can bend over to pick up objects with hips flexed and knees locked.</b></p> <p>The activities now possible with the new design allow the paraplegic child to function at home and in school with relatively little need for adult supervision or assistance.</p> <p><i>Partial support for this work has been provided by the J.M. McDonald Foundation, Cortland, New York.</i></p> <em><b>James A. Brown, O.P.A. </b> Rochester Orthopedic Laboratories, Inc., 1654 Monroe Avenue, Rochester, New York 14618.</em><br /> <div style="width: 400px;"><em><b><br />Gerald A. Tindali, C.P.O. </b> Rochester Orthopedic Laboratories, Inc., 1654 Monroe Avenue, Rochester, New York 14618.</em></div> <div style="width: 400px;"></div> <div style="width: 400px;"><em><br /><b>P.W. Haake, M.D. </b> 220 Alexander Street, Rochester, New York 14610</em></div> <div style="width: 400px;"><em><b><br />Franklin V. Peale, M.D., P.C. </b> 220 Alexander Street, Rochester, New York 14610.</em></div> <div style="width: 400px;"><br /><em><b>Kenneth V. Jackman, Ph.D. </b> Associate Professor of Pediatric Orthopedics, University of Rochester, Rochester, New York 14642.</em><br /><br /></div> <div style="width: 400px;"><em><b>Martha Gram, P.T. </b> Dept. of Pediatrics, University of Rochester, Rochester, New York 14627.</em></div> <div style="width: 400px;"><br /><em><b>Edwin Kinnen, Ph.D. </b> Dept. of Electrical Engn, University of Rochester, Rochester, New York 14627.<br /><br /><br /></em></div> Page Number(s) 24 - 25 Year 1984 Volume 8 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1984_04_024/1984_04_024-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_04_024/1984_04_024-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1984_04_024/1984_04_024-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Rochester Parapodium Creator An entity primarily responsible for making the resource Edwin Kinnen, Ph.D. * Martha Gram, P.T. * Kenneth V. Jackman, Ph.D. * Franklin V. Peale, M.D., P.C. * P.W. Haake, M.D. * Gerald A. Tindali, C.P.O. * James A. Brown, O.P.A. * https://staging.drfop.org/files/original/2fc85c60c7226a13a0b36a4c3f55b706.pdf 1015ca384fb4c55450ab7336157f0e12 https://staging.drfop.org/files/original/9870ea49ca3b524810cc617ce5a3d94f.jpg ab9b271621f72f599c670d82a60509c4 https://staging.drfop.org/files/original/14cc0167c932bde5447863a5f7b623a2.jpg 1cea191f2b4b6608ae4da1574d8fe317 https://staging.drfop.org/files/original/05e104352fa9f9e876932479241f9950.jpg 2f2d99f4d352e789d25910f31122d770 https://staging.drfop.org/files/original/6616944a8dfe6b9525902b40b9dd8b3f.jpg 0ae46995ab7fc9d9679598930bc78367 https://staging.drfop.org/files/original/4d92d55e81af301ff9120f73e722a5ea.jpg d6be1661567bf95eecc853d4a701e159 https://staging.drfop.org/files/original/7f6815a20e1116d8b330d4ffeedec915.jpg 70b9dc35d1c49d7b2367f5786110d7f4 https://staging.drfop.org/files/original/1a03792b27840a1c78fa47f1533aadcc.jpg a1f0ebfdcb8835c34368e4e18a0aa96f https://staging.drfop.org/files/original/d2e5e817ec855cf8a5090203ea04252a.jpg c2e18000a9d63f607414445538a5127a https://staging.drfop.org/files/original/99b1110729d5be53d5372632b1f99f5e.jpg e60ffa11bf1e0160104c6961469365f5 https://staging.drfop.org/files/original/179a4cb425c7c1c3e2b4e69d0deb4b0d.jpg 6936f368155280a6ee861a8d47eae6f4 https://staging.drfop.org/files/original/e257a61c4b3d755547715e26cd4cc4c8.jpg 7c20544d9553748d7ed0bdd741f458a3 https://staging.drfop.org/files/original/aeff19372033051006f60acf23519201.jpg 82814034b6a4eee6b8cea4b79c240fee https://staging.drfop.org/files/original/4c5243190441aaf3d7b39ae66ba22b05.jpg 55814a198f6be93b1165b6dc5f3131a1 https://staging.drfop.org/files/original/7de2b8f37e5098a8bc01f68f89dde50c.jpg 799a900e53acffb7eca6cc27c90c190d https://staging.drfop.org/files/original/ffe762e095ce674cba543f8c6b6af54c.jpg 3cc825142523b27489f284b2df669e90 https://staging.drfop.org/files/original/59e80fe2ca0645265ca467285ab4d708.jpg aaee867706a31c5316cec9088da436e1 https://staging.drfop.org/files/original/db34b03f5f13f15d12b39da96302664b.jpg d5f6e5526a745813d293d449c0128cc6 https://staging.drfop.org/files/original/b1801ada4ed2cd7b7840441a0fe940ba.jpg 187b96b2ae0c03c64bc3bb5daa73d350 https://staging.drfop.org/files/original/505d245ee4399ae61784d79459bbb730.jpg d9906c28819fc1c7f9a42256a7dd469f DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1970_02_019.pdf Year 1970 Volume 14 Issue 2 Page Number(s) 19 - 48 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_019.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1970_02_019.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>Amputees and Their Prostheses</h2> <h5>Elizabeth J Davies. M.A. <a style="text-decoration:none;">*</a><br />Barbara R. Friz, M.S. <a style="text-decoration:none;">*</a><br />Frank W. Clippinger, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p> Information on 8,698 amputations was collected during a period of approximately two years, ending June 30, 1967. This information was extracted from case-record forms provided by 44 prosthetics facilities in 30 states. The case-record form used was initially developed and standardized by the Conference of Prosthetists of the American Orthotic and Prosthetic Association. Its purpose was to encourage prosthetists in the accurate recording of pertinent information relating to the amputee and his prosthesis. Duplicate copies of the case-record forms were submitted to the Committee on Prosthetic-Orthotic Education (CPOE)<a></a>, National Research Council, in order that significant data could be identified and reported. </p> <p> "The Facility Case Record Study: A Preliminary Report"<a></a> and "Children with Amputations"<a></a>, both reporting findings emerging from this study, have been published previously. </p> <p> Data analyzed in the study included those related to age, sex, level and cause of amputations, reamputations, stump length and contractures, work status of amputees, referrals, months to delivery of prosthesis, age of replaced prosthesis and reason for replacement, components most frequently prescribed for upper- and lower-extremity prostheses, and source of payment for prostheses. </p> <h4> Methods</h4> <p> Each of the 44 facilities submitted case record forms on amputees as they were seen. Three forms were utilized, one for the amputee's medical history, one for the lower-extremity prosthesis, and one for the upper-extremity prosthesis. In cases where the meaning of the data was uncertain, follow-up forms were sent to the prosthetics facilities to clarify or add to the information provided. </p> <p> A coding system was devised, and information was transferred from the case-record forms to coding sheets and then to IBM cards and magnetic tape. Selection of pertinent data for retrieval was determined by an ad hoc group and the staff of CPOE. </p> <p> In order to make comparisons between different areas of the country, the states represented in the study were arbitrarily grouped into five geographical regions <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 /> <h4> Subjects</h4> <p> The study included 8,323 amputees with a total of 8,698 amputations. Statistics in this study refer only to patients fitted with a prosthesis; amputees not fitted are not included. <b>Table 1</b> indicates the types of cases included in the study. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Amputees or amputations being fitted for the first time were considered "new" cases. Amputees or amputations being fitted with replacement prostheses were considered to be "old" cases. There was a total of 4,034 "new" amputations and 4,664 "old" amputations <b>Table 2</b>. Amputations in males accounted for 6,848 amputations, and amputations in females, 1,850-a ratio of 3.7:1. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4> Findings </h4> <p><i> Aage of Amputees</i></p> <p> <b>Table 3</b> shows the age of amputees fitted in prosthetics facilities during the two years covered by this study. The incidence of amputations for males peaked in the fifth decade; for females, the peak was reached in the seventh decade. Forty-eight per cent of the amputees were 51 years of age or older, 30 per cent were over 61 years, and 12 per cent were over 71 years. The fact that 23 per cent of the amputees were fitted with either a new or a replacement prosthesis after 65 years of age has Medicare implications. (It should be noted that Medicare was in effect during only the second year of data collection.) </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 3. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i> Level of Amputations </i></p> <p> Amputations of the lower extremity accounted for 86 per cent of the total number of amputations <b>Table 4</b>. Of these, 53 per cent were at the below-knee level. In the upper extremity, 57 per cent of the amputations were at the below-elbow level. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 4. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> There was no significant difference in the incidence of left- and right- side amputation in either the upper or lower extremities. A total of 4,386 left-limb and 4,312 right-limb amputations was reported. The right upper extremity was involved slightly more than the left, 605 to 573, and the left lower extremity fractionally more than the right, 3,813 to 3,707. </p> <p><i> Cause of Amputation</i> </p> <p> Causes of amputation were considered in four categories: congenital, tumor, trauma, and disease. Cases of infection, gangrene, or osteomyelitis resulting from trauma were classified under "trauma." Cases of trauma associated with vascular disease were classified under "disease." </p> <p> Causes of amputation were analyzed by age group and level. Of the 8,698 amputations reported in this study, the cause was known for 8,487 cases; both cause and age were known for 8,394 cases. Fifty per cent of all amputations were caused by trauma, 37.3 per cent by disease, 8.4 per cent were of congenital origin, and 4.3 per cent were due to tumor. <b>Table 5</b> shows the relative incidence of amputation by cause and level. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 5. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In <b>Fig. 2</b> the total number of amputations by cause of amputation and age is indicated. Amputees most frequently fitted or returning for replacement in the first ten years of life were those with congenital limb deficiencies. Amputations for trauma led all other categories fitted or returning for replacement between the ages of 11 through 50. In the third, fourth, and fifth decades, this group accounted for 76 per cent, 82 per cent, and 72 per cent, respectively, of all cases fitted or returning. Of those fitted in the sixth decade of life, the incidence was almost equally distributed between traumatic amputations and amputations due to disease. After age 60, the latter group led all other categories by a ratio of more than 2:1. </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> <i>"New" Cases by Cause</i> </p> <p> Analysis of all amputations entered in the study gives an overview of the type of amputee being seen and fitted in prosthetics facilities, as reported above. Analysis of those being fitted for the first time, however, provides a picture of persons amputated during the two-year period of data collection and gives a better current indication of cause related to age, sex, and level of amputation. </p> <p> It is probable that the statistics on age are slightly distorted, since age was reported as of the time of fitting. Age at the time of amputation, therefore, would be less, and to a variable degree. </p> <p> In the group of "new" amputees, cause was reported for 3,963 cases, and both cause and age for 3,920. <b>Fig. 3</b> indicates the incidence of amputation by age. Of the "new" cases, 60.2 per cent of amputations were caused by disease, 29.1 per cent by trauma, 5.9 per cent by tumor, and 4.8 per cent were of congenital origin. </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> The predominance of trauma as the cause of amputation in the overall amputee population of the study <b>Fig. 2</b> is in striking contrast to the predominance of disease as a cause of amputation when only new patients are considered <b>Fig. 3</b>. In the overall picture, the ratio of trauma to disease is 1.3:1, whereas in new patients the ratio is reversed, and disease as a cause of amputation outnumbers trauma 2:1. </p> <p> Thus, the total sample data obviously includes a considerable number of traumatic amputees who lost their limbs at an earlier age and survived to require replacement prostheses. However, the noteworthy finding is that, in the period surveyed, disease-caused amputations were occurring at double the rate of those attributable to trauma. </p> <p> <i>Congenital. </i>In the 191 reported n males, 86 in females <b>Table 6</b>. Of this number, 137 did not require amputation surgery, while 54 did. This surgery presumably involved the conversion of anomalous limbs to stumps that were more suitable for the fitting of a prosthesis. Eighty-three amputations occurred in the lower extremity, of which 44 were at the below-knee level. Of 108 upper-extremity amputations, 78 were at the below-elbow level. Thirty-two per cent of congenital amputations were not fitted until after 11 years of age. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <i>Tumor. </i>Of 235 "new" amputations caused by tumor, 206 (88 per cent) were of the lower extremity <b>Table 7</b>. There were 120 amputations at the above-knee level, accounting for 58 per cent of the lower-extremity amputations. An additional 27 per cent were at a level higher than above-knee, i.e., hip-disarticulation or hemipelvectomy. Males outnumbered females 130 to 105. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The highest incidence of tumor (66 cases or 29 per cent) occurred in the second decade of life. Within this decade, no particular pattern of incidence is discernible <b>Table 8</b>. These data are somewhat at variance with those reported by Taft and Fishman<a></a> from a study conducted by the staff of New York University Child Prosthetic Studies. This study, which involved a larger sampling (278 children whose amputations were caused by tumor), showed a gradual increase in incidence beginning about the 6-8 year period and peaking in the 14-16 year group. Unfortunately, the age groupings are slightly different from those of our study, so an exact comparison cannot be made. However, both studies agree that tumor occurs most frequently in the second decade by a wide margin. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 8. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> <i>Trauma. </i>Of the 1,156 new cases of amputations resulting from trauma, amputations in males accounted for a total of 1,050, and those in females for 106, a ratio of approximately 10:1 <b>Table 9</b>. The highest incidence of trauma-related amputations occurred in the third decade (250 cases), followed closely by that in the fourth decade (216 cases). The number of amputees in these two decades accounted for 41 per cent of all new cases where age was known. The incidence of amputations in females varied only slightly in each decade between the ages of 11 and 60. The incidence of amputations in males exhibited a sharp rise through the second and third decades, and then receded gradually. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 9. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In every decade the involvement of the lower extremity exceeded that of the upper. Actually, the lower extremity was involved 1.9 times as often as the upper, 753 times as opposed to 403. </p> <p> <i>Disease. </i>Sixty per cent (2,381 cases) of all new amputations were caused by disease <b>Fig. 13</b>. Although males outnumbered females by more than 2:1 in this category, the relative percentages of males and females in each age group were closely parallel, e.g., 980 or 61 per cent of males were over the age of 61 years, while 464 or 62 per cent of females were also over the age of 61. After 40 years of age, a sharp rise in the incidence of amputations caused by disease was noticeable. Approximately one-third of the amputations occurred in the seventh decade. Eighty-five per cent of all new amputees in the disease category were over the age of 51 years, and 49 per cent were in the Medicare age group. </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> In disease-caused "new" amputations, involvement of the lower extremity greatly exceeded that of the upper, the ratio being 73:1. </p> <p> <i>Comparison with Amputee Census</i> </p> <p> The Glattly study<a></a>, reported in 1964 and commonly referred to as the "Amputee Census," included only "new" amputees. It is of interest to compare the findings of that study with the present one. Findings of our study relating to the sex and age of new amputees and the cause, side, and level of amputations closely parallel the findings of the Glattly study. Comparative data of the two studies are depicted in <b>Fig. 4</b>, <b>Fig. 5</b>, <b>Fig. 6</b>, and <b>Fig. 7</b>, and <b>Table 11</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 /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5 </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 11. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In our study, newly fitted amputees 51 years of age and older accounted for 60.2 per cent of the total, as compared with 58.8 per cent in the Amputee Census <b>Fig. 4</b>. In both studies, the highest incidence of amputation was in the seventh decade. Because many geriatric amputees are not fitted with prostheses, the incidence of amputation in the older age groups would presumably be even higher if statistics on nonfitted amputees were included. </p> <p> In both studies, male amputees exceeded female amputees by approximately three to one <b>Fig. 5</b>. </p> <p> The distribution of right- and left-side amputations was almost equal in both studies, and lower-extremity amputations still accounted for about 85 per cent of all new fittings <b>Table 11</b>. In <b>Fig. 6</b> a higher incidence of below-knee amputations and a lower incidence of above-knee amputations were evident in the more recent study. Among new patients in this study, there was a total of 3,254 above-and below-knee amputations. Of these, 50.9 per cent were above-knee. </p> <p> The relative incidence of trauma as a cause of amputation decreased by four per cent from the Glattly to the present study, and the incidence by cause in other categories increased, but by relatively small amounts <b>Fig. 7</b>. </p> <p> <i>Original Level of Amputation for Disease Correlated with Geographical Area and Age</i> </p> <p> The original level of amputation for disease was examined for 2,242 new cases whose amputations were at either the above- or below-knee level. Comparisons were made between below- and above-knee as the choice of amputation level in each of the five geographical areas <b>Table 12</b>. Below-knee appeared to be the site of choice in less than half the total number of cases. The South led the other geographical areas in percentage of amputations at the below-knee level (54 per cent), followed in order by the Midwest (51 per cent), New England (48 per cent), East Central (46 per cent), and the West (45 per cent). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 12. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> A look at the site of the original disease-related amputation for new patients 41 years of age and above revealed some interesting statistics <b>Table 13</b>. In the fifth decade, below-knee was selected in preference to above-knee in 58 per cent of the cases. This percentage gradually decreased over the next two decades to a low of 43 per cent in the seventh decade. After the seventh decade, there was an increase to 47 per cent in the eighth decade and to 50 per cent after the eighth decade. For all new amputations for disease in patients 41 years of age and above, above-knee was selected in 52 per cent of the cases, below-knee in 48 per cent. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 13. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The lack of a consistent pattern in these data is intriguing. A progressive decrease in the proportion of below-knee amputations with increase in age might logically be anticipated. Surgeons, for example, might wish to be more sure of obtaining healing in older patients and elect to amputate at the above-knee level. However, other factors than age of patient obviously enter into the selection of amputation level. </p> <p><i> Specific Causes of Traumatic Amputations</i></p> <p> Trauma was listed as the primary or precipitating cause of 4,306 amputations ("old" and "new" cases). As noted earlier, some of this number were classified in categories other than trauma, since trauma was not considered the primary cause of amputation; hence, the number 4,306 exceeds the number of cases actually coded in the trauma category. Of these 4,306 instances where trauma was mentioned, there were 392 cases where the type of trauma was unknown, so, for purposes of this analysis, reference will be to the 3,914 cases where type was known. </p> <p> <b>Fig. 8</b> summarizes the causes of traumatic amputations. In this category, men were affected ten times as frequently as women: 3,561 to 353. In males, cars, industrial accidents, and war each accounted for approximately 20 per cent of the cases. On the other hand, automobiles were by far the outstanding cause of traumatic amputations in women (49 per cent), with no other cause approaching this in frequency. It is noteworthy that the ratio of male to female automobile-caused amputations was in the order of 4:1, in contrast to the 10:1 overall ratio. Since it is not known whether these female victims were predominantly drivers or riders, the full significance of these data is not clear. </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> <b>Table 14</b> relates cause of trauma to sex, side, and level of amputation. Involvement of the right upper extremity in males was greater than the left. This preponderance was especially evident in farm and industrial accidents and is doubtless related to handedness. In car accidents, the left upper extremity was involved significantly more than the right for both males and females, 62 per cent as compared with 38 per cent. One can speculate that this incidence might be attributable to the fact that many motorists ride with the left elbow extending beyond an open window. In the small sample of train accidents, the involvement of the left upper extremity in males was also considerably greater than the right but, because of the small number, this probably was without significance. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 14. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The left lower limb was involved slightly more than the right in males, and the right and left limbs almost equally in females. </p> <p> <b>Table 15</b> compares causes cited for "new" traumatic amputations in males with those given for "old" traumatic amputations. Twenty-six per cent of the amputations of "old" cases were due to war injuries, whereas only 2 per cent of the new cases were due to this cause. At the time of this study, the Vietnam War had not yet exerted its full impact. The greatest increase in trauma-caused amputations was seen in the industrial-accident category. Industrial accidents caused 29 per cent of the "new" traumatic amputations, but only 15 per cent of the "old" amputations. Elimination of war cases from the total number avoids distortion of the data due to the preponderance of old war injuries, and thus presents a somewhat truer comparative picture of other traumatic causes. With war injuries eliminated, industrial accidents accounted for 29 per cent of the "new" amputations and 20 per cent of the "old" amputations, which still reflects an increased incidence of amputations caused by industrial accidents. Industrial accidents exceeded all other categories as the cause of amputation in new patients. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 15. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i> Reamputations of the Lower Extremity</i></p> <p> Reamputations were studied in relation to cause, original level of amputation, and present level. Level was reported for 396 reamputations of the lower extremity. Some members of this group had second reamputations, but for the purposes of this study, only the original and present level of amputation were considered. An attempt was made to exclude simple revisions that involved no shortening of bone. </p> <p> In reviewing the figures presented here, it should be remembered, again, that only those patients fitted with prostheses at the time of the study are considered. Despite this limitation, analysis of the available data is thought-provoking. Of 396 reamputations reported, 189 were in the disease-related category involving a total of 3,122 cases <b>Table 16</b>, and 182 were in the trauma-caused group with 3,387 total cases <b>Table 17</b>. Thus, reamputations in the first group ran a shade over 6 per cent, those in the second group a shade under 6 per cent. Stated in reverse, approximately 94 per cent of the cases in both groups did not require re-amputation. The statistics for specific levels are also quite fascinating. In disease-related below-knee amputations, approximately 6 per cent required reampu-tation versus approximately 5 per cent in the like trauma group. In the above-knee group, the comparative proportions are 1 per cent versus 0.6 per cent. At the Syme's level, comparative figures are 25 per cent versus 28 per cent, and for partial feet 96 per cent versus 25 per cent. The reasons for the sharp increase in reampu-tations at the last two levels are worthy of further study. It would also be of interest to know whether partial foot amputations, for example, were or were not successfully performed on many patients who were never fitted with prostheses. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 16. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 17. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> For the 189 (48 per cent) reamputations due to disease, <b>Table 16</b> gives the final as compared to the original level. Of 93 below-knee amputations requiring ream-putation, 22 (24 per cent) remained in the same segment, 67 (72 per cent) were converted to an above-knee level, 3 to a knee-disarticulation, and 1 to a hip-disarticula-tion level. Of the 15 original above-knee amputations, 9 were reamputated in the same segment and 6 became hip disarticulations. </p> <p> Of the 11 Syme's reamputations reported, 2 were reamputated to an above-knee level and 9 to a below-knee level. Of the 67 reamputations at the partial foot level, 22 were converted to an above-knee, 41 to below-knee, and 4 to a Syme's level. </p> <p> Causes of reamputation for patients in the disease category were indicated for 181 of the 189 reamputations. In some instances, two causes of reamputation were cited. In each instance where a cause was mentioned, it was counted as contributing to the reamputation. The total number of contributing causes to reamputation in the disease category therefore was 192 <b>Table 18</b>. "Recurrence of the original cause of amputation" accounted for almost half (48 per cent) of the reasons cited for reamputations. This generalized response is interpreted as meaning a continuance of the original vascular problem responsible for the initial amputation. Specific causes cited were a nonhealing wound (18 per cent), gangrene (12 per cent), infection (5 per cent) stump breakdown (3 per cent), and "other" (14 per cent). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 18. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Most reamputations in the disease category occurred very shortly after the original surgery, 49 per cent occurring in less than 1 1/2 months, and 60 per cent occurring in less than 2 1/2 months. Eighty-two per cent occurred in the first year following the amputation. </p> <p> In the category of traumatic amputations, levels for 182 reamputations of the lower extremity were reported. Of the 114 amputations at the below-knee level requiring reamputation, 57 per cent (65 amputations) remained at the below-knee level, a percentage considerably higher than was the case for reamputations due to disease. Forty-five amputations were converted to above-knee levels and 4 were converted to knee disarticulations. There were 29 Syme's reamputations, of which 23 were converted to below-knee, 3 to above-knee, and 3 remained at the Syme's level. Of the 22 partial foot reamputations, 14 were converted to below-knee levels, 7 to Syme's and 1 to above-knee. </p> <p> Causes of reamputation were known for 157 of the trauma cases. As with reamputations in the disease category, every instance where a cause was mentioned was counted. There were 165 contributing causes to reamputations <b>Table 19</b>. In 71 instances (43 per cent), "other" was coded as the cause of reamputation. Included in the "other" category were causes that could not be readily classified, such as "stump not satisfactory for prosthesis," "shorten bone and remove neuroma," "painful stump." The median number of months between amputation and reamputation was six. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 19. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> There were 16 reamputations for congenital amputees and 6 for patients whose amputations were caused by tumor. Three of the latter were reamputated because of recurrence of the tumor. Reported reasons for reamputations in congenital amputees were too diverse for classification, except that 4 reamputations were because of bony overgrowth. </p> <p> <b>Table 20</b> summarizes the total number of reamputations for each level and includes the percentage of reamputations converted to a higher segment or remaining in the same segment. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 20. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Bony overgrowth was cited eight times as a reason for reamputation: four tibial overgrowths, two fibular overgrowths, and two not specified. All of these reamputa-tions were performed on children, with the exception of one on a 27-year-old amputee. While not implicit in the data, it is conceivable that this 27-year-old had had bony overgrowth for a long time prior to reamputation (his first amputation occurred at age 10). </p> <p><i> Stump Length and Contractures</i></p> <p> There were 2,602 above-knee amputations for which the presence or absence of contractures of the hip was reported. Of this group, 1,345 had either no flexion contracture or a contracture of less than 5 deg, and are not included in this analysis, other than the notation that they comprised over half of the group reported. Stumps with 5+ deg of contracture ranged in length from 2 - 2 1/2<i> </i>inches to 14 - 15 1/2 inches. Three stumps had flexion contractures of more than 60 deg. Hip-flexion contractures were greatest in the very short stump. The average contracture at the above-knee level fell in the 5-9 deg range. </p> <p> There were 3,781 below-knee amputations for which the presence or absence of knee contractures was reported. Of this number, only 12 per cent were reported as having contractures of 5 deg or more. In general, the shorter the stump, the more severe the contracture. Considering only those cases reporting contractures of 5 deg or more, stumps averaging more than 7 1/2<i> </i>in. in length had average contractures of between 5 and 9 deg; for stumps between 4 and 7 1/2<i> </i>in. long, contractures averaged between 10 and 14 deg; and for stumps 3 1/2 in. and less in length, contractures averaged 15 to 19 deg. The average contracture, excluding those of less than 5 deg, was 10-14 deg. Three stumps had contractures of 60 deg or more. </p> <p><i> Work Status</i></p> <p> The work status of "old" male amputees between the ages of 21 and 64, with 2,694 amputations, was reported. "New" amputees were not studied, since the majority of the group had not yet had time to return to employment. Eighty-four per cent of the "old" amputees in the cited age group were employed, the highest employment rate (89 per cent) occurring in the 41- to 50-year-old age group <b>Fig. 9</b>. In each of the age groups studied, a higher rate of employment was reported for upper-extremity than for lower-extremity amputees. It should be noted here that only 6.4 per cent of amputees between the ages of 21 and 64 were reported as not being gainfully employed. The remainder of the group (9.3 per cent) were students, retired, or fell into some other category. This percentage of unemployment is a little higher than that reported for the national average for the years 1965, 1966, and 1967 (4.5, 3.8, and 3.8 per cent respectively). </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> The rate of employment in relation to each upper- and lower-extremity amputation level appears in <b>Fig. 10</b> and <b>Fig. 11</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 /><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> Work status was reported for 383 female amputees between the ages of 21 and 64. Of this number, 200 were housewives, 148 were gainfully employed, and only 18 were not gainfully employed. Seventeen had either retired or reported their work status in some other category. </p> <p><i>Referrals</i></p> <p> The majority (58 per cent) of cases fitted at prosthetics facilities were referred by amputee clinics; 26 per cent were referred by physicians; 16 per cent were not referred. Of the "new" cases, 5 per cent were not referred to prosthetics facilities by either a clinic or physician, as contrasted to the 26 per cent of the "old" cases not so referred. </p> <p><i> Months to Delivery of Prostheses</i></p> <p> For "new" amputations, the time from amputation (or from birth for congenital amputees not requiring surgery) to date of delivery of the prosthesis was analyzed by level and cause for the five geographical regions <b>Table 21</b>. The median period to delivery for all prostheses was 6 months. Comparing geographical areas, the median was 5 months for New England, the Midwest and West, 6 months for the South, and 7 months for the East Central region. Of the 3,588 prostheses with times to delivery reported, 71 were delivered in 1 month or less, 67 were not delivered for 99 months or longer. Thirty-seven of the latter were for congenital amputations not requiring surgery, i.e., 37 children were not fitted with their first </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 21. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> prosthesis until after the age of eight years, three months. A comparison of time to delivery by levels indicated that the median time lapse was 5 months for the below-knee prosthesis and 6 months for all other levels. Time to delivery of prostheses ranged from a median of 4 months for below-knee prostheses in the New England area and the West to a median of 10 months for below-elbow prostheses in the East Central region. These data will provide a basis for later comparisons in areas where programs of immediate and early prosthetic fitting have been instituted. </p> <p> Data on months to delivery were analyzed by cause of amputation and related to geographical regions <b>Table 22</b>. The shortest median length of time for delivery was 3 months for congenital amputees who had had surgery. The longest time was for congenital amputations without surgery, where the median was 31 to 36 months; however, it should be recognized here that this median also represents the median age of congenital amputees not requiring surgery who were being fitted for the first time. Median time to delivery for amputations caused by tumor was 4 months; by trauma, 5 months; and by disease, 6 months. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 22. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i> Age of Replaced Prostheses and Reasons for Replacement</i></p> <p> The average age of replaced prostheses for all patients was 6.1 years. For children up to 21 years of age, it was 2.5 years, and for adults, 6.7 years. </p> <p> Comparisons of the ages of replaced prostheses for above- and below-elbow and above- and below-knee amputees in relation to the age of the patient (by decade) are shown in <b>Table 23</b>. In almost every instance, the "life" of the prosthesis increased with the age of the patient. The average life of above-elbow prostheses for 124 amputations was 9.2 years. The range was from 2.5 years for the child through the age of 10 years to 16.7 years for amputees over the age of 61. The average age of below-elbow prostheses for 349 amputations was 6.5 years, ranging from 2.5 years for the child through age 10, to 10.3 years for amputees over age 51. The average age of above-knee prostheses for 1,269 amputations was 6.2 years, with a range from 2.2 years for the child in the first decade, to 8.1 years for amputees over age 71. The below-knee prosthesis had the shortest life, averaging 5.8 years for 2,201 amputations, and ranging from an average of 1.7 years for the child through age 10, to 8.6 years for amputees over 71 years of age. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 23. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> In comparing ages of replaced prostheses by cause of amputation and the sex of the amputee, it is found that prostheses for congenital amputees had the shortest life, averaging 3.5 years, and prostheses for traumatic amputees had the longest life, averaging 6.8 years <b>Table 24</b>. The growth rate of children in the congenital group undoubtedly accounts for the more frequent replacements of prostheses evident here. Replacement of prostheses for patients in the disease category occurred, on average, every 5 years, and there was very little difference between replacements for males and females. The life of prostheses for tumor patients also averaged 5 years; however, prostheses for males in this category needed more frequent replacement, lasting 4.5 years as compared with an average 5.6 years for females. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 24. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> It is interesting to note that the age of replaced prostheses for males averaged 6.2 years, and that of females 5.4 years. The large number of males in the trauma category may account for this difference, inasmuch as the average life of prostheses in this category is longer than in others. </p> <p> <b>Table 25</b> indicates the reason for replacement of prostheses. The majority of prostheses were replaced because they were worn out. "Worn out" was listed as the sole or contributing cause of replacing a prosthesis in 58 per cent of the cases. It was the leading reason for replacing prostheses of persons whose amputations were caused by tumor (50 per cent), trauma (67 per cent), and disease (44 per cent). As would be expected, the primary reason for replacing prostheses of congenital amputees was that the prosthesis was "outgrown." In 52 per cent of replacements for congenital amputees, the prosthesis was outgrown; in 33 per cent of the cases it was worn out. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 25. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> "Unsatisfactory" was cited as the reason for replacement in four per cent of the cases. However, it should be noted that although the "unsatisfactory" category was meant to include only those cases in which problems arose relating to fabrication or patient tolerance, it was often cited for other reasons which rendered the prosthesis unsatisfactory. Had this item been interpreted correctly, the percentage undoubtedly would have been lower. </p> <p> The average age of all "worn out" prostheses that were replaced was 7.6 years <b>Table 26</b>. This exceeds the average age of prostheses replaced for any reason (6.1 years) by a year and a half. This higher age undoubtedly reflects the longer life of the prostheses of traumatic amputees reported above, since "worn out" was the sole or contributing factor for 67 per cent of the replacements in the trauma category. Additionally, the lower average age of all the replaced prostheses was affected by the inclusion of children's prostheses, which had shorter lives. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 26. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Ccomponents for Upper-Extremity Prostheses</i></p> <p> The components most frequently used for upper-extremity prostheses at the above- and below-elbow levels are depicted in <b>Fig. 12a</b>,<b>Fig. 12b</b>. The voluntary-opening hook was used with 87 per cent (201 instances) of the above-elbow prostheses and 90 per cent (517 instances) of below-elbow prostheses. The preference for this type of hook was reflected in all areas except the West, which showed a preference for the voluntary-closing hook with below-elbow prostheses. New England was the only area that did not prescribe the voluntary-closing hook at all. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12a. Most frequently used components for above-elbow prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12b. Most frequently used components for below-elbow prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The hand-type terminal device was utilized to a limited extent, being prescribed 309 times as opposed to the hook-type device which was prescribed 806 times. Many amputees for whom hooks were prescribed were also equipped with hands. Where hand-type devices were reported, the voluntary opening hand was prescribed for above-elbow prostheses 40 per cent of the time (36 cases) and for below-elbow prostheses 36 per cent of the time (79 cases). Both the East Central and Midwest areas preferred voluntary-closing hands for use with above-elbow prostheses. The East Central and Western areas preferred voluntary-closing hands for below-elbow prostheses. New England showed a preference for the passive hand with the below-elbow prosthesis. </p> <p> The simple friction wrist unit was overwhelmingly preferred to quick-change types in all geographical areas, being used with 83 per cent of above-elbow and 85 per cent of below-elbow prostheses. </p> <p> Although the triceps pad was used with 56 per cent of the below-elbow prostheses, its use ranged from 35 per cent in the South to 94 per cent in the New England area. The South preferred the half cuff. Plastic laminate was the cuff material of choice in 61 per cent of the total cases, although the East Central and Western areas preferred leather to the extent of 54 per cent and 55 per cent respectively. </p> <p> The double-wall socket was used in 89 per cent of the above-elbow and 77 per cent of the below-elbow prostheses. Pre-flexed sockets, some of which also had double walls, were used in 11 per cent of the below-elbow prostheses. Sixty-one per cent of the preflexed sockets were utilized by children. </p> <p> In 98 per cent of the upper-extremity prostheses, the sockets were made of plastic. </p> <p> The elbow unit with internal lock was the item of choice for above-elbow prostheses in all geographical areas, being used in 78 per cent of all fittings. Seventeen per cent of all elbow units had spring-flexion assists. Sixty-four per cent of the elbow hinges used in below-elbow prostheses were flexible, the range being from 44 per cent in the West to 92 per cent in New England. The Midwest showed almost equal preference for the single-pivot (47 per cent) and the flexible hinge (50 per cent). </p> <p> Dual-control systems were used in 80 per cent of above-elbow and single control in 96 per cent of the below-elbow prostheses. </p> <p> Eighty-three per cent of the harnesses for above-elbow prostheses were of the figure-eight type, the majority of this group (55 per cent) being equipped with the Northwestern University harness ring. The East Central area and the West showed a preference for the figure-eight harness without the ring. Of the 14 cases with reported type of harness in the West, none used the ring with the figure-eight. The South used the ring to the greatest extent for above-elbow prostheses. </p> <p> Ninety-two per cent of the below-elbow harness were of the figure-eight type, 59 per cent of these being equipped with rings. The East Central, South, and Midwest areas showed greatest preference for the ring figure-eight harness; the New England and Western areas used the figure-eight harness without the ring almost as often as with it. </p> <p> <i>Components for Lower-Extremity Prostheses</i> </p> <p> Components most frequently used for above- and below-knee prostheses appear in <b>Fig. 13a</b>,<b>Fig. 13b</b>. The various geographical areas showed more consistency in prescription of lower-extremity than upper-extremity components. In most instances, only the percentage varied, not the type of component. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13a. Most frequently used components for above-knee prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13b. Most frequently used components for below-knee prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The SACH foot was prescribed for 55 per cent of the above-knee and 73 per cent of the below-knee prostheses. In area comparisons, the South showed the greatest usage of the SACH foot, and the Midwest the lowest. For the above-knee prosthesis, prescription of the SACH foot rose from 76 per cent in the first to 83 per cent in the second decade, and then gradually declined with advancing amputee age. In the below-knee group, the SACH foot was prescribed 96 per cent of the time for children under 10 years of age; the percentage declined steadily to a low of 56 per cent in the eighth decade, then rose to 63 per cent for the group of amputees 81 years of age and over. </p> <p> Wood was used as the shank material in 95 per cent of the above-knee and in 90 per cent of the below-knee prostheses. </p> <p> The most frequently used knee component for above-knee prostheses was the single axis, with friction being used in 74 per cent of the fittings. Twelve per cent of the knees were single axis with manual locks. Eight per cent of the knees were hydraulic, with the West showing the greatest preference (17 per cent) and the Midwest the least (4 per cent). In instances where metal joints were reported for below-knee prostheses, the lap joint was specified in 48 per cent of the cases and the clevis joint in 22 per cent. The type of joint was not specified in 30 per cent of the cases. </p> <p> For above-knee amputees, the quadrilateral socket was used in 85 per cent of the prostheses. It was the overwhelming choice in each of the geographical areas. The socket of choice for below-knee amputations was the patellar-tendon-bearing. Preference for this socket averaged 58 per cent, the South and West showing greatest utilization, 79 per cent and 82 per cent respectively, and the New England and Midwest areas the least utilization, 44 per cent and 47 per cent respectively. </p> <p> Wood was used most often for above-knee sockets, averaging 57 per cent, although the South showed a preference for plastic, using it for 55 per cent of all sockets. Below-knee sockets were most often (55 per cent) fabricated in plastic. New England showed a preference for leather sockets, and the Midwest preferred wood (41 per cent) to either plastic or leather. </p> <p> The pelvic belt was the preferred method of suspension (56 per cent) for above-knee prostheses. Only in the West did the use of suction, either alone or in combination with other suspension, exceed the use of the pelvic belt. In correlating methods of suspension with age, it was noteworthy that during the second, third, and fourth decades, suction alone was preferred to all other types of suspension. In all other decades, the pelvic belt was preferred. </p> <p> In considering types of suspension reported for all below-knee prostheses, the knee cuff alone was the choice of suspension in 36 per cent of the cases. It was least used in the Midwest (22 per cent). The South and West utilized the knee cuff alone most frequently (55 per cent). When type of suspension for the patellar-tendon-bearing prosthesis is analyzed by age group, it is found that, while the knee cuff alone was used for 62 per cent of all </p> <p> the prostheses, greatest usage occurred in the second decade (73 per cent) and next greatest in the third decade (71 per cent). Least use of the knee cuff alone occurred in the very young child (48 per cent), but the inclusion of cases where a waist belt was used in conjunction with the knee cuff raised this percentage to 68. </p> <p><i> Sources of Payment </i></p> <p> <b>Table 27</b>, <b>Table 28</b>, and <b>Table 29</b> indicate the sources of payment for prostheses. More than one source was sometimes listed, in which case they are reported under "combinations of the above "or" "other". Medicare had been in operation only one year prior to the conclusion of this study and presumably would rank considerably higher as a source of payment at the present time. As mentioned earlier, over 23 per cent of the amputees in this study were in the Medicare age bracket. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 27. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 28. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 29. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Source of payment was given for 8,631 prostheses <b>Table 27</b>. The greatest contributors to defraying the costs of prostheses were State Bureaus of Vocational Rehabilitation (22.5 per cent) and the patient himself (22.8 per cent). Next in order were the Veterans Administration (14.3 per cent), welfare (10.8 per cent) and insurance (9.9 per cent). </p> <p> The Children's Bureau paid for 46.5 per cent of the prostheses for children up to the age of 21. Through the wage-earning years, 21 to 64, State Bureaus of Vocational Rehabilitation paid for 31.9 per cent of the prostheses, the amputee for 24.3 per cent, and the Veterans Administration for 19.3 per cent. During the retirement years, 65 and over, the amputee alone paid for 29.9 per cent of the prostheses, Social Security and Medicare for 19.5 per cent, and welfare for 15.3 per cent. </p> <p> A further analysis of sources of payment relating to the wage-earning years yields some interesting facts <b>Table 28</b>. The Veterans Administration paid for 30 per cent of replacement prostheses, but only 10 per cent of new prostheses. This statistic doubtless reflects the continuing supply of prostheses to veterans of World War II and the Korean War and a decreased number of fresh cases. More "new" male amputees were supported by insurance or compensation than "old" male amputees, 24 per cent as opposed to 8 per cent. This may reflect the policy of some insurance companies to pay for the first prosthesis only. On the other hand, it may indicate an increase in opportunity for insuring oneself against disability and a greater awareness of the values of health insurance. In comparing source of payment for males and females in this age group, one notices the higher level of support by the amputees themselves and the Bureaus of Vocational Rehabilitation for the female group, and also the very low percentage of females supported by insurance or compensation. </p> <p> In correlating source of support with occupation, only "old" amputees were considered, since in most instances "new" amputees had not yet returned to work at the time the data forms were submitted. Amputees were studied in three categories: those gainfully employed, those not gainfully employed, and those who were students, housewives, or retired <b>Table 29</b>. </p> <p> Of the 3,055 "old" cases included above, only 187, or 6 per cent, were reported as not being gainfully employed. The Bureaus of Vocational Rehabilitation paid for 35 per cent of the prostheses for the gainfully employed group, the Veterans Administration for 28 per cent, and the amputee for 25 per cent. For the group of amputees not gainfully employed, the Bureaus of Vocational Rehabilitation were the source of payment for 28 per cent of the prostheses, the Veterans Administration for 27 per cent, and welfare for 24 per cent. In the 468 amputations of students, housewives, or retired amputees, 31 per cent of the prostheses were paid for by the amputee, 28 per cent by the Bureaus of Vocational Rehabilitation, and 17 per cent by the Veterans Administration. </p> <h4> Discussion </h4> <p> In recent years, there has been increasing interest in defining the characteristics of the amputee population, and also in providing amputees with functional stumps and prostheses. Much progress has been made in understanding the amputee and his problems, and in the fabrication of improved prosthetic components. This study has sought to document some of the characteristics of the amputee and his prosthesis during a particular period in time-the approximately two years ending June 30, 1967. </p> <p> Certain characteristics of amputees, namely sex and age, and the cause, side, and site of amputation, were well established in Glattly's study of 12,000 new amputees for whom data were collected over a two-year period, ending in 1963. In the present study of over 8,000 amputees, 4,034 of whom were new, data were likewise collected over a two-year period which ended in 1967, four years later. Unless some catastrophic event had occurred immediately before or during either of the two periods, it would be expected that in large samples such as these, the sex and age of the amputee and side and cause of the amputation would be relatively constant. Such was indeed the case, indicating that the sample in the latest study was a valid cross-section of the amputee population. As noted before, neither the Medicare Act nor the conflict in Vietnam had exerted a significant impact on this study. Although medical advances over a number of years have been largely responsible for the increasing age of the amputee, with a resulting shift from trauma to disease as a predominant cause of amputation, such changes would not be expected to exert a significant difference in as short a period as four years. </p> <p> In amputations caused by disease, the site of amputation can be influenced by medical judgment at a particular time. In the vast majority of cases where amputation is categorized as disease, the amputees had vascular insufficiency. For this condition, amputation at a level above the knee had been widely advocated for many years because it was felt that this procedure facilitated healing. It has been found, however, that amputation may be performed at a below-knee level, with primary healing occurring in the majority of cases.<a></a> By preserving the knee joint, amputation at this level greatly enhances the rehabilitation potential of the patient. </p> <p> Burgess has reported that most below-knee amputations for ischemia heal primarily, and with proper prosthetic care do not break down.<a></a> Lim reports that 92 per cent of below-knee amputations were successful when a popliteal pulse was present, and 75 per cent were successful when pulse was absent.<a></a> He also reports a lower mortality rate for below-knee amputees, 16 per cent as opposed to 35 per cent for above-knee amputations. Tracy cites a 90 per cent successful healing rate for below-knee amputations for ischemic gangrene.<a></a></p> <p> Although the increase in the percentage of below-knee amputations in our study, as compared with the Glattly study, is relatively small in view of the <i>potential </i>increase, it is nevertheless an encouraging trend, and it is to be hoped that a dramatic increase will be reflected in future surveys as the results of ongoing educational programs take effect. </p> <p> Although the incidence of amputations due to trauma appears to have declined, as far as percentage of the total amputee population is concerned, this does not necessarily imply a decrease in the overall incidence of traumatic amputations. Actually, the increasing age of amputees, with its corollary of increasing incidence of amputations due to disease, is certainly partly responsible for the decline in percentage of trauma cases. In the younger age groups, trauma continues as the major cause of amputations. The Public Health Service report<a></a> published in 1964 shows that "absence of major extremity," classified as an accident "while at work," occurred almost three times as often as amputation caused by "moving motor vehicles." In the present study, the ratio was closer to 1:1 than 3:1, i.e., moving vehicles as a cause of traumatic amputations was almost equal to that of industrial accident. A higher percentage of auto accidents than industrial accidents occurred in the female group, a pattern which is typical of other reported findings. These results may indicate improved safety controls in industry, or may underscore the soaring rate of automobile accidents, or both. The large number of amputations resulting from trauma continues to have strong implication for improved accident-prevention programs and more effective human-factors engineering. The need for greater safety of design, particularly in cars and industry, continues to be great. </p> <p> It is of interest to note that prosthetic prescription varied among the geographical areas, some areas having a greater tendency than others to incorporate newer prosthetic techniques. It might be expected that the latest prosthetic developments would be incorporated into prosthetic practice in those areas which were near the prosthetic-orthotic educational centers (New York, Chicago, and Los Angeles) or in areas of greatest concentration of prosthetic facilities (California, Pennsylvania, New York, and Illinois), or amputee clinics (New York, Pennsylvania, California, and Texas). With the exception of the West, where newer developments were used in a high percentage of cases, there appeared to be no relationship between the nature of prosthetic services provided and the factors cited above. Both the South and the West showed a more consistent use of newer techniques than did the other areas. </p> <p> The provision of prosthetic services reported in the study indicates that much improvement is to be desired as far as length of time for delivery of the prosthesis is concerned. The time between the date of amputation (or reamputation) and delivery of the prosthesis was inordinately long, ranging from a median of four months for patients whose amputations were caused by tumor to six months for patients with vascular disease. The provision of temporary prostheses and immediate postsurgical fitting of prostheses would help shorten this time lag. </p> <p> The finding that a relatively high percentage of congenital amputees (32 per cent) were not fitted until after their eleventh birthday is distressing. Since current philosophy is to fit congenital amputees at a very early age, it would be interesting to know the reason for this reported delay. Whether the fault lies with amputee clinics, or with parents who are either reluctant to take their children to clinics or are ignorant of the prosthetic opportunities available to them, is not evident from the present analysis. The implication is that more needs to be done at the educational level. The growth and implementation of dynamic treatment programs would surely result in a much more optimistic picture. </p> <p> A composite picture of amputees reported in this study would present the following profile: </p> <ol> <li>The congenital amputee seen in prosthetic facilities was a male under 10 years of age with involvement at the below-knee level. </li><li>The amputee whose amputation was caused by tumor was a male between 11 and 20 years of age whose amputation was at the above-knee level. </li><li>The traumatic amputee was a male now between the ages of 41 and 50 years who had received his amputation between the ages of 21 and 30 years. His amputation was at the below-knee level and was most likely received as a result of a car accident, industrial accident, or war injury. </li><li>The amputee whose amputation was caused by disease was also a male, between the ages of 61 and 70 years, who was amputated during these same years. His amputation was as likely to be at the above-knee level as at the below-knee level. </li></ol> <h4> Summary </h4> <ol> <li>This study, which extended over a two-year period ending in June 1967, presents data on 8,323 amputees with 8,698 amputations, all of whom were fitted with prostheses. </li><li>Of the "new" amputations seen in prosthetic facilities, 60 per cent were caused by disease, 29 per cent by trauma, 6 per cent by tumor, and 5 per cent were of congenital origin. </li><li>Of all amputations, "new" and "old," being fitted in prosthetic facilities, 50 per cent were caused by trauma, 37.3 per cent were caused by disease, 8.4 per cent were of congenital origin, and 4.3 per cent were caused by tumor. </li><li> The greatest incidence of disease-caused amputations occurred in the seventh decade, those of trauma in the third decade, and those of tumor in the second decade. </li><li>Males outnumbered females in every category, the ratio for "new" amputations of males to females being approximately 2:1 for disease, 10:1 for trauma, and 1.2:1 for both congenital causes and tumor. </li><li>Eighty-six per cent of the total number of amputations were of the lower extremity, with 53 per cent of this group being at the below-knee level. </li><li>Although automobile accidents were cited as the single greatest cause of all traumatic amputations, war injuries, industrial accidents, and automobile accidents were cited almost equally for male amputees. </li><li>Forty-eight per cent of all reampu-tations were in the disease category, 60 per cent of these occurring within two and one-half months of the original amputation. The reamputation rate for below-knee amputations caused by disease was not significantly higher than that for trauma-caused amputations-approximately 6 per cent in both instances. </li><li>Degree of contracture reported at both hip and knee varied inversely with the length of the stump. Excluding contractures of less than 5 deg, the average hip flexion contracture for above-knee amputations was in the 5-9 deg range; the average knee flexion contracture for be-low-knee amputations fell in the 10-14 deg range. Fifty-two per cent of those cases reporting presence or absence of contractures had either no contracture or one of less than 5 deg. </li><li> Unemployment rate for "old" male amputees between the ages of 21 and 64 was 6.4 per cent, slightly higher than the national average for the years covered by the report. </li><li>Fifty-eight per cent of patients were referred to prosthetic facilities by amputee clinics, 26 per cent by physicians, and 16 per cent were not referred. </li><li>The median time from amputation to delivery of a prosthesis was six months, the below-knee prosthesis being delivered in the shortest length of time. Congenital amputees who required surgery received prostheses in a median time of three months postsurgery. Patients in the disease category waited the longest time- six months. </li><li> Prostheses had an average life of 6.1 years, with the life of the prosthesis increasing with the age of the patient. Below-knee prostheses generally and prostheses for congenital amputees had the shortest life. Prostheses for males lasted longer than those for females. "Worn out" was the primary reason given for replacing a prosthesis. </li><li>Prosthetic prescription varied in the geographical areas, some regions demonstrating a greater tendency than others to incorporate newer prosthetic techniques. Generally, as the age of the amputee advanced, there was a tendency to use the older types of components, e.g., pelvic hands, articulated ankles. </li><li>The Children's Bureau was the largest single source of financial support for the purchase of prostheses for children, and the State Bureaus of Vocational Rehabilitation provided the greatest financial support for amputees during the wage-earning years. The Veterans Administration paid for a high percentage of prostheses for males who were in the "old" category. In all, the federal government paid entirely for 48 per cent of all prostheses and provided partial support for another 3 per cent. </li></ol> <h4> Acknowledgments </h4> <p> Grateful appreciation is extended to the 44 facility owners and their staffs who provided the data on which this study is based. </p> <p><b>References:</b></p> <ol> <li>Burgess, Ernest M., The below-knee amputation, <i>Bull. Pros. Res., </i>10-9:19-25, Spring 1968. </li> <li>Davies, E. J., B. R. Friz, and F. W. Clippinger, Jr., Children with amputations, <i>Inter-Clinic Inform. Bull., </i>9:3:6-19, December 1969. </li> <li>Friz, Barbara R., and Frank W. Clippinger, Jr., The facility case record study: a preliminary report, <i>Orth. and Pros., </i>23:1:8-17, March 1969. </li> <li>Glattly, H. W., A statistical study of 12,000 new amputees, <i>Southern Med. J., </i>57:1373-1378, November 1964, </li> <li>Lim, R. C, Jr., et al.. Below-knee amputation for ischemic gangrene, <i>Surg. Gynec. Obstet., </i><b>125: </b>493-501, September 1967. </li> <li>Sarmiento, A., and W. D. Warren, A re-evaluation of lower extremity amputations, <i>Surg. Gynec. Obstet., </i>129:799-802, October 1969. </li> <li>Taft, C. B., and S. Fishman, Survival and prosthetic fitting of children amputated for malignancy, <i>Inter-Clinic Inform. Bull., </i>5:5:9-28, February 1966. </li> <li>Tracy, G. D., Below-knee amputation for ischemic gangrene, <i>Pacif. Med. Surg., </i>74:251-253, September-October 1966. </li> <li>U. S. Department of Health, Education, and Welfare, Public Health Service, <i>Impairments due to injury by class and type of accident, United States, July 1959-June 1961, </i>Washington, D.C., 1964. </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>9.</b> </td><td class="clsTextSmall">U. S. Department of Health, Education, and Welfare, Public Health Service, Impairments due to injury by class and type of accident, United States, July 1959-June 1961, Washington, D.C., 1964. </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">Tracy, G. D., Below-knee amputation for ischemic gangrene, Pacif. Med. Surg., 74:251-253, September-October 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Lim, R. C, Jr., et al.. Below-knee amputation for ischemic gangrene, Surg. Gynec. Obstet., 125: 493-501, September 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Taft, C. B., and S. Fishman, Survival and prosthetic fitting of children amputated for malignancy, Inter-Clinic Inform. Bull., 5:5:9-28, February 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Sarmiento, A., and W. D. Warren, A re-evaluation of lower extremity amputations, Surg. Gynec. Obstet., 129:799-802, October 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Glattly, H. W., A statistical study of 12,000 new amputees, Southern Med. J., 57:1373-1378, November 1964, </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">Taft, C. B., and S. Fishman, Survival and prosthetic fitting of children amputated for malignancy, Inter-Clinic Inform. Bull., 5:5:9-28, February 1966. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Davies, E. J., B. R. Friz, and F. W. Clippinger, Jr., Children with amputations, Inter-Clinic Inform. Bull., 9:3:6-19, December 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Friz, Barbara R., and Frank W. Clippinger, Jr., The facility case record study: a preliminary report, Orth. and Pros., 23:1:8-17, 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Lim, R. C, Jr., et al.. Below-knee amputation for ischemic gangrene, Surg. Gynec. Obstet., 125: 493-501, September 1967. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Frank W. Clippinger, M.D. </b></td></tr><tr><td class="clsTextSmall">Professor of Orthopaedic Surgery, Duke University; Chairman, Subcommittee on Prosthetics Clinical Studies, CPOE.</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>Barbara R. Friz, M.S. </b></td></tr><tr><td class="clsTextSmall">Executive Secretary, Committee on Prosthetic-Orthotic Education, Division of Medical Sciences, National Academy of Sciences-National Research Council, Washington, 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>Elizabeth J Davies. M.A. </b></td></tr><tr><td class="clsTextSmall">Formerly Professional Assistant, Committee on Prosthetic-Orthotic Education.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1970_02_019/tmp647-19.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 Amputees and Their Prostheses Creator An entity primarily responsible for making the resource Elizabeth J Davies. M.A. * Barbara R. Friz, M.S. * Frank W. Clippinger, M.D. * https://staging.drfop.org/files/original/b5321419e7289e34cedd7b3e0cbe4493.pdf 1cb64ea6151a427da372f111e67022a4 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_02_041.pdf Year 1969 Volume 13 Issue 2 Page Number(s) 41 - 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/1969_02_041.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_02_041.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>Clinical Study of the Application of the PTB Air-Cushion Socket</h2> <h5>Eric Lyquist <a style="text-decoration:none;">*</a><br /></h5> <p>From January 1966 to September 1968, the Orthopaedic Hospital in Copenhagen conducted a clinical evaluation study of the patellar-tendon-bearing (PTB) air-cushion socket (see p. 1).</p> <p>The Prosthetic/Orthotic Research Department at the hospital fabricated the sockets, using the casting procedure described by Wilson and Lyquist <a></a> and the fabrication procedures described by Lyquist and his associates<a></a>. These procedures and the results of fitting 45 amputees were published in September 1968.<a style="text-decoration:none;">*</a></p> <p>Forty-five amputees were selected for the test series and fitted with air-cushion sockets. Four patients were eventually dropped from the study, three because of their inability to return for re-examination, and one because of her confinement to a wheelchair as a result of progressive vascular disease.</p> <p>The group of 41 amputees consisted of 30 males and 11 females, with ages ranging from 7 to 74 years (average age: 44).</p> <h3>Clinical Evaluation</h3> <p>Seventeen of the amputees had been satisfied wearers of a PTB prosthesis for at least 12 months. After being fitted with air-cushion sockets, 13 noted improved comfort and function, 3 found no change in comfort and function, and 1 was dissatisfied because of nocturnal stump pain.</p> <p>Seven patients had previously been fitted with the standard type of PTB prosthesis, but satisfactory fittings had never been achieved. With fitting of the air-cushion socket, 4 amputees obtained satisfactory comfort and function. One patient was able to wear a modified air-cushion socket with a soft insert. The remaining 2 had to abandon the socket; both had short stumps (2-1/2 in.) with distal hypersensitivity.</p> <p>Seven amputees had previously worn prostheses, but with complications such as ulcerations and secondary distal edema. Six obtained satisfactory comfort and function with the air-cushion socket, but one who had a short stump (2 in.) and extensive skin transplants was fitted after four weeks with a standard PTB prosthesis.</p> <p>Four amputees had successfully worn conventional BK prostheses for periods of 40, 30, 13, and 6 years. Nonetheless, when fitted with an air-cushion socket, each preferred it to the conventional prosthesis.</p> <p>Of the remaining 6 amputees, 5 had never worn a prosthesis. Two of those had distal edema and ulceration, which healed when an air-cushion socket was applied. Another had stump problems not attributable to the prosthesis, but he managed well with the air-cushion socket. A fourth patient had no stump problems, and successfully wore the socket. One amputee had to be fitted with a different type of prosthesis because his stump was hypersensitive distally and the volume was constantly changing.</p> <h3>Summary</h3> <p>Of the 41 amputees fitted with the air-cushion socket, 36 had previously worn prostheses. In that group, 27 noted increased comfort and function, 4 were considered unchanged, 3 returned to wearing a standard PTB prosthesis, and 1 required fitting with a conventional prosthesis. One amputee had previously been fitted with an air-cushion socket by a private pros-thetist, and got along very well. Of the 5 amputees who had not previously worn a prosthesis, 1 was not successfully fitted, but 4 were able to manage well with the air-cushion socket.</p> <p>At the time of this report, 36 of the 41 amputees evaluated in this study were wearing the air-cushion socket. Although extensive final medical examinations of the entire group have not been completed, it is unlikely that the information resulting from those examinations will differ greatly from the results presented in this report.</p> <p><b>References:</b></p> <ol> <li>Lyquist, E., L. A. Wilson, and C. W. Radcliffe, <i>Air-cushion socket for patellar-tendon-bearing below-knee prosthesis, principles and fabrication procedures</i>, Technical Memorandum, Biomechanics Laboratory, University of California, San Francisco and Berkeley, 1965.</li> <li>Wilson, L. A., and E. Lyquist, <i>Plaster bandage wrap cast</i>, Pros. Int., 3:4-5:3-7, 1968.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Prosthetic/Orthotic Research Department technical report (Danish).</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">Lyquist, E., L. A. Wilson, and C. W. Radcliffe, Air-cushion socket for patellar-tendon-bearing below-knee prosthesis, principles and fabrication procedures, Technical Memorandum, Biomechanics Laboratory, University of California, San Francisco and Berkeley, 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Wilson, L. A., and E. Lyquist, Plaster bandage wrap cast, Pros. Int., 3:4-5:3-7, 1968.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Eric Lyquist </b></td></tr><tr><td class="clsTextSmall">Director, Prosthetic/Orthotic Research Department, Orthopaedic Hospital, Copenhagen, Denmark.</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 Clinical Study of the Application of the PTB Air-Cushion Socket Creator An entity primarily responsible for making the resource Eric Lyquist * https://staging.drfop.org/files/original/b4f40bca2c90d2cb7aaabe73acdc9755.pdf 93f307630ba83bd52f500cbae4929830 https://staging.drfop.org/files/original/6ade0b441b483cc9f3804c0eb907cef2.jpg 510989eb599f892c8b2e8c055704eb08 https://staging.drfop.org/files/original/f992d6f159add6551a5927ffdad104a4.jpg 2b3059782381c1b405945cc1df2a65e4 https://staging.drfop.org/files/original/97cfb5d939b20b09ce8eef3379376ff5.jpg 3159b4335f45fb7d187f4e230713fe30 https://staging.drfop.org/files/original/e71107f0f952e070fd0f18a250c50c5e.jpg 3187980e5eb0db54e1fd157d75985aef https://staging.drfop.org/files/original/9f5149248ae20c875ebc879851fc505d.jpg 7975ed4b11b397c330fbd73d34711061 https://staging.drfop.org/files/original/95f314b39e2ef9df0a3d3e113c78841d.jpg 20023369bfd507d6c8b1eaf7c139ccad https://staging.drfop.org/files/original/1e75d8d603b0a37b68c5d88f571954d8.jpg 06838a7e96d784457010a04ffb0d4939 https://staging.drfop.org/files/original/47657fbbbf25bb2870775a5111f1ae16.jpg c6bf99f27ce81525ce4a3c18d6a22984 https://staging.drfop.org/files/original/e2a1a8f0badea8e1360e71eacea7e5ae.jpg 1f9b134869c49e1a7594c8a28780e58c https://staging.drfop.org/files/original/62d143747db0eb1a6cec876a190f8120.jpg 85a7f0afcba88084e4cdc1a630c7606a https://staging.drfop.org/files/original/78e31cec1089a104b5192b24ccb1c522.jpg b7a478f3d3152aeafe4cbc46b503926f https://staging.drfop.org/files/original/a78e4e9e46e8d715eca8b5ddc28d10d1.jpg 63281a59efb08f181a317a6aae358edd DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1969_01_001.pdf Year 1969 Volume 13 Issue 1 Page Number(s) 1 - 12 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_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1969_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Amputations Below the Knee</h2> <h5>Ernest M. Burgess. M.D. <a style="text-decoration:none;">*</a><br />Joseph H. Zettl, C.P. <a style="text-decoration:none;">*</a><br /></h5> <p>The elective amputation must be considered plastic and reconstructive in nature. The need to create a dynamic and sensory motor end-organ should be foremost in the surgeon's mind in planning an amputation, and is emphasized here once more. The below-knee stump no longer hangs suspended in an open-end socket. The variable degrees of pressure and weight-bearing over the entire stump surface afforded by the total-contact patellar-tendon-bearing prosthesis enhance the surgeon's opportunity to fashion a functional terminal end-organ. Stump strength created by surgical muscle stabilization; pliable, sensitive, but nontender skin and scar; adequate soft tissue coverage of bone ends and other pressure-sensitive areas; high ligation and division of nerves to remove neuromata from pressure zones; meticulous rounding and tailoring of bone surfaces; all contribute to an ideal organ for substitute limb application. The atrophic, wasted, bony, below-knee stump so commonly encountered in years past is no longer acceptable. Stump-muscle stabilization, <i>i.e., </i>the attachment of sectioned muscles under appropriate tension to bone (myodesis) and to opposing muscles (myoplasty), is a prime requisite for dynamic stump activity. Muscle stabilization is especially needed in the through-knee and the above-knee amputee. Our experience also justifies its routine use in below-knee amputation. Muscle-to-bone suture does add operative handling of tissues and encircling sutures carry the potential of local muscle constriction. For these reasons myodesis is not recommended for use in the below-knee amputation for vascular disease. The new technique developed by the Prosthetics Research Study utilizes the long posterior myofascial flap sewn anteriorly to anterolateral deep fascia and tibial periosteum and provides a reasonable degree of muscle fixation without risk of strangulation. Muscle-to-bone suture is reserved for the nonischemic patient.</p> <h3>Nonischemic Patients</h3> <p>The optimum level for a below-knee amputation in the presence of adequate blood supply is at the junction of the middle and lower third of the leg. However, the level of amputation will often be determined by the causal pathology, including infection, the degree of scarring of the tissues, and related factors. The surgeon should save all effective length down to optimum level, consistent with providing a comfortable, nontender stump.</p> <p>A cylindrical stump shape is desired. The surgeon should think in terms of producing a "foot-like" organ at the below-knee level. The total-contact socket is the "shoe on the foot." Just as plastic surgical techniques are required in operating on the hand and foot, the same techniques of gentleness in skin and other tissue handling are applicable to amputation surgery. When viewed in this light, the amputation becomes a surgical challenge instead of a distressing surgical exercise. Immediate postsurgical prosthetic fitting not only supports and augments the dynamic approach to rehabilitation, it offers certain physical advantages, <i>i.e., </i>immobilization, appropriate continuous pressure relationships, and comfort. These benefits further justify its incorporation into the over-all management of the below-knee amputee.</p> <h4>Amputation Technique For The Nonishemic Patient</h4> <p>The patient is prepared for surgery in the usual manner. A pneumatic tourniquet is used. Short, broad fishmouth skin flaps are outlined to provide a mediolateral closure. In the nonischemic patient the flaps are fashioned approximately equal in length. It is advisable to cut the flaps long, then trim them at the time of closure to provide correct skin tension without puckering or undue tension. Skin and fascia are reflected together.</p> <p>Scarring, infection, deformity, or other unusual circumstances may necessitate modification of the skin closure. Flaps can be outlined to permit closure in any plane or direction provided the resulting scar is nonadherent, nontender, and able to withstand properly and comfortably wearing of a total-contact socket. Anterior location of the scar, condemned in the past, actually is well tolerated even in elderly patients. The application of principles of plastic surgery in skin management must prevail.</p> <p>In the average adult the tibia is transected 2 1/2 to 3 in. above the distal level of the skin incision. The fibula is divided 3/8 to 1/2<i> </i>in. higher. A reciprocating power saw facilitates clean bone section. The tibial periosteum is elevated about 3/4 in. above the cut end of the tibia and the an-teromedial angle beveled to provide a larger radius on the anteromedial aspect. Careful <i>rounding </i>of the edges with a sharp, fine-tooth file is now done. Bone surfaces must be smooth so as to eliminate the possibility of high unit pressures.</p> <p>When the muscles are to be reattached to bone, a procedure recommended where it is physiologically feasible, 4 to 6 holes not more than 7/64 in. in diameter are drilled through the lateral and posterior periphery of the tibia about 3/8 in. proximal to the distal end. Muscles are sectioned long, the gastrocnemius-soleus is left as a myofascial flap sufficiently long to bring it around the end of the tibia to the anterior surface, and nerves and blood vessels are ligated and divided, the former well above amputation level, the latter at the level of tibial section. The nerves are ligated high, as indicated, but are not pulled down so forcibly that traction-avulsion injury results proximal to ligation.</p> <p>Muscles are now sutured to the bone through the drill holes with medium braided polyester suture and tying the knots within the medullary cavity of the tibia. The loop sutures pass through the body of the major muscle groups and through deep fascia. They should be attached under moderate tension, slightly greater than rest length and therefore capable of providing maximum function. Muscle groups are now sectioned just beyond the end of the tibia except for the gastrocnemius-soleus flap which is left long, beveled, and brought over the end of the tibia as a thinned myofascial flap and sutured to anterior deep fascia and anterior periosteum. Good muscle stability and stump contour are provided by this technique. The moderately bulbous stump will rapidly contour to an ideal cylindrical shape in the rigid postsurgical dressing.</p> <p>The skin flaps are trimmed and closed with interrupted fine polyester sutures in such a manner that no tension is present, yet a firm stump without redundant tissue is provided (<b>Fig. 1</b>). Drainage of the stump is optional. We prefer a through-and-through Penrose drain; however, suction drainage is convenient and some wounds will not require any drainage.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Below-knee stump of nonischemic patient immediately after closure. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Rigid Dressing</h4> <p>The wound is covered with a saline-dampened nonadherent silk or nylon dressing and a small amount of fluffed gauze (2 to 3) is placed over the distal stump end. A sterile three-ply Orion Lycra stump sock is rolled carefully over the stump to avoid damage to the suture lines. The superior portion of the stump sock is held firmly suspended anteriorly and in a proximal direction by an assistant. A simple adjustable shoulder-suspension harness which is interchangeable for right and left can be substituted to achieve the same result.</p> <p>Relief pads of felt or polyurethane are glued to appropriate locations on the stump sock to provide relief for bony prominences. Prefabricated pads are available in a standard size, right and left, but must be trimmed, skived, and beveled in appropriate areas to suit individual requirements. The pads are designed and located to provide relief of pressures over the patella, the tibial tubercle including the tibial crest, and the distal-anterior (bevel) aspect of the tibia. Dow Corning medical adhesive is used to secure the felt relief pads in place while the polyurethane relief pads are provided with an adhesive backing. A sterile reticulated polyurethane distal pad of the proper size is selected and applied to the distal stump end over the tibial relief pads (<b>Fig. 2</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Application of distal polyurethane pad. Other relief pads are already in place. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For the initial part of the rigid dressing, elastic plaster bandage is used because, when pulled within limits of its elasticity, this bandage provides safe and beneficial compression to the stump while conforming well to its contours, providing a smooth, effective, rigid dressing.</p> <p>Before the wrap is started, the tibial relief and distal relief pads are secured in place with one-and-three-quarter turns of elastic plaster bandage (<b>Fig. 3</b>). Firm tension is applied to the distal portion of the stump from a posterior-to-anterior direction, while the plaster bandage is pulled almost to the limit of its elasticity. By supporting the posterior skin flap, tension on the suture line is reduced and the soft tissues are immobilized. The wrap is then started on the distal end and carried prox-imally to a level slightly past mid-thigh while tension is maintained in the bandage. A minimum of two layers is required. Circumferential wrapping is carried out from the lateral to the medial aspect, when viewed from the front, in order to avoid anterior displacement of the gastrocnemius (<b>Fig. 4</b>). Tension in the wrap decreases progressively as the application proceeds proximally to the level of the knee joint where it is simply rolled on up to slightly past mid-thigh. It is important to apply the dressing with firm tension to the distal portion of the stump and to avoid proximal constriction to blood flow. The knee is held in 5 to 15 deg. of flexion controlled by longitudinal tension applied to the stump sock from the proximal end. Owing to the inherent structural weakness of elastic plaster bandage, the initial wrap must be reinforced with conventional plaster bandage and splints. Two splints are applied over the distal portion of the rigid dressing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Beginning the rigid dressing by securing the tibial relief and distal relief pads in place with elastic plaster bandage. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Application of the first layers of the rigid dressing. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>A minimum of two layers of conventional plaster bandage is applied starting at the distal third and wrapping proximally with even, overlapping circular wraps (<b>Fig. 5</b>). At the proximal border of the cast a suspension strap is incorporated anteriorly. For an obese patient with excessive soft tissue over the thigh, a second suspension strap is applied posterolaterally. With the plaster of Paris still wet, the cast is gently compressed with the base of each hand just proximal to the femoral condyles to provide an effective built-in suspension mechanism.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Completed rigid dressing. Note alignment reference line. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After the plaster has hardened sufficiently, the contoured waistbelt is applied to the patient and connected to the strap or straps of the rigid dressing. The prosthetic unit is located and attached to the cast with a roll of conventional plaster bandage (<b>Fig. 6</b>). The pylon is sized and cut to correspond to the length of the sound extremity. A window is cut out of the plaster over the patella to insure complete relief in this area (<b>Fig. 7</b>). The prosthetic unit is then disconnected from the cast socket before the patient is taken to the recovery room.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Attachment of upper portion of prosthetic unit to the rigid dressing. Note alignment 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. 7. Window in rigid dressing to provide complete relief over patella, </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Postsurgical Care</h4> <p>As a rule, a minimum amount of pain is experienced by patients that have been provided with a rigid dressing. It is unusual for drugs stronger than mild opiates and sedatives to be required for relief. A slight degree of weight-bearing on the stump will usually tend to reduce any discomfort that might be present.</p> <p>The patient should be encouraged to stand up and bear some weight on the prosthesis as soon after the first 24-hour period postoperatively as is practicable.</p> <p>The time and extent of ambulation must be determined by the responsible surgeon. Walking training should be carried out only under the direction of a physical therapist or other qualified personnel. Activity should be increased daily as the patient's condition permits. Parallel bars, walkerettes, crutches, and canes are used as aids in ambulation. Two bathroom scales may be used to determine the degree of weight-bearing that is taken on the amputated side. These measurements provide a good guide to the clinic team concerning the progress being made by the patient. The patient should never be allowed to ambulate without supervision. Furthermore, ambulation should not be permitted without the prosthesis because in this case the effect of gravity tends to pull the socket away from the stump, thereby reducing the pressure between stump and socket.</p> <p>On the second postoperative day (48 hours after surgery) the drain is removed. If there does not appear to be any reason for removing the cast, such as elevated body temperature, extreme discomfort, or excessive looseness of fit, the cast is kept in place up to 14 days. If for any reason the cast is removed, whether intentionally or unintentionally, it is mandatory that, if a new cast is indicated, it be applied immediately. During the first two postoperative weeks edema will form rapidly upon removal of the cast and, unless a new cast is reapplied within a very short period, the patient will have to be treated in the conventional manner. The old cast should never be reapplied because of the trauma that is apt to result. When the socket is removed purposely, a cast cutter is used. Often the sutures can be taken out at the time of removal of the first cast, 10 to 14 days after surgery. Sometimes it is necessary to wait until removal of the second cast, 15 to 20 days postoperatively.</p> <p>In many instances the stump will be sufficiently mature and stable for use of a definitive prosthesis at the time the second cast is removed. When this is so, a cast of the stump is taken and appropriate measurements are recorded so that fabrication of a permanent prosthesis can proceed immediately. When the definitive prosthesis is delivered, a light plaster socket mobilizing the knee joint is provided for use when the definitive prosthesis is removed. Use of a plaster socket has proven to be superior to elastic bandages to prevent edema. If delays are anticipated in providing the patient with a definitive prosthesis, the prosthetic unit, pylon, and foot are applied to the short cast to continue ambulation activities.</p> <h3>The Ischemic Patient</h3> <p>Throughout the United States and Canada an estimated 80 per cent of all major, elective, civilian amputations result from ischemia. All but a relatively few involve the lower extremity. Significant advances in surgical and postsurgical management coupled with the use of improved prostheses now allow amputation below the knee in the great majority of these patients.</p> <p>It is difficult to overestimate the importance of the knee in amputee rehabilitation, especially in the older, classical ischemic patient. Debility, impaired vision, poor balance, neuropathy, compromised circulation and joint function in the remaining lower limb, and chronic systemic illness, all emphasize the critical need to save the knee. The older bilateral leg amputee, especially, needs his knees to approach the rehabilitation goal that permits a reasonable degree of ambulation and self-sufficiency. In a consecutive series of 128 unselected major lower-extremity amputations for peripheral vascular disease (1964 through 1968), we have been able to obtain primary healing at below-knee level in 86 per cent. Once healed, the stumps remain healed. With adequate prosthetic care, secondary breakdown will seldom occur. These patients were among the approximately 300 cases requiring amputation of the lower extremity that were used in studying and developing the techniques of fitting prostheses immediately after surgery. As a result of these experiences, separate surgical techniques have been developed for the ischemic patient and for the nonischemic patient.</p> <h4>Level Of Amputation</h4> <p>The great achievements in surgical reconstruction of the peripheral vascular system represent a leading chapter in medical progress during the past two decades. Continuing basic and clinical research throughout the world supports the hope that an even higher percentage of limb salvage can be expected in the years ahead. However, despite the practical effectiveness of modern vascular reconstructive surgery, statistics indicate that amputations for ischemia are increasing both relatively and absolutely in relation to population throughout the western world.</p> <p>When acute or chronic compromise of arterial blood supply reaches a level insufficient to support tissue viability and when reconstructive surgery and nonsurgical supportive measures fail, amputation will be required.</p> <p>Patients requiring amputation are entitled to comparable medical and surgical consideration, comparable team effort, and the same high-level rehabilitation management attending similar patients whose ischemic limbs are treated by vascular reconstruction. Too often, ablative surgery does not command this high estate.</p> <p>Decision to amputate may be simple and evident. Gross necrosis of tissue with demarcation, uncontrollable infection, pain, irreversible neuropathy, alone or in combination, and with results of specific tests to assay circulation, will establish the need to amputate. When all available information poses a serious question as to the possibility of limb salvage by reconstructive surgery rather than amputation, it has been common practice to attempt such surgery, even though extensive. Before questionable extensive reconstructive arterial surgery is carried out, the surgeon should consider critically the overriding probability of its failure with mandatory subsequent amputation. Will the proposed surgery compromise the level of amputation? Will amputee rehabilitation be additionally complicated by further deterioration of general health incident to the extensive surgical attempt at limb salvage? On a number of occasions, below-knee amputations have been performed in ischemic patients who were being considered for possible vascular surgical treatment but in whom, after review of all available information, such surgery might well have damaged the existing blood supply to a degree that an above-knee amputation would then have been required. It is important that the responsible surgeon understand the great rehabilitation value of the knee and weigh all facts relevant to the rehabilitation potential.</p> <p>There is no single test or combination of tests now available that will demonstrate specifically the lowest effective amputation level. Successful below-knee amputations have been obtained repeatedly in patients whose arteriograms indicated complete occlusion of the superficial femoral artery.</p> <p>A careful physical examination is the first requisite in determination of the level of amputation. Appearance of the soft tissues, temperature of the skin, the presence or absence of edema after elevation, growth of hair, level of sensation and acuity, together with palpation of pulses, are all important and cannot be supplanted by laboratory data. Arteriography, plethysmography, thermography, and a number of other objective techniques are useful. These include skin mapping with interar-terial fluorescein, the use of radioactive Xenon #133, and transcutaneous ultrasonic Doppler recordings. Each adds to the available information and assists in level determination. Old established guidelines for determining amputation level are not valid when weighed against recent experience.</p> <p>Unless it is <i>clearly evident </i>that a through-knee or above-knee amputation will be required, the surgeon should prepare the leg for both below-knee and above-knee amputation. Incisions through the skin and muscle preparatory to belowknee surgery can then be carried out quickly.</p> <p>Bleeding and tissue viability can be observed directly and the final decision can now be made as to the level of amputation. Only a few minutes are added to the operative time should one elect the above-knee or through-knee level.</p> <h4>Amputation Technique For The Ischemic Patient</h4> <p>No tourniquet is used. The leg is draped free with the patient supine. Open and infected areas are walled off and shielded by sterile adherent plastic drapes prior to skin preparation. The level of amputation is 3-1/2 to 5 in. below the knee, <i>i.e., </i>a short below-knee stump (<b>Fig. 8</b>). It has been recognized for many years that skin over the posterior leg has better blood supply than that anterior and anterolateral, and a long posterior and a short anterior skin flap are now used routinely. A long anterior flap, or even equal anterior and posterior flaps, should be avoided. The anterior scar resulting from use of a long posterior flap poses no problem in fitting the prosthesis. The modern total-contact below-knee prosthetic socket can accept a stump with scar placement in any position, provided it is nonadherent, well-healed, and nontender, and it is now standard policy in the Prosthetics Research Study to place the scar wherever it will heal most advantageously.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Left, stump of 33-year-old patient on 26th day after amputation because of infection owing to nonunion of the tibia. Right, permanent prosthesis provided same patient on 26th day postoperative. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The anterior skin flap is fashioned approximately at the level of anticipated tibial section. The posterior flap must then be 5 to 6 in. longer to provide proper skin coverage without undue tension (<b>Fig. 9</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Outline of skin flaps for below-knee amputation on typical ischemic patient. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After outlining the skin flaps, dissection is carried down through the deep fascia to the tibia. The periosteum is incised and stripped proximally 1 in. The anterolateral muscles are divided down to the intermuscular septum; blood vessels and nerves are ligated appropriately and severed; and then the tibia and fibula are sectioned, preferably with a power saw. The fibula is cut no more than 3/8 to 1/2 in. above the level of the tibia. Soft tissues are dissected from the posterior aspect of the tibia and fibula down to the level of the posterior transverse division of skin. The leg is then separated and removed. The tibia is very carefully rounded with a short bevel over its anterior and medial aspects. It is important that no rough bone areas or ridges remain. A long bevel is specifically avoided. Nerves are pulled down and sectioned high with a sharp knife. They are not injected, crushed, or cauterized. The major nerves are ligated with a fine suture just above the site of division before the division is made. Encircling suture controls oozing from the blood supply that accompanies the nerve, and it also appears to localize neuroma formation and to lessen overgrowth and adherence to adjacent structures. The posterior muscle mass consisting of the gastrocnemius-soleus and deep flexor group is now beveled and tailored to permit the entire muscle flap to come forward and be sewn anteriorly to the deep fascia of the anterolateral muscle group and to the reflected periosteum over the anterior tibia. Contouring and trimming of the gastrocnemius medially and laterally gives a smooth musculofascial flap stabilized over the end of the bones. The skin is then brought up and closed without subcutaneous suture (<b>Fig. 10</b>). Medial and lateral "dog ears" are contoured moderately. They should not be taken back sufficiently to disturb skin circulation. The immediate postsurgical socket rapidly shapes the stump including moderate skin irregularity at the medial and lateral angles. The wound is drained deep to the muscle flap, <i>i.e., </i>to bone. Through-and-through drain or suction drainage may be used. An immediate postsurgical rigid dressing and prosthesis are then applied.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Below-knee stump of typical ischemic patient showing position of suture line. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Postsurgical Care</h4> <p>Drains are removed 48 hours after surgery. If the patient's general condition permits, ambulation with guarded weight-bearing is begun 24 to 48 hours following surgery. The advantages of upright activity with limited stance and gait are obvious. However, only touch-down weight-bearing not exceeding 25 lb. is allowed until the initial cast is changed. Personnel in charge of the patient should be instructed carefully as to their responsibility in preventing the patient from bearing excessive weight or from falling.</p> <p>The postsurgical management with an immediate prosthesis has resulted in much less pain than previously encountered. Postoperative pain is generally of a diffuse aching type. Complaint of localized pain almost always indicates abnormal pressure and requires inspection of the stump and change of the socket. Unless complications develop, <i>i.e., </i>evidence of infection, excessive loosening of the socket, or severe pain, the initial rigid dressing should be left intact until the time of anticipated suture removal, usually two to two-and-one-half weeks following surgery. The cast is then removed, with the patient under sedation but not anesthesia, the wound is inspected, sutures are removed if indicated, and a new temporary prosthesis is applied. By this time the patient is usually ready for unsupported crutch ambulation and discharge from the hospital. A temporary prosthesis is worn continuously until a definitive limb is provided. Ordinarily the final limb can be fabricated, fitted, and worn four to five weeks following below-knee amputation. Typical ischemic patients are shown in <b>Fig. 11</b> and <b>Fig. 12</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. A 69-year-old, white male had multiple difficulties consisting of arteriosclerosis obliterans with complete right superficial femoral occlusion, diabetes mellitus, arteriosclerotic heart disease with mitral insufficiency, and coronary occlusion. No reconstructive vascular surgery was considered to be feasible. The preoperative condition of his foot is indicated on the left. Good stump healing was achieved by the 25th postoperative day, center. The definitive prosthesis was applied on the 28th postoperative day, right. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. A 73-year-old, white female with severe chronic peripheral vascular disease without diabetes. Two attempts at femoral popliteal bypass graft had been made in the three weeks prior to "breakdown" of the graft operative sites. Progressive gangrene of the foot had ensued with demarcation just above the ankle level. Figure in upper left shows the appearance of the leg prior to amputation. A short below-knee level of amputation was selected and a long posterior musculocutaneous flap developed, upper right. The appearance of the below-knee stump at 19 and 29 days following surgery is indicated in the lower figures. The definitive prosthesis was fitted on the 32nd postoperative day. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Necrosis of skin flaps can result from either inadequate blood supply or undue pressure. If the level of amputation is so low that the blood supply is insufficient to support a below-knee amputation, it will be evident at the initial cast change. The decision then to amputate at a higher level should be made promptly. Re-amputation rate in the PRS series to through-knee or above-knee over the four-year period has been 9.4 per cent. As experience and techniques have improved, the re-amputation rate for below-knee cases with ischemia has continued to decrease. The surgeon, of course, likes to avoid all re-amputations. However, salvage of the knee is of such paramount importance that an occasional re-amputation may be required if we are to save all knee joints possible in view of our inadequate means for determining the best level for amputation.</p> <h3>Summary and Conclusions</h3> <p>Below-knee amputation is statistically by far the most important major amputation used today. The vast majority of major lower-extremity amputations performed for ischemia will heal primarily and remain healed at below-knee level. The below-knee amputation for ischemia is short in length, the posterior skin and myofascial flaps are fashioned long, and the technique is precise. The resulting stump is cylindrical in shape, well-padded, comfortable, and easily fitted with modern below-knee prostheses of the total-contact type. An immediate postsurgical prosthesis is an integral part of the over-all below-knee amputee management in both the ischemic and nonischemic patient. Restoration of function and rehabilitation of the below-knee amputee, both unilateral and bilateral, have improved in almost spectacular fashion when the guidelines and management which have been outlined are followed.</p> <p><b>References:</b></p> <ol> <li>Baddeley, R. M., and J. C. Fulford, <i>The use of arteriography in conservative amputations forlesions of the feet in diabetes mellitus</i>, Brit. J. Surg., 51:633-658, September 1964.</li> <li>Berlemont, M., <i>Notre experience de I'appareillageprecoce des amputes des membres inferieursaux Etablissements Helio-Marinsde Berck</i>, Ann. Med. Phys., Tome IV, No.4, October-November-December 1961.</li> <li>Berlemont, M., <i>L'appareillage des amputes des membres inferieurs sur la table d'operations,paper given at the International Congress of Physical Medicine</i>, Paris, 1964.</li> <li>Bickel, William H., <i>Amputations below the knee in occlusive arterial disease</i>, Surg. Clin. N. Amer., Mayo Clinic Number, August 1943.</li> <li>Bickel, William H., and R. K. Ghormley, <i>Amputations below the knee in occlusive arterial disease</i>, Proc. Mayo Clinic, 18:361, 1943.</li> <li>Block, M. S., and F. W. Whitehouse, <i>Below knee amputation in patients with diabetes mellitus</i>, Arch. Surg., 87:682-689, October 1963.</li> <li>Bradham, R. R., and R. D. Smoak, <i>Amputations of the lower extremity used for arteriosclerosis obliterans</i>, Arch. Surg., 90:60-64, January 1965.</li> <li>Burgess, Ernest M., <i>The below-knee amputation</i>, Inter-Clinic Inform. Bull., 8:4, January 1969.</li> <li>Burgess, E. M., and R. L. Romano, <i>The management of lower extremity amputees using immediate postsurgical prostheses</i>, Clin. Orthop., 57:137-146, 1968.</li> <li>Burgess, E. M., and R. L. Romano, <i>New day for leg amputees</i>, Rehab. Rec, July-August 1965.</li> <li>Burgess, E. M., and J. H. Zettl, <i>Immediate postsurgical prosthetics</i>, Orthop. Pros. Appl. J., June 1967.</li> <li>Burgess, Ernest M., Joseph E. Traub, and A.Bennett Wilson, Jr., <i>Immediate postsurgical prosthetics in the management of lower extremity amputees</i>, Prosthetic and Sensory AidsService, U.S. Veterans Administration, 1967.</li> <li>Compere, Clinton L., <i>Early fitting of prosthesis following amputation</i>, Surg. Clin. N. Amer., 48:1:215-226, 1968.</li> <li>Dederich, Rolf, <i>Die muskelplastische Stumpfkorrektur</i>, Zentralbl. Chir., 81:29:1194-1206, 1956.</li> <li>Dederich, Rolf, <i>Plastic treatment of the muscles and bone in amputation surgery</i>, J. Bone Joint Surg.,45B:l:60-66, February 1963.</li> <li>Eraklis, A., and W. Brownell, <i>Below knee amputations in patients with severe arterial insufficiency</i>, New Eng. J. Med., 269:938-942, October 1963.</li> <li>Ertl, Johann, <i>Uber Amputationsstumpfe</i>, Chirurg, 20:218-224, May 1949.</li> <li>Glattly, Harold W., <i>A preliminary report on the amputee census</i>, Artif. Limbs, 7:1:5-10, Spring 1963.</li> <li>Golbranson, F. L., Charles Asbelle, and Donald Strand, <i>Immediate postsurgical fitting and early ambulation</i>, Clin. Orthop., 56:119-131, 1968.</li> <li>Guthrie, G. J., <i>A treatise on gun-shot wounds</i>, Ed. 2, Burgess and Hill, London, 1820.</li> <li>Harris, P. D., S. I. Schwartz, and J. A. DeWeese, <i>Midcalf amputation for peripheral vascular disease</i>, Arch. Surg., 82:381-383, March 1961.</li> <li>Hey, William, <i>Practical observations in surgery</i>, Ed. 3, Cadell and Davies, London, 1814.</li> <li>Hoar, C. S., Jr., and J. Torres, <i>Evaluation of below-the-knee amputation in the treatment of diabetic gangrene</i>, New Eng. J. Med., 266: 440-443, March 1962.</li> <li>Jansen, Knud, <i>Amputation, a manual of principles and methods</i>, World Veterans Federation, Paris, 1965.</li> <li>Kelly, P. J., and J. M. Janes, <i>Criteria for determining the proper level of amputation in occlusive vascular disease: A review of 232 amputations</i>, J. Bone Joint Surg., 39A:833-891, July 1957.</li> <li>Kendrick, R. R., <i>Below knee amputation in arteriosclerotic gangrene</i>, Brit. J. Surg., 44:13-17, July 1956.</li> <li>Loon, Henry E., <i>Below-knee amputation surgery</i>, Artif. Limbs, 6:1:86-99, June 1962.</li> <li>Loon, Henry E., <i>Biological and biomechanical principles in amputation surgery</i>, Prosthetics International, Committee on Prostheses, Braces, and Technical Aids, International Society for the Welfare of Cripples,Copenhagen, 1960.</li> <li>Mondry, F., <i>Der Muskelkraftige Ober-und Unterschenkelstumpf</i>, Chirurg, 23:517-519, November 1952.</li> <li>Murphy, Eugene F., and A. Bennett Wilson, Jr., <i>Anatomical and physiological considerations in below-knee prosthetics</i>, Artif. Limbs, 6:2:4-15, 1962.</li> <li>Pedersen, Herbert E., <i>Lower extremity amputations for gangrene</i>, The American Academy of Orthopaedic Surgeons Instructional Course Lectures, 15:262, 1958.</li> <li>Pedersen, H. E., R. L. LaMont, and R. H. Ramsey, <i>Below-knee amputation for gangrene</i>, Southern Med. J., July 1964. Reprinted in Orthop. Pros. Appl. J., 18:281- 287, December 1964.</li> <li>Radcliffe, C. W., and James Foort, <i>The patellar tendon-bearing below-knee prosthesis</i>, Biomechanics Laboratory, University of California. Berkeley and San Francisco, 1961.</li> <li>Robb, H. J., L. F. Jacobsen, and B. Jordan, <i>Midcalf amputation in the ischemic extremity: Use of lateral and medial flap</i>, Arch. Surg., 91:506-508, September 1965.</li> <li>Rosenberg, N., <i>Midleg amputation in patients with necrotic leg muscles</i>, Arch. Surg., 81:614-617, October 1960.</li> <li>Silbert, Samuel, <i>Mid-leg amputations for gangrene in the diabetic</i>, Ann. Surg., 127:503, 1948.</li> <li>Slocum, D. B., <i>An atlas of amputations</i>, C. V. Mosby, St. Louis, 1959.</li> <li>Smith, B. C,<i> Amputation through lower third of leg for diabetic and arteriosclerotic gangrene</i>, Arch. Surg., 27:267, 1933.</li> <li>Tillgren, C., <i>Obliterative arterial disease of the lower limbs: A study of the course of the disease</i>, Acta Med. Scand., 178:103-119, July 1965.</li> <li><i>Manual of below-knee prosthetics</i>, University of California, San Francisco, Biomechanics Laboratory, November 1959.</li> <li>Weiss, Marian, personal communication and demonstration, Konstancin Rehabilitation Hospital, Poland, 1964.</li> <li>Weiss, Marian,<i> Neurological implications of fitting artificial limbs immediately after amputation surgery</i>. Report of Workshop Panel on Lower-Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February 1966.</li> <li>Weiss, Marian, <i>Myoplasty—immediate fitting—ambulation, paper presented at the Sessions of the World Commission on Research in Rehabilitation</i>, Tenth World Congress of the International Society, Wiesbaden, Germany, September, 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>Joseph H. Zettl, C.P. </b></td></tr><tr><td class="clsTextSmall">Director, Prosthetics Research Study, Seattle, Wash.</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>Ernest M. Burgess. M.D. </b></td></tr><tr><td class="clsTextSmall">Principal Investigator, Prosthetics Research Study, Seattle, Wash., and Director of Amputations and Congenital Defects Service, Children's Orthopedic Hospital, Seattle, Wash. This study was conducted under Contract V5261P-438 with the Veterans Administration.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1969_01_001/spring69-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1969_01_001/spring69-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1969_01_001/spring69-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1969_01_001/spring69-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1969_01_001/spring69-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1969_01_001/spring69-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1969_01_001/spring69-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1969_01_001/spring69-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1969_01_001/spring69-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1969_01_001/spring69-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1969_01_001/spring69-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1969_01_001/spring69-12.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Amputations Below the Knee Creator An entity primarily responsible for making the resource Ernest M. Burgess. M.D. * Joseph H. Zettl, C.P. * https://staging.drfop.org/files/original/baa690570cdf9103498cc78a51072780.pdf efeb1aaeccfa288eeec9bc5ecd38a00c https://staging.drfop.org/files/original/02116dc22518c1eb39c68be56eeadcbe.jpg 8a184304fcba8cc4b1780900d847a8a3 https://staging.drfop.org/files/original/5d633c5174ca141632fa4a4f1e21747b.jpg 5e04ded931d40f7f74cd630cd3fa88fd https://staging.drfop.org/files/original/d54d587bc683285e12a948e28325014e.jpg 7ac002016da544b27b8905e5ce7e190c https://staging.drfop.org/files/original/2d411a366a5894b21122ede2a2d07a78.jpg c37bdd60e381a074882dba174d8ebb45 https://staging.drfop.org/files/original/b3276065c28d0d1acc9bd4fbbc1682bd.jpg 161db3ea42e5ab5ea0b8020149c71991 https://staging.drfop.org/files/original/634383156fceaec626e209462b0523ec.jpg 846701e1d084860d18e51ec6f7c5a191 https://staging.drfop.org/files/original/3534840b8b9014b939dcf553b7d798a6.jpg 4ccf1cb63eb1401e3b40b6c3e79e7463 https://staging.drfop.org/files/original/cd15263c33b6e8fe70f3974c54e1df63.jpg 0ea4cec660c63647ee6e63d27d767ee7 https://staging.drfop.org/files/original/5b000331efb05bcdc1dbbad2cfa91b16.jpg 3ca6176c57505618b576214526d5f2fd https://staging.drfop.org/files/original/721dba1469c7361d052d71dc63510353.jpg 45e5a147daaf98d9a8290c41165c37e9 https://staging.drfop.org/files/original/1693caaecd751197fb1a87e816bd59c1.jpg b812afdf152beffe304e924d2710b595 https://staging.drfop.org/files/original/7790ac1614e11c427aa22f45d0c2dd52.jpg 073ddc987fa51b9507a6a6c4ab2381e6 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_02_004.pdf Year 1955 Volume 2 Issue 2 Page Number(s) 4 - 21 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_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_02_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Anthropology and Social Significance of the Human Hand</h2> <h5>Ethel J. Alpenfels, D.Sc. <a style="text-decoration:none;">*</a><br /></h5> <p>A definitive study of the anthropology of the human hand has yet to be written. Certain investigators, notably Krogman<a></a>, Schultz<a></a>, Ashley-Montagu<a></a>, Clark<a></a>, and Huxley<a></a>, have done intensive work on specific aspects of the morphology of the human hand. Nevertheless, the paucity of published studies, the fragmentary nature of the research, and the failure to attempt any but the most general conclusions make it difficult to summarize in a short article the present status of the hand in human evolution. Authorities differ both in opinion and in practice as to the value of anthropometric measurements in tracing the lines along which specialization has moved in the evolution of the hand. Published materials on the social significance of the hand are, however, numerous, and the importance of the hand as an organ both of performance and of perception has been recognized in all fields of the social sciences.</p> <p>Man alone has a hand. He uses it as a tool, as a symbol, and as a weapon. A whole literature of legend, folklore, superstition, and myth has been built up around the human hand. As an organ of performance it serves as eyes for the blind, the mute talk with it, and it has become a symbol of salutation, supplication, and condemnation. The hand has played a part in the creative life of every known society, and it has come to be symbolic or representative of the <i>whole </i>person in art, in drama, and in the dance. Students of constitutional types have used the hand as a means of classification, and the correlation between mental ability and manual dexterity has been the subject of much research. At the University of Pennsylvania, Krogman, using x-rays of the hand, currently is demonstrating new and important aspects of the interrelation of a child's growth and mental age. Thus the hand, perhaps because it is also dominant in the world of action, has come to be interpreted and understood best in its social aspects.</p> <p>But in a sense the human hand is a paradox. Although it is said to be the highest achievement of primate evolution, research to date shows it to be no more than a variation of a primitive vertebrate plan. The successive stages of evolution give proof, if proof be needed, that our sensitive and mobile hands, with their opposable thumbs, are part of man's vertebrate ancestry.</p> <p>In the suborder Lemuroidea, both recent and extinct, are found pawlike hands. The fourth digit<a style="text-decoration:none;">*</a> is elongated and, together with the first digit, acts like a pair of pincers to grasp a bough. Hooten<a></a> has pointed out that this is an adaptation found in all the lemurs, enabling them to maintain a more secure hold on boughs of large diameter. In lemurs, all of the digits are flat-nailed (except in the aye-aye, which has kept a number of primitive anatomical features), and several modifications appear in the carpal pattern. <b>(Fig. 1)</b></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. One conventional method of identifying the digits of the hand. Some authorities prefer to think of the hand as possessing a thumb and four fingers. Both methods of nomenclature occur throughout this issue of Artificial Limbs. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the suborder Tarsioidea, entirely arboreal, specialization of the hind limbs for hopping frees the hands not only for grasping but for feeding as well. The hind limb is longer than the forelimb, all of the terminal phalanges are flat-nailed, and the terminal digital pads have curious discs, almost like suction cups, enabling the tarsier to support himself on a smooth surface.</p> <p>These and other adaptations foreshadow higher primate development (<b>Fig. 2</b>), but we must look further to find man's place in the primate scheme. The suborder Anthropoidea, the third and highest of the primate group, includes larger arboreal forms. Longer fore limbs, together with a relatively shorter thumb (approaching atrophy in some forms), provide a means of brachiation. It has been suggested that the short thumb is related to the specialization of the hand as a grasping mechanism, permitting a quick release of the hand in swinging from one branch to another. But in this suborder the hands still retain their primitive features, and only in certain of the Old World Monkeys do the proportions of the digits approach those of man. The emancipated hands of the anthropoids, with thumbs that rotate and oppose the other finger tips, are directed by a more complex nervous system and a larger and better developed brain. Liberation of the hand may have been one of the decisive forces in the descent of certain anthropoids to the ground.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Comparative proportions (not relative size) of the hands of man and of certain related ancestral forms. Top row, left to right, hands of a tarsier, of a lemur, and of a Rhesus monkey. Bottom row, left to right, hands of a chimpanzee, of a human with atypical simian characteristics, and of normal man. In all cases except that of the lemur, the digital formula is 3 &gt; 4 &gt; 2 &gt; 5 &gt; 1. From Jones<a></a>, by permission of Bailliere, Tindall, and Cox, Ltd. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Evolution of the Hand</h3> <h4>Links with the Past</h4> <p>Man's hand retains the ancient pentadactyl pattern found in early vertebrates. Geological records show that, during the Devonian period of Silurian times, primitive sharks appeared having typical paired fins corresponding to the paired limbs in man, and these organs were destined to give rise to later and higher forms. But there is a great difference belween the paired limbs of the early forerunners of present-day fishes and the pentadactyl limbs of other vertebrates. All of the steps are not yet clear, and the gap between the ancient fishes and the amphibians has not yet been bridged, but it appears that in the early amphibians the migration from water to land led to adaptations and modifications, especially in the area of the shoulder and pelvic girdles.</p> <p>These early ancestors of the primates had short legs, which grew progressively longer in the mammalian stage<a></a> and they walked flat-footed. The ability of the limbs to rotate brought about changes in the entire body. Striking homologies can be found in the hand and arm of man, the wing of a bat, and the foreleg of the frog. Where there are fewer digits, as in the hoof of the horse or the wing of the bird, the reduction has been due to adaptation to special environmental conditions.<a></a> Such reductions make for greater speed in the specialized limbs of the horse.</p> <h4>Upright Posture and Differentiation</h4> <p>The release of the hand from the requirements of locomotion, accompanied by the specialization of the foot and hind limbs for that purpose, led to upright posture (<b>Fig. 3</b>). Evidences of divergent evolutionary trends in the primate order are clearly distinguishable in the primate hand, especially those relating to limb length and trunk length (<b>Fig. 4</b>). Only the mountain gorilla has a hand shorter than that of man, not only with respect to limb length but in relation to trunk length. The longest hands among the great apes are those of the gibbon, the orangutan, and the chimpanzee. Specialists in the evolution of the hand have attributed the long, slender hands of these genera to brachiation and suspension, behavior that elongates not only the arms but, the hands as well, especially the fingers and the metacarpal bones.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The evolution of the hand (top row) and foot (bottom row), as revealed in skeletal structure. A, a primitive reptile; B, C, mammal-like reptiles; D, a lemur, representing a primitive mammalian type; E, man. Note the reduction in the number of joints in the toes, the specialization of the proximal ankle bones in mammals, some reduction in the number of wrist and ankle bones, and the variations in the thumb and great toe From Romer<a></a>, by permission of The University of Chicago Press </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig 4. Exact diagrammatic front views of the four largest primates at fully adult age, drawn from detailed measurements on actual specimens, hair omitted, and all reduced to the same trunk height. From Romer<a></a>, by permission of The University of Chicago Press. Originally constructed by A. H. Schultz. Note that, from orang to chimp to gorilla to man, both limb length and hand length generally decrease with respect to trunk height. Only the gorilla has a hand shorter than that of man. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As for the length of the thumb, man andthe other great apes show sharp divergence, especially when the thumb is considered with respect to hand length. As contrasted with the short thumb of the anthropoid apes, man's thumb is long and well developed. Attempts to explain this difference have led to an either-or position. Either the thumbs of the apes have atrophied as a result of their arboreal life or man's thumbs have lengthened in the evolutionary process.</p> <h4>The Shoulder and Upper Arm</h4> <p>In man the shoulder and upper arm are adapted for strength. As for the other portions of the arm down to and including the hand, the more distal the part the more it is adapted for complex and delicate functions and the less for strength. The pectoral girdle in man consists of three bones. The scapula is directed dorsally, the coracoid process extends forward and downward to meet the sternum, and, anterior to the coracoid, the clavicle connects scapula and sternum. Because the pectoral girdle is not joined directly to the spine, though it may articulate with the sternum, the structure permits great freedom of motion in the shoulder area. Briefly, the human arm, supported and controled by a large number of muscles, together with the elbow and wrist joints, gives freedom to a hand that has become the willing servant of the human intellect.</p> <h4>Man's Opposable Thumb</h4> <p>The powerful and well-developed thumb of man is one of his few uniquely human characteristics. Through successive stages of vertebrate evolution, the thumb has separated from the other fingers and developed specialized musculature. In the Anthropoidea, the feature of opposability led to greater tactile and exploratory facility. Man's thumb, comparatively twice as long as that of some of the anthropoids, reveals a steady increase in absolute and relative length (<b>Fig. 2</b> and <b>Fig. 4</b>) and, at the same time, the steady development of opposability, extensibility, and flexibility. When the "hand" of the ape is compared with the hand of man it becomes, in the words of Krogman<a></a> a "misnomer." In the ape, hands are hands by definition only. Although man's hand, the end-product of our evolutionary development, retains the basic, primitive, pentadactyl pattern common to all land vertebrates, it nevertheless is uniquely human. The earliest animal footprint known (from the Permian of the Tambach in Thuringia) is so similar in appearance to that of the human hand that the animal which left the fossil print was named "Cheirotherium," or the "handbeast" <a></a></p> <h4>Variations of the Human Hand</h4> <p>The morphological pattern of man's hand shows its affinity to the "hands" of other animals. But while man has kept the primitive pattern, other animals have specialized. In birds, for example, the hand has become a wing, in the horse a hoof, in the whale a flipper, in the dog a paw, and so on. According to Hooton<a></a>, Crawford has demonstrated the difference between tool-using, as in man, and tool-growing, as in most animals. Animals use no tools other than those developed out of the materials furnished by their own bodies. Man, however, was<a></a> "the first animal to grow a limb outside himself by making tools out of wood and stone." Furthermore, the limbs of animals are specialized for single purposes only. The horse can run, the mole can dig, but neither can climb; man makes instruments that are imitations of the body tools of other animals a digging stick, an awl, a scraper, or a dagger.<a></a> The power and versatility of the human hand rests, in part, upon its generalized pattern. But it is the human brain, with its intricate and elaborated nervous system, that coordinates man's eye and hand. Thus, man is born with a hand free to do the bidding of his expanded brain.</p> <h3>The Anthropometry of the Hand</h3> <h4>Early Studies</h4> <p>The past fifty years have seen a gradual increase in the literature devoted to the anthropometry of the human body. But until that time, individual investigators had gone their separate ways, and there was little concurrence on standardization of the measurements to be employed, on the way in which these measurements were to be taken, or on the instruments to be used. Furthermore, just as in the osteological studies conducted in anthropological museums, early research on living animals was devoted largely to the head and facial features, and only later was study extended to the remainder of the body. Hence the dearth of anthropometric studies on the hand is easy to understand. Lacking, also, are routine osteometric recordings and systematic measurements and indices that could provide the comparative anatomical data necessary for a definitive work on the evolution of the human hand.</p> <h4>The Lack of Data</h4> <p>Authorities appear to agree that no part of the human body has been as neglected as has the hand.<a></a> The reasons for this situation are many, but perhaps the most important one is the scarcity of fossilized primate hands, probably owing to the fact that these bones are small, fragile, and easily destroyed by the action of the forces of nature. Nor are the anthropological collections of complete hands of the modern anthropoids anywhere near adequate. During the past few years, individual investigators and museums have been attempting to increase the number of complete hands available for study, but the collections still are quite inadequate. Moreover, as was demonstrated at the University of Chicago, skeletons often turn out to be composites of many separate individuals and, therefore, of little use in anthropometric studies.<a></a> These handicaps, together with the complexity and the extreme variations found in the human hand, make it exceedingly difficult to get accurate results.</p> <h4>The New Focus</h4> <p>The early work in comparative anthropometry was devoted entirely lo race differentiation.<a></a> At the present time, however, that interest is lagging, and extensive growth studies of the epiphyseal closures of the metacarpals and the phalanges are being conducted at the University of Pennsylvania.<a></a> The x-ray technique, used for many years, has become the major tool by means of which the anthro-pometrist and anatomist can study living persons. It is dependable and important, especially in studying the highly differentiated parts of the human hand.</p> <h4>Classification</h4> <p>The morphology of the hand has proved useful in classifying hand types. Wechsler's system<a></a> is based upon four hand dimensions (<b>Fig. 5</b>). From all possible combinations of length and three breadths, he derives six index categories, as shown in <b>Table 1</b>. Thus, the long, narrow hand type in man would be, for example, 1-1-1-2-4-3, that of the short, broad hand 4-4-4-4-4-4.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Hand measurements according to Wechsler. From Krogman<a></a>, by permission of Ciba <i>Symposia</i>. </p><ol> <li><i>Stylion radiale, </i>at tip of radial styloid process.</li><li><i>Stylion idnare, </i>at tip of ulnar styloid process.</li><li><i>Interslylion, </i>mid-point of line connecting 1 and 2.</li><li><i>Daclylion III, </i>at tip of third finger.</li><li><i>Metacarpale radiale, </i>at metacarpophalangeal junction of index finger.</li><li><i>Metacarpale ulnare, </i>at metacarpophalangeal junction of little finger.</li><li><i>Proxindicion, </i>at proximal interphalangeal junction of index finger.</li><li><i>Ulnoquintion, </i>at intersection on ulnar side of little finger of line perpendicular <i>[sic] </i>to length dimension, drawn from 7.</li><li><i>Dislindicion, </i>at distal interphalangeal junction of index finger.</li><li><i>Ulnoquartion, </i>at intersection on ulnar side of ring finger of line perpendicular <i>[sic] </i>to length dimension, drawn from 9.</li></ol> <p></p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1 </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Handedness in Man</h3> <h4>Right and Left - Good and Evil</h4> <p>The cultural world in which man lives, both in preliterate and in technologically advanced societies, tends to be a "right-handed" world. Cross cultural studies reveal that different sides of the body, the left or the right, are associated with different social activities. In India, the right side and the right hand perform tasks considered to be "clean," while the left side and the left hand perform tasks considered to be "unclean." The two types of activities are separated rigidly. The right hand, for example, is used for cooking and eating, whereas the left hand is used in bathing, elimination, or activities associated with sex. Indeed, it is common in many areas of the world to find food related to the right hand, while the left hand is associated with sex.<a></a></p> <p>The right and left hand have come to symbolize good as opposed to evil, gods as opposed to demons. Hence, they are considered as two forces constantly at war with one another. The shadow plays of the Balinese illustrate the widespread association of good and evil with the right and left side respectively. The mystic story teller takes the marionettes out one by one, placing the "good" and "noble" characters at his right side and, at the left, the "evil" and "sinister" characters. In the end, truth and goodness always win, which demonstrates the triumph of the magical powers of the right side. At all important life crisesbirth, death, marriage, initiation ceremoniesthis magic balance between left and right is maintained. Among the Tiv of Nigeria, the afterbirth of a boy child is always buried to the left of the door in order to propitiate the evil spirits residing there. In Bali, a boy's placenta is buried on the right and a girl's on the left side of the entrance to the house.<a></a></p> <h4>Caste and The Hand</h4> <p>The symbolism of the hands in ceremonial rites has, in various ways, come to indicate social class and caste. Among the Balinese, for example, it is a mark of social distinction to wear long nails, but only the priest may wear them on both hands. The giant-god of pre-Hindu times is believed to have carved out all of the caves with the fingernails of his left hand. The Indian caste system is noted for a unique feature in that many of the castes are divided into two sections called the "right-hand" (Balagai) and the "left-hand" (Yedagai) castes. Certain socially lower artisan castes, such as workers in leather, belong to the left-hand subgroup.<a></a> Among the Motu of Papua, the moieties are grouped by the left and right hand. Members of the right-hand moiety have senior status in matters of inheritance, while members of the left hand moiety have junior descent status.<a></a></p> <h4>Other Influences</h4> <p>Music for the piano usually is written in such a way that the melody is carried by the right hand. Threads in bolts, pipes, and even in glass jars are right-handed. Soup and gravy ladles, fish forks, and meat grindersin fact, the majority of our manufactured products are designed for the right-handed individual. Can the custom of men buttoning their coats on the right side and women on the left be a survival from our primitive past when the right was reserved for men because it was "good" and the left for women because it was "evil"? Our society is belatedly recognizing the right of sinistrodextral people to full participation in our culture. Banks are issuing left handed checkbooks, left-handed armchair desks have been introduced in schools, and left-handed scissors and other implements and tools now are available.</p> <h4>Handedness in Early Man</h4> <p>Whatever the reasons for associating right with "good" and left with "evil," the fact remains that man is predominantly right-handed, a fact that appears to have been true even in prehistoric times. Early writers explained the enigma of right-handedness in the Lamarckian sense of "use and disuse." They noted that, since the heart was located on the left side of the body, the warrior carried his shield in his left hand. The right hand was free and, through more frequent use, developed in both size and dexterity. This "acquired" characteristic was passed on to succeeding generations.</p> <p>During the nineteenth century, as the authenticity of plant and animal fossils was established, and with the growth of anthropology as a more exact science, numerous archaeological sites were excavated. By the beginning of the twentieth century, thousands of artifacts had been uncovered, more precise data were available, and the picture of life in prehistoric times began to emerge in greater detail. The oldest implement found in Europe was beveled for grasping between the right thumb and first finger. The implements of primitive Paleolithic sculptors were found to approximate in number and in form those of modern sculptors. All of the tools uncovered in a Spanish cave, said to have been inhabited during Solutrean times, are designed to fit the hand, and, from the almost perfect adaptation of these instruments, we may infer that these ancient artists were right-handed.<a></a> Based upon the frequency of left-handed flint tools found <i>in situ </i>in France, other authorities, Krogman<a></a> for example, note that the incidence of left-handedness increased during the New Stone Age.</p> <h4>Handedness in Apes</h4> <p>During the past three decades, handedness in the apes has been studied extensively in the United States. Yerkes <a></a>, in his classical work on the apes, found that handedness appears in chimpanzees. He points out that they use one hand consistently for certain purposes and the other hand for other activities. He says, however, that right-handed dominance has not been demonstrated and that the three types of motor activity found in man (right-and left-handedness and ambidexterity) occur with about equal frequency.</p> <h4>The Chick Embryo</h4> <p>The problem of left- and right-handedness in chickens has been reported. At about the 38th hour in the chick embryo, certain processes are initiated that result in what may be termed very loosely a "right-handed embryo." In certain chemicals, the molecular structure is "left-handed" in that it is of the nature of the mirror image of the "right-handed" counterpart. After a number of hours of incubation, fertile chicken eggs exposed to such "left-handed" chemicals evidence a "left-handed" type of flexure of the developing brain.</p> <h4>Asymmetry</h4> <p>Yerkes<a></a> holds with the current opinion that asymmetry of the left and right hand (<b>Fig. 6</b>) is related to a general asymmetry of the entire body. The right and left leg in man, for example, also differ in strength and in dexterity. Similarly, the right lung is slightly heavier, the abdominal viscera are heavier on the right side, both the spine and pelvic regions display asymmetry, and hence the center of gravity of the body is slightly to the right. Kahn<a></a> reports a number of experiments which demonstrate that, owing to this asymmetry, every blind wandering ends in a circle. Thus, man cannot write, nor walk, nor drive a car blindfolded without becoming a victim of his physical asymmetry.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Typical difference between the right and left hands of a single individual. The right has a shorter palm and longer fingers, and the long longitudinal line is more marked. From Wolff.<a></a> by permission of Methucn and Co., Ltd. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Endocranial casts of the brain cavities of fossil and of modern man support this evidence, and here too asymmetry appears. The left occipital portion of the brain predominates to produce right-handedness, a fact established by Smith.<a></a> One school of thought claims that this asymmetry of the brain represents a primitive character in the higher apes and man. According to Clark<a></a>, however, Keith maintains that, on the contrary, asymmetry represents an evolutionary advance.</p> <p>The general physical asymmetry of the body is associated with a social asymmetry in our human prejudice against the left side. The human preference for right-handed tools and artifacts has, somehow, invaded the social and moral life. There also is a <i>sinistra </i>and <i>dextera </i>view of the world now fixed in our vocabulary.</p> <h4>Handedness in Language</h4> <p>We speak of dexterity (from the Latin "dexter," connoting "right," "favorable") in referring to skill, and this idea has been traced back to Sanskrit, the ancient literary language of India. From the category of physical things, the right hand has reached out to influence many other areas of human life. To be "orthodox" is to follow the "right" or "true" opinion. The concept of legal justice comes from the French "droit," meaning "right" or "law." Contrariwise, the word "left" symbolizes "evil," "weak," "awkward." The word for "left" in French is "gauche," meaning "awkward." The Latin "sinister," meaning "left," rarely applies to that which threatens but, rather, to that which is known to act covertly or insidiously. The bar sinister is the heraldic symbol of bastardy. A man who marries below his social rank gives his left hand, not his right, to his bride. Thus, in our own culture today there survive in our language and customs the social implications that historically have characterized handedness in man.</p> <h3>The Hand as a Sensory Organ</h3> <h4>The Sensory Experience</h4> <p>Although prehension is the major function of the hand, the hand is, at the same time, one of man's primary sense organs. This tactile quality provides sensory experience that may be grouped into four general categories.<a></a> The first consists of "surface sensations" stimulation generated by touching tangible objects. The second is termed "space-filling" stimulation generated by pulling the hand through liquid substance. "Spacelike sensations," comprising the third category, relate to the touch of distinctively shaped objects felt through a heavy material. Finally, there are "penetrable-surface sensations," experienced, for example, by a physician as he palpates some part of the body to locate, through the outer layer of flesh, some abnormal condition in deeper tissue.</p> <p>Movement is indispensable in sensory experience, and experimentation demonstrates that even the "imaginary" touch sensations are located in the finger tips. According to Katz<a></a>, it is quite impossible to call up the image of touch without, in imagination, moving the hand. The moment we imagine our hands at rest, the image becomes uncertain or disappears.</p> <p>When body and ambient temperature are equalized, the hand may be used as an instrument for the perception of the relative levels of heat and cold. Preliminary determination of body temperature can be determined by placing the hand on the forehead. In folk society, for example, where accurate measures of determining fever temperature are not available, a normal hand placed upon the forehead is used to determine the presence of fever.</p> <h4>A Percussive Tool</h4> <p>The human hand can also be used as a percussion instrument. With an apparatus which he called "the percussion phantom,"<a style="text-decoration:none;">*</a> von Gotzen found that vibratory impulses generated by finger percussion can be felt even when the auditory sense is eliminated.</p> <h4>A Vibratory Tool</h4> <p>Vibratory sensations, as perceived by the hand, are of importance in teaching the deaf to speak. By placing one hand on the larynx of a speaker and the other hand on his own larynx, a deaf-mute learns the vibration patterns of speech sounds. When the patterns "heard" by his left and right hand are identical, the student has succeeded in imitating the sound. Helen Keller utilizes the vibratory phenomena when she "hears" music by placing her hand on the piano.</p> <h3>The Human Hand in Art</h3> <p>Through the ages the human hand has appeared in all of the creative arts of every culture.<a></a> A single line, a schematic portrayal, a simple gesture of the hand, and character and personality stand revealed as clearly as they are seen in the human face. Recently, in the Kefauver investigation of crime in New York City, the television camera focused on the hands of a witness, and millions in the television audience watched while hands expressed feelings that man has taught his face to disguise.</p> <p>In the creative arts, the hand speaks, and one senses the tremendous power of the hand to convey human emotions. The hands are the organs of the body which, except for the face, have been used most often in the various art forms to express human feeling. The hands point or lead or command; the hands cry out in agony or they lie quietly sleeping; the hands have moods, character, and, in a wider sense, their own particular beauty. From prehistoric times to our own day, in every society known to science, the hands symbolize cultural behaviors, values, and beliefs.</p> <h4>Painting and Sculpture</h4> <p>Many studies of the hand appear in the traditions of western art. From schematic and conventional hand portraits, the artists of the fifteenth century began to draw anatomically correct hands, and, slowly but surely, the hand was seen as having a personality and a culture of its own. Albrecht Durer (1471-1528) devoted a lifetime to the study of anatomy, and in his studies of hands the lines, the curves, the veins, the wrinkles delineate the complexity of the human hand (<b>Fig. 7</b>). In another medium, the French sculptor Auguste Rodin (1840-1917) deliberately used the hands to create unmatched works of art.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Famed "Hands of an Apostle Praying," by Albrecht Diirer (a.d. 1471-1528). Courtesy The Public Library, Washington, D. C. The original hangs in the Albertina Museum in Vienna. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Prehistoric Artist</h4> <p>Early man left records in shallow caves, in rock shelters, and, in the great period of art during late Paleolithic times, on the walls of the innermost recesses of caves in France and Spain In the ancient engravings and the wall paintings found in caves in eastern Spain, the arms and legs perform animated gestures in running, in drawing a bow, in gathering honey, and in the dance.</p> <p>The human hand appears in quasi magico-religious silhouettes of complete or partially mutilated hands outlined in color on the walls of the grotto of Gargas in the Pyrenees Mountains. The fingers appear to be cut off at the distal end of the first phalanx, with one or more digits missing entirely. Curiously, the thumb never is amputated. The same type of finger mutilation is found in wall paintings in the caves of central Australia. Apparently the practice was customary among the early Aurignacian people of Paleolithic times, and it also is reported in other preliterate tribes. According to Osborn <a></a>, Breuil believes that painting had its beginning in these stencilled contours produced by laying the hands against the limestone walls and spreading red and black paint on the surrounding area. In other examples, the hand was covered with pigment and pressed against the wall.</p> <h4>The Dance</h4> <p>The formal patterns and definite movements of the dance make it one of the greatest of the interpretative arts. It is, apparently, also one of the oldest arts. Whether viewed from a recreational, religious, or aesthetic standpoint, this expression of culture has attained meaning and intensity through movement of the hands. Joint dances between the sexes are rare among primitive tribes, and the hand thus has been liberated for gestures and symbolic movements. In India, the hands can tell an entire story. In Australia, among one of the most technologically simple tribes, the movements of the hands make the dance merge into drama. Indeed, it is difficult to separate the dance from music and from drama, but in each of these art forms it is the hand that gives meaning to words spoken. Perhaps the rhythm produced by the hands in clapping and in slapping the body originally led to music and to the dance.</p> <h3>The Hand in Culture and Society</h3> <h4>Language Abstractions</h4> <p>Because the human hand is an organ of performance, it is not surprising that the hand should "manipulate" ("to lead by the hand") the human vocabulary. The hand receives the "mandate" (from Latin "manus," for "hand," plus "dare," "to give") from the brain, and to "manage" is to govern, direct, or control. Thus, man "commends" (which originally meant "to place in one's hands") and "commands," both words related to "mandate" and, therefore, to the Latin "manus," for "hand."</p> <p>With its basic movements for grasping objects (page 33), the human hand also is "handy" ("dexterous," "to have two right hands") for grasping ideas. To "comprehend" is to "seize" (Latin, "capere," "to seize"), from which we derive such words as "perceive," "conceive," and "receive." Thus, by various shades of meaning, the human hand not only "hands down" information but "picks" it up. The human hand also is an organ of perception and thus lends itself to the most abstract concepts. "Handsome" originally meant "dexterous." "To feel" is connected somehow with the Greek word for hand, "palame." To say in Latin "dicere" means "to point." We touch, feel, handle, finger, thumb, paw, grope, palpate, and stroke objects.</p> <h4>One and One Are Two</h4> <p>Man's hand not only manipulates and grasps, and makes and points, but it counts as well. Counting is very different from what we loosely term "number sense," an attribute that man shares with other animals. In its real connotation, counting appears to be an exclusively human characteristic, and numbers, like so many abstractions, begin with the human body. The old Roman numerals I, II, III, and IIII<a style="text-decoration:none;">*</a> are thought to be representations of the fingers. In certain of the less well-known languages, the word for hand gives us the word for five. "Five" also has come to mean "hand," and in English the slang expression "give us five" once meant "to shake hands."</p> <p>One example of the use of hands in counting is that of the Mafulu mountain people, who do not use pebbles or sticks but instead use the hands and feet.<a></a> Here counting is accomplished by the use of two numerals, "one" and "two." In indicating "one," the hand first is stretched open to indicate "nothing," the thumb then is closed down meaning "one," the first digit closed down meaning "two," and so on, until all of the fingers of one hand are closed. The process is repeated with the other hand, and, to count to 20, the clenched fist points to the feet and to all of the right and left toes. If the count is above 20 (usually only when important occasions demand, such as counting pigs for a ceremony) another man is called to stand beside the first. If the number goes as high as 83, five men join. Four men go through the entire process, and the last man closes the first three digits.</p> <h4>Man the Measuree</h4> <p>Equally important has been the use of the hand as a unit of measurement. Tables showing the use of body organs as units of measure have been established for volume, surface. width, and length (<b>Fig. 8</b>). The earliest records show that the use of the index finger for indicating length was a widespread custom. In Europe the height of a man was estimated by a definite number of finger lengths based upon the measurement of the middle finger. In Latvia, the length of the middle finger was used to measure lengths for women's stockings or woolen socks (three times the length of one's middle finger). Sixteen times the length of the middle finger equals the normal human stride. The hand and thumb were used to measure width, 12 thumb widths being equal to one foot. Tools were made by the eldest member of the family and adjusted to the hand grasp. Thus, a scythe blade for an adult man was as long as nine or ten widths of the clenched hand, eight for an adult woman, and seven or eight for an adolescent (<b>Fig. 9</b>). The same pattern is found through much of eastern and northeastern Europe today.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Natural units of measure, still in use by Latvian and other European peasants. From Drillis.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. The method, common among Latvian and other European peasants even today, of arriving at the proper dimensions for farm tools using the hand as the unit of measurement. From Drillis.<a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Some Tribal Customs</h4> <p>In the Sun Dance of the Plains Indians of the United States, finger joints were occasionally pledged as a thank-offering for recovery from illness or to ensure revenge for a slain relative.<a></a> Cole<a></a> reports that individual warriors among the tribes of Mindanao carried home a hand as evidence of a successful fight and that at such times festivals were held to celebrate the event. Among the Tinguian tribes of the Philippine Islands, joints of the little fingers were added to ear lobes and brains to make a liquor that was served to the dancers. Here, as in most areas of the world, the brew was consumed not for nourishment but in order to secure that part of the enemies' bodies thought to house strength and valor.</p> <p>Such reports may throw light upon the presence of the mutilated hands found on the walls of the European caves and dating from late Paleolithic times. The scarcity of drawings of the human form in cave paintings may be related in some way to the belief, still found among certain of our "primitive" contemporaries, that realistic portraits might give an enemy magic power. Possibly, through some similar process of sympathetic magic, the hand has already become a symbol to be portrayed realistically in religious ritual.</p> <h4>The Fingerprint</h4> <p>Human hands have been used in various cultures as a means of positive identification. In ancient China, fingerprints were used to sign or to autograph paintings. They are doubly valuable as "signatures" because they cannot be altered or forged, and the intricate patterns of whorls, circular and folded loops, and arches differ from finger to finger and from individual to individual. As the person grows, his individual fingerprint patterns increase in size but do not change in geometric proportions. In 1882, Bertillon, a young French anthropologist, began to develop his famous system for identification of criminals by a physical description based upon eleven anthropometric measurements, deformities, and impressions of lines and markings of the finger tips. The Bertillon system of fingerprints has been used internationally and has proved valuable for physical identification.</p> <h3>Some Other Considerations</h3> <h4>Occultism, Symbolism, and Ritualism</h4> <p>In an anatomical sense, each hand is unique. Every hand betrays its possessor by characteristic mo/ement patterns, by peculiarities of gesture, or by occupational stigmata arising from physical and mechanical causes. From these characteristics, palmistry and a branch of occultism known as "chiromancy" have, for centuries, attempted to read the past, present, and future of individuals. Since early antiquity, numerous scholars of repute have concerned themselves with studies in palmistry. According to D'Arpentigny<a></a>, Plato, Aristotle, Galen, Albertus Magnus, the Ptolemies, Avicenna, Averroes, Antiochus Tibertus, Tricasso (<b>Fig. 10</b>), Taisnier, Belot, and others have handed down lengthy treatises on the subject, and the observations of these early writers still prevail in our own modern times (<b>Fig. 11</b>). Palmists are interested chiefly in the surface of the handlines, stars, crosses, islandsand have divided the life line into seventy parts, each part symbolic of one of man's allotted seventy years of life. Chirognomists study the shape and form of the entire hand, in addition to surface characteristics.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Principal lines and mounts of the hand as charted by Patritio Tricasso da Cerasari (Tricassus the Mantuan), a celebrated chiromancer of the sixteenth century. From Lenssen<a></a>, by permission of The Studio Publications, Inc., New York City. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. The mounts and principal lines of the hand and the interpretative functions traditionally assigned to the several areas. Authorities differ in detail, but all follow the same general pattern. In palmistry, which dates from antiquity and which has been the subject of serious discussion by numerous scholars, including Aristotle, the relative development of the mounts and lines is considered to show the comparative ability of the subject to implement the talents and qualities associated with the individual features. Generally the mounts are seven in number, the eighth (Mount of Neptune) occurring in a comparatively small number of cases. Reference to the sun, moon, and planets relates, of course, to the influence which, in early philosophy, these celestial bodies were thought to exercise upon the course of an individual's life. Modern astrology calls upon similar relationships. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>But it is in the realm of quasi magic and symbolism that the hand reaches its highest cultural significance. For the great majority of mankind who think in concrete rather than in abstract terms, graphic representations of superhumanity are related to the human body. The Hindu of India symbolizes this super-humanity by the multiplication of the most important parts of the body, which, to him, are the head, the arms, and the hands. Since arms and hands are extremely useful, a twelve-armed god demonstrates the power and the strength denied a two-armed god. Such thinking may appear grotesque to the Westerner, but the Hindu, accustomed to symbolic thinking, knows that man is not so constructed, nor does he wish that he were. He simply recognizes that power and wisdom and strength may be expressed quantitatively.<a></a>The Moslem often wears a small image of the hand around his neck to ward off the evil eye.</p> <p>Not only in the eastern world does the hand play an important part in the ritual usages but in western culture as well. The pentagram, the five-pointed star, is said to have been derived from an ancient custom of covering the face with the open fingers of the hand. That practice gradually was replaced by invoking the numeral "five," a convention that persists today in countries in central Europe. In Latvia, for example, the pentagram now appears on barns as a protective device.</p> <p>Finally, the hand has become symbolic of human sentiment. We bless and we salute by raising the hand in various ways. The gentle laying on of hands is at once a symbol of benediction and, as among certain religious sects, the means of curing the sick and of drawing out the evil spirits that reside within the body. In legal practice, oaths are taken in court by the simultaneous use of both hands, right hand up and the left hand on the Bible. We close a bargain by shaking hands, we raise our hands in salutation, and a man takes a woman's hand in marriage. Contrariwise, the hand may express condemnation, malediction, and final judgment. In cursing we point the hand at the enemy. In ancient Rome, thumbs down ("pollice verso") sentenced the gladiator to death. Thus, the hand has become an expository of human sentiment. It can express love, hate, doubt, questioning, hospitality, judgment, rejection, or acceptance.</p> <h4>The Hand and Good Health</h4> <p>The handshake may become an index to personality and representative of the <i>whole </i>person. The cold, limp hand, the strong, firm grasp, the moist palm, the dry palm, all help us to create a mental image of personality. To the trained hand of the physician, the cold, moist, flabby handshake often reveals clues relating to physical condition. Such a handshake often is a symbol of physical illness or an indication of an emotional disturbance. To the trained eye of the doctor the hand tells even more. The coloring, texture, lines, and creases sometimes reveal sickness or health. A trembling, warm, moist hand may mean overactivity of the thyroid, redness may indicate gout, a bluish appearance may indicate a certain kind of heart disease, and bad cases of malnutrition and diet deficiency frequently are reflected in the hand. There are many variations in the appearance of each hand, but the danger signals can be read only by the skilled hand and eye of a physician.</p> <h4>The Hand in Expression</h4> <p>The hand has also become associated with certain ethnic and nationality groups, for specific hand gestures have been associated with certain cultural types. Indeed, it has been said of the Italians that they never speak a language, that they caress it. Because movement of the hands serves to emphasize the spoken word, all of us find it difficult to speak while our hands remain perfectly still. A dramatic presentation of the use of the hand in conversation was portrayed through the medium of modern dance in a performance by a group at New York University involving an interpretation of an adolescent the telephone (<b>Fig. 11</b>). talking over No word was spoken, but the wide variety of gestures made clear to everyone what the performer was saying. The cult and the culture of the "teen-ager" in our country was delineated as sharply through the dance as it could have been through the medium of the written word.</p> <h3>Conclusion</h3> <p>From its basic use, prehension, which grew out of anatomical development, the human hand gradually has evolved until it is now also an effective instrument for symbolic and aesthetic interpretation. Man's capable and sentient hand not only serves as a tool but it wields tools as well, and it has in addition the ability to take the place of other body organs. Because of its remarkable adaptability to functional requirements, as compared with the specialization in the forelimb of other animals, the hand is largely responsible for the creative manifestations that characterize the human species and that distinguish it from all other known forms of life. The hands are, as Kant is reported to have said, "man's outer brain."</p> <h3>Acknowledgment</h3> <p>For valued help in obtaining the illustrations which accompany this article, the author is indebted to Marian Blumler, staff member of the Library, National Academy of Sciences National Research Council, who conducted a search of source material and arranged for loan of the necessary documents.</p> <p><b>References:</b></p> <ol> <li>Adam, Leonhard, <i>Primitive art</i>, Harmendsworth Middlesex, Penquin Books, Ltd., rev. ed., 1949.</li> <li>Ashley-Montagu, Francis M., <i>On the primatethumb</i>, Am. J. Phys. Anthropol., 16(2):291 (1931).</li> <li>Boas, Franz, <i>Primitive art</i>, H. Aschehoug, Oslo, 1927. pp. 344, 349.</li> <li>Boyd, William C, <i>Genetics and the races of man; an introduction to modern physical anthropology</i>, Heath, Boston, 1950. pp. 16-17.</li> <li>Clark, W. E. Le Gros, <i>Early forerunners of man; a morphological study of the evolutionary origin of the primates</i>, Bailliere, Tindall, and Cox, London, 1934. pp. 103-140.</li> <li>Cole, Fay-Cooper, <i>Lectures</i>, University of Chicago, 1940-41.</li> <li>D'Arpentigny, C. S., <i>The science of the hand</i>, translated from the French by Ed. Heron-Allen, Ward, Lock, and Bowden, London, 1895.</li> <li>Drillis, Rudolf J., <i>Darba riki [Tools]</i>, in <i>Lalviesu konversacijas vardnica [Latvian encyclopedia]</i>, A. Gulbis, Riga, 1928-29. Vol. 3, p. 4611.</li> <li>Drillis, Rudolf J., <i>Mcri [Units of measure]</i>, in <i>Latvieiu konversacijas vardnica [Latvian encyclopedia]</i>, A. Gulbis, Riga, 1928-29. Vol. 14, p. 26691.</li> <li>Flory, Charles D., <i>Osseous development in the hand as an index of skeletal development</i>, Society for Research in Child Development, Monographs, Vol. 1, No. 3, National Research Council, 1936.</li> <li>Hodges, Paul C, <i>An epiphyseal chart</i>, Am. J. Roentgenol., 30(6): 809 (1933).</li> <li>Hooton, Earnest A., <i>Up from the ape</i>, Macmillan, New York, 1931.</li> <li>Huxley, J., <i>From fin to fingers: the evolution of man's hand</i>, Illustrated London News, December 1930. pp. 1138-39.</li> <li>Jones, Frederic Wood, <i>The principles of anatomy as seen in the hand</i>, 2nd ed., Williams and Wilkins, Baltimore, 1942.</li> <li>Kahn, Fritz,<i> Man in structure and function</i>, Alfred A. Knopf, New York, 1943. Vol. 1, pp. 1515-16.</li> <li>Katz, David, <i>On the psychology of the human hand</i>,Bulletin Vol. 32, No. 10, University of Maine Studies, Second Series, No. 14, <i>The vibratory sense and other lectures</i>, The University Press, Orono, 1930. pp. 75-78.</li> <li>Krogman, Wilton M., <i>The anthropology of the hand</i>, Ciba Symposia, 4(4):1294 (1942). '</li> <li>Lenssen, Heidi, <i>Hands in nature and art</i>, Studio Publications, New York, 1949.</li> <li>Mead, Margaret, el al., <i>Cultural patterns and technical change</i>, World Federation for Mental Health, UNESCO, Igsel Press, Ltd., Deventer, Holland, 1953.</li> <li>Mierzecki, H., <i>Symbolism and palhognomy of the hand</i>, Ciba Symposia, 4(4):1319 (1942). '</li> <li>O'Malley, L. S. S., <i>Indian caste customs</i>, Macmilan, New York, 1932. pp. 21-22.</li> <li>Osborn, Henry F., <i>Men of the Old Stone Age, their environment, life, and art</i>, 3rd ed., Scribner, New York, 1919.</li> <li>Personal communication from Margaret Cormack, Brooklyn College.</li> <li>Reininger, W., <i>The hand in art</i>, Ciba Symposia, (4):1323 (1942).</li> <li>Romer, Alfred Sherwood, <i>Man and the vertebrates</i>, University of Chicago Press, Chicago, 1933.</li> <li>Romer, Alfred Sherwood, <i>Man and the vertebrates</i>, 2nd ed., University of Chicago Press, Chicago, 1937. Especially pp. 27-28, 41-42, 363-70.</li> <li>Rosenstiel, Annette, <i>The Motu of Papua-New Guinea: a study of successful acculturation</i>, Ph.D. thesis, Columbia University, 1953. Microfilm.</li> <li>Schultz, Adolph H., <i>Characters common to higher primates and characters specific for man</i>, Quart. Rev. Biol., ll(4):425-455; ll(3):259-283, 434-437 (1936).</li> <li>Schultz, Adolph H., <i>The skeleton of the trunk and limbs of higher primates</i>, Human Biol., 2(3):303 (1930).</li> <li>Smith, Grafton E., <i>The evolution of man</i>; essays, 2nd ed., Oxford University Press, 1927.</li> <li>Wilder, Harris H., <i>A laboratory manual of anthropometry</i>, Blakiston, Philadelphia, 1920. pp. 84-109.</li> <li>Wiser, Charlotte V., and William H. Wiser, <i>Behindmud walls</i>, Harper, New York, 1930.</li> <li>Wolff, Charlotte, <i>The human hand</i>, Methuen, London, 1942.</li> <li>Wright, W. B., <i>Tools and the man</i>, George Bell and Sons, Ltd., London, 1939.</li> <li>Yerkes, Robert M., <i>Chimpanzees; a laboratory colony</i>, Yale University Press, New Haven, 1943.</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>23.</b> </td><td class="clsTextSmall">Personal communication from Margaret Cormack, Brooklyn College.</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>18.</b> </td><td class="clsTextSmall">Lenssen, Heidi, Hands in nature and art, Studio Publications, New York, 1949.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Mierzecki, H., Symbolism and palhognomy of the hand, Ciba Symposia, 4(4):1319 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">D'Arpentigny, C. S., The science of the hand, translated from the French by Ed. Heron-Allen, Ward, Lock, and Bowden, London, 1895.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Cole, Fay-Cooper, Lectures, University of Chicago, 1940-41.</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>32.</b> </td><td class="clsTextSmall">Wiser, Charlotte V., and William H. Wiser, Behindmud walls, Harper, New York, 1930.</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">Drillis, Rudolf J., Darba riki [Tools], in Lalviesu konversacijas vardnica [Latvian encyclopedia], A. Gulbis, Riga, 1928-29. Vol. 3, p. 4611.</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">Drillis, Rudolf J., Mcri [Units of measure], in Latvieiu konversacijas vardnica [Latvian encyclopedia], A. Gulbis, Riga, 1928-29. Vol. 14, p. 26691.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Cole, Fay-Cooper, Lectures, University of Chicago, 1940-41.</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">IV is a later development.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Osborn, Henry F., Men of the Old Stone Age, their environment, life, and art, 3rd ed., Scribner, New York, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Adam, Leonhard, Primitive art, Harmendsworth Middlesex, Penquin Books, Ltd., rev. ed., 1949.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Boas, Franz, Primitive art, H. Aschehoug, Oslo, 1927. pp. 344, 349.</td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Reininger, W., The hand in art, Ciba Symposia, (4):1323 (1942).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Katz (16) describes the apparatus as a square wooden box, about 60 centimeters long by 8 centimeters deep, and open at the top. Around the top edge a strip of felt is fitted, and over the whole a thick cardboard square is fastened; this side of the box is clamped on with metal clips. The cardboard is strong enough to resist considerable pressure without sagging. On the underside of the cardboard, i.e., inside the box, objects of different shapesfor example, round, elliptical, or heart-shaped objectsare pasted to substantial pieces of lead which appear either as matrices or as patrices, i.e., they are cut into or cut out of lead. The thickness of the plate is chosen according to the degree of difficulty of the percussion task to be presented to the student. In general, the thicker the plate, the easier the task. The plates are so arranged that the figure is located in the middle of ihe underside of the cardboard. Each cardboard is fitted with one figure (if necessary, composed of two parts), so that there are as many cardboards as there are figures required for the test. Students were asked to determine, through percussion alone, the form of figures cut into or out of the lead plates.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Katz, David, On the psychology of the human hand,Bulletin Vol. 32, No. 10, University of Maine Studies, Second Series, No. 14, The vibratory sense and other lectures, The University Press, Orono, 1930. pp. 75-78.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Katz, David, On the psychology of the human hand,Bulletin Vol. 32, No. 10, University of Maine Studies, Second Series, No. 14, The vibratory sense and other lectures, The University Press, Orono, 1930. pp. 75-78.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, Early forerunners of man; a morphological study of the evolutionary origin of the primates, Bailliere, Tindall, and Cox, London, 1934. pp. 103-140.</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>30.</b> </td><td class="clsTextSmall">Smith, Grafton E., The evolution of man; essays, 2nd ed., Oxford University Press, 1927.</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>33.</b> </td><td class="clsTextSmall">Wolff, Charlotte, The human hand, Methuen, London, 1942.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Kahn, Fritz, Man in structure and function, Alfred A. Knopf, New York, 1943. Vol. 1, pp. 1515-16.</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>35.</b> </td><td class="clsTextSmall">Yerkes, Robert M., Chimpanzees; a laboratory colony, Yale University Press, New Haven, 1943.</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>35.</b> </td><td class="clsTextSmall">Yerkes, Robert M., Chimpanzees; a laboratory colony, Yale University Press, New Haven, 1943.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Krogman, Wilton M., The anthropology of the hand, Ciba Symposia, 4(4):1294 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Osborn, Henry F., Men of the Old Stone Age, their environment, life, and art, 3rd ed., Scribner, New York, 1919.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">Rosenstiel, Annette, The Motu of Papua-New Guinea: a study of successful acculturation, Ph.D. thesis, Columbia University, 1953. Microfilm.</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>21.</b> </td><td class="clsTextSmall">O'Malley, L. S. S., Indian caste customs, Macmilan, New York, 1932. pp. 21-22.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Cole, Fay-Cooper, Lectures, University of Chicago, 1940-41.</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>19.</b> </td><td class="clsTextSmall">Mead, Margaret, el al., Cultural patterns and technical change, World Federation for Mental Health, UNESCO, Igsel Press, Ltd., Deventer, Holland, 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Hodges, Paul C, An epiphyseal chart, Am. J. Roentgenol., 30(6): 809 (1933).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Krogman, Wilton M., The anthropology of the hand, Ciba Symposia, 4(4):1294 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Hodges, Paul C, An epiphyseal chart, Am. J. Roentgenol., 30(6): 809 (1933).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Boyd, William C, Genetics and the races of man; an introduction to modern physical anthropology, Heath, Boston, 1950. pp. 16-17.</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">Flory, Charles D., Osseous development in the hand as an index of skeletal development, Society for Research in Child Development, Monographs, Vol. 1, No. 3, National Research Council, 1936.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Ashley-Montagu, Francis M., On the primatethumb, Am. J. Phys. Anthropol., 16(2):291 (1931).</td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Wilder, Harris H., A laboratory manual of anthropometry, Blakiston, Philadelphia, 1920. pp. 84-109.</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>34.</b> </td><td class="clsTextSmall">Wright, W. B., Tools and the man, George Bell and Sons, Ltd., London, 1939.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hooton, Earnest A., Up from the ape, Macmillan, New York, 1931.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hooton, Earnest A., Up from the ape, Macmillan, New York, 1931.</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">Ashley-Montagu, Francis M., On the primatethumb, Am. J. Phys. Anthropol., 16(2):291 (1931).</td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, Early forerunners of man; a morphological study of the evolutionary origin of the primates, Bailliere, Tindall, and Cox, London, 1934. pp. 103-140.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hooton, Earnest A., Up from the ape, Macmillan, New York, 1931.</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Krogman, Wilton M., The anthropology of the hand, Ciba Symposia, 4(4):1294 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Krogman, Wilton M., The anthropology of the hand, Ciba Symposia, 4(4):1294 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Romer, Alfred Sherwood, Man and the vertebrates, University of Chicago Press, Chicago, 1933.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>25.</b> </td><td class="clsTextSmall">Romer, Alfred Sherwood, Man and the vertebrates, University of Chicago Press, Chicago, 1933.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, Early forerunners of man; a morphological study of the evolutionary origin of the primates, Bailliere, Tindall, and Cox, London, 1934. pp. 103-140.</td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Huxley, J., From fin to fingers: the evolution of man's hand, Illustrated London News, December 1930. pp. 1138-39.</td></tr><tr><td class="clsTextSmall"><b> 26.</b> </td><td class="clsTextSmall">Romer, Alfred Sherwood, Man and the vertebrates, 2nd ed., University of Chicago Press, Chicago, 1937. Especially pp. 27-28, 41-42, 363-70.</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>26.</b> </td><td class="clsTextSmall">Romer, Alfred Sherwood, Man and the vertebrates, 2nd ed., University of Chicago Press, Chicago, 1937. Especially pp. 27-28, 41-42, 363-70.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Jones, Frederic Wood, The principles of anatomy as seen in the hand, 2nd ed., Williams and Wilkins, Baltimore, 1942.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hooton, Earnest A., Up from the ape, Macmillan, New York, 1931.</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">Meaning that digit corresponding to the ring finger in man. Among anatomists generally, at least two systems for identifying hand digits are in accepted scientific usage, often interchangeably by the same writer. A common convention is to number the digits from I to V, beginning with the thumb as digit I and ending with the little finger as digit V (Fig. 1). But many competent writers, thinking of the hand as having a thumb and four fingers, label the fingers as first, second, third, and fourth, meaning the index finger, the middle finger, the ring finger, and the little finger or pinkie, respectively. Throughout this issue of Artificial Limbs, it is considered that the normal hand has five digits, one of which is a thumb, the other four being fingers. A digit is here referred to with the understanding that digit I is the thumb Fingers are referred to as being numbered beginning with the index finger as the first finger.-Ed.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Huxley, J., From fin to fingers: the evolution of man's hand, Illustrated London News, December 1930. pp. 1138-39.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Clark, W. E. Le Gros, Early forerunners of man; a morphological study of the evolutionary origin of the primates, Bailliere, Tindall, and Cox, London, 1934. pp. 103-140.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Ashley-Montagu, Francis M., On the primatethumb, Am. J. Phys. Anthropol., 16(2):291 (1931).</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>28.</b> </td><td class="clsTextSmall">Schultz, Adolph H., Characters common to higher primates and characters specific for man, Quart. Rev. Biol., ll(4):425-455; ll(3):259-283, 434-437 (1936).</td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Schultz, Adolph H., The skeleton of the trunk and limbs of higher primates, Human Biol., 2(3):303 (1930).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Krogman, Wilton M., The anthropology of the hand, Ciba Symposia, 4(4):1294 (1942). '</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Ethel J. Alpenfels, D.Sc. </b></td></tr><tr><td class="clsTextSmall"> Professor of Anthropology, New York University, New York City.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_02_004/table1.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_02_004/1955-MayOCRBatch-12.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Anthropology and Social Significance of the Human Hand Creator An entity primarily responsible for making the resource Ethel J. Alpenfels, D.Sc. * 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/387c7a200b8c8e82a1549ac460dc2643.pdf 6cdf715e6bd5043fe4e42bf3b3884a24 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_02_001.pdf Year 1958 Volume 5 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/1958_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_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>The NYU Field Studies-A Postscript</h2> <h5>Eugene F. Murphy, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <blockquote> <p>Well, one of the two (who will soon be here)—<br /> But <em>which</em> of the two it is not quite clear—<br /> Is the Royal Prince you married!<br /> Search in and out and round about<br /> And you'll discover never<br />A tale so free from every doubt—<br /> All probable, possible shadow of doubt—<br /> All possible doubt whatever!<br /> —- W. S. Gilbert, 1889</p> </blockquote> <p>In preparing a report on extensive research, a modern investigator faces the same problems as the Grand Inquisitor. He may be able to furnish explicit answers to all the minor questions and to delimit the possible solutions of major problems. Only in fortunate circumstances can he provide final answers to all the questions originally posed.</p> <p>This, the second of two issues of Artificial Limbs to be devoted to the NYU Field Studies of 1953-55 (see issue for Spring 1958), offers a wealth of censuslike information on fascinating problems revealed in the course of studying extraordinarily large samples of upper-extremity amputees and their prostheses. It answers with overwhelming affirmation a critical amd highly pertinent question; Do modern concepts of upper-extremity prosthetics truly represent substantial improvement over previous practices? But this favorable broad conclusion demands by virtue of its own importance respect for certain essential qualifications more or less obvious from the circumstances of study if not from the nature of the study itself.</p> <p>Largely because the samples in the NYU Field Studies included such high percentages of veterans of World War II and Korea, many of the amputees treated had already received organized care and training in military amputation centers. Moreover, many had already reaped some early benefits of the Artificial Limb Program. New and supposedly improved devices and techniques had already been developed and applied progressively over a period of half a dozen years, and the U. S. Veterans Administration was already operating Orthopedic and Prosthetic Appliance Clinic Teams in some 30 key cities. Though at the time members of these clinic teams were concerned largely with the suction-socket program and with lower-extremity problems generally, they were so stimulated by the special courses at UCLA, and so encouraged by the monthly visits of NYU field representatives, as to tackle problems in upper-extremity prosthetics and to expand their perspective from simple application of mechanical gadgets to genuine concern for all aspects of the resulting man-machine system. And consequently the results here given are clearly weighted by disproportionate inclusion of the comparatively young and otherwise healthy adult male with special advantages not ordinarily then to be had by the amputee population at large.</p> <p>The nature of the subject matter is something else again. In any investigation so intimately associated with the individual proclivities of human beings, and particularly one of the magnitude indicated, the variables to be controlled are many and diverse, and the data to be had are especially voluminous. Although census counts may provide clues to major influences, and although modern electronic computers may furnish effective correlations and satisfying proof of statistical significance, prosthetics problems in clinical practice are not apt thus to be fully solved because, as in polio, cancer, and numerous other kinds of human disorder, there is generally no single "necessary and sufficient condition" but instead a rather large number of interrelated factors which, added or subtracted in proportions variously weighted, may easily tip the balance for or against clinical usefulness and research success. Thus effective application of the present findings calls for the exercise of keen discrimination over and above that required by the limitations of the sample studied.</p> <p>Despite the existing correlations, therefore, the NYU Field Studies leave unsolved, or at best still subject to serious debate, some disquieting major questions. Why, for example, did a few amputees prefer their old arms over the newer ones? How well did the new prostheses pass the comfort aspects of the checkout tests required? Are the checkout standards adequate? Were complaints about terminal devices heavily correlated with mechanical failure? Of many such puzzlers, some might be resolved by further analysis and correlation of the mountainous data now embalmed in the form of 29 punched cards for each of several hundred amputees. Others indicate the need for further research in the social sciences, while still others constitute a continuing challenge for designers of devices, developers of techniques, and sponsors of research.</p> <p>Perhaps even more fascinating than the yet unsolved questions of physical and mechanical significance are the hints at the nature of amputee psychology. Still needed are thoughtful studies of the problems of realistic acceptance of amputation losses, of objective appraisal of the possibilities for rehabilitation, of the influence of amputee expectations on success in restoration, and of the potentialities for improvement through counseling and guidance both for the patient and for the public as regards attitudes toward what is still called "handicap." Serious consideration of some of the points raised in the present volume may be expected to temper success with humility and hence possibly to afford a degree of wisdom not otherwise to be had. Here, then, is a byproduct perhaps more valuable in the long view than are the actual conclusions it is now possible to formulate.</p> <p>In these investigations, NYU faced and overcame in the conduct of its own studies many practical difficulties in addition to the complex problems inherent in investigations in limb prosthetics. It recruited from a highly restricted labor force a field staff of persons able to observe and assess clinical procedures effectively and willing to travel two weeks in every four during a period of uncertain tenure. It thereby quickly established relationships with VA facilities throughout the country and, even more important, with the numerous private clinic teams that NYU helped to foster, and it maintained checkout standards despite differences in interpretation from one clinic to another. The correlations and insights here presented have all come from the very persons who helped to collect the data, and the summaries have all been prepared with the help of former field men who have since transferred to other NYU projects or who have now left the NYU facilities entirely.</p> <p>Recognizing residual deficiencies, facing unresolved problems, and yet expressing gratitude for the substantial achievements described in NYU's unprecedented two-number contribution to Artificial Limbs, we may now, in the acknowledged infancy of the art and science of limb prosthetics, justifiably substitute "books" for "babes" in the familiar characterization by the Grand Inquisitor:</p> <blockquote><p>Both of the babes were strong and stout,<br />And, considering all things, clever,<br />Of that there is no manner of doubt—<br />No probable, possible shadow of doubt—<br />No possible doubt whatever.</p> </blockquote> <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, U. S. Veterans Administration, 252 Seventh Ave., New York 1, N. Y.</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 The NYU Field Studies-A Postscript Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. * https://staging.drfop.org/files/original/de497b398ace75dc2d796c805105fa2b.pdf 27d26b0e9c1554ef1390a967e60ce082 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1963_01_001.pdf Year 1963 Volume 7 Issue 1 Page Number(s) 1 - 4 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1963_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1963_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Transition</h2> <h5>Eugene F. Murphy, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p> With this issue, <i>Artificial Limbs </i>embarks upon a new pattern of activity, changing from monographs covering major aspects to issues with articles on more diversified topics related to artificial limbs. A brief review of the philosophy and contents of prior publications may illuminate the logic of this transition. </p> <p> In nearly every issue, stress has been laid upon the management of the amputee through a clinic team. This noble idea, arising from the follow-up of the cases fitted immediately after the suction-socket schools in 1947, was destined to have a profound impact not only upon prosthetics but also, through this program and many parallel developments, upon the management of other disabilities as well. </p> <p> Early issues, many of them now out of print, were devoted to explanations of the total program of research, development, and evaluation in the fields of upper- and lower-extremity prosthetics. In a series of monographs, with copious references, <i>Artificial Limbs </i>has considered nearly every important level of amputation and has discussed the medical and psychological management of amputees, whether typical cases or those with special problems. Other related journals and reference books have become available to the clinician and to the research scholar. </p> <p> With the establishment of this solid base of reference literature, both in previous issues of this journal and elsewhere, it now seems appropriate to deviate from the classic monograph style so as to permit relatively more rapid publication and greater freedom in pursuing timely yet widely varied topics. In the past, one of the major causes for frustrating delay in the publication of this journal has been the necessity to wait upon the last manuscript needed to round out a comprehensive monograph. Those concerned with the policy of the journal, of course, have long recognized that more rapid publication of a reasonably useful document could be obtained with far less effort and suspense. A series of manuscripts, each individually worthy yet not necessarily directly related to the others, could simply be accumulated until the bundle "weighed enough to print." </p> <p> The articles in this transitional issue, however, are related to the background of past issues and to other publications of the Committee on Prosthetics Research and Development. In the traditional role of the editorial or lead article, this is an attempt to correlate the articles in this issue, to comment on them, and to stimulate each reader to apply them to his problems. </p> <p> Dr. Glattly's preliminary report on a survey of amputees, conducted with the cooperation of the prosthetics profession of this country, discloses a number of fascinating facts yet leads to interesting speculations. Obviously, the information in the article is related to the important considerations of methods of treatment for each level of amputation covered in past monographs and in the "case studies" issue of Spring 1957. Improved prostheses are available for every level of amputation; but perhaps more important are the principles of management valid for all levels which have evolved since World War II. The great preponderance of geriatric amputees in civilian practice points up the value of the report arising from a conference sponsored by CPRD in 1961-<i>The Geriatric Amputee. </i>At the other extreme, the number of child or juvenile amputees emphasizes the importance of the work of CPRD's Subcommittee on Child Prosthetics Problems and of the slowly growing number of special children's clinics engaged in a cooperative program. Fortunately, high-level and bilateral upper-extremity amputees are relatively limited in number, but they especially emphasize the need for auxiliary power, as discussed in the record of a conference held at Lake Arrowhead, California, in 1960 under the auspices of CPRD-<i>The Application of External Power in Prosthetics and Orthotics.</i> </p> <p> Indeed, the entire problem of amputation emphasizes the role of the Committee on Prosthetics Education and Information in widely disseminating information to the medical and paramedical professions through their professional schools, and local and national meetings, and by exhibits, publications, films, and slides. In fulfilling its important role, CPEI will join CPRD in sponsoring <i>Artificial Limbs, </i>beginning with the next issue. Dr. William J. Erdman, II, a member of CPEI, will join the Editorial Board. </p> <p> Mr. Colin A. McLaurin's article on independent-control harnessing for upper-extremity prostheses is clearly related to previous issues on the upper-extremity problem as a whole, harnessing for artificial arms, and discussions of problem cases. Elbow flexion independent of operation of the terminal device has long been sought, as shown by the patent literature in this country and by the German literature of World War I. Immediately after World War II, many of the amputees working with Northrop Aircraft in the relatively warm climate and casual atmosphere of Los Angeles preferred to sacrifice independent control in favor of simplicity of harnessing. However, the amputees fitted in the relatively cooler German climate by Professor Hepp after his return from his 1951 trip to the United States laboratories were more willing to accept his expert judgment that some form of "triple control" was important for function. Thus they were more willing to tolerate the more restrictive type of harness. As a result of experience with problem cases seen at the Rehabilitation Institute of Chicago and at the Michigan Area Child Amputee Center at Grand Rapids, Mr. McLaurin and Mr. Sammons have decided that independent control is important for selected amputees. Their suggestions, presented in one of the major articles of this issue, deserve careful consideration. </p> <p> The article on porous laminates in this issue, by Mr. Hill and Dr. Leonard of the Army Prosthetics Research Laboratory, is closely related to the discussion of perspiration and its consequences in a past issue on dermatological problems of amputation stumps. Readers of that classic will no doubt remember the cartoons of gremlins representing perspiration and bacteria attacking the stump within the typical air-tight socket. Porous sockets in the past have been only imperfectly approximated with porous, wicklike stump socks worn within wooden or metal shells, sometimes with numerous drilled holes, or in sockets molded of leather, which is slightly porous but undesirable from so many other hygienic aspects. The typical above-knee suction sockets of lacquered solid wood or of molded plastic laminate, both completely impermeable, have been worn without a stump sock. An early goal of the Sarah Mellon Scaife Foundation Fellowship on Orthopedic Appliances at Mellon Institute, in 1947 and following, was the development of a porous-plastic material. Though techniques of the time for attaining porosity were not satisfactory, the project made an important indirect step-the introduction to the orthotics and prosthetics field of epoxy laminate which later proved to be a key feature in the early development of porous laminates. After many years of effort, techniques only recently have been developed for the production of porous laminates of polyester resins as well as epoxy. </p> <p> The adjustable coupling for alignment of lower-extremity prostheses, developed by Messrs. Staros and Gardner of the Veterans Administration Prosthetics Center, is obviously related to the early issue of May 1954 in which tools to aid in achieving alignment based upon biomechanical principles were discussed by Professor Radcliffe. The adjustable coupling is particularly useful in aligning prostheses containing special knee joints intended for better control of the limb, though it is also applicable in alignment of the patellar-tendon-bearing below-knee prosthesis. The present coupling, useful though it is, seems only a step toward a light, expendable coupling which may be left in the prosthesis, thus obviating the need for transfer of alignment. </p> <p> Though amputees represent a relatively small fraction of the disabled of the country, the serious physical and psychological aspects of their problems demand special attention. Neglect of these severely disabled persons has sometimes, as at the end of World War II, been the cause of public criticism and emotional or even unjust reactions. It is gratifying that, since then, the systematic and steady work of many devoted individuals and organizations has led to the body of knowledge outlined in the literature now available and to many thousands of persons being trained through intensive short courses in the field, and thus to the present happier state when this highly specialized publication may move from a series of monographs to the greater freedom enjoyed by other journals. </p> <p> Eventually, it is hoped to cover such other problems as fluid mechanisms and children's prosthetics, to provide a review of clinical experience, and to enter the much broader and more complex field of bracing, or orthotics. Also, it will be a pleasure to consider for publication voluntary contributions, without placing continual pressure upon a few devoted contributors. In the meantime comments will be appreciated from our readers throughout the world. </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, Veterans Administration, 252 Seventh Ave., New York 1, N Y.; member, Editorial Board, Artificial Limbs.</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 Transition Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. * https://staging.drfop.org/files/original/4762f350fbaca4d7dceedcfd3c7d363e.pdf 7281217b29c631bcd7ebf10f4c376c5e DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_02_001.pdf Year 1965 Volume 9 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/1965_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_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>The Score</h2> <h5>Eugene F. Murphy, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The past twenty years of the Artificial Limb Program comprise predominantly a series of wins, a few losses, and some ties awaiting replays. Participants, coaches, and managers in this prolonged struggle against nature and ignorance have enjoyed some spectacular seasons, but they also have endured grueling practice and frustrating defeats. </p> <p>Wide interest in artificial limbs accompanies major wars. Ancient armorers made cleverly articulated limbs. The Napoleonic and Crimean Wars stimulated active development in Europe. The American Civil War led to numerous private inventions of prostheses. During World War I vigorous and systematic programs were conducted on both sides. These ended soon after the war, partly because of inflation and other disturbances, and partly because of confidence that limbs had been substantially improved. Everywhere there was a return to "normalcy," but the general impression that amputations are infrequent in peacetime is erroneous. Dr. Glattly's recent survey <i>(Artificial Limbs, </i>Spring 1963) corroborates the claim that for a variety of reasons very substantial numbers of civilians face this major operation in peacetime. </p> <p>In World War II both the Army and the Navy of the United States set up large amputation centers to provide definitive surgery, artificial limbs, and other rehabilitation. Both Services introduced some new materials and mechanisms. To combat severe shortages they used prefabricated, standardized parts and division of labor for fitting and assembling instead of the slow, painstaking custom craftsmanship in very small shops typical of the American limb industry. Dramatic successes occurred. Nevertheless, Service Centers, amputees, commercial limb shops, and, increasingly, the general public were made conscious of the severe limitations of even the best prostheses. </p> <p>The Surgeon General of the Army, therefore, called a conference in January 1945 which was supposed to agree upon the best available prosthetic components. The principal conclusion was that <i>none </i>of the available limbs was really adequate, so research was needed. </p> <p>The Surgeon General then asked the National Research Council to set up a committee to conduct a research and development program. The resulting committee and its descendants have had a variety of designations, membership, organizational structures, and sponsors. Originally the work was supported by the wartime Office of Scientific Research and Development, then by the Army. The Veterans Administration, for many years the sole sponsor of contractual research in prosthetics, still continues important support, but in recent years various agencies within the Department of Health, Education, and Welfare have assumed major financial responsibility. </p> <p>When the original Committee on Prosthetic Devices asked its surgeons to appraise the artificial limbs available in the summer of 1945, the two chief demands to its engineers were for development of a functional artificial hand that looked normal and for stance-phase stability for above-knee artificial legs, presumably from a lock released during swing phase. Patent files and technical literature were littered with descriptions of inadequate attempts by several generations of inventors. </p> <p>The surgeons' demands reflected a primary conception of the Committee's role to concentrate on <i>devices, </i>susceptible to engineering design. In an era when many orthopaedists still were active in military amputation centers and physical medicine was only emerging, the surgeons were not yet concerned with development of new surgical techniques or with prosthetics education. </p> <p>Neither were the surgeons primarily concerned with fitting, though its importance was realized. The second subcontract of the Committee, to develop further a saucer socket for the hip-disarticulation case, was with the Research Institute Foundation, a tiny laboratory which had been set up by the Artificial Limb Manufacturers Association. (This project incidentally initiated a number of ideas which later and independently were developed vigorously at larger laboratories.) Both Committee and limb industry a score of years ago considered the fitting of limbs to be a handicraft, often a sculpture-like art, learned by long experience but scarcely susceptible to systematic research. </p> <p>German studies of alignment principles in World War I had relatively little immediate impact on American practices. Alignment of the above-knee prosthesis in 1945 typically placed the artificial foot far out under the head of the femur "so the amputee would not fall over to the amputated side" and made the axis of the socket bore vertical "so as not to give in to flexion contracture." Thus, while standing on the prosthesis, the amputee leaned against his pelvic band and mechanical hip joint, stressing them severely, in an effort to shift his center of gravity nearer to the foot. Likewise, after exhausting the possibilities of lordosis and unsymmetrical gait in an effort to control a free knee joint after maximum hyperextension of a slightly flexed stump in a straight socket, the recent amputee demanded a mechanical knee lock; a stiff heel bumper or a "long" prosthetic step (caused by inadequate knee friction) only increased instability at heel contact and made the demand for a knee lock more insistent. </p> <p>The early years of the Artificial Limb Program were dramatic, in some senses wasteful, yet in others very fruitful. Some efforts were lost, but unquestionably the whole field of upper-extremity prosthetics was changed for the better by fundamental studies, development, and improved management of the individual amputee. Some unilateral amputees found the APRL hand adequately functional, and careful testing proved its cosmetic glove passed unrecognized in a wide variety of social situations. Thus one complaint was at least marginally resolved. </p> <p>Vigorous study of locomotion proceeded concurrently with numerous development projects. Reintroduction of the suction socket, almost a side activity, forced attention to principles of fitting and alignment, to fostering of cooperation among doctor, limb fitter, therapist, and amputee, and to prosthetics education. Improved alignment as well as added gait training reduced the clamor for knee locks for stance control, and attention shifted toward the swing phase. Several swing-phase mechanisms are now widely used. The Henschke-Mauch Model "A" hydraulic stance-plus-swing-control mechanism has finally been recommended after prolonged development and evaluation. If clinical application studies of the Henschke-Mauch Model "A," including application to recent amputees, prove as encouraging as now seems likely, this device will answer at last the second complaint of the surgeons back in 1945. </p> <p>But many problems remain. The Program has gradually spread its field of vision beyond the mere development of mechanical components. Fundamental research has provided data on locomotion, biomechanics, muscle action, pain, and other problems. Clinical studies have been made of amputation surgery, cineplasty, myoplasty, and early postsurgical fitting, though further studies of surgery and wound healing are needed. Fitting and alignment now can profit from better anatomical and biomechanical principles, new shop tools, improved materials, clearer analysis of defects, and greater insight into causes. The necessary skill and artistry of the increasingly professional prosthetist can be used more effectively. The team principle has become widely practiced, to the reassurance of all concerned. </p> <p>Continuing soul-searching has steadily spurred the participants in this battle against ignorance. The best artificial limbs are still crude. Very little has yet been done about orthotics, deliberately kept in abeyance because braces are worn for such a wide variety of conditions that analysis is difficult. The Subcommittee on Sensory Aids, resuming the tasks of the wartime Committee on Sensory Devices, is only beginning its task of reviewing the present VA projects on aids for the blind. CPRD is studying its possibilities and responsibilities in the broad field of bioengineering. </p> <p>The past score of years has given the Committee an intensive series of encounters, sometimes bruising-but often exhilarating-with problems of mechanisms, their human users, the man-machine interfaces, and the idio-syncracies of the professions concerned. </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">Member, Editorial Board, Artificial Limbs; Chief, Research and Development Division, Prosthetic and Sensory Aids Service, Veterans Administration, 252 Seventh Ave., New York, N. Y. 10001.</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 The Score Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. * https://staging.drfop.org/files/original/79a235e1d4c4ac4171b6ad7c96f90851.pdf 7d14943ca2f5c25f952db617169ffdde https://staging.drfop.org/files/original/d93a7f5e6bfbb40a83f52c51fc6a67a0.jpg db9f1ea0b3a5c0dae6916c1ef66fda44 https://staging.drfop.org/files/original/7cfe500718aa89f77b72e9954ceaa92a.jpg bc918fbb4fd53f2e78ad4605c3abc065 https://staging.drfop.org/files/original/f998e66b14d6b1f834d759185e8e31cc.jpg 690db42406a21e4599e9835f0033c37a https://staging.drfop.org/files/original/559362f3b4c65498619fab8d04b2e42d.jpg f404f1ed2a48fcbad91850fac32efb17 https://staging.drfop.org/files/original/7af014f5d48267ea4832e4f0ba735e65.jpg 609b9bfd8cf0cad72c5cf2fd2ea68995 https://staging.drfop.org/files/original/6da85b1d4d85e1ce07a103930d4575b1.jpg c18a528ba271b6327ebd72aa14550653 https://staging.drfop.org/files/original/1c2e54190c5087e85a7fbc06ef5d358c.jpg 475202f1811c126dfb0443740358cd5a https://staging.drfop.org/files/original/77afa88f7126e3389bfeddccc24b5a2f.jpg 96215102b821993251b391e9acb6d3f2 https://staging.drfop.org/files/original/2371fc89399f73ef4387072b2b40d799.jpg 18b9d437398b6a98ea408c303b0a1ee2 https://staging.drfop.org/files/original/d8cedb74083df4c71c32c360d03b67b8.jpg 5808de98d275b210021d7c661d2ff3d9 https://staging.drfop.org/files/original/163c3b8f65e454aba7ec0bfafdbca66a.jpg 0cb901d66c2c9cdede16bf37b1b551a7 https://staging.drfop.org/files/original/345ce876e71543363ff3c14412c219fb.jpg 8d1848456d7991653f7e3dcad092df20 https://staging.drfop.org/files/original/24ae1765809e82da9084f33c1af4ad5d.jpg 45f56fde2581a9b627c3e7b20f49bae8 https://staging.drfop.org/files/original/684aa5896d82c06bec7a0f958890cadb.jpg b8ce7048f8e79c9339b98b24877b4692 https://staging.drfop.org/files/original/c0e25772039790e312707e0a3e972640.jpg 74351e8b3732f843b1e09d0acc3a1e30 https://staging.drfop.org/files/original/fa307185379e510f725ef82250490487.jpg 90909e24310f83b7ade0e3c07b5cd24b https://staging.drfop.org/files/original/339a789db42e3eea242dd8c322350790.jpg 50a04b08971e95aabb20ffd944f2163c DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1962_02_004.pdf Year 1962 Volume 6 Issue 2 Page Number(s) 4 - 15 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/1962_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1962_02_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Anatomical and Physiological Considerations in Below-Knee Prosthetics</h2> <h5>Eugene F. Murphy, Ph.D. <a style="text-decoration:none;">*</a><br />A. Bennett Wilson, Jr. <a style="text-decoration:none;">*</a><br /></h5> <p>One of the most difficult problems in the design of prostheses is the development of the best means of attaching the prosthesis to the wearer. In lower-extremity cases, transmission of forces between stump and prosthesis is of primary importance. To effect efficient transmission of forces, a stable connection between stump and prosthesis is necessary. At the same time comfort and freedom of motion must be maintained to as high a degree as possible. All of these goals are affected by anatomical and physiological characteristics of the stump and the next proximal joint, and often of the joint above that.</p> <p>Stability is provided most often by encasing the stump in a socket to a point near the first proximal joint. The soft tissues of the stump are not especially ideal for providing resistance to the torques and moments imposed on them by a socket during use of a prosthesis. If the tissues are compressed in an attempt to provide maximum stability, circulation will be impaired; if the socket is too loose, a false-joint effect is produced resulting in abnormally high unit pressures at proximal and distal points, chafing, and a reduction in ability to control the prosthesis. Thus, extreme care must be exercised in socket design and fabrication if the optimum condition is to be obtained.</p> <p>When weight-bearing can be achieved through the long bones, as in the case of many disarticulations and certain special types of amputation, the socket is designed to permit loads to be carried through the end of the bone in the stump. If most of the weight-bearing needed cannot be achieved through the end, some other areas must be found to provide the transmission of forces necessary during standing. For all of these reasons, then, it is extremely important that prosthetists and others responsible for the design of sockets take into consideration certain anatomical and physiological factors in the management of the amputee. In no other case is it more important than in that of the below-knee amputee.</p> <h3>Function of the Below-Knee Stump</h3> <p>Because most of the insertions of the muscles and ligaments that control the knee are located on the tibia and fibula at points close to the knee joint (<b>Fig. 1</b>, <b>Fig. 2</b>, <b>Fig. 3</b>), amputation below the knee rarely affects the function of the knee joint. An exception is the gastrocnemius which originates from the posterior portion of each of the femoral condyles and has for its insertion the Achilles tendon, thus acting as a flexor. Upon amputation, however, the distal end of the gastrocnemius often becomes reattached to the tibia, and the remaining musculature is thus available to assist the flexors and perhaps to aid in preventing dislocation of the fibula with respect to the tibia. Thus the moment that can be generated about the knee in the parasagittal plane by a typical below-knee amputee is approximately the same as that before amputation. Because, in general, the ligaments are left untouched, mediolateral stability of the below-knee amputee usually is not affected.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Posterior view of left knee joint, showing anterior ligaments. Redrawn from Gray's <i>Anatomy.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The major muscles that flex and extend the knee joint. From <i>The Patellar-Tendon-Bearing Below-Knee Prosthesis (4).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. X-rays of a typical below-knee slump <i>. A,</i> Anterior view; <i>B,</i> medial view. Courtesy <i>Veterans Admlnistration Prosthetics Center.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Those muscles which have origins on the tibia and fibula, and which control ankle and foot motion, have been severed and consequently atrophy, resulting generally in a bony, conical-shaped stump (<b>Fig. 4</b>). The amount and type of atrophy that takes place depend of course upon surgical technique and postoperative care.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Lateral and anterior views of a typical well formed, right below knee stump Courtesy <i>Veterans Ad-ministration Prosthetics Center.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In very short below-knee stumps, removal of the fibula (<b>Fig. 5</b>) is sometimes performed to prevent lateral and posterior deviation with uncomfortable protrusion at the distal end. Such deviation is generally thought to be caused by frictional engagement on the socket wall (with inadequate relief) or by action of the biceps femoris. In any below-knee amputee, the distal ligamentous attachment near the ankle is missing, and in short stumps the interosseus membrane (<b>Fig. 6</b>) between the remnants of the tibia and the fibula is presumably inadequate, partly because the proximal opening for the vessels leaves only a small amount of the membrane, and particularly because atrophy of intervening muscles leaves some slack in the membrane. Removal of the fibular head, though, implies that the tendon of the biceps femoris, as well as the fibular collateral ligament, should be reattached with appropriate lengths and at suitable centers on the tibia. A bone bridge from fibula to tibia that would restore stability between tibia and fibula as well as increase the possibilities for bearing weight on the end of the stump would seem to be preferable to removal of the fibula.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Roentgenogram of a short below-knee stump in which lateral deviation and rotation of the fibula have taken place. <i>Courtesy University of California Medical School.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 6. Anterior ligamentous structure of the right knee.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>The Knee Joint</h3> <p> The knee joint formed by the condyles of the femur and tibia (<b>Fig. 3</b>, <b>Fig. 7</b>) allows about 160 dcg. of flexion. It is classified as a synovial joint, or one that is provided with synovial Quid, and the friction developed between the moving surfaces of an unimpaired joint is of an unusually low magnitude as compared with moving joints in machinery.<a></a> It is not a simple hinge joint with a single axis of rotation. Because movement of the tibia with respect to the femur is a combination of gliding and rolling actions, and because of the shape of the contacting surfaces, the instantaneous center of rotation of the knee varies with each degree of flexion. Though the exact course of the instantaneous centers for different individuals cannot be described with present knowledge, a general idea of the typical area through which they move can be had (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. Major structures that form the knee joint. From <i>The Patellar-Tendon-Bearing Below-Knee Prosthesis (4).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 8. Section through the medial condyle of the femur and through the tibia. The center of curvature is shown for three parts of the articular surface. As gliding occurs in the joint, the instantaneous center moves along the curve connecting these centers of curvature. From Elftman (2).</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For many years it has been common practice to divide the responsibility of weight-bearing between the below-knee stump and the thigh by use of simple hinge joints (located along the medial and lateral aspects of the knee) connecting a thigh corset to the socket and shank (<b>Fig. 9</b>). But, because the center of rotation of the knee moves constantly while flexion or extension takes place, any artificial joint attached on the outside of the leg and thigh that does not follow the complex pattern of the human joint will cause relative motion between the body parts and the prosthesis. Since there is not available an artificial joint that simulates normal movement, it appears highly desirable to provide the below-knee amputee with a prosthesis that does not require side joints, even though the tissues in the stump and thigh are capable of absorbing the effects of some relative motion.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 9. Some examples of the so-called "conventional" below-knee prosthesis offered by prosthetists for more than a century. Note the sidebars, corset, relatively low brim, and free space at distal end of socket.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Weight-Bearing</h3> <p>If sidebars are to be avoided, obviously all of the weight-bearing loads must be transmitted through the stump to the skeletal system. Some areas on the stump are better suited to assume these loads than others. In the light of present knowledge and technology it is necessary to design and construct the socket so that the pressures imposed on specific areas, whether by normal repeated loads encountered during walking or whether by single emergency loads, are not of values that exceed the varying tolerances of the different tissues of the stump. And just as obviously some means other than sidebars and thigh corset must be found to maintain the limb on the stump. If, however, the necessary mediolateral stability is not present, there is no known recourse except to use at least one sidebar and generally two.</p> <h4>The Patellar Ligament</h4> <p>Extension of the knee is effected by the contraction of the quadriceps muscle, so named because it has four distinct components. However, they merge into a single tendon which inserts on the anterior portion of the tibia just below its head (<b>Fig. 6</b>). Embedded in this tendon is the patella (<b>Fig. 7</b>), which is therefore a sesamoid bone, the largest in the body. Its function is twofold. While acting as a guide for the quadriceps tendon by following the vertical groove between the femoral condyles, it also tends to increase the lever arm of the quadriceps acting about the knee axis. Its cartilaginous underbody tends to produce very little friction as it slides over the anterior surface of the femur. That part of the quadriceps tendon between the patella and the insertion, frequently referred to as the patellar ligament (<b>Fig. 10</b>), is composed of extremely tough fibers which stretch insignificantly under normal tensile loads along the long axis and is particularly suited to take compressive loads anteroposteriorly. Because of the inextensible quality of the quadriceps tendon, there can be little or no relative motion between the patella and the tibia when the quadriceps develops tension, a condition which permits compressive loads over the quadriceps tendon, perpendicular to the fibers, up to the proximal edge of the patella. The sharp lower edge of the patella, though, is relatively unsuited for weight-bearing.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Schematic drawing showing the nearly complete lack of relative motion between patella and tibia during flexion of the knee. The inextensibility of the patellar ligament prevents the patella from moving proximally with respect to the tibia. From Marks <i>(3).</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Branching out from the quadriceps tendon on each side above the patella are the lateral and medial retinacula (<b>Fig. 6</b>), which insert on the flares of the tibia. Like the patellar ligament, these tendons are capable of weight-bearing.</p> <p>If the socket wall contains an indentation (<b>Fig. 11</b>) between the lower edge of the patella and the tendinous insertion, some initial tension is placed on the tendon. The upper surface of the indentation also permits the tendon to assume a load with a larger vertical component than would be the case if the indentation were not present (<b>Fig. 12</b>). Moreover, when the socket is aligned so that a slight amount of initial flexion is present when the wearer is in the standing position, both initial tension in the quadriceps tendon and the vertical components of load-bearing are enhanced.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 11. Vertical cross-section of anterior portion of socket designed to take maximum advantage of patellar ligament for transmission of weight-bearing loads. Compare with Figure 12.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 12. Vertical cross-section of anterior portion of socket with little provision for use of the patellar ligament for transmission of weight-bearing loads. Note the small vertical component of the force between socket and stump in this area as compared to the condition shown in Figure 11.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Flares of the Tibial Condyles</h4> <p>By virtue of its wedgelike shape and the nature of its thin, tough, overlying tissues, the upper portion of the tibia can assume part of the weight-bearing load by distribution of pressure over the medial and lateral flares of the condyles. Because part of the lateral flare of the tibial condyle is obscured by the head of the fibula, the medial flare offers most of the weight-bearing area.</p> <p><b>Fig. 13</b> shows horizontal cross sections of the tibia below the condyles superimposed on each other. Thus it can be seen that there is available potentially a considerable difference in horizontal area over which to distribute vertical forces to balance body weight. If the socket is aligned so that the stump is forced into a slightly flexed position when the wearer is standing erect, the horizontal components are reduced, the requirements for counter-pressure over the posterior wall are less, and therefore the risk of pressure over the major vessels and nerves in the rear is reduced. Proximity to relatively sensitive zones like the head of the fibula (typically present under the lateral flare), the sharp tibial crest, and the rough tibial tubercle greatly reduces the useful area on the anterolateral portion. The medial flare, though seemingly smaller than the lateral, is quite effective in providing support.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Horizontal cross-sections of leg at four different levels. View below leg shows level <i>A</i> superimposed on level <i>D</i> to illustrate the horizontal area potentially available for vertical support along the sloping areas of the tibia. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Tibial Crest</h4> <p>The shaft of the tibia is roughly triangular in horizontal section, one apex, the tibial crest, lying in the anterior portion of the leg (<b>Fig. 13</b>). The anteromedial wall of the tibia is covered with a thin layer of tissues and is admirably suited to assume some of the weight-bearing stresses. In the normal limb, the anterolateral wall of the tibia is covered by the tibialis anterior, which inserts in the region of the foot. Upon amputation, the tibialis atrophies but can still transmit, without discomfort, considerable load to the anterolateral wall. But the tibial crest itself cannot assume a weight-bearing load because of the high unit pressures that would necessarily develop over the knifelike ridge. For the same reason, compressive stresses cannot be tolerated either at the lateral aspect of the distal end of the fibula or at the anterior aspect of the distal end of the tibia.</p> <h4>The Head of the Fibula</h4> <p>Because the common peroneal nerve passes on the lateral side below the head of the fibula, only very low pressure can be tolerated in that area. Also, for bony stumps it is sometimes necessary to provide a groove proximally from the region of the head of the fibula in order to permit entry of the stump into the socket. <b>Fig. 14</b> shows in a somewhat exaggerated way how a socket is shaped to preclude the application of pressure in tender areas.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 14. Cross-section showing typical method of avoiding pressure between socket and tender areas on stump, in this case the area about the head of the fibula.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Distal End of the Stump</h4> <p>Few below-knee stumps will tolerate very much pressure on the distal end, presumably because of the shearing stresses developed between soft tissues and the cut end of bone. Short stumps, where amputation was made through cancellous bone, and those cases where a bridge of bone has formed between the distal ends of the tibia and fibula, accidentally or surgically, are exceptions to the rule.</p> <h3>Stability</h3> <p> Vertical pressures on the areas projected on the horizontal plane, and hence total vertical forces, unhappily can be obtained only as <i>components</i> of the larger unit pressures and total forces exerted at right angles to the obiquely sloping surfaces of the stump, the thin but tough underlying tissues, and ultimately the bone (<b>Fig. 15</b>). Because these surfaces slope, there must be forces <i>in</i> the horizontal plane. Because the slowly curving surfaces slope generally <i>inward</i> toward the longitudinal axis of the tibia, in the frontal plane that fraction of the horizontal components of the sloping forces from the socket acting on the broad medial aspect of the condyles must oppose the corresponding components of the force acting on the more limited lateral aspect, resulting in over-all compression or constriction of the stump. Any net imbalance near the condyles may be counteracted by a distal horizontal force to yield in the frontal plane a moment balanced elsewhere. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 15. Schematic drawing showing the approximate direction of forces acting on the flares of the tibial condyles. The vector representing the force on the lateral side is shown in true view in the lower sketch. Note the components developed in the horizontal plane. The components shown must of course be balanced by other forces in the horizontal plane.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Because both the medial and lateral condyles slope generally <i>backward,</i> the horizontal components in parasagittal planes would tend to force the stump backward and hence allow it to slip downward off the sloping shelves matching the tissues overlying the condyles. Similarly, forces on the patellar ligament and retinacula have components directed rearwardly. Obviously, counterpressures from the rear wall must be so distributed over the stump as to develop adequate counter-forces without pressure sufficient to cause pain at any point, restrict return circulation, or interfere with adequate knee flexion during sitting. Superimposed on these forces acting in the horizontal plane as a result of vertical weight-bearing there generally are other forces, high on one aspect of the stump and low on the opposite, forming couples related to mediolateral stability, forcible knee extension, and so on. </p> <p>The optimum level for the rear brim of the socket is the popliteal crease. Though as high a brim as feasible is desirable to provide greater area for horizontal counterpressure, a rigid socket brim above this level on the posterior aspect will seriously restrict knee flexion; one below results in bulging of the tissues over the brim during flexion.</p> <p>The medial and lateral aspects of the socket wall should be carried to about the level of the proximal edge of the patella to enhance mediolateral stability.</p> <h3>The Hamstrings</h3> <p>The most important flexors of the knee are the hamstrings, which have two areas of insertions-one on the posterior aspect of the medial tibial condyle, the other on the posterolateral aspect of the head of the fibula (<b>Fig. 2</b>). As flexion occurs and the tibia and fibula rotate with respect to the femur, the hamstrings move away from the center of the femur. To prevent bunching of the tissues in the popliteal space during substantial knee flexion, especially during sitting, the brim of the socket should be brought precisely to the level of the popliteal crease. Because the two insertions of the hamstrings are below this level, interference between the hamstring tendons and the brim of the socket would occur when the knee is flexed were appropriate grooves, or cutouts, not provided in the rear portion of the brim. The medial groove is generally deeper than the lateral because the insertion of the semi-tendinosus is more distal on the tibia than the insertion of the biceps femoris is on the fibula.</p> <h3>Edema</h3> <p> One of the causes of edema is an unbalanced condition in the interchange of materials between blood and body cells by way of the capillary and lymphatic systems, <i>i.e.,</i> more fluid is pumped temporarily into the exchange system than is pumped out. An imbalance can be the result of either mechanical or biochemical factors. The wearing of a limb is not likely to lead to the formation of chemicals that produce edema, but it can produce mechanical factors that do. The action of voluntary muscle working within the normally intact fascial envelope is responsible in part for the return of the blood to the venous system via the capillary and lymphatic systems, and hence factors that alter normal muscle activity can contribute to the formation of edema. Further, concentrated pressures in one area can cause edema in a distal area either by inhibiting muscle action or by restricting the low-pressure venous or lymphatic return systems and thus are to be avoided. For this reason, when relief is required for bony prominences or tender areas, the indentation in the socket wall should be flared gently. Relief should never be provided by a hole or window which removes external counterpressure from a localized area while maintaining support or even constriction elsewhere. </p> <p>Also to be avoided is a combination of a tight fit in the proximal portion of the socket and a loose fit distally. Under such circumstances the venous and lymphatic systems can be constricted to the point that edema is produced.</p> <p>Gentle external pressure on soft tissues offers a mechanical aid to the return of blood to the venous system. The equivalent can be obtained by encasing the entire stump with the socket in such a manner that at least a slight amount of pressure is brought to bear over the soft tissues as the prosthesis is used.</p> <h3>The Composite Socket</h3> <p>The shape of the socket in which the anatomical and physiological factors discussed above are taken into account is shown in <b>Fig. 16</b> and <b>Fig. 17</b>. The anterior brim is brought to the level of the center of the patella; a horizontal indentation is provided at the midpoint of the patellar ligament to induce tension in the ligament and at the same time to afford a more horizontal weight-bearing surface; the lateral and medial aspects of the brim are brought about level with the proximal edge of the patella to assist in providing mediolateral stability; grooves are incorporated into the posterior brim of the socket to accommodate the hamstring tendons during flexion; the entire stump is encased; and areas for relief of bony prominences are flared gently to avoid radical changes in pressure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 16. Cutaway view of the patellar-tendon-bearing socket incorporated in a thin-walled plastic shank. Note especially cuff-suspension strap, high lateral and medial walls, and the total-contact feature.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 17. Posterior view of brim of PTB socket for a right stump. Note that the medial wall is slightly lower than the lateral. Not shown is the soft inner liner commonly used.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The socket shown was developed by the Biomechanics Laboratory of the University of California<a></a> after a thorough study of previous practices and after an analysis of the anatomical, physiological, and biomechanical factors involved. The socket is installed in the prosthesis so that the knee is in some 5 to 8 deg. of flexion when the patient is standing erect. This slight degree of initial flexion not only places the weight-bearing loads on the stump in a direction that reduces the unit stresses and shearing forces but also relieves the popliteal area of some pressure as well. In addition, use of the quadriceps is encouraged, and the risk of overloading ligaments as a result of excessive hyperextension is reduced. </p> <p> Because of the difficulty in achieving a truly intimate fit, and for lack of an accurate method of measuring forces between the stump and the socket, use of a soft liner is recommended. The liner, usually of sponge rubber 1/8 in. thick on the sides, slightly thicker on the end, and covered with leather, reduces the chances of abrupt changes in stress. </p> <p>Suspension usually can be effected by a simple cuff above the femoral condyles attached to the shank by flexible straps, but a waist belt or sidebars and corset may be used if necessary.</p> <p>The entire prosthesis has come to be known as the "patellar-tendon-bearing leg," or simply the "PTB leg," perhaps useful as a code name but an unfortunate nomenclature if taken literally, not only because it describes only a part of one functional aspect offered by the prosthesis but also because even that portion would more rightly be termed "patellar-liga-ment-bearing" or "quadriceps-tendon-bearing."</p> <p>Sidebars and corset may be indicated in cases where rather extreme mediolateral instability of the knee is present or where muscles which control the knee have been impaired to the extent that exercise will not strengthen them. Sidebars and corset with ischial support may be indicated either for cases where bone or joint impairments prevent any of the long bones from assuming weight-bearing loads or for those where the skin is of such nature that the imposition of the required loading is simply out of the question. In addition, certain occupations might be carried out more readily if sidebars were used. Except for such limitations, virtually all below-knee amputees with healthy stumps can derive benefit from the PTB prosthesis with cuff suspension, provided the clinic team fully understands the underlying principles in the design and provided also that the prosthetist has the skill necessary to incorporate the essential features into the finished prosthesis.</p> <h3>Acknowledgment</h3> <p>The authors wish to acknowledge the gracious assistance and guidance afforded by Herbert Elftman and Gabriel Rosenkranz in the preparation of this article.</p> <p><b>References:</b></p> <ol> <li> Charnley, John, <i>The lubrication of animal joints,</i> in <i>Symposium on Biomechanics,</i> The Institution of Mechanical Engineers, London, 1959, pp. 12-22. </li> <li> Elftman, Herbert, <i>The functional structure of the lower limb,</i> Chapter 14 in Klopsteg and Wilson's <i>Human limbs and their substitutes,</i> McGraw-Hill, 1954. </li> <li> Marks, George E., <i>Treatise on artificial limbs,</i> A. A. Marks Co., New York, 1899. </li> <li> University of California, Biomechanics Laboratory (Berkeley and San Francisco), <i>The patellar-tendon-bearing below-knee prosthesis,</i> 1961. </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>4.</b> </td><td class="clsTextSmall"> University of California, Biomechanics Laboratory (Berkeley and San Francisco), The patellar-tendon-bearing below-knee prosthesis, 1961. </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"> Charnley, John, The lubrication of animal joints, in Symposium on Biomechanics, The Institution of Mechanical Engineers, London, 1959, pp. 12-22. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>A. Bennett Wilson, Jr. </b></td></tr><tr><td class="clsTextSmall">Staff Engineer, Committee on Prosthetics Research and Development, National Academy of Sciences - National Research Council, 2101 Constitution Avenue, 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>Eugene F. Murphy, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Research and Development Division, Prosthetic and Sensory Aids Service, Veterans Administration, 252 Seventh Avenue, New York City.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-07.jpg Figure 8 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-08.jpg Figure 9 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-09.jpg Figure 10 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1962_02_004/tmp623-17.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 Anatomical and Physiological Considerations in Below-Knee Prosthetics Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. * A. Bennett Wilson, Jr. * https://staging.drfop.org/files/original/e0d0a9bb3f547362ad9876b219fa7714.pdf 9335229897eae76821807d7a78f7836d Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_02_078.pdf Text Any textual data included in the document <h2>In Support of the Hook</h2> <h5>Eugene F. Murphy, Ph.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>If this were a perfect world, each person would have two perfect, versatile, beautiful hands. Unfortunately, there are individuals who lack one or both of these exquisite devices, whether cogenitally or adventitiously. Thus far, any substitute can only represent a very limited compromise and partial selection of varying fractions among the many desirable functions and cosmetic features needed for a true replacement. There seems no reasonable hope of providing the numerous muscles, nerves, reflexes and voluntary controls needed to position and stabilize mechanical imitations of the multiple joints in the natural hand. Because uncontrolled flexibility, like a loose chain, is merely unstable, the designer is forced to limit the joints severely, providing fixed curves which offer rigidity, yet maximize function.</p> <p>Fortunately, the customary wrist disconnect mechanisms allow reasonable interchanges to suit specific needs. These changes may not be quite as simple for the amputee as for the normal person who dons warm gloves for cold weather, picks up tongs, tweezers, or pliers to "handle" hot, tiny, or rough objects, or scrubs and manicures in preparation for a party. Nevertheless, the possibility of interchange does allow considerable versatility rather than a forced, even heartbreaking, choice of a single limited terminal device. Each amputee may use an artificial hand with substantial but limited function, and lifelike cosmetic glove when appearance is important, but, then change to a considerably more functional terminal device when appropriate, much like changing evening or business clothes to sports clothes or overalls.<a></a> In this context of voluntary choice, then, let us consider the appropriate roles for split mechanical hooks.</p> <p>Note that we can assume that we are far beyond the single hook with sharpened point made notorious by Captain Hook, useful as that was in its time. For the near future, though, we seem limited in practice to a single active control that provides adequate force at any point in a reasonable range of motion and is capable of rapid change, delicate adjustment, and prolonged holding, and preferably offers substantial sensory feedback. The typical Bowden cable (secured to shoulder harness, activated by body motion, and providing some sensory feedback from kinesthetic awareness of human joint position and tactual perception of pressures) provides a substantial degree of function. A source of external power under a single voluntary control, whether valve, switch, or myoelectric signal, may have greater or lesser speed of response, precision of adjustment, and maximum force, but so far it probably supplies less sensory feedback. Occasional adjustments, locking, or presetting of parts can be made by a unilateral amputee with the other hand or by a bilateral amputee through gross motion of the prosthesis to press the terminal device against an object, or squeeze it between the knees, etc.</p> <p>Thus far, both practical clinical experience and research studies have indicated that additional substantial sources of power, control, and feedback are so limited that they are better used for other functions like elbow flexion, elbow locking, or perhaps wrist rotation instead of for additional motions within a hand or hook. If additional practical sources do become available, of course, they can be used to improve both hand and hook by reshaping either for still greater versatility, or to actuate and release a lock, thereby improving both devices. The hook, though, is intrinsically more versatile than a mechanical hand of equivalent control and sophistication.</p> <p>It may be useful to recall that the Klingert artificial arm and hand at the end of the Eighteenth Century attempted to control some, ten independent motions by cords ending in knobs which the unilateral amputee could move with his good hand along a vest-like garment.<a></a> Presumably the user soon decided to use the good hand directly for most tasks!</p> <p>Like many current robots, remotely operated manipulators for nuclear "hot cells" have typically been designed with seven degrees of freedom, including grasp by simultaneous and equal motion of opposing surfaces of the terminal device. Usually a single able-bodied operator has controlled two manual master-slave manipulators, one with each arm, plus assorted leg and body motions to assist in positioning. Even so, we were told some years ago,<a></a> performance of relatively simple tasks typically took eight to ten times the time needed to do them directly with the bare hands, and early unilateral electrical manipulators took over ten times as long as mechanical master-slaves! At a series of conferences called Project ROSE with participants in the prosthetics research program and others,<a></a> experts from the nuclear and space programs seemed awed to learn that no bilateral arm amputee (even though substantially limited in independent body motions) needed anywhere near that additional time to perform complex tasks of industry or of daily living. The current interest in applications of robotics to aid quadriplegics may help to revive these interdisciplinary exchanges.</p> <p>It may be suggested that the performance advantages of the amputee lie not only in motivation, past therapy, and full-time usage, but in basic design philosophy. The classic UCLA studies summarized by Taylor<a></a> and Taylor and Schwarz<a></a> pointed out the great complexity of the human hand and upper extremity, analyzed the motions and forces used for a variety of activities, suggested reasonable priorities and limitations, and preset or limited position selections in contrast to the equal priority and great range assigned to all motions in many manipulators. The designs of prosthetic hooks typically provide a fixed point of reference for arm placement in the fixed finger. This allows relatively easy and accurate positioning against one side of an object, followed by closing of the hook to surround and grip the object as securely as desired. (The slowly moving thumb or "finger" of the Northwestern University<a></a> synergetic hand or hook substantially follows this concept, with the rapidly moving member(s) encircling and the high-force thumb then clamping.) In contrast, if both hook fingers (or the thumb opposing the index and middle fingers of a hand) move simultaneously, the user must initially position the arm in relation to an imaginary centerline while mentally allowing for subsequent (perhaps even unequal) motion of the opposing surfaces. This harder task can be learned by long practice and tolerance of frequent error (as we know from sports involving catching objects), but it seems relatively risky for approaching tall unstable objects like laboratory glassware. It also requires good vision, emphasizing the importance of the large safety window in a hot cell and the limitations of periscopes, mirrors, and television systems.</p> <p>The vast resources of the human hand allow very rapid shaping, grasping, and squeezing to hold objects of assorted sizes, with a reflex adaptation that grips more tightly if slippage starts yet also minimizes the risk of crushing fragile objects. A natural hand spontaneously exerts only modestly more gripping force than needed, whereas the amputee tends to overgrip. With a single control, an artificial terminal device must have a single general shape, though the opposing fingers of the hook may be markedly different. They should encircle and pull in objects within a wide range of sizes rather than extruding them from a V-shaped clamp. At least three contact points are needed for stability; two flat tongs are inadequate or at least require substantial forces to grip rounded objects. The two-position thumb of the APRL hand, preset to normal or wider positions by pressure against some object, is helpful but does not allow the flattening needed to enter pockets.</p> <p>Attempts have been made to provide unusually large thumb motion. This is to allow the choice of palmar prehension of the finger tips against the thumb or more complete flexion of the fingers into the palm, e.g., the Tomovic Beograd (Belgrade) hand.<a></a> That kind of versatility requires at least sensor pads and relatively complex logic such as that used by Tomovic or preferably a second hand control. The addition of independent lateral prehension of the thumb, in which the thumb is rotated to press against the partially flexed fingers, is a commonly used human motion, but is limited to small objects and is not considered useful as the primary grip. It might even require dedication of a third control to the terminal device.</p> <p>In contrast to the severe limitations of an artificial hand with present control sources, a split mechanical hook or other gripping tool may be designed to grasp objects of a wide range of sizes, yet remain sufficiently slim near its closed position to enter pockets to retrieve coins or other objects. Instead of imitating natural form and motion, the hook can be designed solely for function, attaining a sleek though mechanical appearance. In addition, it can be used to push, pull, pry, hammer, touch and hold hot or cold objects, and in general perform many tasks for which even the wonderful human hand requires tools. By ingenious shaping of fingers and choice of axis, the same hook may be used as tweezers for pins, to securely grip many medium-sized objects of daily life, and to surround and lift large objects.</p> <p>Mass-produced hook fingers (in contrast to earlier hand-forged and slightly variable models) may be economically provided with vulcanized rubber lining for higher friction while retaining a slippery metallic outer surface. (In early field tests with this feature, everyone liked the ability to slip easily into pockets or sleeves. However, one subject, who was long accustomed to starting a sewing machine by pushing the flywheel, complained of the absence of the chemical laboratory tubing used over older hooks. Nothing is perfect!) There may well be a major role for softer external surfaces, especially for children's terminal devices so to prevent injuries. Obviously, the materials should be nontoxic, non-allergenic, noncarcinogenic, and durable.</p> <p>The APRL and Northrop-Sierra hooks were designed with symmetrical lyre-shaped aluminum fingers held to the case by jam nuts, allowing replacement. Among the many unfinished items on the old research agendas discussed at the frequent conferences and workshops, was the deployment of stainless steel fingers and alternative shapes, including axes canted in relation to a thin sheet gripped by the hook fingers. Occasionally, there was speculation about color in place of the customary polished metal, or of a cosmetic glove designed to fit over a hook.</p> <p>Greater use of the three-jaw chuck concept, characterized by the index and middle fingers of the APRL hand moving in somewhat inclined planes toward the thumb, is sometimes suggested. However, greater stability must be balanced against greater bulk when closed.</p> <p>The literature, particularly in patents, discloses a great variety of concepts and shapes of terminal devices. Many were invented by amputees to meet their individual needs, especially in farming or industry. Some designers, notably Steeper in England, emphasized development of many special-purpose tools for daily living as well as for agriculture, industry, and avocations, together with disconnect devices for easy interchange. The demonstrator typically had a fitted case carrying a wide assortment. English colleagues have mentioned that a specific amputee typically received a dress hand, a split mechanical hook, perhaps a single tool appropriate to his particular trade, and (particularly in the case of a bilateral) a long straight split device helpful for grasping toilet paper.</p> <p>Since 1945, American research programs have emphasized the development of devices to permit any amputee to independently conduct the activities of daily living. Bimanual activities are so varied, due to the size of objects and the gripping force and dexterity required, that vocational guidance for a motivated amputee should include the selection of appropriate vocations which can be carried out with the same device(s) used in daily living. Indeed, most personal tasks are performed on or close to the body, perhaps suggesting wrist flexion devices, whereas vocational tasks normally are conducted on a table or workbench that do not require wrist flexion.</p> <p>A wide network of clinic teams is available to assist amputees select a prosthesis, return to former occupation, or choose a new vocation. In addition to a reasonably functional hand with cosmetic glove, the unilateral normally receives a versatile hook. The bilateral amputee rarely can function adequately with two artificial hands; sometimes he can use one hand and one hook, if appearance is more crucial than dynamic and independent function. Commonly, the bilateral amputee selects two hooks for routine use.</p> <p>Fortunately the number of bilateral amputees is very small, yet their needs are particularly great. Paradoxically, to meet their special needs, it has been necessary to first develop devices and techniques which are sufficiently versatile and which are accepted by a majority of the much larger unilateral market (and the professionals who serve amputees). Though present terminal devices are useful and cosmetically acceptable, further research on the specific problems of bilateral amputees is needed.<br /><br /><em><b>*Eugene F. Murphy, Ph.D. </b> Dr. Murphy resides in New York City and has long been associated with the American Prosthetic/Orthotic R&amp;D Program. For many years he was in charge of the VA's office of Technology Trades and Editor of the Bulletin of Prosthetic Research.</em></p> <p><b>References:</b></p> <ol> <li><a href="al/1955_02_047.asp">Dembo, Tamara, and Ester Tane-Baskin, "The Noticeability of the Cosmetic Glove," <i>Artificial Limbs</i>, 2(2), pp. 47-56, May, 1955.</a></li> <li>Borchardt, M., et al., <i>Ersatzglieder und Arbeitshilfen</i>, Berlin, Springer, pp. 404-405, 1919.</li> <li>Goertz, Ray, <i>Advancements in Teleoperator Systems, A colloquium held at the University of Denver February 26-27, 1969</i>, Washington, Office of Technology Utilization, National Aeronautics and Space Administration, NASA SP-5081,pp. 176-186, 1970.</li> <li>Murphy, Eugene F., "Manipulators and Upper-Extremity Prosthetics, <i>Bulletin of Prosthetic Research</i>, 10(2), pp. 107-117, 1964.</li> <li>Taylor, Craig, "The Biomechanics of the Normal and of the Amputated Upper Extremity," in Paul E. Klopsteg, Philip D. Wilson, et al., <i>Human Limbs and their Substitutes</i>, pp. 169-221, New York, McGraw-Hill, 1954; reprint edition New York, Hafner, 1968.</li> <li><a href="al/1955_03_004.asp">Taylor, Craig, "The Biomechanics of Control in Upper-Extremity Prostheses," <i>Artificial Limbs</i>, 2(3), pp. 4-25, 1955</a>; reprinted in <i>Selected Articles from Artificial Limbs</i>, Huntington, N. Y., Krieger, pp. 63-84.</li> <li><a href="al/1955_02_022.asp">Taylor, Craig, and Robert J. Schwarz, "The Anatomy and Mechanics of the Human Hand," <i>Artificial Limbs</i>, 2(2), pp. 22-35, 1955</a>; reprinted in <i>Selected Articles from Artificial Limbs</i>, Huntington, N. Y., Krieger, pp. 49-62.</li> <li>Childress, Dudley S., John N. Billock, and Robert G. Thompson, "A Search for Better Limbs: Prosthetics Research at Northwestern University, "<i>Bulletin of Prosthetic Research</i>, 10(22), pp. 200-212, 1974.</li> <li>Veterans Administration Prosthetics Center Research, <i>Bulletin of Prosthetic Research</i>, 10(9), pp. 142-144.</li> </ol> Page Number(s) 78 - 81 Year 1986 Volume 10 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource In Support of the Hook Creator An entity primarily responsible for making the resource Eugene F. Murphy, Ph.D. *