6 20 371 https://staging.drfop.org/files/original/bb5505172d6f91d3b4c1078c76732cdd.pdf 5f258ce3f8db62c96aded278f4214167 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1958_01_001.pdf Year 1958 Volume 5 Issue 1 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_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1958_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>Evaluation Revalued</h2> <h5>Robert E. Stewart, D.D.S. <a style="text-decoration:none;">*</a><br /></h5> <p>In any sound program of research and development, whatever the intended goal, there must inevitably come a time when extensive evaluation of the product is indicated. Less than fifty years ago, systematic tests of new concepts were performed more or less routinely by private inventors dedicated to proper self-appraisal as occasion warranted. In a period less sophisticated technologically, this fashion in science served its purpose adequately and well. But with the growth in a more modern era of the large and vastly more complicated system of scientific inquiry, such as we know it today in government and industry alike, the requirement for periodic assessment of experimental results has led to the development of the independent testing laboratory, either as a part of the basic organization or as a separate contracting institution. So indispensable has this phase of technical investigation become that now large sums of money are spent annually in support of evaluation groups who themselves commonly engage at least in part in research aimed at improving their own methods and techniques.</p> <p>With respect to these matters, the Artificial Limb Program has exhibited ostensibly no basic deviation from the general pattern now characteristic of other broad exploratory projects involving the cooperation of various specialists in otherwise distinct disciplines. But because of the peculiar nature of the amputee problem, the particular state of the art of limb prosthetics, especially in the upper extremity, and the demands of rather unusual external influences of one kind or another, the approach to systematic evaluation has in this case evolved out of a unique history and has, consequently, given rise to some valuable results in research and education of which the influence was not fully anticipated in the beginning.</p> <p>Although in that portion of ALP devoted to the upper extremity much of the initial investigation was directed toward all-purpose, or "ideal," prostheses for selected levels of arm amputation, it was soon recognized that the desired objectives would be served more effectively were a variety of components made available for assembly into various combinations the better to provide for the particular needs of the individual patient. As these components were developed, prototypes and, later, production units were subjected to systematic testing by the Prosthetic Devices Study, an organization established for this specific purpose within the Research Division of the College of Engineering of New York University.</p> <p>At this point, evaluation generally furnished much needed data concerning the usefulness and reliability of individual units in direct comparison with previous similar parts but without regard for the influence of socket fit, type of harness and harness adjustment, type and extent of training, individual amputee preference, and other factors. Because methods suitable for the evaluation of techniques had yet to be introduced, early evaluations of components brought with them the subtle dangers of misinterpretation owing to the indirect effects of pre-existing errors in socket or harness, to say nothing of the possibility of the influence of one component upon the performance of another used in conjunction. In these circumstances, a great deal was left to be desired in reference to the over-all problem of upper-extremity prosthetics.</p> <p>To fill the gap, there was initiated in 1950, in the Department of Engineering at the University of California at Los Angeles, the so-called "Case Study," with the purpose of bringing together all available information, of viewing systematically the results obtained by use of various combinations of devices and techniques, and thus of developing a set of general principles of management for the upper-extremity amputee. As the Case Study progressed, there arose an increasing awareness of the necessity for teamwork in the proper application of such knowledge as there was, and by 1952 the Prosthetic Devices Study was called upon to conduct an evaluation of the results of the UCLA Case Study.</p> <p>It was obvious that, if such an evaluation were to be conclusive, large numbers of cases under varying geographical conditions would be needed for observation and that therefore the services of a number of clinic teams throughout the country would be required. Although the Prosthetic and Sensory Aids Service of the Veterans Administration, long the chief sponsor of the Artificial Limb Program, had already established some thirty prosthetic clinic teams, and although these groups were readily available for participation, it was patently mandatory that they be trained in the latest methods before any reliable program of evaluation could be initiated. Accordingly, short-term courses for clinic team members physicians, therapists, and prosthetists were organized and conducted at UCLA beginning in 1953. The formation of new clinic teams outside the VA framework was encouraged, and these, along with a few private clinic teams already in existence, were invited to participate.</p> <p>The education program leading to the Upper-Extremity Field Studies, the name applied to this part of the NYU evaluation work, proved to be a pioneering effort in its own right. While results of research were being made available to clinic teams for general use in a remarkably short time after the initiation of laboratory work, the continued association of clinic personnel with the research program through participation in the Field Studies had a definite impact on those responsible for amputee care. Thus the Field Studies came to be a series of complex investigations designed not only to evaluate the usefulness of available upper-extremity prostheses but also to determine the effectiveness of the management procedures elucidated by the UCLA Case Study. Simultaneously, and almost unavoidably, the process of accumulating voluminous clinical data on one segment of the population led to a general upgrading of industry practices in amputee service and furnished the basis for further research into the needs, physical and mental, of the armless.</p> <p>Because the NYU Field Studies represent the first, and thus far the only, attempt in the United States to appraise the status of upper-extremity prosthetics directly and on such a broad scale, and because the results present such a wealth of information not available elsewhere, this and the following issue of Artificial Limbs are given over to presentation of a series of summary articles divided into two parts the first (this number) concerned with the educative aspects of the work, the second (Autumn 1958, Vol. 5, No. 2) with the research implications. For those who would undertake further study and interpretation in the interest of scholarship, the original data, far too detailed for thorough analysis by other than biostatisticians, are available in the College of Engineering of New York University, New York City.</p> <p>In reviewing the material offered here, it is appropriate to keep in mind that the Field Studies constituted a new voyage into an area in which both subject matter and method of approach were uncharted and unexplored. Understandably beset by all the problems of design, organization, and execution typical of adventures into the unknown, they now reveal certain deficiencies most readily viewed with benefit of hindsight. In all probability, the true value of the Field Studies remains to be had in the further application of the principles not only in the field of limb prosthetics but in other, more general areas of physical handicap as well.</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>Robert E. Stewart, D.D.S. </b></td></tr><tr><td class="clsTextSmall">Director, Prosthetic and Sensory Aids Service, U. S. Veterans Administration, Washington 25, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Evaluation Revalued Creator An entity primarily responsible for making the resource Robert E. Stewart, D.D.S. * https://staging.drfop.org/files/original/9719948f0ff1fbce02da39e6232a4372.pdf 5e4f12bcbae522e74f4012c60724a3a5 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_03_011.pdf Text Any textual data included in the document <h2>Evolution of the AK Socket</h2> <h5>H. R. Lehneis, Ph.D., CPO&nbsp;</h5> <p>The lead article for this issue of <i>C.P.O</i>., "Sockets, Linings, and Interfaces," by Dr. Eugene Murphy represents the culmination of many years of research, writing, and studying the principles of socket design and interfaces.</p> <p>Admittedly, very little advance has been made in AK socket design since the development of the total contact socket. Today, the principles espoused by Dr. Murphy of selective flexibility/rigidity of socket interfaces can be realized in clinical practice.</p> <p>There is a pressing need to re-evaluate the traditional quadrilateral AK socket design in light of the drastic changes over the years in the amputee patient population. Today, the vast majority of AK amputees are geriatrics—a complete reversal from the time of development of the quadrilaterally-shaped socket. Most practitioners would agree that the most prevalent complaint of geriatric amputees is discomfort. This is not surprising, considering that most geriatric amputees suffer from reduced muscle tone, sensation, and vascularity.</p> <p>Thus, it has been proposed by this author to re-examine the cross-sectional configuration of AK sockets to specifically address the physiological alterations in stump shape and consistency of geriatric amputees, to evolve a socket design specific for this patient population. Such new configuration, combined with contemporary interface materials, e.g., silicone, copolymer inserts, and selective flexibility/rigidity, should lead to much improved physiological and biomechanical function and comfort (see <a href="cpo/1984_01.asp">Winter issue <i>C.P.O.</i>—Vol. 8, No. 1</a>).</p> <p>Other attempts to improve comfort are seen in Scandinavian socket designs in which the entire socket is semi-flexible except for the medial wall and a portion of the proximal brim area. In the Ockenfels design, the socket contains selective fenestrations and an inner elastic cloth liner or sock to prevent window edema. The so-called Contoured Adducted Trochanteric Controlled Alignment Method (CAT-CAM), developed by Sabolich, is to not only improve comfort but supposedly the patient's gait pattern.</p> <p>Now that these new developments are emerging, it seems rather puzzling, in retrospect, that there was such a long hiatus in the application of soft or flexible interface materials in AK sockets. And so it appears that we are on the verge of a major breakthrough, particularly in AK socket design and interface materials. Though not universally practiced, these noteworthy developments will change the practice of prosthetics in dramatic ways to improve comfort and function our patients so much deserve.</p> Page Number(s) 11 - 11 Year 1984 Volume 8 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Evolution of the AK Socket Creator An entity primarily responsible for making the resource H. R. Lehneis, Ph.D., CPO  https://staging.drfop.org/files/original/d6ec4f4cef4fe2b96b5552ee4bba10a9.pdf 8f92cb1131cf047459895a5704ecc878 https://staging.drfop.org/files/original/998b11fabd198c71f6abd4bf6b516e92.jpg 315bfea7ae8512dca9b0928e26cca16c https://staging.drfop.org/files/original/a791344928dd5ce06a9dafb331b696fb.jpg 79ef2482afd24d2c7b2c8dd1b65284ec https://staging.drfop.org/files/original/4134d8561dbb4b9e1a573017e6502b8b.jpg 800248e585502a10a8018e210a065fa7 https://staging.drfop.org/files/original/9954f37265beca7bc0641bc84005faec.jpg a22bede040881a6d70bf53010ced6d35 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1968_01_020.pdf Year 1968 Volume 12 Issue 1 Page Number(s) 20 - 24 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1968_01_020.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1968_01_020.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>Experience with the Münster-Type Below-Elbow Prosthesis, a Preliminary Report</h2> <h5>Charles H. Epps, Jr., M.D. <a style="text-decoration:none;">*</a><br />John H. Hile <a style="text-decoration:none;">*</a><br /></h5> <p>The Münster technique, an attempt to obviate the traditional problems associated with fitting short and very short below-elbow amputees with split sockets and step-up hinges, has been described in some detail. <a></a> However, individual clinic experience in fitting Münster-type prostheses to patients has not been well documented. Following publication of a manual of instruction for the Münster-type below-elbow prosthesis by New York University in 1965, <a></a> the Juvenile Amputee Clinic of the District of Columbia General Hospital undertook the routine fitting of short below-elbow cases with these prostheses. The principles of construction and fitting outlined in the New York University manual were followed very closely. This article presents an analysis of patients fitted with the Münster-type prosthesis at the Juvenile Amputee Clinic.</p> <h3>Scope of the Study</h3> <p>Fourteen patients were fitted with a total of 24 Münster-type below-elbow prostheses between 1965 and 1967. The group comprised eight female and six male patients. The right upper extremity was involved in eight patients, the left in six. There were no bilateral cases. One ten-year-old boy had an amputation of traumatic etiology; the remaining 13 patients had congenital deficiencies. An 11-month-old infant is not included in the analysis because her family moved to another city shortly after her fitting, and no long-term follow-up data could be obtained. Stump length ranged from 1 1/4 in. to 7 in., with all but two stumps measuring less than 4 in. The distribution was as follows:</p> <table> <tbody><tr> <th> <p>Number of Patients  </p> </th> <th> <p>Stump Length (in.)</p> </th></tr> <tr> <td> <p>1</p> </td> <td> <p>1 1/4</p> </td> </tr> <tr> <td> <p>1</p> </td> <td> <p>1 1/2</p> </td> </tr> <tr> <td> <p>1</p> </td> <td> <p>1 7/8</p> </td> </tr> <tr> <td> <p>2</p> </td> <td> <p>2</p> </td> </tr> <tr> <td> <p>1</p> </td> <td> <p>2 1/2</p> </td> </tr> <tr> <td> <p>2</p> </td> <td> <p>2 3/4</p> </td> </tr> <tr> <td> <p>1</p> </td> <td> <p>3 1/4</p> </td> </tr> <tr> <td> <p>2</p> </td> <td> <p>3 3/4</p> </td> </tr> <tr> <td> <p>1</p> </td> <td> <p>4</p> </td> </tr> <tr> <td> <p>1</p> </td> <td> <p>7</p> </td> </tr> <tr> <td> <p><b>Total: 13</b></p> </td> <td> <p> </p> </td> </tr></tbody></table> <p>Seven of the patients had been previously fitted by conventional means, and seven had never worn a prosthesis. It is interesting to note that only one of the previous prostheses had been of the split-socket type, the others being preflexed.</p> <p>During the study period, two patients received three prostheses, six received two prostheses, and six had single fittings. In the multiple fittings, the shortest period before replacement was five months, and the longest 26 months. The average for the entire 13 patients on whom adequate follow-up information was obtained was 11.8 months. The three patients requiring replacement at five to six months gained weight rapidly or experienced spurts in growth.</p> <h3>Fabrication and Fitting Procedures</h3> <p>Taking the wrap cast is one of the most critical steps in the preparation of Münster-type prostheses. Use of a proper molding grip is essential to the success of the technique. It was found that the stump of an infant is more difficult to cast than that of an older child because of the discrepancy between the size of the infant's stump and the hands of the prosthetist. Accentuation of the groove for the patient's ulna formed by the thenar and the hypothenar eminences of the pros-thetist's hand seems to be less critical in casting the infant's stump than in casting the stump of the older child or adult. The difference is probably due to the generous layer of subcutaneous fat so characteristic of infancy. No special efforts were made to relieve the olecranon during casting, but a buildup was added to the positive model of the stump. Important factors during casting are pressure at the posterior distal surface of the humerus above the epicondyle level and the two-fingered pressure on either side of the biceps tendon. On small patients, the prosthetist's middle finger is slightly bent because of the different lengths of the index and middle fingers (<b>Fig. 1</b>). A symmetrical socket brim which provides overall fit is the goal (<b>Fig. 2</b>). Aside from these minor differences, the casting and all the construction procedures followed the Xew York University manual exactly.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Molding grip. Note slight flexion of middle finger. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. End view of symmetrical socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The simplified harness system commonly referred to as the figure-nine harness, with the cable reaction point located on the proximal posterior portion of the socket, was used in the series. For the nine-month-old patient a small triceps pad with conventional figure-eight harness was used, in order to make the prosthesis more secure (<b>Fig. 3</b>). It was believed that the nine-month-old patient might be able to remove the prosthesis without the additional suspension provided by the triceps pad and the anterior forked strap.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Nine-month-old female infant (P.M.) with short below-elbow stump fitted with triceps pad and figure-eight harness for additional suspension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Evaluation</h3> <p>The value of the prosthesis was judged on two bases. First, the reactions of the patient and his parents were considered. Second, patient response and performance were compared with the checkout criteria published in the New York University manual.</p> <p>All patients and parents were pleased with the Minister-type prosthesis. The simplified harness and light weight were consistently mentioned as favorable features. It was interesting to note that the seven patients who had previously worn other types definitely preferred the Münster-type. The patient who had worn the split socket was even more emphatic in his approval, as were his parents.</p> <p>Standard checkout forms were used in the clinic. However, for purposes of this study, special attention was given to certain specific items: range of motion with and without prosthesis, stability, and control-system efficiency. These data are summarized in <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>Terminal-device openings were recorded for all patients within the limits of 30 deg. and 90 deg. of elbow flexion and were considered acceptable. The number of rubber bands varied between one-half a band to three, depending upon the functional requirements of the patients.</p> <p>The recorded ranges of elbow motion without the prosthesis illustrate the hyperextension so characteristic of upper-extremity terminal transverse partial hemimelia. Maximum flexion varied from 80 deg. to 100 deg. with the prostheses for most patients. In all instances, full terminal-device opening was obtained at maximum forearm flexion. The test of full terminal-device opening at the mouth did not apply, because the terminal device could not be brought to the mouth. However, since all the patients were unilateral amputees, the flexion ranges were considered acceptable.</p> <p>Retention of the prosthesis under axial load testing revealed suspension stability to be excellent, as most prostheses tolerated one-third of the child's weight without excursion of the socket. The greatest slippage recorded was one-half in.</p> <p>Control-system efficiency was better than 80 per cent in one-half of the prostheses, and in no instance was the percentage less than the 71 per cent recorded in one case.</p> <p>Perspiration has not been a problem even during humid summer days. All patients used cotton stockinette stump socks for insertion of the stump, with the ends tucked back into the forearm shell after donning. It is believed that the opening provided in the medial socket wall for this purpose may have been a significant factor in heat regulation.</p> <h3>Summary</h3> <p>An analysis of experience in fitting a total of 23 Münster-type prostheses to 13 patients has been presented. The prostheses were fitted, with very minor modifications in casting technique, according to the New York University fabrication manual. Actually, the differences were more quantitative than qualitative.</p> <p>It should be mentioned that the clinic prosthetist attended the pilot course in Münster-type fabrication technique at New York University. This technique is best acquired through firsthand instruction rather than by reading a manual.</p> <p>The results have been gratifying. The parents and patients found the prcsthesis acceptable, and in seven cases preferred it to other types that had been previously worn.</p> <p>Although the range of motion in the prosthesis did not always equal the expected 70 deg. of active flexion, function was acceptable. The stability achieved was excellent. In no case was there more than 1/2-in. displacement of socket on the stump with one-third of body weight in axial pull.</p> <p>The control-system efficiency was within acceptable limits in all cases, with one-half checking out at 80 per cent or better.</p> <p>On the basis of this limited experience, it is believed that the Münster-type prosthesis is the fitting of choice for the child with a unilateral short or very short below-elbow amputation.</p> <p><b>References:</b></p> <ol> <li>Fishman, Sidney, and Hector W. Kay, <i>The Münster-type below-elbow socket, an evaluation</i>, Artif. Limbs, Autumn 1964, pp. 4-14.</li> <li>Kay, Hector W., Kevin A. Cody, George Hartmann,and Dominick E. Casella, <i>The Münster-type below-elbow socket, a fabrication technique</i>, Artif. Limbs, Autumn 1965, pp. 4-25.</li> <li>New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, <i>The "Münster" type fabrication technique for below-elbow prostheses</i>, June 1964.</li> <li>New York University, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science,<i> A fabrication manual for the "Muenster" type below-elbow prosthesis</i>, April 1965.</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">New York University, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, A fabrication manual for the 'Muenster' type below-elbow prosthesis, April 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Fishman, Sidney, and Hector W. Kay, The Münster-type below-elbow socket, an evaluation, Artif. Limbs, Autumn 1964, pp. 4-14.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Kay, Hector W., Kevin A. Cody, George Hartmann,and Dominick E. Casella, The Münster-type below-elbow socket, a fabrication technique, Artif. Limbs, Autumn 1965, pp. 4-25.</td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">New York University, Adult Prosthetic Studies, Research Division, School of Engineering and Science, The 'Münster' type fabrication technique for below-elbow prostheses, June 1964.</td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">New York University, Prosthetic and Orthotic Studies, Research Division, School of Engineering and Science, A fabrication manual for the 'Muenster' type below-elbow prosthesis, April 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>John H. Hile </b></td></tr><tr><td class="clsTextSmall">Clinic Prosthetist, Juvenile Amputee Clinic, District of Columbia General Hospital, Washington, D.C. 20003.</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>Charles H. Epps, Jr., M.D. </b></td></tr><tr><td class="clsTextSmall">Chief, Juvenile Amputee Clinic, District of Columbia General Hospital, Washington, D.C. 20003; Chief, Division of Orthopaedic Surgery, Howard University College of Medicine, 520 W St., N.W., Washington, D.C. 20001.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 2 http://www.oandplibrary.org/al/images/1968_01_020/spring68d-01.jpg Figure 3 http://www.oandplibrary.org/al/images/1968_01_020/spring68d-02.jpg Figure 4 http://www.oandplibrary.org/al/images/1968_01_020/spring68d-03.jpg Figure 5 http://www.oandplibrary.org/al/images/1968_01_020/spring68d-04.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Experience with the Münster-Type Below-Elbow Prosthesis, a Preliminary Report Creator An entity primarily responsible for making the resource Charles H. Epps, Jr., M.D. * John H. Hile * https://staging.drfop.org/files/original/0bbc53a6aa62aebf038a53dd53472ffc.pdf 54b8c595e4ec188d6a8b8159ebc5c71f https://staging.drfop.org/files/original/b31f453e857faf7e7c85a9dc242a2129.jpg 9df96fc4ee9a837d85bbaece371c46fc https://staging.drfop.org/files/original/0ee976b743595cde154bc870afa7a224.jpg a3b8fbd6a6cea81286d669f3a25bd448 https://staging.drfop.org/files/original/63c4901b6d5f332233ffdb0f2c00b116.jpg 1c1cb3009b38e53630bde0cda90c9c89 https://staging.drfop.org/files/original/37f7edd8f4b869d37f92eb967037f82a.jpg 117dc9625d7e146431f643fdb0d17f6d https://staging.drfop.org/files/original/79cc93918eb2d23f152ee4043b75be4e.jpg cc9511daf3e04fdecb2f5c18ed011951 https://staging.drfop.org/files/original/a3b0d6d764f90dc9b9f455667be76a39.jpg 27c4183a32ace08a6dfa6980ba988b0c Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1986_03_101.pdf Text Any textual data included in the document <h2>Experience with the Use of Alginate in Transparent Diagnostic Below-Knee Sockets</h2> <h5>C. Michael Schlich, C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />Tony Lucy&nbsp;</h5> <p>Transparent test sockets have been available in various materials for more than ten years,<a></a> but their use has not been as widespread or as routine as one would expect. Only recently has the emergence of new materials and new evaluation techniques, as well as third-party awareness and reimbursement, made the use of test or check sockets more appealing.</p> <p>The objective of this article is to present a refined technique for using test sockets and aliginate to guarantee that total contact exists between socket and stump. This technique has been developed as a standard procedure for each and every below-knee amputee fitted with a prosthesis at the University of Virginia. We consider it to be the single most important and recent technique for enhancing the fit of prostheses for our below-knee amputees.</p> <p>Robert Hayes, CP., described his alginate technique first in 1975 in <i>Orthotics and Prosthetics</i><a></a> and more recently in an updated version in <i>Clinical Prosthetics and Orthotics</i>.<a></a> In 1984, Timothy Staats, CP.,<a></a> described a technique for introducing alginate into the negative cast mold, which is used as a test socket after molding. No doubt there are other prosthetists using similar or variations of these techniques. However, the important point is not who or how many are using the technique, but how many still do not use this technique for refining below-knee socket fit.</p> <p>Equally important is the fact that any system of diagnostic socket evaluation should be more than just algination. The routine use of multiple, transparent, skin-fit sockets, evaluated both statically and dynamically as a progressive system, will provide assurance of optimum socket fit. It seems rather obvious that if amputees can ambulate successfully with a skin-fit, hard socket, then use of a definitive socket with a minimal number of prosthetic socks, with or without a soft liner, will be that much more comfortable and successful.</p> <p>A 12" x 12" sheet of 3/8" thick Durr-Plex<a></a> or Thermocheck<a></a> is used for the average below-knee socket. This material is transparent, strong and rigid, is easily vacuum formed (<a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-1.jpg"><b>Fig. 1</b></a>) using the frame and platen technique, and can be modified later by spot heating. Of course, any other transparent material that can be vacuum formed is equally suitable.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-1.jpg">Figure 1.</a> A transparent socket is vacuum-formed over a plaster cast that has been modified in the usual manner.</strong><br /> <p>Lubrication of the stump with petroleum jelly, or equivalent lubricant, is necessary for donning the check socket when it is used without a prosthetic sock. The patient then stands bearing weight in the test socket, which rests on a platform or stand that can be adjusted in height so that weight-bearing is the same on each side and the pelvis is level (<a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-2.jpg"><b>Fig. 2</b></a>). While the patient continues to stand, the stump in the transparent socket is evaluated by identifying changes in skin color. Blanching, or even whiteness, indicates that the pressure levels are acceptable. Excessive shiny blanching indicates increased pressure, which is perhaps excessive. Redness indicates voids or lack of total contact. If a patient complains of too much pressure when an area is surrounded by red, then algina-tion should provide relief by establishing total contact. If the patient complains of too much pressure when an area is surrounded by white and blanching, relief is provided by spot heating and stretching the socket in the area of complaint. A thin flat probe, like a corset stay, is often useful for specifically locating pressure areas for purging small pockets of trapped air, or gauging skin tensions within the socket (<a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-3.jpg"><b>Fig. 3</b></a>).</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-2.jpg">Figure 2</a>. The patient bears one half of his weight in the transparent socket for evaluation of fit by the prosthetist observing the color of the skin<br /></strong><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-3.jpg">Figure 3.</a> Evaluation of fit by observation can be augmented by use of a flat slender probe.</strong><br /> <p>A reliable technique for the evaluation and modification of the fit of below-knee diagnostic test sockets is available using the dental material, alginate. The viscosity and other properties of alginate makes it suitable for: (1) filling any voids between the socket and stump to insure total contact, or total surface bearing; (2) providing proper compression of soft tissues for better distribution of weight-bearing pressures.</p> <p>A mixture of 20 grams of powdered alginate<a style="text-decoration: none;">*</a> and 6 ounces of water provides the proper ratio and amount for most below-knee patients. The water should be lukewarm and dyed with food coloring to provide a definite contrast in color to the skin and socket.</p> <p>The socket is sanded lightly on the inside to promote adherence of the alginate, and escape holes are drilled medially and laterally approximately one inch proximal to the distal end. Small pin holes are also drilled over void areas to allow air to escape as the alginate fills. The water and powder are mixed with an electric drill and paint stirrer, and then poured into the test socket and slushed around the walls to completely coat the inside of the socket. The patient then enters the socket and stands with equal weight-bearing bilaterally. The alginate fills void areas, establishing total contact. The excess is evacuated, and gelling occurs in one to three minutes (<a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-4.jpg"><b>Fig. 4</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-5.jpg"><b>Fig. 5</b></a>). The patient is then seated and the socket is carefully removed, after breaking the suction seal. The alginate will adhere to the inside of the socket.</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-4.jpg">Figure 4.</a> Alginate fills void areas while patient bears one half of his weight into the socket. Excess alginate flows through small relief holes drilled for this purpose.</strong><br /><br /><strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-5.jpg">Figure 5.</a> Alginate solution cures between one and three minutes.</strong><br /> <p>When the socket is filled with plaster, a positive model that has been redefined by the alginate under weight-bearing conditions is obtained. When the plaster has set, the test socket is removed by cutting it off. The alginate will adhere to the cured plaster model (<a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-6.jpg"><b>Fig. 6</b></a>).</p> <strong><a href="http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-6.jpg">Figure 6.</a> Alginate is removed from new positive model before smoothing and vacuum-forming definitive socket or a new check socket.</strong><br /> <p>The new positive model is now evaluated. Information such as location and thickness of the alginate fill is useful feedback concerning the original casting and model modification. At this point the alginate is removed and the new positive model is smoothed using sand screen. The model is now ready either for use as a follow-up transparent test socket or for fabricating a definitive socket.</p> <p>If one chooses to proceed with the definitive socket, prosthetic socks are added over the model before the liner or socket is fabricated to allow for the thickness of socks desired in the final fit.</p> <h3>Results</h3> <p>Records were kept and studied for a series of 40 below-knee amputees fitted using the alginate test socket system. The data recorded were: (1) location of areas filled by alginate (i.e. voids in the prealginated socket); (2) thickness of fill with respect to location; and (3) results of dynamic and final fittings (i.e. adjustments required to improve socket fit at post-algination fitting sessions).</p> <p>Areas filled with alginate were very consistent and included the posterior distal soft tissue area, the tibial tubercle, the lateral tibial flare, and the anterior distal tibia. As the series progressed, the model modification technique changed based on this previous experience. As a result, the thickness of the alginate fillers gradually decreased, as did the plaster build-up over bony prominences on the original model. None of the 40 subjects required socket adjustments to improve comfort or fit at the time of dynamic alignment, delivery alignment, or delivery of the prosthesis.</p> <p>We have been involved, either directly or indirectly, with fitting more than 150 patients in this manner. The use of alginate with multiple transparent test sockets is a valuable tool in patient management and helps provide better below-knee sockets through improved weight-bearing pressure distribution.</p> <p><b>References:</b></p> <ol> <li>Durr-Fillauer Medical, Inc. 2710 Amnicola Highway, Chattanooga, Tennessee 37406.</li> <li>Friddle's Orthopedic Appliance, P.O. Box AR, Honea Path, South Carolina 29654.</li> <li><a href="cpo/1985_03_013.asp">Hayes, Robert F., "A Below-Knee Weight-Bearing Pressure Formed Socket Technique," <i>Clinical Prosthetics and Orthotics</i>, 9:3, Summer, 1985, pp. 13-16.</a></li> <li>Hayes, Robert, F., "A Below-Knee Weight-Bearing Pressure Formed Socket Technique, <i>Orthotics and Prosthetics</i>, 26:1, March, 1972, pp. 1-13.</li> <li>Mooney, V. and R. Snelson, "Fabrication and Application Of Transparent Polycarbonate Sockets, <i>Orthotics and Prosthetics</i>, 26:1, March, 1972, pp. 1-13.</li> <li>Staats, Timothy, "Advanced Prosthetic Techniques For Below-Knee Amputation," <i>Orthopedics</i>, 8:2, February, 1985, pp. 249-258.</li> <li><a href="cpo/1985_03_011.asp">Quigley, Michael, Jr., "The Role of Test Socket Procedures In Today's Prosthetic Practices," <i>Clinical Prosthetics and Orthotics</i>, 9:3, pp. 11-12.</a></li> </ol> <b>Footnote</b> Type II, Normal Set Alginate, Coe Laboratories, Inc. Chicago, Illinois 60658<br /><br /><em><b>*C. Michael Schlich, C.P.O. </b> C. Michael Schuch, C.P.O., and Tony Lucy are with the Department of Orthopedics and Rehabilitation at the University of Virginia.<br /><br /><br /></em> Page Number(s) 101 - 104 Year 1986 Volume 10 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1986_03_101/1986_03_101-6.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Experience with the Use of Alginate in Transparent Diagnostic Below-Knee Sockets Creator An entity primarily responsible for making the resource C. Michael Schlich, C.P.O. * Tony Lucy  https://staging.drfop.org/files/original/300fec58bb900f1c7824dd89bd4bbaae.pdf 76815d70cedf1bca701b131c7ff7e1e3 https://staging.drfop.org/files/original/900377a01eea06be7f175e196b90925d.jpg f2357efa66a29ce5c62e4d968a6ccfa9 https://staging.drfop.org/files/original/9f83d9cea044e7f3c97f76b921831c78.jpg 7eebd4fbeda2d03e63a1e5aa08d4ee8c https://staging.drfop.org/files/original/210a566f2d7906636a17a4da061ba64f.jpg a9a6af01b0842bab00a8484934d9b946 https://staging.drfop.org/files/original/1576a7cdca5985ca39b8dfd73643a26d.jpg cd929d3b6f4cf06461d5d6085b38b978 https://staging.drfop.org/files/original/7f40b03606f628d72d01f42ac743588c.jpg 7d7945a45ce4611bc7826c5b4eb56bac https://staging.drfop.org/files/original/60fd60e81e861bcade3d43e96948c6ed.jpg 616e1eafc83246f42671d97fe4d7cb35 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1965_01_014.pdf Year 1965 Volume 13 Issue 1 Page Number(s) 14 - 22 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_01_014.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1965_01_014.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>Experiences with the PTB Prosthesis</h2> <h5>Georg Bakalim, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>The original patellar-tendon-bearing (PTB) prosthesis was constructed at the Biomechanics Laboratory of the University of California. For details regarding the anatomical and physiological considerations<a></a>, the biomechanics<a></a>, and the construction<a></a>, the reader is referred to the June 1962 issue of <i>Artificial Limbs.</i></p> <p>In Finland about 1,000 PTB prostheses have been manufactured since 1959. Although the name of these prostheses and the main principle of their construction imply that weight is borne on the lower patellar ligament (<b>Fig. 1</b>), this is not the only weight-bearing area. Both tibial condyles and, to some extent, the distal end of the stump share the weight. The distribution of weight in these areas necessitates truly individual fitting.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Vertical cross section of anterior portion of PTB socket. The supporting force, as shown by the arrow, acts on the lower patellar ligament. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>For technical details of fabrication of PTB prostheses, the reader is referred to the issue of <i>Artificial Limbs </i>which has been cited. Here it is sufficient to say that a plaster cast of the stump is taken first. Then an intimately fitting, distally closed socket of hard plastic and a socket insert of sponge rubber are made. Distally, the socket is joined to a wooden shank, to which a SACH foot is attached (see <b>Fig. 2</b> for views of a finished prosthesis). It is not essential that the socket be made of plastic, but at present this seems to be the best material available. It is relatively easy to laminate a plastic shell from a plaster model. The plastic socket withstands moisture and is, therefore, relatively resistant to perspiration, and it is readily cleaned. The drawbacks are the airtightness of the material, the risk of its causing allergic reactions, and, perhaps, the poorer heat insulation in cold weather compared with materials previously used. These points will be discussed later.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Finished PTB prosthesis using supracondylar cuff as only means of suspension. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In the Department of the State Supervisor of Prosthetic Services of the Ministry of Social Affairs, a follow-up study has been made of amputees fitted with PTB prostheses. Initially, the amputees are given, for trial, prostheses which are not quite finished, although fit for wear. After three weeks the patients and their prostheses are examined at the Department of the State Supervisor, where either the prostheses are approved, or some modification, correction, or repair is prescribed. Only after this examination are the prostheses given their final finish. This applies to all prostheses paid for by the state. Six months after the patients have been fitted with their PTB prostheses a questionnaire is sent to them. At the Department of the State Supervisor, record cards are kept for all amputees, on which are entered notations concerning modifications and repairs. Thus it is easy to check on what happens to the various prostheses.</p> <p>This article is based on the examinations of the amputees and their prostheses three weeks after the initial issue, data obtained from the questionnaires distributed to the amputees when they have worn their prostheses for six months, and data obtained from the record cards.</p> <p>The study covers 228 amputees fitted with PTB prostheses. Prostheses from different workshops differ somewhat from each other, since standardization of the products is a problem in Finland, as it is elsewhere, perhaps. Therefore, only genuine PTB prostheses have been included in this study.</p> <p><b>Fig. 3</b> shows the ages of the amputees, disclosing that the age group of 40-54 years is the largest. The youngest patient was 20, while the oldest was 75. Ex-servicemen account for 94.3 per cent of the series. The remainder are insured civilians. Only one of the cases in the series was a recent amputee whose initial fitting was with a PTB prosthesis. This does not imply that recent amputees are fitted for theoretical reasons with so-called "conventional" prostheses. On the contrary, it should be an advantage to be fitted from the outset with a PTB prosthesis, although it goes without saying that recent amputees offer special problems because of the longer duration of stump changes.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Ages of the amputees when they were fitted with PTB prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Table 1</b> shows the occupations of the patients in the series. From the standpoint of prescription, it is of major interest to ascertain whether the PTB prosthesis can be worn while performing heavy labor, considering the absence of a thigh corset and the greater stress on the knee joint.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Table 1</b> discloses that the series includes 59 farmers or smallholders, 21 industrial workers, two lumbermen, and 7 painters. It stands to reason that amputees, whenever possible, choose labor that is not very heavy. Many farmers admitted that they had abandoned the heaviest tasks. However, others in the series mentioned lumbering as a part-time occupation. It was learned that some amputees had worn the PTB prosthesis without a thigh corset while walking on soft, uneven ground and on snow; in other cases, a short above-knee corset had been added almost immediately or when the PTB prosthesis had been worn for some time. It is apparent that stump length and the stability of the knee are important factors.</p> <p><b>Fig. 4</b> shows the lengths of the stumps in the series. In general, cases with a stump length of less than 12 cm. required a thigh corset, the length of which was about one-half or one-third the length of the thigh corset of a conventional prosthesis. The shortest stump in the series measured 6 cm., and the longest 35 cm. The series includes nine bilateral amputees (3.9 per cent).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Lengths of the amputation stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Replies to the questionnaire are presented below:</p> <ol> <li><i>Have you worn your prosthesis regularly; if not, for how long have you worn it? </i>According to the replies, 210 amputees (92.1 per cent) had worn their prostheses regularly from the outset.</li><li><i>Why have you not been able to wear your prosthesis regularly? </i>When the replies were compared with the record cards, it appeared that 18 (7.9 per cent) had not been able to wear their prostheses regularly. In three cases the cause could not be elicited. In 15 cases the causes were as follows:</li></ol> <ul> <li>The skin became irritated in three cases, and in one case an allergy set in.</li> <li>In two cases the socket became too loose.</li> <li>The stump did not tolerate the pressure; it became tender.</li> <li>There was pressure on the stump when the patient drove his car.</li> <li>Ulceration of the stump occurred in three cases.</li> <li>The prosthesis was cold in the winter, and it slipped off when the patient walked in the snow.</li> <li>The stump swelled when the patient was riding a bicycle.</li> <li>Stairs were a problem.</li> <li>The closed socket caused excessive perspiration of the stump.</li> </ul> <p>3. <i>Have you worn your prosthesis </i>(a) <i>when working indoors, (b) when working outdoors, (c) when working outdoors in very cold weather? </i>A total of 223 (97.8 per cent) had worn their prostheses while working indoors; 208 (91.2 per cent), while working outdoors; and 140 (61.4 per cent), while working outdoors in very cold weather.</p> <p>4. <i>Have you worn your prosthesis in some additional</i>- <i>part-time</i>-<i>occupation? </i>(The intention was to elicit data regarding incidental jobs, recreation, and hobbies.) Only 21 replies were obtained on this point. One patient was a chauffeur, two were building their own houses, one was building a summer cottage, two fished, five were doing agricultural work, three did lumbering, six did gardening, and one was a night watchman.</p> <p>5. <i>Have you previously used a prosthesis of some other material (wood, leather, or light metal)? </i>The majority had used conventional prostheses of wood or leather. Only a few had worn prostheses of light metal. Some amputees had had prostheses of all three materials in the course of years.</p> <p>6. <i>Have you been satisfied with your prosthesis? </i>There were 206 (90.4 per cent) satisfied wearers. Only 22 (9.6 per cent) complained.</p> <p>7. <i>Do you think this prosthesis is {a) better than, (b) just as good as, (c) not as good as your previous limb? </i>The replies were as follows:</p> <table> <tbody><tr> <td> <p>Better than previous prostheses</p> </td> <td> <p>   207 ( 90.8 per cent)</p> </td> </tr> <tr> <td> <p>Just as good as previous prostheses</p> </td> <td> <p>   8 ( 3.5 per cent)</p> </td> </tr> <tr> <td> <p>Not as good as previous prostheses</p> </td> <td> <p>   12 ( 5.3 per cent)</p> </td> </tr> <tr> <td> <p>First prosthesis (recent amputee)</p> </td> <td> <p>   1 ( 0.4 per cent)</p> </td> </tr> <tr> <td> <p><b>Total</b></p> </td> <td> <p>   <b>228 (100.0 per cent)</b></p> </td> </tr> </tbody></table> <p>The great majority were satisfied with the PTB prosthesis. What appealed to them most was its lightness and the freedom from a thigh corset. This enabled the development of the thigh muscles in a short time. However, not all the amputees were able to manage without a thigh corset.</p> <p>8. <i>What defects or drawbacks have you observed in your PTB prosthesis? </i>Listed below are the complaints of 26 amputees (12.3 per cent). In eight cases the complaints apply mainly to the stump, and in 18 to the prosthesis, but it is not always possible to distinguish sharply between the two.</p> <table> <tbody><tr> <td> <p><b>Amputation stump</b></p> </td> <td> <p><b>Prosthesis</b></p> </td> </tr> <tr> <td> <p>Allergic reaction</p> </td> <td> <p>Cold in the winter (two cases)</p> </td> </tr> <tr> <td> <p>Circulatory disturbance</p> </td> <td> <p>Socket closed and too warm (three cases)</p> </td> </tr> <tr> <td> <p>Ulceration</p> </td> <td> <p>Socket became too loose (two cases)</p> </td> </tr> <tr> <td> <p>Itching</p> </td> <td> <p>Socket pressed on the stump</p> </td> </tr> <tr> <td> <p>Stump shrinkage</p> </td> <td> <p>Flexion of the knee during work impossible because socket extends above knee</p> </td> </tr> <tr> <td> <p>Perspiration</p> </td> <td> <p>Unstable on slippery ground and without a thigh corset</p> </td> </tr> <tr> <td> <p>Edema</p> </td> <td> <p>Unstable in soft snow</p> </td> </tr> <tr> <td> <p>Fatigue</p> </td> <td> <p>Unstable on soft ground </p> </td> </tr> <tr> <td> <p></p> </td> <td> <p>Excessive strain on the knee without a thigh corset</p> </td> </tr> <tr> <td> <p></p> </td> <td> <p>Insert wears out too rapidly </p> </td> </tr> <tr> <td> <p></p> </td> <td> <p>Heel of the SACH foot is too soft</p> </td> </tr> <tr> <td> <p></p> </td> <td> <p>Toe of the SACH foot gradually bends upward</p> </td> </tr> <tr> <td> <p></p> </td> <td> <p>Toe wears out too rapidly</p> </td> </tr> <tr> <td> <p></p> </td> <td> <p>Difficult to ski</p> </td> </tr> </tbody></table> <p>9. <i>Has perspiration in the amputation stump constituted a problem? </i>The replies were as follows:</p> <table> <tbody><tr> <td> <p>Perspiration a problem</p> </td> <td> <p>   161 (70.6 per cent)</p> </td> </tr> <tr> <td> <p>Perspiration not a problem</p> </td> <td> <p>   39 (17.1 per cent)</p> </td> </tr> <tr> <td> <p>Initially excessive perspiration, later not</p> </td> <td> <p>   19 (8.3 percent)</p> </td> </tr> <tr> <td> <p>Less perspiration than with other prostheses</p> </td> <td> <p>   9 (4.0 per cent)</p> </td> </tr> <tr> <td> <p><b>Total</b></p> </td> <td> <p>   <b>228 (100.0 per cent)</b></p> </td> </tr> </tbody></table> <p>Owing to the closed, air-tight socket, perspiration was a major problem, particularly in the summer. It should be borne in mind, however, that this problem also occurs with conventional prostheses, although perhaps not to the same degree. The possibilities for reducing the perspiration problem are discussed later.</p> <p><i>10. Has the skin on the stump tolerated the prosthesis? </i>The skin tolerated the prosthesis well in <b>190 </b>cases (83.9 per cent), better than with other types of prostheses in 14 cases (6.5 per cent), and not so well as with others in 24 cases (9.2 per cent).</p> <p><i>11. Have reddening of the skin and eczema occurred? </i>A total of 75 amputees complained of reddening and eczema, while 153 had no such symptoms.</p> <p><i>12. Did reddening, eczema, or ulceration of the stump occur before you started using a PTB prosthesis, and, if so, for how long? </i>In 157 cases (68.9 per cent) such symptoms had arisen from the use of conventional prostheses of wood, leather, or light metal.</p> <p><i>13. What are your experiences with the new prosthesis outdoors in cold weather? </i>A total of 142 amputees had worn their prostheses outdoors during the winter, and temperatures of -20 to -40 deg. C had caused no problem. Many had skied as much as 30 km. Only five (3.5 per cent) had found the new prosthesis too cold. Replies were as follows:</p> <table> <tbody><tr> <td> <p>No complaints</p> </td> <td> <p>   111 ( 78.2 per cent)</p> </td> </tr> <tr> <td> <p>Better than previous prostheses</p> </td> <td> <p>   5 (3.5 per cent)</p> </td> </tr> <tr> <td> <p>Somewhat colder than previous prostheses</p> </td> <td> <p>   21 (14.8 per cent)</p> </td> </tr> <tr> <td> <p>Very cold</p> </td> <td> <p>   5 (3.5 per cent)</p> </td> </tr> <tr> <td> <p><b>Total</b></p> </td> <td> <p><b>   142 (100.0 per cent)</b></p> </td> </tr> </tbody></table> <p>It developed from the replies that the vast majority of the patients had been able to wear their PTB prostheses regularly from the outset. Eighteen amputees had experienced discomfort of various kinds. In many cases there were only minor complaints, and the source of the trouble was readily dealt with. Sometimes the complaints related to phenomena always associated with the manufacture and fitting of prostheses.</p> <p>It is noteworthy, too, that the patients wore their prostheses while performing hard labor.</p> <p>The vast majority of the patients were satisfied. The dissatisfied wearers numbered 22 (9.6 per cent). The causes for complaint are specified in <b>Table 2</b>. The ages and stump lengths of these patients are indicated in the tabulation to permit evaluation of their possible influence. Data regarding all the modifications needed to make the prostheses fit for use, even the smallest repairs, were obtainable from the amputee cards.</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 is a characteristic feature of the PTB prosthesis that it immediately starts remodeling the stump, because of the intimate fit of the socket. During the first few weeks the stump shrinks, so that the socket becomes too loose. It can be seen in <b>Table 2</b> that this occurred in 11 cases, or 50 per cent of the dissatisfied wearers. These patients were fitted with a new socket insert, and occasionally also with a new socket shell, which implies that a large part of the prosthesis had to be rebuilt. In many cases the insert had to be modified several times. These possibilities must be reckoned with when this type of prosthesis is prescribed.</p> <p>The regeneration of the thigh muscles in those who managed without a thigh corset has already been mentioned. This phenomenon results from the greater muscular activity required to control the movements and the stability of the knee with the PTB prosthesis. After three weeks none of the wearers was able to use his old prosthesis with a thigh corset, because the corset had become too tight.</p> <p>The genuine PTB prosthesis is furnished with only a narrow strap fixing it above the knee. In six cases it was necessary later to provide a thigh corset with sidebars, but the length of the corset was one-third to one-half of what is usual for conventional prostheses. These amputees had stumps which measured 12,13,15,19, 22, and 25 cm., respectively. Only half of these can be said to be particularly short. Obviously, the need for a thigh corset depends not only upon the length and shape of the stump, but also upon the stability of the knee. In three of the cases the knee had been strained. In one case the PTB prosthesis, even after being furnished with a thigh corset and sidebars, had to be replaced with a conventional prosthesis, but this was an exceptional case.</p> <p>Excessive perspiration in the stump, particularly during the summer, constituted a major problem. The closed socket insert and the airtight material are its main causes, but the muscular atrophy because of inactivity and the resultant poor circulation contribute. A gradual decrease in perspiration might be expected to occur, considering the development of the musculature and improved circulation resulting in all amputees who manage without a thigh corset, and considering also the pump effect exerted on the stump by the tight-fitting socket. A similar effect has been observed as a result of placing a sponge-rubber pad at the bottom of conventional prostheses of patients with chronic eczema and ulceration of the stump (<i>1</i>). In the present series, however, a later decrease of perspiration was observed in only 8.3 per cent of the cases. In addition, four per cent reported that perspiration has all the time been less of a problem with the new prostheses.</p> <p>When perspiration of the stump is excessive, skin complications-eczema and ulceration- are likely to occur. Data on skin symptoms in the present series were compared with corresponding data relating to the use of conventional prostheses. The comparison is hampered by the fact that the observation time is shorter for the PTB prostheses than for the older types. Results of the comparison were as follows:</p> <table> <tbody><tr> <th><p></p> </th> <th><p>PTB</p> </th> <th><p>Conventional Prostheses</p> </th> </tr> <tr> <td> <p>Reddening, eczema, ulceration</p> </td> <td> <p>   75 (32.9 percent)</p> </td> <td> <p>   157 (68.9 percent)</p> </td> </tr> <tr> <td> <p>No complications</p> </td> <td> <p>   153 (67.1 per cent)</p> </td> <td> <p>   71 (31.1 per cent)</p> </td> </tr> <tr> <td> <p><b>Total</b></p> </td> <td> <p>   228 (100.0 per cent)</p> </td> <td> <p>   228 (100.0 per cent)</p> </td> </tr> </tbody></table> <p>It appears that with the PTB prosthesis skin complications were about half as common as with conventional prostheses.</p> <p>In cold winter weather, the PTB prosthesis is somewhat colder than prostheses made of leather or wood, but nonetheless satisfactory and fit for use.</p> <p>In general, the difficulties arising in the present series were due mainly to reduction in the volume of the amputation stump, instability of the knee, and, in some cases, shortness of the stump, which necessitated the construction of a thigh corset. Also, skin complications sometimes occurred as a result of the excessive perspiration caused by the closed-socket insert. The first-mentioned circumstances were easy to cope with, while the skin changes constituted a real problem. In some cases, an opening was made in the distal end of the socket insert, or a number of small holes were drilled in the socket. In certain cases, a sponge-rubber pad was utilized, partly to exert a continuous light pressure on the stump and partly to absorb the moisture accumulating in the bottom of the socket insert.</p> <p>When the PTB prosthesis was first introduced into Finland, we hesitated to prescribe it to amputees who move about much outdoors on soft ground; for instance, on fields and meadows, in the forest, and on snow. This group of persons consists mainly of farmers and lumbermen and the population of northernmost Finland. Our apprehensions have been confirmed only in occasional cases, and the general impression of the PTB prosthesis is favorable. The advantages far outweigh the drawbacks. In particular, the lightness of this prosthesis, the hygienic properties of the plastic material, and the regeneration of the thigh muscles should be emphasized.</p> <p>Reference to the literature shows that others have encountered the same problems that are described here. Frank A. Witteck <a></a>, writing in the June 1962 issue of <i>Artificial Limbs, </i>warned against prescribing the PTB prosthesis in cases with instability of the knee, to very heavy amputees, and in bilateral cases. However, if the stumps have been satisfactory, we have even fitted bilateral cases with PTB prostheses, and no special problems have occurred.</p> <p>In our experience, the PTB prosthesis is con-traindicated only in cases with instability of the knee and with very short stumps or with stumps of unsatisfactory shape.</p> <p>Because numerous, careful fittings are required in these cases, it is desirable that a prosthetist's shop be within easy reach. The PTB prosthesis makes heavy demands on the skill of the manufacturer.</p> <h3>Summary</h3> <p>This study was carried out on 228 amputees fitted with PTB prostheses. It is based on personal follow-up examinations, replies to questionnaires, and data obtained from record cards kept on the amputees.</p> <p>The age group 40 through 54 years is the largest. War veterans comprise 94.3 per cent of the series, the remainder being insured civilians. In some cases the prostheses were worn by amputees engaged in heavy labor under difficult conditions. Of the amputees, 92.1 per cent were able to wear their prostheses regularly from the outset, and 90.4 per cent were very satisfied. In particular, they emphasized the lightness of the prostheses and the absence of tight thigh corsets, resulting in a sense of ease and freedom.</p> <p>In some cases, complications were caused by a decrease in stump volume, a result of the intimate fit of the socket. This necessitated a change of socket insert, which is readily accomplished, and sometimes of the socket shell as well, which in effect amounts to making a new prosthesis. In certain cases, instability of the knee, the shape of the stump, and a stump length less than the optimum gave rise to symptoms which could be alleviated only by giving the amputee a thigh corset. The series includes four such cases (1.8 per cent).</p> <p>PTB prostheses were also prescribed in bilateral cases, of which there were nine (3.9 per cent).</p> <p>The study shows that the PTB prosthesis has been successfully worn in cold winter weather, although it is somewhat colder than prostheses made of wood or leather.</p> <p>In all the amputees the thigh muscles developed enormously within a few weeks.</p> <p>Excessive perspiration in the stump was a problem in many cases. This phenomenon is due to the intimate fit of the plastic socket. A gradual decrease of the perspiration was noted in 8.3 per cent. However, four per cent stated that, from the outset, perspiration had been less of a problem than with their previous prostheses. It should be borne in mind that during the warm season perspiration tends to be a problem with all prostheses.</p> <p>The PTB prosthesis without a thigh corset is contraindicated in cases with instability of the knee and in cases with a very short stump or with a stump of unsatisfactory shape. Furthermore, caution is indicated in the prescription of this prosthesis to farmers, lumbermen, and others who move on soft and slippery ground.</p> <p>The PTB prosthesis requires very careful fitting, and extreme care must be exercised in its manufacture. In cases where there is a long distance between the place of residence and the prosthetics facility, this is not perhaps the most appropriate type of prosthesis.</p> <p><b>References:</b></p> <ol> <li>Bakalim, Georg, Sponge rubber pad in the prosthesis in cases of chronic dermatitis and ulceration in the stump, Acta orthop. scandinav., 1:117, 1964.</li> <li>Fleer, Bryson, and A. Bennett Wilson, Jr., Construction of the patellar-tendon-bearing below-knee prosthesis, Artificial Limbs, June 1962, pp. 25-73.</li> <li>Murphy, Eugene F., and A. Bennett Wilson, Jr., Anatomical and physiological considerations in below-knee prosthetics, Artificial Limbs, June 1962, pp. 4-15.</li> <li>Radcliffe, Charles W., The biomechanics of below-knee prostheses in normal, level, bipedal walking, Artificial Limbs, June 1962, pp. 16-24.</li> <li>Witteck, Frank A., Some experience with patellar-tendon-bearing below-knee prostheses, Artificial Limbs, June 1962, pp. 74-85.</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>5.</b> </td><td class="clsTextSmall">Witteck, Frank A., Some experience with patellar-tendon-bearing below-knee prostheses, Artificial Limbs, June 1962, pp. 74-85.</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">Fleer, Bryson, and A. Bennett Wilson, Jr., Construction of the patellar-tendon-bearing below-knee prosthesis, Artificial Limbs, June 1962, pp. 25-73.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Radcliffe, Charles W., The biomechanics of below-knee prostheses in normal, level, bipedal walking, Artificial Limbs, June 1962, pp. 16-24.</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">Murphy, Eugene F., and A. Bennett Wilson, Jr., Anatomical and physiological considerations in below-knee prosthetics, Artificial Limbs, June 1962, pp. 4-15.</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>Georg Bakalim, M.D. </b></td></tr><tr><td class="clsTextSmall">State Supervisor of Prosthetic Services, Ministry of Social Affairs, Helsinki, Finland.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1965_01_014/tmp1F18-12.jpg Figure 2 http://www.oandplibrary.org/al/images/1965_01_014/tmp1F18-13.jpg Figure 3 http://www.oandplibrary.org/al/images/1965_01_014/tmp1F18-14.jpg Figure 4 http://www.oandplibrary.org/al/images/1965_01_014/tmp1F18-15.jpg Figure 5 http://www.oandplibrary.org/al/images/1965_01_014/tmp1F18-16.jpg Figure 10 http://www.oandplibrary.org/al/images/1965_01_014/tmp1F18-17.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 Experiences with the PTB Prosthesis Creator An entity primarily responsible for making the resource Georg Bakalim, M.D. * https://staging.drfop.org/files/original/7904e0df9f82ca12c7c4e5cd88f6db97.pdf 28eeacacfe9b1b5e4ac2b081f46ce305 https://staging.drfop.org/files/original/82e7e39858aab0ffb26247e4ac66f8ff.jpg 9f927c763f3c0a435205f628539e33fd https://staging.drfop.org/files/original/959f68367f7cae905c928c179c005a3f.jpg 53b45497795ecaf6b411058791a39c7b https://staging.drfop.org/files/original/7b0e5455441dc18eff98d48d86415fb7.jpg bd46345d3be76766394dec62eb977ef7 https://staging.drfop.org/files/original/6c178a7d49b2ae565c5fdd88f9b45441.jpg dca58414c4ca42c275c9827d838c88d0 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_01_051.pdf Year 1967 Volume 11 Issue 1 Page Number(s) 51 - 57 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1967_01_051.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_01_051.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>Experiences with the Total-Contact Prosthesis</h2> <h5>Georg Bakalim, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>At the request of the Finnish Disabled Ex-Servicemen's Association, New York University arranged for a series of lectures on the fabrication of total-contact, above-knee sockets to be given in Helsinki in 1963. The lectures were intended for prosthetists and other interested persons. Since then some 300 prostheses of this type have been fabricated in Finland.</p> <p>The total-contact socket <a></a> is a further development of the conventional open-end socket. The proximal portion of a total-contact socket has the same contours as the corresponding portion of an open-end socket. The ischial seat, the relatively high anterior and lateral walls, the bulge into the femoral triangle, and the reliefs for the rectus femoris, for the adductor longus, and for the hamstring tendons are similar in both the open-end socket and the total-contact socket. The main difference is that the total-contact socket completely encases the stump, while the open-end socket, as its name implies, is open distally.</p> <p>This means that, in the total-contact socket, the stump end is surrounded by a vacuum which keeps the prosthesis in position without a pelvic joint and belt. The total-contact socket is kept in place by its intimate fit around the stump. There is a moderate vacuum during swing phase. The intimate fit of the total-contact socket, which is made of plastic, has been designed with a view toward imitating the mechanism of the physiological pumping action performed by the muscles while walking. the patellar-tendon-bearing (PTB) prosthesis acts in a similar fashion. The pumping effect is accomplished by the amputee as he walks. In fact, a principal advantage of the total-contact socket is the mild, gentle counterpressure on the distal end of the stump during the stance phase. This positive pressure, alternating with the negative during the swing phase, improves circulation and reduces edema in the stump.</p> <p>The total-contact socket is designed to reduce pressure on the stump proximally and increase the pressure distally. In cases where the diaphysis has been cut, the stump end never tolerates strong pressure. Therefore, pressure must be very carefully modified in each case.</p> <p>Distally, the plastic socket is joined to a wooden knee. The shank, too, is made of wood, to which a SACH foot is attached. Plastic has certain advantages over other materials. It is readily washed with soap and water. The surface can be made very smooth and free from pores. The chief drawback is airtightness. Plastic does not permit an exchange of air. The result is perspiration, particularly in the summer. Sweat gradually breaks down the plastic. In winter plastic is cold. Sometimes there are allergic reactions to plastic.</p> <p>In the Department of the State Supervisor of Prosthetic Services of the Ministry of Social Affairs, a follow-up study has been made of amputees fitted with total-contact prostheses. Initially, the amputees are given, for trial, prostheses which are not quite finished, although fit for wear. Some four to six weeks later the patients and their prostheses are examined at the Department of the State Supervisor, where the prostheses are approved or some modification or correction is prescribed. Only after this examination are the prostheses given their final finish. This applies to all prostheses paid for by the state. Six months after the patients have been fitted with their prostheses a questionnaire is sent to them, which they accomplish and return.</p> <p>Record cards are kept for all amputees on which are entered notations concerning new prostheses, repairs, and modifications.</p> <p>The present study covers 150 amputees fitted with total-contact prostheses. Of the amputees, 143 (95.3 per cent) were ex-servicemen and 7 (4.7 per cent) were insured civilians.</p> <p><b>Fig. 1</b>, which shows the ages of the amputees, indicates that the age group of 40 to 54 years is the largest. The high mean age of the ex-servicemen is accounted for by the time that has elapsed since World War II. The series includes two cases from the Finnish civil war of 1918. The youngest amputee was 24, the oldest 67. Only one was a recent amputee. In principle, every above-knee amputee should be fitted with a total-contact prosthesis from the outset in order to become used to it as soon as possible. This would accelerate the remodeling of the stump. Still, the stump of a recent amputee is often tender and swollen for some time. The total-contact prosthesis demands much of the stump. Consequently, a recent amputee may need a new socket at frequent intervals.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Ages of the amputees when they were fitted with total-contact prostheses. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Table 1</b> shows the occupations of the patients in the series. It is of major interest to ascertain whether the total-contact prosthesis can be worn while performing heavy labor of different kinds, particularly outdoors and at low temperatures. In northern Finland temperatures may be as low as -40 deg. C. Therefore, the occupations have been precisely specified. Whenever possible, amputees will usually choose labor that is not too heavy. The series includes 23 farmers (15.3 per cent), 1 lumberman, and 11 fitters. After World War II, retraining of invalids was arranged in the form of courses for watchmakers, storekeepers, fitters, shoemakers, etc. These occupations appear in the table.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><b>Fig. 2</b> shows the lengths of the amputation stumps. The total-contact prosthesis has been worn successfully by amputees whose stumps measured only 10 cm to 15 cm. This series includes 10 such cases, but in two of these cases it became necessary to abandon the total-contact prosthesis. One of these patients received a conventional, wooden, open-end prosthesis; the other was fitted with a leather prosthesis.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Lengths of the amputation stumps. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>These cases (No. 8 and No. 9 in <b>Table 2</b>) will be discussed later.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 2. Amputees Who Could Not Wear the Total-Contact Prosthesis </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Replies to the questionnaire are presented below:</p> <ol> <li><i>Have you worn your prosthesis regularly; if not, for how long have you worn itf </i>According to the replies, 108 (72 per cent) had worn their prostheses regularly, while 42 (28 per cent) had not been able to do so for a variety of reasons.</li><li><i>Why have you not been able to wear your prosthesis regularly? </i>The replies were compared with the record cards, and causes were elicited as follows: <ul> <li>The knee joint in the prosthesis was too stiff.</li> <li>In eight cases there was profuse perspiration and a repulsive odor.</li> <li>In one case the prosthesis was too warm in the summer and too cold in the winter.</li> <li>In one case the prosthesis was too cold in the winter.</li> <li>In five cases the socket did not fit.</li> <li>The amputee put on weight and the socket became too tight.</li> <li>The inner surface of the socket became granular.</li> <li>The stump swelled.</li> <li>There were pains in the stump.</li> <li>Walking was difficult because of a heart condition.</li> <li>In two cases the socket split.</li> <li>There was a jarring sound from the knee joint of the prosthesis.</li> <li>In one case the amputee was so used to his old prosthesis that he preferred it.</li> <li>The SACH foot became loose, the socket was tight, and the knee mechanism functioned differently from what it did in the old prosthesis.</li> <li>In three cases the skin became irritated.</li> <li>In one case the stump was operated upon after the prosthesis had been finished.</li> <li>The socket became too wide.</li> <li>The stiffness of the knee mechanism was a hindrance while fishing.</li> <li>The socket became too tight.</li> <li>In many cases modification and repair of the prosthesis put an end to the trouble.</li> </ul></li><li><i>Have you worn your prosthesis (a) when working indoors, </i>(b) <i>when working outdoors, (c) when working outdoors in very cold weather? </i>Of those replying to the questionnaire, 128 (85.3 per cent) had worn their prostheses while working indoors, 100 (66.7 per cent) had worn their prostheses while working outdoors, and 72 (48.0 per cent) had worn them outdoors in very cold weather. Some amputees had been in a position to wear the prosthesis only during the warm season at the time of the questionnaire.</li><li><i>Have you worn your prosthesis in some additional</i>-<i>part-time</i>-<i>occupation? </i>(The intention was to elicit data regarding incidental jobs, recreation, and hobbies.) Only eight amputees indicated that they had such activities: fishing in one case, gardening in one case, agricultural work and lumbering in two, work as a doorkeeper in one case, two cases in which the patients had built their own cottages, and one case in which the amputee participated in ball games.</li><li><i>Have you previously used a prosthesis of some other material (wood, leather, or light metal)? </i>Conventional prostheses of wood had been worn by 147 amputees (98 per cent), one (0.7 per cent) had worn a leather prosthesis, and one (0.7 per cent) had worn a prosthesis of light metal. One patient (0.7 per cent) was a recent amputee and had been fitted with his first prosthesis.</li><li><i>Have you been satisfied with your prosthesis? </i>There were 112 (74.5 per cent) satisfied wearers and 38 (25.5 per cent) who were dissatisfied.</li><li><i>Do you think this prosthesis is (a) better than, (b) just as good as, </i>(<i>c</i>) <i>not as good as your previous limb? </i>The replies were as follows: <br /> <table> <tbody><tr><td> <p>Better</p> </td> <td> <p>   81 (54.0 per cent)</p> </td> </tr> <tr><td> <p>Just as good</p> </td> <td> <p>   36 (24.0 per cent)</p> </td> </tr> <tr><td> <p>Not as good</p> </td> <td> <p>   33 (22.0 per cent)</p> </td> </tr> </tbody></table><br /></li><li><i>What defects or drawbacks have you observed in your total-contact prosthesis? </i>Listed below are the complaints of 39 patients (26 per cent). In 32 cases the stump had caused trouble and in seven cases there was something wrong with the prosthesis. But no sharp distinction can be drawn between these two groups. Quite frequently, the prosthesis is the ultimate source of the discomfort.<br /> <table> <tbody><tr> <td> <p><b>Amputation stump</b></p> </td> <td> <p></p> </td> </tr> <tr> <td> <p>The skin did not tolerate the prosthesis</p> </td> <td> <p>   12</p> </td> </tr> <tr> <td> <p>Perspiration from the stump and an unpleasant odor</p> </td> <td> <p>   15</p> </td> </tr> <tr> <td> <p>Cold in winter</p> </td> <td> <p>   2</p> </td> </tr> <tr> <td> <p>Stump end became discolored</p> </td> <td> <p>   1</p> </td> </tr> <tr> <td> <p>Warm in summer, cold in winter</p> </td> <td> <p>   2</p> </td> </tr> <tr> <td> <p>Totals</p> </td> <td> <p>   32</p> </td> </tr> </tbody></table><br /> <table> <tbody><tr> <td> <p><b>Prosthesis</b></p> </td> <td> <p></p> </td> </tr> <tr><td> <p>Plastic socket split</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p>Socket was too closed</p> </td> <td> <p>   2</p> </td> </tr> <tr><td> <p>Socket did not fit</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p>Socket too tight</p> </td> <td> <p>   1</p> </td> </tr> <tr><td> <p>Totals</p> </td> <td> <p>   7</p> </td> </tr> </tbody></table><br /> </li><li><i>Has perspiration of the stump constituted a problem? </i>In 33 cases (22 per cent) perspiration had been profuse, in 99 cases (66 per cent) moderate, and in 17 (11.3 per cent) it had caused no trouble. Only one patient (0.7 per cent) stated that perspiration gradually became less of a problem. As a rule, summer was the worst season from this standpoint.</li><li><i>Has perspiration caused any repulsive odorf </i>The replies of 113 amputees (74.7 per cent) were in the affirmative, while 37 patients (25.3 per cent) replied in the negative. When the odor of the sweat in the closed socket mingled with the odor of the plastic, which is particularly strong in new sockets still containing traces of the solvents used in the fabrication, the effect is extremely disagreeable to both the amputee and his environment. The plastic socket can be washed with soap and water, but personal hygiene varies widely. Many patients have stated that perspiration is not a major problem, if the stump and the prosthesis are washed regularly.</li><li><i>Has the skin on the stump tolerated the total-contact prosthesis? </i>In 118 cases (79.0 per cent) the skin on the stump had shown no symptoms, while in 32 cases (21.0 per cent) it had not tolerated the strain of the intimate fit of the socket.</li><li><i>Have reddening of the skin and eczema occurred? </i>In 51 cases (34 per cent) there had been reddening, which may be a transient phenomenon of no significance, but 23 amputees (15.3 per cent) had had eczema, and ulceration had occurred in 18 cases (12 per cent).</li><li><i>Has the end of the stump become discolored after adoption of the new prosthesis? </i>Discoloration of the end of the stump had occurred in 34 cases (22.7 per cent). This phenomenon is the result of circulatory disturbances in the end of the stump. The most frequent cause is that pressure on the blood vessels is too strong.</li><li><i>Did reddening, eczema, or ulceration of the stump occur before you started wearing a total-contact prosthesis? </i>Reddening had occurred in 60 cases (40 per cent), eczema in 45 (20 per cent), and ulceration in 5 <i>(3.3 </i>per cent). These replies do not differ greatly from those to question No. 12. But it must be remembered that the previous, conventional prosthesis of wood, leather, or light metal had been worn for a long time, while the total-contact prosthesis had been worn only one-half year to one year. Therefore, the two groups cannot be directly compared.</li><li><i>What are your experiences with the new prosthesis outdoors in cold weather? </i>Thirty-two patients (35.1 per cent) had not experienced discomfort during the winter, while 61 (64.9 per cent) had found their prostheses very cold.</li><li><i>Have you skied with the new prosthesis? </i>Only 23 (15.3 per cent) patients answered in the affirmative. As a rule, above-knee amputees are not likely to participate in this sport. The below-knee amputees found on skis are much more numerous.</li><li><i>If you experienced phantom pains previously, have they been aggravated or alleviated after adoption of the new prosthesis? </i>The replies were as follows:<br /> <table> <tbody><tr> <td> <p>No previous phantom pains</p> </td> <td> <p>   32 (22 per cent)</p> </td> </tr> <tr> <td> <p>Phantom pains aggravated</p> </td> <td> <p>   15 (10 per cent)</p> </td> </tr> <tr> <td> <p>Phantom pains unchanged</p> </td> <td> <p>   94 (62.3 per cent)</p> </td> </tr> <tr> <td> <p>Phantom pains alleviated</p> </td> <td> <p>   8 (5.3 per cent)</p> </td> </tr> <tr> <td> <p>Total</p> </td> <td> <p>   149 (99.6 per cent)</p> </td> </tr> </tbody></table><br /></li><li><i>Have you had pains in the amputation stump (a) after adoption of the new prosthesis, (b) with the old prosthesis? </i>Sixty-six patients (44 per cent) had experienced pain after adoption of the new prosthesis, and 66 (44 per cent) had had pains while wearing their old limb. In this respect the type of prosthesis seemed to make no difference. But it should be noted that no direct comparison is possible because the total-contact prosthesis had been worn for a shorter period than the old one. In nine cases the total-contact prosthesis was abandoned in favor of the open-end prosthesis previously worn. These cases were subjected to a more detailed study, presented in <b>Table 2</b>.</li></ol> <p>The table discloses that the occupations of the patients had little to do with the failure. The ages of the patients did not differ from the mean age of the series as a whole. In two cases the stump was short, 12 cm and 15 cm, respectively. In the entire series there were 10 stumps measuring 10 cm to 15 cm, three measuring 16 cm, six measuring 17 cm, and five measuring 18 cm. In all cases except the two mentioned at first, fitting with a total-contact prosthesis proved successful. In general, short stumps constitute a problem to the prosthetist. No. 8 in <b>Table 2</b> was one of a number of amputees who had not been able to wear any prosthesis without complications. No. 9 was the only patient who was tested for allergy.</p> <p>As appears from the replies to the questionnaire, perspiration and skin changes constituted problems in the wearing of total-contact prostheses. These troubles arose from the properties of the socket: its intimate fit around the stump, and the airtightness of the plastic material. Partly because of the solvents used in the fabrication, the plastic socket sometimes has an irritating effect on the skin, especially when it is new. This irritation is increased by the decomposition of the sweat caused by the heat of the closed socket. In a considerable number of cases, however, the difficulties may have been caused by inadequate curing of the plastic laminate. Also, prostheses made of wood or leather are not free from perspiration.</p> <p>The possible occurrence of allergic reactions is another problem. In Finland, amputees suspected of allergy are remitted to the Dermatological Department of the Helsinki University Central Hospital. The present series includes only one such case. Perhaps the question of allergy has not been sufficiently taken into account.</p> <p>The majority of the remaining troubles were readily dealt with in the prosthetist's shop.</p> <p>It should be emphasized, however, that the view of the total-contact prosthesis derived from the replies that have been reported may be too unfavorable. To the amputee, it is a great advantage to be able to walk with greater ease than with a conventional prosthesis, because of the firm adherence of the total-contact socket to the stump. No pelvic joint and belt are needed. As mentioned earlier in this article, a principal advantage of the total-contact socket is the mild, gentle counterpressure on the distal end of the stump during the stance phase. This positive pressure, alternating with the negative during the swing phase, assists circulation. Some of the cases with derma-tologic problems had poor fits, usually as the result of stump changes. In a number of cases, the difficulties may well have been caused by inadequate curing of the plastic laminate. Also, a number of the problems did not relate to the principle of the total-contact socket as such but would have occurred with other designs.</p> <h3>Summary</h3> <p>This study was performed on 150 amputees fitted with total-contact prostheses. It is based on personal follow-up examinations, replies to questionnaires, and data obtained from record cards kept on the amputees.</p> <p>The age group 40 through 54 years is the largest. War veterans constitute the majority (96.3 per cent of the series).</p> <p>Seventy-two per cent had worn their prostheses regularly from the outset, and 74.5 per cent were satisfied with them. The airtightness of the socket elicited unfavorable reactions from the skin of a number of the patients (21 per cent). Twenty-two per cent of the amputees complained of profuse, and 66 per cent of moderate, perspiration of the stump. Some of the cases with dermatological problems had poorly fitting sockets, usually as the result of stump changes. In a considerable number of the cases, the difficulties may well have resulted from inadequate curing of the plastic laminate. The majority of the problems were readily dealt with in the prosthetist's shop.</p> <p>The skin requires meticulous hygiene. In contrast to leather and wood, the plastic socket is readily washed. Conventional prostheses are not free from dermatological problems.</p> <p>The total-contact prosthesis has been used in the performance of heavy labor and while outdoors in cold weather.</p> <p>Some of the problems of the patients did not relate to the principle of the total-contact socket and would have occurred with other designs.</p> <p>The gentle, alternating, positive and negative pressure afforded by the total-contact socket to the patient as he walks improves the circulation of the stump and constitutes one of the socket's main advantages.</p> <p><b>References:</b></p> <ol> <li>Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, University of California, Biomechanics Laboratory (Berkeley and San Francisco), 1963.</li> <li>Foort, J., and N. C. Johnson, Edema in lower-extremity amputees, University of California, Biomechanics Laboratory (Berkeley and San Francisco), 1962.</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">Foort, J., Adjustable-brim fitting of the total-contact above-knee socket, University of California, Biomechanics Laboratory (Berkeley and San Francisco), 1963.</td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Foort, J., and N. C. Johnson, Edema in lower-extremity amputees, University of California, Biomechanics Laboratory (Berkeley and San Francisco), 1962.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Georg Bakalim, M.D. </b></td></tr><tr><td class="clsTextSmall">State Supervisor of Prosthetic Services, Ministry of Social Affairs, Helsinki, Finland.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1967_01_051/1967_01_051-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1967_01_051/1967_01_051-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1967_01_051/1967_01_051-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1967_01_051/1967_01_051-4.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Experiences with the Total-Contact Prosthesis Creator An entity primarily responsible for making the resource Georg Bakalim, M.D. * https://staging.drfop.org/files/original/f922814d211b608a697466e29490333b.pdf e5a35d98b2c617e7f9ded283ff5dafa7 https://staging.drfop.org/files/original/48cf7ac67e217521f3acb7e40d6b2a38.jpg f5a6cea41ca17f732cb253daf7918897 https://staging.drfop.org/files/original/16410b5f62b683ff0be5f6a0ef4730a6.jpg d8aa785829781cb0896ecc82863c789c https://staging.drfop.org/files/original/433b014b1a43a6614856053945b2243c.jpg 2b4c04387bc7f8a8bdc413c6109662d3 https://staging.drfop.org/files/original/843d131b77b5dc6c8f18d58702881340.jpg 5f4eff514a08be3ae5daaa303dc0cf7d https://staging.drfop.org/files/original/e575b525f13cc42d25f865c4db4ecb9e.jpg fc78601c78357e69128fc5a5290b83fd https://staging.drfop.org/files/original/e6ca2fa5bfd699bce64bf63899c6d86a.jpg ce75e70e35780221d326a363fc1dc05e https://staging.drfop.org/files/original/d803b3cc574d377eee5137bfd10f9db9.jpg 29d55e95bcb3a6b15f4a6b98f2c189e0 https://staging.drfop.org/files/original/5bc2ecf5e9ba7ac10a96388a62f09100.jpg e82f3d9d247bb7790f21711a8885532f https://staging.drfop.org/files/original/4de87b8d2e769e4c1287a208354fc8dc.jpg 70855f2c86c26331cc6fba80045e7553 https://staging.drfop.org/files/original/197022ec795072639ae32d2c689f1dc8.jpg 3cfec86e35d1b3315dafa497908e73ac https://staging.drfop.org/files/original/b4962dbe7236d6656d2297e42960d167.jpg 0970a72bbd0016a1fd49b37ead35272e DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1967_02_005.pdf Year 1967 Volume 11 Issue 2 Page Number(s) 5 - 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/1967_02_005.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1967_02_005.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>External Power in Prosthetics and Orthotics, an Overview</h2> <h5>James B. Reswick, Sc.D. <a style="text-decoration:none;">*</a><br />Lojze Vodovnik, D.Sc. <a style="text-decoration:none;">*</a><br /></h5> <p>The large number of persons who could be materially helped if highly developed orthotics and prosthetics systems were available is not generally appreciated. The conquest of infectious diseases has increased life expectancy to the point where disability caused by the failure of physiological systems is common in old age. The ever-increasing rate of injuries resulting from vehicle accidents adds to the numbers of paralyzed and maimed, and at the present time the Vietnam conflict is adding its toll.</p> <p>Detailed statistics are difficult to obtain, but it has been estimated that there are 25,000 to 30,000 amputations per year in the United States from all causes. The Veterans Administration reported 25,000 lower-extremity and 6,000 upper-extremity service-connected cases treated during 1967 (incomplete figures), resulting from several wars. There are no immediately available statistics related to the Vietnam conflict.</p> <p>Dr. Virginia Badger <a style="text-decoration:none;">*</a> has estimated the numbers of patients in the United States with various types of rheumatic, arthritic, and neurological disorders, including quadriplegia, as follows: <b>Table 1</b></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>Of these patients, Dr. Badger estimates that <i>2</i> million could benefit markedly from orthotic devices, provided that the difficult problems of patient acceptance could be overcome.</p> <p>Unfortunately, much remains to be done in defining the need more precisely. Many persons suffering from neurological disorders are not recorded in hospital statistics; and, if they are, the nature of their disability is not. The specific types and numbers of disabilities need to be codified in a way which could lead to the development of engineering specifications and decisions on priorities of effort and specific engineering designs.</p> <h3>The Man-Machine System</h3> <p>The human being and his assistive device comprise a man-machine system. When the orthotics or prosthetics system uses external power and is operated by means of feedback control, the result is a cybernetic system in the true sense of the term. <b>Fig. 1</b> illustrates the possible information paths of an orthotics or a prosthetics system. The following important elements are depicted: I. Signal Sources; II. Transducers; III. Signal Processors; IV. Output Systems; V. Feedback Receptors; and VI. Local Feedback. In addition to these physically identifiable elements, an important element in the performance of the system is the capability of man to learn to use a complex assistive device (VII. Adaptive Learning). Here, age and motivation are important; for example, "thalidomide children" show tremendous learning capacity with complex prostheses, while many geriatric lower-extremity amputees are not able, or are not motivated, to use an artificial leg.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Elements of a prosthetics or an orthotics system. I. Signal Sources: muscle motion, electromyographic, electroneurographic, electroencephalographic, eyeball motion, sound. II . Transducers: direct connections, switches, valves, proportional analog, proportional digital, electrodes, radio transmitters. III. Signal Processors: on-off, electromyographic, coupled function devices, proportional or velocity control systems, adaptive computer. IV. Output Systems: communication devices, environment and tools designed to work with the orthotics or prosthetics system, vehicles controlled by the orthotics or prosthetics system. IV. A. Prosthetic: terminal devices, upper-extremity components, lower-extremity components. IV. B. Orthotic: splints and casts, implant bone supports, body-powered splints, externally controlled splints, externally powered splints, functional electrical stimulation. V. Feedback Receptors: vision, hearing, proprioception, touch, "stereo" vibration, "stereo" electrical stimulation. VI. Local Feedback: Pressure sensors, slippage sensors, position, velocity, force. VII. Adaptive Learning. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This article will discuss each of the elements of the prosthetics or orthotics system depicted in <b>Fig. 1</b>, briefly indicating the present levels of research activity and future possibilities.</p> <h4>I. Signal Sources</h4> <p>The human desire to initiate movement of an orthotics or a prosthetics system originates at some conscious level in the central nervous system, but it must take the form of some voluntary physical action if a result is to be achieved. This action may be, for example, a simple muscle movement resulting in the closing of a switch, the pressing of a key, or the very sophisticated use of the tongue (<b>Fig. 2</b>) to activate a keyboard of miniature switches.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The Rancho Los Amigos Hospital electric arm orthosis. The various degrees of freedom are actuated by a series of bidirectional microswitches placed in front of the patient's mouth and operated by his tongue. A number of these devices are in use. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Recently, electrical signals associated with muscle and neuron activity have been explored for use as control signals. Although electro-neurographic (ENG) signals seem attractive because of their proximity to the central nervous system<a></a>, the practical difficulty of maintaining electrodes proximal to nerves in human subjects over extended periods of time has not been overcome. Instead, the more accessible electromyographic (EMG) signals have been used as sources of control signals. Most practical to date has been the use of so-called surface EMG signals obtained by means of electrodes resting on the surface of the skin near a muscle whose electrical activity is to be detected.</p> <p>A number of prosthetic hands and some hand orthoses have been developed to operate from EMG signals picked up through surface skin electrodes.<a></a> More recently, interest has grown in obtaining EMG signals from within a muscle. Such intramuscular EMG signals exhibit a wider range (from single motor unit pulses to signals of many asynchronous pulse combinations) and are more free from "cross talk" resulting from the activity of neighboring muscles.<a></a> Practical use of intramuscular EMG signals requires either wire electrodes which penetrate the skin and which can exist for long periods of time without breaking or promoting infection (<b>Fig. 3</b>), or the development of implantable radio transmitters capable of long-term operation (<b>Fig. 4</b> and <b>Fig. 5</b>) <i>(35,37.) </i>Future research will undoubtedly press in both of these directions.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. A monopolar, helically wound, percutaneous electrode. It is used to detect electrical activity within a muscle. The electrode is inserted into the proper muscle by a hypodermic needle which, when withdrawn, leaves the electrode comfortably implanted. A surface connector protects the electrode-skin interface. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Miniature FM radio transmitter used to obtain electromyographic signals by complete implantation. The signals are received externally and, after processing, can be used as control inputs in a control system. The transmitter shown will be encapsulated in epoxy and coated with medical grade silicone rubber. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Transmitters implanted in a human and attached to the trapezius muscles. The electromyographic signal obtained by lifting the shoulder ( a motion possessed by many quadriplegics) was used to drive a variable-speed motor, a bidirectional prehensile hand splint, and a multilevel selector. The transmitter was turned on by changing the state of a magnetic switch influenced by an external magnetic field. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Many other sources for voluntary signals from the human being have been suggested from time to time. The electroencephalogram (EEG) signal is often mentioned, but, to date, it has been used only as an on-off switch responding to the presence or absence of the alpha rhythm <i>. </i><a></a> Enticing as the idea may be, many years must pass before thoughts will will be transformed directly into meaningful electrical signals.</p> <p>The human voice, including whistles and the like, has been proposed and used as a signal source. Much research at present is devoted to machine recognition of human speech for voice-operated typewriters and for speaking directly to a computer <i>. </i><a></a> These efforts show promise, but they are probably far too complicated at present to be considered for use in a prosthetics or an orthotics system. The human eye has also been used to switch devices by means of ultrasonic and infrared reflections <i>. </i><a></a> Unfortunately, many such promising sources of control signals are involved in the normal activities of living, such as eating, looking around, speaking, and the like. This could be a disadvantage when the patient desired to control his orthotics or prosthetics system with a signal such as sound while he was talking or eating <i>.</i><a></a> </p> <h4>II. Transducers</h4> <p>Transducers are the devices used to change physiological phenomena into engineering signals that provide inputs to signal processors and output systems. A transducer may be as simple as an on-off switch or as complicated as an implantable FM radio transmitter. Some elements of orthotics and prosthetics systems are difficult to classify. Bowden cables used to transmit shoulder movements to an amputee's terminal device are an example. More recently, hydraulic systems which function as a wire cable have been demonstrated <i>. </i><a></a> Such systems combine the roles of transducer and actuator in a single unit.</p> <p>Electric switches and pneumatic-hydraulic control valves which convert body movements into changes in electric current or fluid flow are highly developed. Many types of reliable, very small electric switches have been easily adapted to prosthetics and orthotics systems, but, in the case of hydraulic and pneumatic control valves, it has been necessary to develop a number of appropriate special valves.</p> <p>Not so widely used in prosthetics and orthotics systems, but highly developed for general instrumentation purposes, is a wide range of proportional analog and digital transducers capable of converting pressure or movement into voltage or current changes. These devices range from analog potentiometers and capacitive and inductive devices which convert motion to smooth voltage changes, to linear transducers which produce pulse-coded signals proportional to incremental changes or absolute position. Also available are the very ingenious accelerometers and other motion transducers developed for space research and guidance control systems. Accelerometers have been used in at least one head-motion-activated control system <i>.</i><a></a> </p> <p>Generally speaking, the mechanical-to-electric transducers have been highly developed, but only limited use has been made of their capabilities in prosthetics and orthotics systems. This does not imply, however, that a number of mechanical - to - electric transducers are immediately available for use in prosthetics and orthotics systems. An actual application often requires either a major redesign or a new design to take into account the unique problems inherent in physiological-data transduction. It is appropriate to mention here the National Aeronautics and Space Administration's Space Technology Utilization Program, in which NASA is actively searching for ways to apply transducers developed for space applications in orthotics and prosthetics systems.</p> <p>The recent interest in electrophysiological signals for control of orthotics and prosthetics systems has focused attention on the development of electrodes. A large variety of surface electrodes used in electrocardiographic diagnosis and long-term monitoring systems is already available. From space technology come the "spray-on" electrodes and other surface electrodes used in telemetry and in obtaining physiological data from astronauts.</p> <p>Two main approaches exist for obtaining EMG signals from within a muscle, namely: percutaneous wires inserted by means of hypodermic needles; and surgically implanted radio-transmitting devices. In the first method, wires leading through the surface of the skin from inside the muscle must be capable of flexing as the muscle moves and maintaining contact with motor units for many months. Present indications are that tissue-reaction and infection at the point of exit from the skin are minimal. Some newly developed silastic-im-pregnated spiral electrodes show promise of solving the problem of mechanical reliability <i>. </i><a></a> Similar problems exist for the electrodes of surgically implanted devices. In fact, the electrodes may well prove to be the weakest link in a biotransmitting system. It is well known that electrode failures in heart pacers continue to be a vexing problem. Research will continue to find ways to prevent metal fatigue and to discover contact materials which produce no body-tissue reaction, and which do not corrode and weaken.</p> <p>In the foregoing paragraph, electrodes were discussed in the context of signal-sensing devices. Their importance is much more critical in transducers used for the electrical stimulation of muscle, as in the case of functional electrical stimulation to be described later on in this article, and in heart pacemakers and bladder stimulators, which have been excluded from this discussion of orthotics and prosthetics systems. The relatively higher currents associated with electrical stimulation, as compared with detection of electrophysiological signals, create problems. It is believed that the material, corrosion, and tissue-reaction problems associated with electrodes for picking up signals are not severe and can be easily overcome through present technology.</p> <p>Electrical powering, long-term body acceptance, and sealing of the package are the issues around the active transmitters used for detecting electrophysiological signals from within the body and the passive and active implantable transducers for electrical stimulation of muscles. At present, all such experimental devices are powered by mercury cell batteries. Much effort is being devoted to minimize total electrical power requirements and to obtain electrical energy from within the body through mechanical and chemical transformers.<a></a> Battery-powered biotransmitters of a total size of 0.1 cu. in. have operated continuously for 200 hr. and, intermittently, over a three-month period in dogs. An EMG transmitter was first implanted in a human being in Sweden in 1966 <i>. </i><a></a> More recently, one was implanted in a subject in Cleveland, Ohio <i>. </i><a></a> Many problems remain to be overcome before such transmitters can be used routinely in the clinical situation, but progress with packaging techniques which produce no tissue-reaction in animals over long periods of time, and with electrode designs which can survive mechanical and electrolytic effects, indicates that prototype systems will be evaluated in human subjects within the year.</p> <h4>III. Signal Processors</h4> <p>This discussion of signal processors is concerned primarily with the special electronic and computer-type systems used for converting low-level control signals containing noise and artifacts to useful, high-level input for orthotic or prosthetic devices.</p> <p>Although not specifically designed for signal processing, the mechanical and hydraulic characteristics of many systems may be viewed as signal processors. For example, the speed of response of a gas-powered orthotics or prosthetics system is often limited by the size of the valve openings and tubing used in the system. In this way, the on-off characteristic of the valve is converted inherently into a velocity output and is so observed by the patient. In fact, subjects are often very much aware of the noises and speeds of response associated with their control devices, and improve their skills with practice and knowledge of how the system will perform for given input operations.</p> <p>Signal processors designed specifically to alter electrical wave forms include a wide range of circuits used for processing EMG information. Most such circuits involve rectification, integration, and various nonlinear components used to reject noise and provide the smoothest possible electrical systems for operating the orthotic or prosthetic device. Since the EMG signal, especially when detected from within the muscle, consists of an asynchronous train of pulses, signal conditioners based upon digital - signal - handling theory are being developed. Some of these systems would "clean up" the pulse signals from within a muscle to the point where they might be used as direct signals into a digital computer.</p> <p>Under another kind of theory for signal processing, combined or patterned functions are produced from one or more inputs. Among body-powered orthotic devices, the linkage feeders widely used by quadriplegics are an example.<a></a> These mechanical linkage systems support the forearm and allow the patient to convert shoulder and trunk movement into controlled movement of his hand. When given a controlled prehensile function, patients often learn to feed themselves and perform many other useful tasks. Externally powered arm prostheses have been designed for children, with coupled movements such that the programmed movement of an eating implement is obtained by the child through a single input action.<a></a> The conversion of a single input action to interrelated movements of each part of the prosthesis may be regarded as a type of signal processing, especially when one considers the possibility of using an elecrical computer to do the same sort of thing. The sophisticated prosthetic hands built in France and, more recently, in Yugoslavia and Japan,<a></a> in which a simple set of input signals is mechanically converted to a smoothly closing movement of all fingers, constitute a type of signal processing.</p> <p>Another type of signal processing is found in the automatic control systems used in some orthotic and prosthetic devices (<b>Fig. 6</b>). Recently, interest has developed in systems possessing automatic proportional and velocity control. Such systems differ from so-called "open-loop" systems in that feedback position or force signals are fed back to the control system itself rather than the patient. The patient provides command signals, such as a new position, to which the control system automatically responds. Such techniques have not been widely used in orthotics and prosthetics systems to date, but they have been demonstrated in research prototypes and will probably find increasing application <i>.</i><a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. A prototype automatic prehension system developed at the Army Medical Biomechanical Research Laboratory. It includes miniaturized electronics, a motor-driven No. 4 hand, and a thumb sensor. A cosmetic glove is worn over the assembly. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Most human motor activity is a combination of direct conscious control and patterned movements which are coordinated at levels below the conscious nervous system. Many research projects are now concerned with using computers or high-speed data processors to perform for an advanced prosthetics or orthotics system what the lower motor neuron system does for the human being. The problem is essentially one of information-channel capacity, wherein much information may be required to control a complex device but only limited channels are available for converting the desires of the patient into electrical command signals.<a></a> </p> <p>One approach to this problem was the Case Research Arm Aid, Mark I (<b>Fig. 7</b>), <a></a> which used a computer with pre-programmed tapes for a number of activities of daily living. The quadriplegic patient was required to select the portion of tape appropriate for the action he wished to accomplish, but he did not need to be actively involved once the action had started. More recently, proposals have been made for using computers adaptively to learn to provide patterned functions. The idea would be to store within the computer patterns or subroutines for elementary body movements which combine to produce walking or upper-extremity movement. The subject would then provide only "coarse" information about where he wanted his limb to go, and the computer would calculate according to some pre-programmed strategy how best to move his limb most efficiently from one place to another. The tremendous progress in machine computation has opened unlimited possibilities for research in such systems which can be reduced practically to patient needs. One can visualize, for example, a paralyzed leg being electrically stimulated according to a patterned program stored in a solid-state, micrologic computer worn on the belt. Although such a system can be imagined, it will be many years before it is technically and economically feasible.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The Case Research Arm Aid, Mark I. The pneumatic system shown allowed five degrees of freedom through the shoulder, arm, and wrist. Modifications being made include conversion from a pre-programmed tape control to computer-calculated trajectories by means of myoelectric input control signals. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>IV. Output Systems</h4> <p>In the past, most of the research, development, and clinical application of orthotics and prosthetics systems has been concerned with the output systems, for these are the hardware devices which perform the functions required by the handicapped person. Through intuition, designers have shown awareness of control and feedback, but their attention has been primarily directed toward the powering and fitting of devices to improve the function of the handicapped.</p> <p>Almost all the elements in the man-machine systems are applicable to both orthotics and prosthetics; but, when output systems are considered, it is necessary to discuss orthoses and prostheses independently, except for certain communication devices which apply to both. For example, much effort has been devoted to modifying telephone, recorder, typewriter, radio and television equipment for easier use by handicapped persons. Touch dialing, alone, is an important asset. Tape-recording and typewriters operated through coded signals from the tongue or voice make it possible for the paralyzed person to carry on a business and communicate with friends.</p> <p>In addition to communication devices, attention has also been given to the development of special tools and machines so that the handicapped can perform useful work. Interestingly, much of the philosophy in the development of such tools is common with the development of special tools for astronauts to use in space. This occurs because the normal man in an alien environment is similar in many respects to the handicapped man in a normal environment. Vehicles for the transportation of handicapped persons, including powered wheelchairs (<b>Fig. 8</b>) and modified automobiles, must also be included in output systems for the handicapped.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Ampersand Research, Highland View Hospital, three-level electromyographic control of wheelchair and flexorhinge splint. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Prosthetics</i></p> <p>The term "prosthesis" brings to mind artificial hands, arms, and legs. The historical development of these artificial limbs is an extensive and fascinating study in itself. Although seemingly simple and perhaps crude, the cable-controlled, rubber-band hooks commonly used by below-elbow amputees are, in fact, quite sophisticated, and many amputees have developed remarkable dexterity with them. Probably many years will elapse before the users of EMG-controlled, electrically powered hands achieve the same level of reliability and dexterity now found in thousands of skilled hook-users around the world.</p> <p>The problem is much more severe for the above - elbow and shoulder - disarticulation amputee, especially the bilateral case. It is a fact that when a patient has one good arm the margin of increase in function provided by a prosthetic second arm is often too small to make it worth his while to learn to use it. Much effort is now under way to provide improved functions for high-level amputees, especially bilateral cases. The most successful systems to date are powered by gas or electricity.<a></a> Each clinical application represents a major engineering achievement, and each one is usually somewhat different from all others. This is the real limitation in the development of sophisticated upper-extremity systems, for the problem of fitting and the nature of disability are so different among the relatively limited numbers of amputee patients and congenitally deformed children that the sophisticated engineering required is often economically unjustified. However, the obvious challenge presented by the creation of an artificial human limb continues to fire the imagination of engineers throughout the world, and one may expect continued progress.</p> <p>The case for the lower-extremity prostheses is somewhat different, because a man cannot walk with just one leg. Much effort has been devoted to developing lower-extremity prostheses for both above-knee and below-knee amputees. A successful prosthetic application requires close collaboration between the orthopaedic surgeon and the prosthetist. Thoughtful planning concerning the nature of the stump to be produced can make a great difference in the effectiveness of the final prosthesis. Walking is one of the most sophisticated patterned functions in man. Many muscles are interrelated in producing a gait of minimum energy expenditure. One area of intensive research has been the study of human gait in order to improve the design of lower-extremity prosthetic and orthotic devices. Although considerable data have been gained through cinematography and EMG studies, there is still much to be learned, and one can expect continuing research in this area.<a></a> </p> <p>Lower-extremity prostheses are more complicated than one might imagine. The acceleration sequences required for normal human gait are not produced by a simple pendulum swing. Instead, one must build nonlinear damping devices into a lower-extremity prosthesis to control the swing phase so that it will approximate that of a normal human being. In the simplest versions, disks of leather are used to provide this friction. Recently, nonlinear and hydraulic devices have been built into artificial limbs. These hydraulic devices still suffer occasionally from seal and other failures, but they have been successfully used by amputees under a Veterans Administration evaluation program.</p> <p>The problem of socket design and fitting is still under investigation, for one must transfer considerable forces to the limb, both in direct compression and in torsion. Sockets providing total-surface contact, air cushions, "breathing effect" and special types of support have been developed. For a number of years, researchers have attempted to measure the pressure distributions occurring under dynamic conditions within lower-extremity sockets. In general, these attempts have not been successful, and this remains a challenging area for future research. Such pressure-distribution data are urgently needed for the intelligent design of lower-extremity prostheses and, in some cases, for upper-extremity devices.</p> <p><i>Orthotics</i></p> <p>The first orthoses were the splints used to support a fractured limb and the canes and crutches used by early man. Bracing of weakened limbs due to neurological disorders and the therapeutic appliances used to overcome deformities have been widely applied by the orthopaedic surgeon and his collaborating orthotist. Through surgical reconstruction and tendon transplants, the orthopaedic surgeon can provide concepts for rehabilitation which complement improved engineering systems.<a></a> The future possibilities of such combined surgical intervention and engineering systems development have been only hinted at and much research undoubtedly will be carried on between the engineer and the surgeon in this area.</p> <p>A number of new, externally powered, and controlled splint systems are being made available to paralyzed patients. A kind of race is now occurring between the proponents of gas-powered orthotics systems and electrically powered systems. Actually, these systems are highly competitive when one considers the energy-storage capacity and weight of motors and batteries as compared to gas actuators and storage containers. The gas-powered systems still provide the best force-to-weight capability, but electric motors are being improved continuously and the overall simplicity of an all-electric system has many advantages.<a></a> </p> <p>A number of prehensile splints to provide grasp to paralyzed patients have been applied routinely, and many new multiaxis powered splints are being applied.<a></a> As in the case of the complex prosthesis, the need for many different approaches to meet the many different types of disability in paralysis or neurological disorders has slowed down the broad development of externally powered orthotic systems. We believe, however, that engineering developments will soon reach the point where such systems will be widely applied to the very large number of patients who can benefit from increased functions, especially in old age. Expanded research and development in externally powered orthoses for both upper and lower extremities is certainly going to occur.</p> <p>A promising new approach is being investigated throughout the world. This approach suggests the use of electrical stimulation of muscles for functional activity. <a></a> While electrical stimulation of muscles has been used extensively for a number of years in diagnosis and in therapy, its use for functional action has only recently been studied. The increased sophistication of electronic systems and the possibility of passive and active implants suggest the realization of controlled muscle activity. Such systems would certainly operate in parallel with some sort of external functional bracing, for in the foreseeable future one can imagine only a limited number of agonist and antagonist muscles being functionally stimulated.</p> <p>There is much to be learned about whether denervated muscles can be kept in an active stimulatable condition for long periods of time and whether intact lower motor systems will respond to controlled stimulation without inducing spasticity and other aberrations. The progress to date, however, is exciting and it is urged that serious consideration be given to programs of electrical stimulation of the muscles of recent victims of neuron lesions so that the atrophy of involved muscles can be retarded awaiting the day that functional stimulation can be made available.</p> <p>Expanded research around the understanding of the process of functional stimulation and physiologic factors in muscle stimulation, both from a physiological and an engineering point of view, is to be expected.</p> <h4>V. and VI. Feedback Receptors and Local Feedback</h4> <p>A human being controlling either the most simple or the most complex assistive device must have feedback information. In normal human motor activity, feedback comes via sight, sound, touch (pressure), and proprioceptive senses. These normal feedback channels are always impaired to some degree in handicapped persons and may be altogether missing. The visual path is still the most important for control in most orthotics and prosthetics systems, but much research has been undertaken recently to relieve the patient of the need to keep his eyes consciously fastened on each part of an output task. The sounds of electric motors and gas-operated systems provide many cues for feedback control, some of which may not be consciously appreciated by the subject. Many amputees learn to interpret reflected forces and motions through Bowden cables and other body-powered components.</p> <p>Much interest in sensory feedback research has been shown throughout the world, but only minimal progress has been made to date. Stereo effects are also being investigated, including transducers which produce vibration of varying phase and intensity at two points on the surface of the skin from which a sensation of spatial position proportional to an actual position can be produced <i>. </i><a></a> The possibility of producing a similar spatial position sense through "stereo" electrical stimulation at two different points on the surface of the skin is also being investigated.</p> <p>Recently proposed orthotics and prosthetics systems, using data processes, may require local feedback which is not processed by the human. <b>Fig. 1</b> indicates some paths which are analogous to some afferent paths in lower motor neuron systems in the human. Systems to select the grasping pressure in terminal devices have been developed. A recent approach to the problem at the Army Medical Biomechanical Research Laboratory uses a sound pickup to detect incipient slip in lieu of pressure to modulate the force applied in an artificial hand <i>.</i><a></a> </p> <p>To date, feedback control of orthotics and prosthetics systems has been severely limited by the inability to provide effective artificial sensory feedback, and will constitute a major barrier to overall system effectiveness for some years to come. It seems clear that a maximum research effort should be made to develop effective pseudosensory feedback signals, not only for orthotics and prosthetics systems, but also for sensory aids to the blind and deaf- areas which are, of course, closely related.</p> <h4>VII. Adaptive Learning</h4> <p>The success of any orthotics or prosthetics system or device must depend on acceptance by a patient and his abilty to learn to use it effectively. If the device proves to be more trouble than it is worth, it will be rejected. Thousands of rejected devices now rest in closets and dark corners.</p> <p>An important element of an orthotics or prosthetics system is the capability of a patient, whether young or old, to learn to employ his device skillfully <i>.</i><a></a> </p> <p>As new systems become ever more complex with many degrees of freedom (moving elements), the problem of control becomes more difficult.<a></a> One may visualize a multi-axis orthosis controlled by EMG signals from six or more voluntarily excited muscles (<b>Fig. 9</b>). An unanswered question remains as to how well the patient can train the six or more muscles to perform the functions required, especially when the functions may be very different from those for which the muscle was naturally used. The authors have discussed this difference between so-called naturally conditioned communication channels (NCCC) and operant-conditioned communication channels (OCCC) (<b>Fig. 10</b>) <i>. </i><a></a> It appears intuitively correct to use the naturally conditioned channels wherever possible as signal sources for natural functions. The EMG-controlled artificial hands previously referred to use signals obtained from the prehensile extensors and flexors so that the amputee may open and close his artificial hand with the same muscles he would have used prior to the amputation. However, as degrees of freedom increase and the nature of the disability precludes naturally conditioned sources, one is forced to employ other muscles, such as the auriculares muscles behind the ears<a></a> or the trapezius muscles in the shoulders, as signal sources.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. A test of the feasibility of exercising three degrees of freedom by means of myoelectric control. Six muscle sites received percutaneous electrodes, all in the forearm. The six sites were then connected to a model hand trainer possessing three degrees of freedom. The motions of the trainer could be controlled to correspond with those of the control muscles. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. Schematic representation of naturally conditioned communication channels (NCCC) and operant-conditioned communication channels (OCCC). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It is clear that much research on these issues remains to be done. Age is certainly an important factor, for it is known that young children adapt very much more easily to orthotic and prosthetic devices than do older persons. Learning capability is closely related to the amount of information being received by the patient through his feedback channels and to the amount of patterning and programming that can be done at the signal-processing level. No doubt the future will bring clarification of these matters.</p> <h3>Evaluation</h3> <p>Before closing, a major problem which continues to face the American orthotics and proshetics research, development, and clinical application program should be mentioned. This is the important issue of effective <i>evaluation. </i>Evaluation does not stand alone as a specific activity. The theory that a prototype developed by one group can be taken over by a separate evaluation agency to determine if it "works," and if it works can then be taken over by a manufacturer for production, just does not often succeed in practice. Problems in the medical engineering field of prosthetics and orthotics development are immensely complicated, and often the true nature of the problem to be solved is not undertood until one or two attempts have been made at solution. A constant interplay between the needs of the patient, the requirements of the physician, and the technical development by the engineer must be maintained. It is the rule, rather than the exception, that most new developments brought to the prototype stage require continued research and redesign. It seldom happens that a first-prototype development can be picked up and replicated in quantity for the field.</p> <p>The implication of the foregoing remarks is that the evaluation process is a continuing and integral part of the overall design-development process and is perhaps the hardest and most expensive part. To date, inadequate funds have been allocated for its accomplishment in grant programs. The result has been that not nearly so many fruits have accrued from the research and development programs as might otherwise have been the case.</p> <p>The specific need could be met by providing an overall systems-management function for the broad spectrum of activities throughout the nation. This systems-management function would be a cooperative effort authorized by federal government agencies and their advising groups. The lessons learned by the National Aeronautics and Space Administration in the management of the space effort seem applicable here, and it is the strong recommendation of these authors that the need for systems management in the broad field of orthotics and prosthetics research and development be recognized.</p> <p><b>References:</b></p> <ol> <li>Alldredge, R. H., and E. F. Murphy, Prostheticsresearch and the amputation surgeon, Artificial Limbs, pp. 4-46, September 1954.</li> <li>Allen, J. R., A. Karchak, V. L. Nickel, and R.nelson, The Rancho electric arm, Proc. 3rd Annual Rocky Mountain Bioengineering Symposium, pp. 79-82, 1966.</li> <li>Alter, R., Bioelectric control of prostheses, MITechnical Report 446, Cambridge, Mass., December 1966.</li> <li>Basmajian, J. V., M. Baeza, and C. Fabrigar,Conscious control and training of individual spinal motor neurons in normal human subjects, J. of New Drugs, 5(2):78-85, March-April 1965.</li> <li>Battye, C. K., A. Nightingale, and J. Whillis,The use of myoelectric currents in the operation of prosthesis, J. Bone and Joint Surg., 37B:506, 1955.</li> <li>Bennett, Robert L., The evolution of the GeorgiaWarm Springs Foundation feeder, Artificial Limbs, Spring 1966.</li> <li>Bontrager, E., M.Sc. thesis, Case Institute ofechnology, Cleveland, 1965.</li> <li>Bottomley, A. H., Myoelectric control of poweredprostheses, J. Bone and Joint Surg., 47B:411-415, 1965.</li> <li>Bottomley, A. H., and T. K. Cowell, An artificialhand controlled by the nerves, New Scientist, pp. 668-671, March 12, 1964.</li> <li>Bottomley, A. H., A. B. Kinnier Wilson, and A.ightingale, Muscle substitutes and myoelectric control, J. Brit. Institution of Radio Engineers, 26(6), December 1963.</li> <li>Brejdo, M. G., V. S. Gurfinkle, A. Ye. Kobrinskii,. A. Sysiu, M. L. Celtin, and A. S. Jakobson, O biolektricskoj sisteme upravlenija, Problemy kybernetiki, Gs. izd., fizikomatematiceskoj, literatury, Moscow, 1959.</li> <li>Close, J. R., E. D. Nickel, and F. N. Todd, Motorunit action potential counts, J. Bone and Joint Surg., 42-A(7): 1207-1222, October 1960.</li> <li>Close, J. R., E. D. Nickel, and F. N. Todd, Singlemotor unit action potentials, Clinical Orthopaedics, 42:171-190, 1965.</li> <li>Corell, R., Research and development of the CaseResearch Arm Aid, Ph.D. thesis, Case Institute of Technology, 1964.</li> <li>Crochetiere, W. J., L. Vodovnik, and J. B. Reswick,Electrical stimulation of skeletal muscle: a study of muscle as an actuator, Med. and Biol. Eng., 5:111-125, 1967.</li> <li>Dewan, E. M., Communication by electroencephalog-raphy, Special Report No. 12, Air Force Research Laboratory, Cambridge, Mass., November 1964.</li> <li>Dimitrijevic, M. R., Use of physiological mechanismsin the electrical control of paralyzed extremities, International Symposium on External Control of Human Extremities, Dubrovnik, 1966.</li> <li>Dorcas, D. S., and R. N. Scott, A three-state myo-electric control, Med. and Biol. Eng., 4:367-370, Pergamon Press, 1966.</li> <li>Engen, T. J., Powered upper extremity orthoticdevelopment, Progress Report, Texas Institute for Rehabilitation and Research, September 1967.</li> <li>Freedy, A., and J. Lyman, An information theoryapproach to control of externally powered artificial arms, Paper read at combined meeting of Panel on Control of External Power and Panel on Upper-Extremity Orthotics, Subcommittee on Design and Development, Committee on Prosthetics Research and Development, New York, May 1967.</li> <li>Gracanin, F., and M. R. Dimitrijevic, Applicationof functional stimulation in rehabilitation of neurological patients, International Symposium on Rehabilitation in Neurology, Prague, September 1966.</li> <li>Grahn, E. C, Electrical actuators in prosthetics andorthotics, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 172-185, 1966.</li> <li>Groth, H., and J. Lyman, A functional evaluationof several surgical techniques for establishing prosthetic control sites, Biotechnology Laboratory Technical Report No. 2, University of California (Los Angeles), June 1959.</li> <li>Highland View Hospital, Ampersand report, Cleve-and, September 1966.</li> <li>Hirsch, C, E. Kaiser, and I. Petersen, Telemetry ofmyopotentials, Acta Orthop. Scand., 37:156-165, 1966.</li> <li>Horn, G. W., Muscle voltage moves artificial hand,lectronics, October 11, 1963.</li> <li>Inman, V. T., Human locomotion, Can. Med. Ass.., 94:1047-1054, 1966.</li> <li>Karchak, A., J. R. Allen, V. L. Nickel, and R.nelson, The electric hand splint, Orthop. and Prosth. Appliance J., pp. 135-136, June 1965.</li> <li>Kay, Hector W. Conclusions of a conference onlinkage feeders, Artificial Limbs, Spring 1966.</li> <li>Kay, Hector W., and Nancy V. Appoldt, Prelimi-nary design analysis of linkage feeders, Artificial Limbs, Spring 1966.</li> <li>Kestenback, H. J., A feasibility study of smallradioisotopic batteries for medical implants, Report SSG-67-32, Case Institute of Technology, 1967.</li> <li>Kiessling, E. A., Carbon dioxide as a source of ex-ternal power for prosthetic devices, The application of external power in prosthetics and orthotics, National Academy of Sciences-National Research Council, Publication 874, pp. 79-87, 1961.</li> <li>Kiessling, E. A., Pneumatic prosthetic components:rigid servo mechanisms and their control valves, The application of external power in prosthetics and orthotics, National Academy of Sciences- National Research Council, Publication 874, pp. 116-131, 1961.</li> <li>Kinnier Wilson, A. B., Design of a motorized elbowsplint, Proc. Int. Symposium on the Application of Automatic Control in Prosthetic Design, pp. 6-9, Belgrade, 1962.</li> <li>Ko, W., Progress in miniaturized biotelemetry, Bio-cience, 15(2):118-120, 1966.</li> <li>Ko, W., Piezoelectric energy converter for electronicimplants, Proc. 19th Conference on Engineering in Medicine and Biology, San Francisco, p. 67, 1966.</li> <li>Ko, W., and M. R. Neuman, Implant biotelemetryand microelectronics, Science, 156:351-360, April 21, 1967.</li> <li>Kobrinskii, A. Ye., Bioelectric control of prostheticdevices, Herald of the Academy of Sciences, USSR, 30(7):58-61, July 1960.</li> <li>Kralj, A., L. Vodovnik, and M. Borovsak, Elec-tronic circuits used to obtain some functional movements by means of electrical stimulation, 2nd European Symposium on Medical Electronics, London, 1967.</li> <li>Litton Systems (Canada) Ltd., Research on myo-electric devices, D.I.R. Project No. E-74, DRB 9301-02, Toronto, 1967.</li> <li>Long, C, and B. Ebskov, Research applications ofmyoelectric control, presented at the 43rd Annual Session of the American Congress of Physical Medicine and Rehabilitation, 1965.</li> <li>Long, C, and V. Masciarelli, An electrophysiologicsplint for the hand, Arch. Phys. Med. and Rehab., 44:499, 1963.</li> <li>Lucaccini, L., A. Freedy, and J. Lyman, Externallypowered upper extremity prosthetic systems: studies of sensory motor control, Dept. of Eng. Report 67-12, University of California (Los Angeles), March 1967.</li> <li>Lucaccini, L. F., P. K. Kaiser, and J. Lyman, TheFrench electric hand: some observations and conclusions, Bull, of Prosth. Research, Veterans Administration, BPR 10-6, pp. 30-51, Fall 1966.</li> <li>Lyman, J., Biotechnology Laboratory Progress Re-ort No. 61-76, University of California (Los Angeles), September 1961.</li> <li>Lyman, J., Biotechnology Laboratory Progresseport No. 62-F, University of California (Los Angeles), December 1961.</li> <li>McGhee, R. B., Finite state control of quadrupedlocomotion, Report USCE 186, University of Southern California, December 1966.</li> <li>McLaurin, C. A., Control of externally poweredprosthetic and orthotic devices by musculoskeletal movement, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 10-19, 1966.</li> <li>McLaurin, C. A., On the use of electricity in upperextremity prostheses, J. Bone and Joint Surg., <b>47B: </b>448, 1965.</li> <li>Marquardt, E., Biomechanical control of pneumaticprostheses with special consideration of the sequential control, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 20-31, 1966.</li> <li>Massie, H., Cardiac pacemaker without batteries, 18th Conference on Engineering in Medicine and Biology, Philadelphia, 1965.</li> <li>Mott, W. E., and L. Sagan, Bioengineering problemsof implantable radioisotopic powered heart devices, San Diego Biomedical Engineering Symposium, 1967.</li> <li>Murphy, E. F., The swing phase of walking withabove-knee prosthesis, Bull, of Prosth. Research, Veterans Administration, BPR 10-1, pp. 5-39, Spring 1964.</li> <li>National Academy of Sciences-National Researchouncil, The application of external power in prosthetics and orthotics, Publication 874, 1961.</li> <li>National Academy of Sciences-National Researchouncil, The control of external power in upper-extremity rehabilitation, Publication 1352, 1966.</li> <li>Olson, H. F., Speech processing systems, IEEEpectrum, pp. 90-102, February 1964.</li> <li>Pearson, J. R., Gas-power sources and actuators forprosthetic and orthotic devices, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 186-201, 1966.</li> <li>Rakic, M., An automatic hand prosthesis, Med.lectron. Biol. Eng., 2:47, 1964.</li> <li>Reynolds, L. W., Utilization of bioelectricity aspower supply, Aerospace Med., February 1964.</li> <li>Salisbury, L. L., and A. B. Colman, A mechanicalhand with automatic proportional control of prehension, Technical Report 6611, Army Medical Biomechanical Research Laboratory, Walter Reed Army Medical Center, May 1966.</li> <li>Scott, R. N., A method for inserting wire electrodesfor electromyography, IEEE Transactions on Bio-Medical Engineering, BME-12(l):46-47, January 1965.</li> <li>Scott, R. N., Myo-electric control, Science J., pp. 2-8, March 1966.</li> <li>Scott, R. N., Myoelectric control of prostheses, Arch. Phys. Med. and Rehab., 47:174-181, March 1966.</li> <li>Scott, R. N., Myo-electric control systems, Reporto. 5, University of New Brunswick Bio-Engineering Institute, December 1965; No. 6, January 1967.</li> <li>Selwyn, D., Head-mounted inertial servo control forhandicapped, 6th Annual Symposium of the Professional Group on Human Factors in Electronics, Boston, May 1965.</li> <li>Sherman, E. D., A. L. Lippay, and G. Gingras,Prosthesis given new perspectives by external power, Hospital Management, pp. 44-49, November 1965.</li> <li>Spaco, Inc., The sight switch, Huntsville, Ala.,pril 1965.</li> <li>Stanford Research Institute, Experiments in tactualperception, Technical Report AFAL-TR-65-75_rJuly 1965.</li> <li>Suzuki, R., An automatic hand prosthesis, Jap,lectron. Eng., 2(1):39-41, January 1965.</li> <li>Tomovic, R., and G. Boni, An adaptive artificialhand, IRE Trans. Auto. Control, pp. 3-10^ April 1962.</li> <li>Tomovic, R., and R. B. McGhee, A finite stateapproach to the synthesis of bioengineering control-systems, IEEE Trans. Human Factors, HFE-7,. No. 2, June 1966.</li> <li>Trombly, C. A., Principles of operant conditioningrelated to orthotic training of quadriplegic patients, Amer. J. Occup. Ther., 20:217-220, September-October 1966.</li> <li>Vodovnik, L., W. J. Crochetiere, and J. B. Reswick,Control of a skeletal joint by electrical stimulation of antagonists, Med. and Biol. Eng., 5:97-109,1967.</li> <li>Vodovnik, L., C. Long, J. B. Reswick, A. Lippay,nd D. Starbuck, Myoelectric control of paralyzed muscles, IEEE Trans., BME-12, pp. 169-172, 1965.</li> <li>Vodovnik, L., et ah, Some topics on man-machinecommunication in orthotic and prosthetic systems, EDC Report 4-67-16, Case Institute of Technology, Cleveland, 1967.</li> <li>Waring, W., and V. L. Nickel, Powered braces withmyoelectric controls, Orthop. and Prosth. Appliance J., pp. 228-230, September 1965.</li> <li>Wasserman, W. L., Human amplifiers, Sci. and Technol., October 1964.</li> <li>Weltman, G., H. Groth, and J. Lyman, An analysisof bioelectrical prosthesis control, Biotechnology Laboratory Technical Report No. 1, Dept. of Eng. Report No. 59-49, University of California (Los Angeles), July 1959.</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>7.</b> </td><td class="clsTextSmall">Bontrager, E., M.Sc. thesis, Case Institute ofechnology, Cleveland, 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>75.</b> </td><td class="clsTextSmall">Vodovnik, L., et ah, Some topics on man-machinecommunication in orthotic and prosthetic systems, EDC Report 4-67-16, Case Institute of Technology, Cleveland, 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>References</b></td></tr><tr><td class="clsTextSmall"><b>45.</b> </td><td class="clsTextSmall">Lyman, J., Biotechnology Laboratory Progress Re-ort No. 61-76, University of California (Los Angeles), September 1961.</td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Lyman, J., Biotechnology Laboratory Progresseport No. 62-F, University of California (Los Angeles), December 1961.</td></tr><tr><td class="clsTextSmall"><b>78.</b> </td><td class="clsTextSmall">Weltman, G., H. Groth, and J. Lyman, An analysisof bioelectrical prosthesis control, Biotechnology Laboratory Technical Report No. 1, Dept. of Eng. Report No. 59-49, University of California (Los Angeles), July 1959.</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>72.</b> </td><td class="clsTextSmall">Trombly, C. A., Principles of operant conditioningrelated to orthotic training of quadriplegic patients, Amer. J. Occup. Ther., 20:217-220, 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>60.</b> </td><td class="clsTextSmall">Salisbury, L. L., and A. B. Colman, A mechanicalhand with automatic proportional control of prehension, Technical Report 6611, Army Medical Biomechanical Research Laboratory, Walter Reed Army Medical Center, May 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>68.</b> </td><td class="clsTextSmall">Stanford Research Institute, Experiments in tactualperception, Technical Report AFAL-TR-65-75r July 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Crochetiere, W. J., L. Vodovnik, and J. B. Reswick,Electrical stimulation of skeletal muscle: a study of muscle as an actuator, Med. and Biol. Eng., 5:111-125, 1967.</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Dimitrijevic, M. R., Use of physiological mechanismsin the electrical control of paralyzed extremities, International Symposium on External Control of Human Extremities, Dubrovnik, 1966.</td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Gracanin, F., and M. R. Dimitrijevic, Applicationof functional stimulation in rehabilitation of neurological patients, International Symposium on Rehabilitation in Neurology, Prague, September 1966.</td></tr><tr><td class="clsTextSmall"><b>39.</b> </td><td class="clsTextSmall">Kralj, A., L. Vodovnik, and M. Borovsak, Elec-tronic circuits used to obtain some functional movements by means of electrical stimulation, 2nd European Symposium on Medical Electronics, London, 1967.</td></tr><tr><td class="clsTextSmall"><b>42.</b> </td><td class="clsTextSmall">Long, C, and V. Masciarelli, An electrophysiologicsplint for the hand, Arch. Phys. Med. and Rehab., 44:499, 1963.</td></tr><tr><td class="clsTextSmall"><b>73.</b> </td><td class="clsTextSmall">Vodovnik, L., W. J. Crochetiere, and J. B. Reswick,Control of a skeletal joint by electrical stimulation of antagonists, Med. and Biol. Eng., 5:97-109,1967.</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>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Allen, J. R., A. Karchak, V. L. Nickel, and R.nelson, The Rancho electric arm, Proc. 3rd Annual Rocky Mountain Bioengineering Symposium, pp. 79-82, 1966.</td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Engen, T. J., Powered upper extremity orthoticdevelopment, Progress Report, Texas Institute for Rehabilitation and Research, September 1967.</td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Karchak, A., J. R. Allen, V. L. Nickel, and R.nelson, The electric hand splint, Orthop. and Prosth. Appliance J., pp. 135-136, June 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Grahn, E. C, Electrical actuators in prosthetics andorthotics, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 172-185, 1966.</td></tr><tr><td class="clsTextSmall"><b>57.</b> </td><td class="clsTextSmall">Pearson, J. R., Gas-power sources and actuators forprosthetic and orthotic devices, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 186-201, 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>References</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, R. H., and E. F. Murphy, Prostheticsresearch and the amputation surgeon, Artificial Limbs, pp. 4-46, September 1954.</td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Groth, H., and J. Lyman, A functional evaluationof several surgical techniques for establishing prosthetic control sites, Biotechnology Laboratory Technical Report No. 2, University of California (Los Angeles), June 1959.</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>27.</b> </td><td class="clsTextSmall">Inman, V. T., Human locomotion, Can. Med. Ass.., 94:1047-1054, 1966.</td></tr><tr><td class="clsTextSmall"><b>53.</b> </td><td class="clsTextSmall">Murphy, E. F., The swing phase of walking withabove-knee prosthesis, Bull, of Prosth. Research, Veterans Administration, BPR 10-1, pp. 5-39, Spring 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>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Allen, J. R., A. Karchak, V. L. Nickel, and R.nelson, The Rancho electric arm, Proc. 3rd Annual Rocky Mountain Bioengineering Symposium, pp. 79-82, 1966.</td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Engen, T. J., Powered upper extremity orthoticdevelopment, Progress Report, Texas Institute for Rehabilitation and Research, September 1967.</td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">Karchak, A., J. R. Allen, V. L. Nickel, and R.nelson, The electric hand splint, Orthop. and Prosth. Appliance J., pp. 135-136, June 1965.</td></tr><tr><td class="clsTextSmall"><b>32.</b> </td><td class="clsTextSmall">Kiessling, E. A., Carbon dioxide as a source of ex-ternal power for prosthetic devices, The application of external power in prosthetics and orthotics, National Academy of Sciences-National Research Council, Publication 874, pp. 79-87, 1961.</td></tr><tr><td class="clsTextSmall"><b>33.</b> </td><td class="clsTextSmall">Kiessling, E. A., Pneumatic prosthetic components:rigid servo mechanisms and their control valves, The application of external power in prosthetics and orthotics, National Academy of Sciences- National Research Council, Publication 874, pp. 116-131, 1961.</td></tr><tr><td class="clsTextSmall"><b>34.</b> </td><td class="clsTextSmall">Kinnier Wilson, A. B., Design of a motorized elbowsplint, Proc. Int. Symposium on the Application of Automatic Control in Prosthetic Design, pp. 6-9, Belgrade, 1962.</td></tr><tr><td class="clsTextSmall"><b>50.</b> </td><td class="clsTextSmall">Marquardt, E., Biomechanical control of pneumaticprostheses with special consideration of the sequential control, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 20-31, 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>References</b></td></tr><tr><td class="clsTextSmall"><b>47.</b> </td><td class="clsTextSmall">McGhee, R. B., Finite state control of quadrupedlocomotion, Report USCE 186, University of Southern California, December 1966.</td></tr><tr><td class="clsTextSmall"><b>71.</b> </td><td class="clsTextSmall">Tomovic, R., and R. B. McGhee, A finite stateapproach to the synthesis of bioengineering control-systems, IEEE Trans. Human Factors, HFE-7,. No. 2, June 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>14.</b> </td><td class="clsTextSmall">Corell, R., Research and development of the CaseResearch Arm Aid, Ph.D. thesis, Case Institute of Technology, 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>References</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">Freedy, A., and J. Lyman, An information theoryapproach to control of externally powered artificial arms, Paper read at combined meeting of Panel on Control of External Power and Panel on Upper-Extremity Orthotics, Subcommittee on Design and Development, Committee on Prosthetics Research and Development, New York, May 1967.</td></tr><tr><td class="clsTextSmall"><b>43.</b> </td><td class="clsTextSmall">Lucaccini, L., A. Freedy, and J. Lyman, Externallypowered upper extremity prosthetic systems: studies of sensory motor control, Dept. of Eng. Report 67-12, University of California (Los Angeles), March 1967.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>60.</b> </td><td class="clsTextSmall">Salisbury, L. L., and A. B. Colman, A mechanicalhand with automatic proportional control of prehension, Technical Report 6611, Army Medical Biomechanical Research Laboratory, Walter Reed Army Medical Center, May 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>44.</b> </td><td class="clsTextSmall">Lucaccini, L. F., P. K. Kaiser, and J. Lyman, TheFrench electric hand: some observations and conclusions, Bull, of Prosth. Research, Veterans Administration, BPR 10-6, pp. 30-51, Fall 1966.</td></tr><tr><td class="clsTextSmall"><b>46.</b> </td><td class="clsTextSmall">Lyman, J., Biotechnology Laboratory Progresseport No. 62-F, University of California (Los Angeles), December 1961.</td></tr><tr><td class="clsTextSmall"><b>58.</b> </td><td class="clsTextSmall">Rakic, M., An automatic hand prosthesis, Med.lectron. Biol. Eng., 2:47, 1964.</td></tr><tr><td class="clsTextSmall"><b>69.</b> </td><td class="clsTextSmall">Suzuki, R., An automatic hand prosthesis, Jap,lectron. Eng., 2(1):39-41, January 1965.</td></tr><tr><td class="clsTextSmall"><b>70.</b> </td><td class="clsTextSmall">Tomovic, R., and G. Boni, An adaptive artificialhand, IRE Trans. Auto. Control, pp. 3-10^ April 1962.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>48.</b> </td><td class="clsTextSmall">McLaurin, C. A., Control of externally poweredprosthetic and orthotic devices by musculoskeletal movement, The control of external power in upper-extremity rehabilitation, National Academy of Sciences-National Research Council, Publication 1352, pp. 10-19, 1966.</td></tr><tr><td class="clsTextSmall"><b>49.</b> </td><td class="clsTextSmall">McLaurin, C. A., On the use of electricity in upperextremity prostheses, J. Bone and Joint Surg., 47B: 448, 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Bennett, Robert L., The evolution of the GeorgiaWarm Springs Foundation feeder, Artificial Limbs, Spring 1966.</td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Kay, Hector W. Conclusions of a conference onlinkage feeders, Artificial Limbs, Spring 1966.</td></tr><tr><td class="clsTextSmall"><b>30.</b> </td><td class="clsTextSmall">Kay, Hector W., and Nancy V. Appoldt, Prelimi-nary design analysis of linkage feeders, Artificial Limbs, Spring 1966.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>75.</b> </td><td class="clsTextSmall">Vodovnik, L., et ah, Some topics on man-machinecommunication in orthotic and prosthetic systems, EDC Report 4-67-16, Case Institute of Technology, Cleveland, 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>25.</b> </td><td class="clsTextSmall">Hirsch, C, E. Kaiser, and I. Petersen, Telemetry ofmyopotentials, Acta Orthop. Scand., 37:156-165, 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>References</b></td></tr><tr><td class="clsTextSmall"><b>31.</b> </td><td class="clsTextSmall">Kestenback, H. J., A feasibility study of smallradioisotopic batteries for medical implants, Report SSG-67-32, Case Institute of Technology, 1967.</td></tr><tr><td class="clsTextSmall"><b>36.</b> </td><td class="clsTextSmall">Ko, W., Piezoelectric energy converter for electronicimplants, Proc. 19th Conference on Engineering in Medicine and Biology, San Francisco, p. 67, 1966.</td></tr><tr><td class="clsTextSmall"><b> 51.</b> </td><td class="clsTextSmall">Massie, H., Cardiac pacemaker without batteries, 18th Conference on Engineering in Medicine and Biology, Philadelphia, 1965.</td></tr><tr><td class="clsTextSmall"><b>52.</b> </td><td class="clsTextSmall">Mott, W. E., and L. Sagan, Bioengineering problemsof implantable radioisotopic powered heart devices, San Diego Biomedical Engineering Symposium, 1967.</td></tr><tr><td class="clsTextSmall"><b>59.</b> </td><td class="clsTextSmall">Reynolds, L. W., Utilization of bioelectricity aspower supply, Aerospace Med., February 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>75.</b> </td><td class="clsTextSmall">Vodovnik, L., et ah, Some topics on man-machinecommunication in orthotic and prosthetic systems, EDC Report 4-67-16, Case Institute of Technology, Cleveland, 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>65.</b> </td><td class="clsTextSmall">Selwyn, D., Head-mounted inertial servo control forhandicapped, 6th Annual Symposium of the Professional Group on Human Factors in Electronics, Boston, May 1965.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>54.</b> </td><td class="clsTextSmall">National Academy of Sciences-National Researchouncil, The application of external power in prosthetics and orthotics, Publication 874, 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>14.</b> </td><td class="clsTextSmall">Corell, R., Research and development of the CaseResearch Arm Aid, Ph.D. thesis, Case Institute of Technology, 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>67.</b> </td><td class="clsTextSmall">Spaco, Inc., The sight switch, Huntsville, Ala.,pril 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>56.</b> </td><td class="clsTextSmall">Olson, H. F., Speech processing systems, IEEEpectrum, pp. 90-102, February 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>16.</b> </td><td class="clsTextSmall">Dewan, E. M., Communication by electroencephalog-raphy, Special Report No. 12, Air Force Research Laboratory, Cambridge, Mass., 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>References</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Basmajian, J. V., M. Baeza, and C. Fabrigar,Conscious control and training of individual spinal motor neurons in normal human subjects, J. of New Drugs, 5(2):78-85, March-April 1965.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Close, J. R., E. D. Nickel, and F. N. Todd, Motorunit action potential counts, J. Bone and Joint Surg., 42-A(7): 1207-1222, October 1960.</td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Close, J. R., E. D. Nickel, and F. N. Todd, Singlemotor unit action potentials, Clinical Orthopaedics, 42:171-190, 1965.</td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Highland View Hospital, Ampersand report, Cleve-and, September 1966.</td></tr><tr><td class="clsTextSmall"><b>61.</b> </td><td class="clsTextSmall">Scott, R. N., A method for inserting wire electrodesfor electromyography, IEEE Transactions on Bio-Medical Engineering, BME-12(l):46-47, January 1965.</td></tr><tr><td class="clsTextSmall"><b>62.</b> </td><td class="clsTextSmall">Scott, R. N., Myo-electric control, Science J., pp. 2-8, March 1966.</td></tr><tr><td class="clsTextSmall"><b>63.</b> </td><td class="clsTextSmall">Scott, R. N., Myoelectric control of prostheses, Arch. Phys. Med. and Rehab., 47:174-181, March 1966.</td></tr><tr><td class="clsTextSmall"><b>64.</b> </td><td class="clsTextSmall">Scott, R. N., Myo-electric control systems, Reporto. 5, University of New Brunswick Bio-Engineering Institute, December 1965; No. 6, January 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>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Battye, C. K., A. Nightingale, and J. Whillis,The use of myoelectric currents in the operation of prosthesis, J. Bone and Joint Surg., 37B:506, 1955.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Bennett, Robert L., The evolution of the GeorgiaWarm Springs Foundation feeder, Artificial Limbs, Spring 1966.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Bottomley, A. H., Myoelectric control of poweredprostheses, J. Bone and Joint Surg., 47B:411-415, 1965.</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Bottomley, A. H., and T. K. Cowell, An artificialhand controlled by the nerves, New Scientist, pp. 668-671, March 12, 1964.</td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">Bottomley, A. H., A. B. Kinnier Wilson, and A.ightingale, Muscle substitutes and myoelectric control, J. Brit. Institution of Radio Engineers, 26(6), December 1963.</td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Brejdo, M. G., V. S. Gurfinkle, A. Ye. Kobrinskii,. A. Sysiu, M. L. Celtin, and A. S. Jakobson, O biolektricskoj sisteme upravlenija, Problemy kybernetiki, Gs. izd., fizikomatematiceskoj, literatury, Moscow, 1959.</td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Close, J. R., E. D. Nickel, and F. N. Todd, Motorunit action potential counts, J. Bone and Joint Surg., 42-A(7): 1207-1222, October 1960.</td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall">Dorcas, D. S., and R. N. Scott, A three-state myo-electric control, Med. and Biol. Eng., 4:367-370, Pergamon Press, 1966.</td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Horn, G. W., Muscle voltage moves artificial hand,lectronics, October 11, 1963.</td></tr><tr><td class="clsTextSmall"><b>38.</b> </td><td class="clsTextSmall">Kobrinskii, A. Ye., Bioelectric control of prostheticdevices, Herald of the Academy of Sciences, USSR, 30(7):58-61, July 1960.</td></tr><tr><td class="clsTextSmall"><b>40.</b> </td><td class="clsTextSmall">Litton Systems (Canada) Ltd., Research on myo-electric devices, D.I.R. Project No. E-74, DRB 9301-02, Toronto, 1967.</td></tr><tr><td class="clsTextSmall"><b>41.</b> </td><td class="clsTextSmall">Long, C, and B. Ebskov, Research applications ofmyoelectric control, presented at the 43rd Annual Session of the American Congress of Physical Medicine and Rehabilitation, 1965.</td></tr><tr><td class="clsTextSmall"><b> 66.</b> </td><td class="clsTextSmall">Sherman, E. D., A. L. Lippay, and G. Gingras,Prosthesis given new perspectives by external power, Hospital Management, pp. 44-49, November 1965.</td></tr><tr><td class="clsTextSmall"><b>76.</b> </td><td class="clsTextSmall">Waring, W., and V. L. Nickel, Powered braces withmyoelectric controls, Orthop. and Prosth. Appliance J., pp. 228-230, September 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>3.</b> </td><td class="clsTextSmall">Alter, R., Bioelectric control of prostheses, MITechnical Report 446, Cambridge, Mass., December 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Instructor in Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Mo. Data has estimated the numbers of patients in the United States with presented at combined meeting of the Panel on Control of External Power and the Panel on Upper-Extremity Orthotics of the Subcommittee on Design and Development, Committee on Prosthetics Research and Development, in New York, N.Y., May 15-17, 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>Lojze Vodovnik, D.Sc. </b></td></tr><tr><td class="clsTextSmall">Assistant Professor of Engineering, Engineering Design Center, Case Western Reserve University, University Circle, Cleveland, Ohio 44106, and Associate Professor of Electrical Engineering, University of Ljubljana, Yugoslavia.</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 B. Reswick, Sc.D. </b></td></tr><tr><td class="clsTextSmall">Leonard Case Professor of Engineering and Director of the Engineering Design Center, Case Western Reserve University, University Circle, Cleveland, Ohio 44106.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1967_02_005/aut67t-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1967_02_005/aut67-01.jpg Figure 3 http://www.oandplibrary.org/al/images/1967_02_005/aut67-02.jpg Figure 4 http://www.oandplibrary.org/al/images/1967_02_005/aut67-03.jpg Figure 5 http://www.oandplibrary.org/al/images/1967_02_005/aut67-04.jpg Figure 6 http://www.oandplibrary.org/al/images/1967_02_005/aut67-05.jpg Figure 7 http://www.oandplibrary.org/al/images/1967_02_005/aut67-06.jpg Figure 8 http://www.oandplibrary.org/al/images/1967_02_005/aut67-07.jpg Figure 9 http://www.oandplibrary.org/al/images/1967_02_005/aut67-08.jpg Figure 10 http://www.oandplibrary.org/al/images/1967_02_005/aut67-09.jpg Figure 11 http://www.oandplibrary.org/al/images/1967_02_005/aut67-10.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 External Power in Prosthetics and Orthotics, an Overview Creator An entity primarily responsible for making the resource James B. Reswick, Sc.D. * Lojze Vodovnik, D.Sc. * https://staging.drfop.org/files/original/aafea6cea49faeadc6dba48217d2ee06.pdf 1144c6f189f7e6d76ebed402cfb5d44c Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_01_017.pdf Text Any textual data included in the document <h2>Externally Powered Prostheses for Children: 1984</h2> <h5>Charles H. Epps, Jr., M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Not so many years ago children with upper limb deficiencies who appeared in our clinic with body powered prostheses asked for an arm like the one used by the six million dollar man. The television character routinely performed miraculous feats of strength and prehension that made the body powered prostheses look primitive by comparison. I was unable to satisfy such requests at that time. Now, at least for some patients, the long sought externally powered fitting is possible. The available arms do not approach that of the six million dollar man, but we have the means of fitting the below-elbow patient with a myoelectric prosthesis that is gratifying to patient and parents. In our own setting, two factors have converged to make this possible.</p> <p>First, the most important development in our clinic has been the affiliation of the local Variety Club, which established a Limb Bank. The concept is simple, the Variety Tent raises funds for myoelectric limbs, component parts and services. In some cases, the cost of the entire prosthesis is underwritten; in other situations Variety pays the balance not covered by insurance depending upon family finances. There are also components and spare parts available for repairs, courtesy of Variety. Such components keep the down time to a minimum and eliminate the need for two myoelectric prostheses. This arrangement developed between the Juvenile Amputee Clinic (Maternal and Child Health and Crippled Children's Services) at D.C. General Hospital and Washington, D.C.'s Variety Tent Number 11 is an example of how a public-private relationship can benefit the patient. Variety Tents are operational in Grand Rapids, Michigan; Memphis, Tennessee; Detroit, Michigan; Los Angeles, California; Toronto, Canada and other cities.</p> <p>Secondly, the technology has been available for a number of years, but we delayed because of the cost of myoelectric fittings and because the policies of many insurance carriers did not include such devices. It seemed undesirable to fit a child if one could not reasonably expect to continue with subsequent fittings and provide timely repairs. Sörbye in 1971 was among the first to apply myoelectrics to the young preschool amputee. His group operating in the government support health system in Sweden overcame these same problems by providing each patient with two prostheses. The second remained on the shelf as a back-up limb when the first needed repairs. In this manner, down time was eliminated and the child was not without the prosthesis.</p> <p>In the United States there has been a recent change in the policies of many third-party insurance carriers. Today, most will provide funds not only for the initial prosthesis but for replacements and necessary repairs, a not inconsequential cost. Some insurance companies pay total cost while others pay a fixed percentage.</p> <h3>External Power</h3> <p>Over the years, a number of battery powered switch operated devices have become available. The Michigan Feeding Arm was specifically designed to assistance in eating activities and was the first externally powered device developed in the United States for the pediatric age patient. In the early 1970's the Ontario Crippled Children's Center developed the OCCC Coordinated Arm. This was followed by the OCCC Elbow. Both were operated by switches and were designed for the 4-10 year age group. The Michigan Electric Hook (10x size) appeared in 1973 and was appropriate for the child approximately 2-10 years. Its successor, the Michigan Area Child Amputee Clinic Hook (MACAC) (10x size) was an improved version of the earlier hook designed for the same age group. In 1977 we saw the advent of a second elbow, the NYU Motor Lock Elbow, sized for a child six to a small teenager. This item remains experimental. To overcome the objectionable operational noise of the previous powered elbows, the NYU "Hush" Electric Elbow was developed in 1982. A versatile unit, it can be operated by push button or harness pull. Complimenting this armamentarium is the switch operated NYU Prehension Actuator (1982) which is applicable to any cable voluntary opening terminal device. More recently, the Utah Elbow was developed for the adult population but may be used with a child about age 12 years; it can be used with any terminal device and utilizes a dual site myoelectric system.</p> <h3>Myoelectric</h3> <p>The available myoelectric devices also offer a spectrum of choices. There is the University of New Brunswick System which is appropriate for ages 12 and up. This unit uses a surface electrode over one muscle. A small contraction is for closing and a strong contraction for opening. Relaxation of muscle contraction stops the hand at the current position. Sweden contributed the Systemteknik hand in two sizes; 2-6 years for the small child and 5-9 years for the larger child. The unit utilizes a single or double myoelectric electrode. The Steeper hand produced in England has the same size and age indication and similar choice of myoelectric controls. The German contribution is the Otto Bock System covering ages nine to adult with a dual myoelectric site system. These units are expensive but commercially available. The absence of a myoelectric unit developed in the United States is conspicuous.</p> <p>This array of devices presents a challenge to the physician prescribing external power for his patient. There are wide differences in the weight which may be crucial in the young patient with a short stump. However, all are heavy when compared to the body powered prostheses. The battery systems vary from 5 volt to 12 volt with varying useful life after charging. The prescription, therefore, is best written as a collaborative effort by the physician, the prosthetist, and the occupational therapist who has evaluated the patient and will provide the training.</p> <h3>Patient Benefit</h3> <p>After witnessing the satisfaction of the patient and parents after a successful fitting has been accomplished, there is no doubt that external power is preferred over body power in most instances. Function seems more natural when hand opening and closing are controlled by forearm extensor and flexor muscle activity. It is obvious that the psychological benefit of the cosmetic effect is profound on patient and parents alike. The dramatic change can be seen even with the initial application of the arm. External power and myoelectric applications are now state-of-the-art in below elbow cases and should be made available to all who have the interest and proper indications.</p> <h3>The Challenge</h3> <p>There is still much to be done for the amelia and the high above elbow amputee. Efforts must continue to bring the maximum degree of function to patients who are less well served at present. The numbers of patients in this category are small and there are not the normal incentives to manufacturers to expend funds for research and development in this area. The Federal Government may have to support the requisite research to accomplish the necessary break-through. It is ironic that the below elbow patient who enjoys reasonably good function with conventional prostheses would benefit most from the new technology. This is explicable when we realize that this level of limb deficiency makes the task easier. Although the numbers of high level deficiency patients by contrast is small, the need is great. We must continue to work for solutions for these patients who remain underserved at this time.</p> <em><b>*Charles H. Epps, Jr., M.D. </b> Charles H. Epp, Jr., M.D. is Professor and Chief at the Division of Orthopedic Surgery at Howard University Hospital, 2041 Georgia Avenue, N.W., Washington, D.C. 20060.<br /><br /><br /></em> Page Number(s) 17 - 18 Year 1985 Volume 9 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Externally Powered Prostheses for Children: 1984 Creator An entity primarily responsible for making the resource Charles H. Epps, Jr., M.D. * https://staging.drfop.org/files/original/51f5adc7b73ba20f64f5b1072208d97e.pdf 22b566ecc169422c3f86252d9a20be5e https://staging.drfop.org/files/original/3af9a5ff106766a98f790a31724a2a1f.jpg f6e27c5ae43c78cb08a394d78fa3b275 https://staging.drfop.org/files/original/2aff81bed2e3b007be1b8792137c5788.jpg 28e771b1094c0b1209ef81372fd82ce6 https://staging.drfop.org/files/original/41beee5399a82e0e40acfda675701aad.jpg f1003cc7f042f683207455f6a189e513 https://staging.drfop.org/files/original/90ef2a1233e04d701819d9715038383f.jpg 4d02c130bcdd0706cf18f7b6fc0dd0be https://staging.drfop.org/files/original/634d5ee7cc369045d31e39da291ee0d3.jpg d7e48a87b19caa8b90142027b54ae166 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/1978_01_001.pdf Text Any textual data included in the document <h2>Externally Powered Upper-Limb Prostheses</h2> <h5>A. Bennett Wilson, Jr.&nbsp;</h5> <p>The earliest reference to externally powered upper-limb prostheses seems to be in connection with experiments that took place in Germany about 1918 in which electromagnets were used to close the fingers of an artificial hand <a></a>. The next reported effort apparently is the research and development program proposed and carried out by Alderson <a></a> on electrically powered arm systems during 1946-1952 with support from International Business Machines, Inc. and the Veterans Administration.</p> <p>Initial results of the Alderson-IBM project (<b>Fig. 1</b>) were quite impressive with respect to operation, but an extensive evaluation at UCLA in 1951 revealed that a disproportionate amount of mental effort by the wearer was required for use of the various systems<a></a>. As a result of the findings of the UCLA study, and because only a limited amount of money was available for work in artificial limbs, the Advisory Committee on Artificial Limbs (later the Committee on Prosthetics Research and Development) of the National Academy of Sciences recommended that development of actuators be delayed until sufficient research could be carried out concerning the control problem so as to provide means for control of the prosthesis without conscious thought by the wearer.</p> <strong><a href="/files/original/3af9a5ff106766a98f790a31724a2a1f.jpg">Fig. 1</a>. An early model of the Alderson-IBM Electric Arm.</strong><br /> <p>A project was initiated at UCLA about 1953 to explore various control methods. Among the various studies conducted at UCLA was an evaluation of the so-called Vaduz hand (<b>Fig. 2</b>)<a></a>, a design that originated in Lichtenstein which used bulging of the residual muscles in a forearm stump to provide control of an electrically actuated artificial hand. Some rather positive findings were overshadowed by the poor quality of the one unit that was available at the time, and perhaps by the introduction by Russia in 1958 of a "thought control" electric arm<a></a>. The Russian device actually consisted of an electric hand controlled by myoelectric signals from the residual forearm agonists and antagonists of a below-elbow amputee.</p> <strong><a href="/files/original/2aff81bed2e3b007be1b8792137c5788.jpg">Fig. 2</a>. The "Valduz" hand and control system.</strong><br /> <p>The "Thalidomide tragedy"<a></a> in 1958-1962 prompted England and Canada to secure manufacturing rights to the Russian design, but fabrication and distribution was not successful in either country. The "Thalidomide tragedy" also encouraged work at the University of Heidelberg in the development of pneumatically powered artificial arm systems<a></a>, and an agreement was obtained by Kessler and Kiessling<a></a> for continuation of this work in the U.S. (<b>Fig. 3</b>). This project was carried out between 1960 and 1969. Again the problem of control was the primary reason for discontinuing the work.</p> <strong><a href="/files/original/41beee5399a82e0e40acfda675701aad.jpg">Fig. 3</a>. On the pneumatic above-elbow systems developed by Kiessting at the American Institute for Prosthetic Research.</strong><br /> <p>Because of the Thalidomide tragedy, Sweden<a></a> also launched a modest program in development of externally powered upper-limb prostheses about 1960. Work in this area has been carried out continuously since, but with no commercially available devices resulting, as far as is known at this time.</p> <p>The Russian design caused an Austrian group, Viennatone, and the Otto Bock Company in Germany to develop and market about 1962 similar devices. A few years later Hannes Schmidl began fitting externally powered artificial arms on a relatively large scale at the INAIL Center, Budrio, Italy and continues to do so to the present time<a></a>. Pneumatic models were used initially, but all designs used now are electric.</p> <p>Simpson<a></a>, at the Princess Margaret Rose Hospital, Edinburgh, Scotland uses routinely pneumatic prostheses for a group of "Thalidomide" children, but his design is not widely available elsewhere.</p> <p>In 1960 while on Sabbatical study at the University of Southern California Tomovic from the Institute Pupin, Belgrade, suggested the use of electromechanical pressure sensitive systems to aid in solution to the control problem by introducing closed-loop feedback systems<a></a>. A number of prototypes (<b>Fig. 4</b>) were designed and fabricated upon the return of Tomovic to Yugoslavia. Results of evaluation were also overshadowed by poor workmanship and engineering, and work on this was abandoned about 1968.</p> <strong><a href="/files/original/90ef2a1233e04d701819d9715038383f.jpg">Fig. 4.</a> The "Belgrade" hand and control system.</strong><br /> <p>McLaurin, while at Northwestern University, designed the so-called Michigan feeding arm about 1960 which used a linkage to coordinate motions about the elbow and the wrist to make it possible for young bilateral children amputees to feed themselves<a></a>. This device met with considerable success in the clinical setting, but never became a commercial success.</p> <p>McLaurin continued work in electrical arms for children at the Ontario Crippled Childrens Centre, Toronto, between 1963 and 1975. Although he was able to persuade the Variety Club to develop a facility for manufacturing, at cost, some of the products of research as a philanthropic endeavor, to date only an electric elbow has been made available, but because of the low volume the cost is extremely high in spite of subsidization.</p> <p>In the late sixties a number of efforts in the U.S. were directed toward the development of electric elbows. By 1969 three designs were considered ready for clinical evaluation, the "Boston" elbow developed by M.I.T. and Liberty Mutual Insurance Co., the AMBRL elbow, developed by the Army Medical Biomedical Research Laboratory, and a design by Rancho Los Amigos Hospital. The clinical evaluation program was organized and coordinated by CPRD in 1969-70<a></a>.</p> <p>Of 20 subjects in the study only 3 elected to retain the electric device. Two of these subjects had physical problems that made operation of the body powered prosthesis more difficult than would have been the case otherwise. Out of this experience came a revised set of design criteria and objectives.</p> <p>In addition to all of these efforts, research and development programs in externally powered artificial arms have been carried out in the U.S. at Temple University - Moss Rehabilitation Hospital <a></a>, Northwestern University (<b>Fig. 5</b>)<a></a>, Veterans Administration Prosthetic Center, Duke University, Rancho Los Amigos Hospital, University of California at Los Angeles, the University of Colorado, and Johns Hopkins University<a></a>.</p> <strong><a href="/files/original/634d5ee7cc369045d31e39da291ee0d3.jpg">Fig. 5</a>. The self-contained and self-suspended below-elbow system using myoelectric controls developed at Northwestern University.</strong><br /> <p>Sweden, Great Britain, Italy, Germany, Russia, and others have continued to support research and development in this field.</p> <p>Yet today it is very difficult to obtain an electric or pneumatic arm in the United States, other than the electrically operated hands that are suitable for below-elbow patients. We will be pleased to hear the opinions of readers of the NEWSLETTER concerning the reasons for this.<br /><br /><i>A. Bennett Wilson, Jr.</i><br />March 16, 1978</p> <p><b>References:</b></p> <ol> <li>Alderson, Samuel W., <i>The electric arm</i>, (Chapter 13 in Klop-steg and Wilson's "Human Limbs and Their Substitutes," McGraw-Hill, 1954, reprinted by Hafner Press, 1969).</li> <li>Battye, C.K., A. Nightingale, and J. Whillis, <i>"The use of myoelectric currents in the operation of prostheses,"</i> J. Bone Joint Surg., 37-B, 506, Aug. 1955.</li> <li>Berger, N., and CR. Huppert, <i>The use of electrical and mechanical muscular forces for the control of an electrical prosthesis</i>, Amer. J. Occup. Ther., 6:110-14, 1952.</li> <li>Childress, D.S., et al., <i>Myoelectric immediate postsurgical procedure: A concept for fitting the upper-extremity amputee</i>, Artif. Limbs, Vol. 13, No. 2, Autumn, 1969.</li> <li>Committee on Prosthetics Research and Development, <i>Externally powered prosthetic elbows - a clinical evaluation</i>, Report E-4 National Academy of Sciences, 1970.</li> <li>Committee on Prosthetics Research and Development, <i>The application of external power in prosthetics and orthotics</i>, National Academy of Sciences, Publication 874, 1961.</li> <li>Committee on Prosthetics Research and Development, <i>The control of external power in upper-extremity rehabilitation</i>, National Academy of Sciences, Publication 1352, 1966.</li> <li>Dankmeyer, Charles H., Sr., Charles H. Dankmeyer, Jr., and Martin P. Massey, <i>An externally powered modular system for upper-limb prosthesis</i>, Orth, and Pros., 26:3, Sept. 1972.</li> <li>Frantz, CH., <i>An evolution in the care of the child amputee</i>, Artif. Limbs, Vol. 10, No. 1, Spring 1966.</li> <li>Kadefors, R., et al., <i>Stryning av armprotes med myosignaler</i>, Electronic 3:42-49, 1967.</li> <li>Kessler, H.H., and Kiessling, E.A., <i>Pneumatic arm prosthesis</i>, Am J. Nursing, 65:6: June 1965</li> <li>Kobrinski, A.E., Bolkhovit-in, S.V., Voskoboinikova, L.M., Ioffe, D.M., Polyan, E.P., Popov, B.P., Slavutski, Y.L., Sysin, A.Y., and Yakobson, Y.S.: <i>Problems of bioelectric control in automatic and remote control</i>. Proceedings of the First International Congress of the International Federation of Automatic Control, Moscow, 1960, London, Butterworth &amp; Co. (Publishers) Ltd., 1961, Vol. 2, p. 619.</li> <li>Marquardt, E., <i>Heidelberg pneumatic arm prosthesis</i>, J. Bone and Joint Surgery, 47-B:3:425-434, August 1965.</li> <li>Rakic, M., Practical design of a hand prosthesis with sensory elements, Proceedings of the Interna-, tional Symposium of the Application of Automatic Control in Prosthetics Design, 103-119, August 27-31, 1962, Belgrade, Yugoslavia.</li> <li>Reiter, R., <i>Eine neue electro-kuntshand</i>, Grenzgeb. Med., 4, 133, 1948.</li> <li>Schlesinger, G., <i>Der Mechanische aufbau der kunst-chanische aufbau der kunstlichen glieder</i>, in Ersatzglieder und Arbeitshilfen, Borchartd, M., et al., Eds., J. Springer, Berlin, 1919.</li> <li>Schmeisser, Gerhard, Wood-row Seamone, and C. Howard Hoshall, <i>Early clinical experience with the Johns Hopkins externally powered modular system for upper-limb prostheses</i>, Orth, and Pros. 26:3, Sept. 1972.</li> <li>Schmidl, Hannes, <i>The I.N.A.I.L. experience fitting upper-limb dysmelia patients with myoelectric control</i>, Bull Pros. Res. 10-27, Spring 1977.</li> <li>Scott, R.N., <i>Myo-electric control</i>, Science J., 2-7, March 1966.</li> <li>Simpson, D.C., <i>An experimental design for a powered prosthesis for children</i>, Health, Scottish Home and Health Department Bulletin, 22:4:75-78, October 1964.</li> <li>Tomovic, R., and G. Boni, <i>An adaptive artificial hand</i>, IRE Transactions on Automatic Control, 3-10, April 1962.</li> <li>Wirta, R.W., Taylor, D.R., and Finley, F.R., <i>Engineering principles in the control of external power by myoelectric signals</i>. Archives of Physical Medicine, 49:294-296, 1968.</li> </ol> Page Number(s) 1 - 4 Year 1978 Volume 2 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1978_01_001/1978_01_001-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1978_01_001/1978_01_001-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1978_01_001/1978_01_001-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1978_01_001/1978_01_001-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1978_01_001/1978_01_001-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Externally Powered Upper-Limb Prostheses Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr.  https://staging.drfop.org/files/original/6f7e3f82472638ae5c7d6a8fe6502b0c.pdf aafc0735d891c3ca5b70c59e5b9e4dca https://staging.drfop.org/files/original/c8b4856c8000a6349f542a3fc1d9792b.jpg 155701ed19ed5a4cc064357783299d6f https://staging.drfop.org/files/original/f42bc1634981d3ce3923261609c448f0.jpg 86bbb24b5c5ea6d276b246de92acb3e4 https://staging.drfop.org/files/original/9e3ce64e754060714e02f7e869bb56c1.jpg bcc33ceb1a17e7d1665e8600710bf8c7 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/1978_03_001.pdf Text Any textual data included in the document <h2>Externally-Powered Upper-Limb Prostheses: An American Dilemma</h2> <h5>Charles H. Epps, Jr., M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The discussion by A. Bennett Wilson, Jr., in Vol, 2, of the Prosthetic and Orthotic Clinic Newsletter is an excellent historical summary of the saga of externally powered upper-limb prostheses. Ben Wilson has brought to this forum an abundance of personal knowledge about the development of these devices that can only be known by one who has been intimately involved with the problem. I think it also raises the question, when one considers the present state of the art and the availability of American made components why more could not have been done and is not being done.</p> <p>As one who has been intimately involved in the treatment of patients with upper-limb deficiency for the past 17 years, I have experienced the frustrations that are unique to this area of medical delivery. In the Juvenile Amputee Clinic at the D,C. General Hospital, in Washington, D.C., we have cared for almost 300 children with one or more limb deficiencies, I remember, vividly, when I first began this work in 1961, telling parents that in five years we should have available for the child (bilateral upper amelia), a good set of externally powered arms. Much to my chagrin, five years later we were unable to deliver this needed service to a degree that satisfied the patient or the Clinic Team. After 17 years, there are still unfulfilled expectations.</p> <p><b><a href="/files/original/c8b4856c8000a6349f542a3fc1d9792b.jpg">Fig. 1.</a> This male was born with bilateral upper amelia and lower complete phocomelia. After acquisition of sitting balance, he was fitted with a shoulder disarticulation type prosthesis with nudge control for elbow lock and unlock and with terminal device and forearm lift control by chest expansion. At age five, a Michigan Feeder Arm was applied, and his feeding time and ease of eating were enhanced.</b></p> <p>One then has to ask the question, why has there not been greater progress in the United States? Research money has been available, to a limited extent and powered arms have been developed. These events have been developed historically by Ben and will not be reported in any depth here. I would mention the Michigan Feeder Arm, which was a very useful arm for the purpose of eating, in the young age group. Once the child became older, there was no model available. The Michigan Electric Hook was developed out of a similar need and can be purchased commercially today. We are using, at the present time, a number of these in our clinic. The Coordinated Arm, developed at the Ontario Crippled Children's Center, and which succeeded the feeding arm, can be purchased from a Variety Village in Toronto, Canada, but the problem is that this unit is suitable only for the younger child. There is literally nothing as good as the Coordinated Arm available for the older child or adult.</p> <p><b><a href="/files/original/f42bc1634981d3ce3923261609c448f0.jpg">Fig. 2.</a> A fourteen-year-old with partial transverse hemimelia fitted with a Otto Bock Myoelectric hand that is available in a kit as shown. The battery pack can be attached to the belt. The shirt covers the wire and the socket resulting in excellent cosmesis.</b></p> <p>Another approach we have utilized is the combination of the OCCC electric elbow with the Michigan electric hook, in what we have termed a "Hybrid" prosthesis. Today, our experience has been satisfactory, as we are able to combine both units to operate with a single electrical system, supplied by one battery. Even under these circumstances, it is very difficult to import the electric elbows from Canada. The cost is not inconsequential, when one considers that the purchase of both items will be close to $1,000 and then one has to consider the cost of fabrication.</p> <p>The net result is that unless one is extremely zealous, it is not possible to supply children with severe limb deficiencies with externally powered devices. When they are supplied, there are mechanical problems, electrical problems, and frequent repairs are necessary. The "down time" is considerable. For this reason, many clinicians and patients have been discouraged and have abandoned use of these devices.</p> <p><b><a href="/files/original/9e3ce64e754060714e02f7e869bb56c1.jpg">Fig. 3</a>. This youngster with right upper phocomelia and left amelia was given an opposition post early. A standard left shoulder-disarticulation prosthesis provided little function. A hybrid system utilizing an OCCC electric elbow and a Michigan Electric Hook, provides greater function. Both units are powered by one battery pack.</b></p> <p>It is ironic that the greatest development has been made for the patient with the below elbow deficiency. The Otto Bock System is available in a number of sizes and provides excellent cosmesis and function. Our experience has been satisfactory with this device. The cost, however, is considerable and this may be one reason that this prosthesis has not been applied extensively in this Country, in spite of the fact that there are large numbers of children with below-elbow level deficiencies. It is also a fact that below-elbow patients function quite well with body powered equipment. In either case, American industry has not been at the forefront. The majority of commercially available devices today have been developed in Europe or Canada.</p> <p>I recently had the opportunity to visit Doctor Rolf Sorbye, in Orebro Sweden, who in collaboration with Systemteknik has developed an excellent below-elbow self-contained self-suspended prosthesis, using myeoelectric control. This device has been fitted to a number of children as young as 18 months and the results are extremely promising. Two prostheses are fabricated for each patient so that there is no "down time" when one prosthesis becomes inoperative and needs bench repairs. The cost per patient therefore, is approximately $6,000 for the pair of arms. There is under development, at the present time, in Sweden, another multi-functional hand (also for the below-elbow level), which will provide powered function for grasp, release, dorsi- and palmar flexion of the wrist, and supination and pronation of the forearm. The project is funded by a joint effort on the part of the Swedish Government and private industry. It is unfortunate that we have not been able to have a similar effort in this Country. Dr. Dudley Childress, at Northwestern University has developed an excellent self-contained, self-suspended below-elbow system, using myeoelectric control. The fact of the matter is that this and similar devices, developed in this Country, have not found a manufacturing outlet for disbursement. It is, therefore, a financial matter that in the face of limited demand the manufacturers cannot produce these items at a cost that will make it profitable. It seems to me, therefore, that this is an area, where the Government should intervene and subsidize this effort. There are numerous precedents throughout industry in this regard. The railroads, the airlines, and the shipbuilders have been subsidized. The renal dialysis program is one health area where Government is presently providing a subsidy. The precedent is there. There also needs to be an effective lobbying effort mounted, not only by the profession, but by the affected individuals, that is, patients and their parents. I believe that this is the essence of the problem. The technical "know how" is available but what is lacking is sufficient funding to make these devices in sufficient numbers so that they can become available to patients. It is fortunate that there are not a large number of patients. Ironically, were there large numbers of patients and a large demand, then the cost, of course, would be reduced. In the absence of this unfavorable manufacturing circumstance, subsidies must be given to industry so that the necessary devices can be produced and made available at reasonable cost.</p> <p>Another aspect of the problem, which is paradoxical, is that there has been so much effort put into the below-elbow level, where the need, as I see it, is not nearly as great as it is in the above-elbow and the shoulder-disarticulation levels. The patients with more proximal limb deficiencies are greatly in need of externally powered devices. Yet the powered devices that are available for the proximal cases, are not the most efficient. The available commercial items, even at great cost, are not representative of the best technology available in this country, today. This can be partially explained by the fact that the numbers of patients affected at the higher level are substantially less than those at the below-elbow level. It is also natural to work on problems where success is more readily obtained. The challenge is there at the shoulder-disarticulation level and the above-elbow level, where these patients desperately need more function. There is need in this country for a concerted effort to develop and provide powered arms for patients with the more proximal limb deficiencies. It is a blight on our record as a nation, with such sophisticated technology and industrial and productive capacity, that this area of human need has been so long unfulfilled.</p> <h5><b>Charles H. Epps, Jr., M.D.<br />Professor and Chief, Division of Orthopaedic Surgery, Howard University, Washington, D.C.</b></h5> Page Number(s) 1 - 3 Year 1978 Volume 2 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1978_03_001/1978_03_001-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1978_03_001/1978_03_001-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1978_03_001/1978_03_001-3.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 Externally-Powered Upper-Limb Prostheses: An American Dilemma Creator An entity primarily responsible for making the resource Charles H. Epps, Jr., M.D. * 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. Hittenberger, CP * https://staging.drfop.org/files/original/24569bdd864815d62f5dd7408a6f94ed.png 4908fc7001411690e1901bcbf63d7785 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 FAMC Badge https://staging.drfop.org/files/original/61a2fb11b7da32710eee905515de8f06.jpg c2347a862234afea56e70c8f32f049be 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 FAMC Historic Photo https://staging.drfop.org/files/original/eb7af921f4b32f8e97132e548f88898b.pdf b3171ca328eee50b5195df04b2d0c788 https://staging.drfop.org/files/original/8b668143ca8ff4ec00d38bdaca0e8295.jpeg 8099103e73990942586441d921a16c1c https://staging.drfop.org/files/original/3bb0ef66a8d97b487e2406e04dfe528a.jpg 657f28db4b18efbba8fdf19ced12aefc https://staging.drfop.org/files/original/c874cf9cf5f6cd93cbfd7caefebfdb17.jpg 3a422d3bde70187bd6eacbad0b5b61bd https://staging.drfop.org/files/original/8ae5ce0e382f544320be566569a2f206.jpg e3914b13228afa24f44648b12154099a Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1981_03_007.pdf Text Any textual data included in the document <h2>Feedback For Electrically Powered Prostheses And Orthoses</h2> <h5>Warren Frisina, B.E. (in M.E.)&nbsp;<a style="text-decoration: none;">*</a><br />James A. Reeve, B.S. (in E.E.)&nbsp;<a style="text-decoration: none;">*</a></h5> <p style="font-size: 60%;"><i>All rights reserved © Warren Frisina 1981</i></p> <p><i>This research was supported by the National Institute of Handicapped Research under the designation of New York University Medical Center as a Research and Training Center.</i></p> <p>Basically, pressure feedback systems for upper limb electrically powered prostheses consist of sensors about the prehensile area, electronic processing circuits, and actuators that contact the body. Sensors require careful installation and tend to be vulnerable to damage. Processing circuits leave that much more delicate equipment to coordinate. Actuators sometimes unduly complicate construction and fitting.</p> <p>The system to be described here makes use of the characteristic current response of an electric motor encountering a load—current increases in proportion to the load. This response is directly employed as the combined feedback/actuating signal. It is sent to a miniature direct current electric motor⁴ (<a href="/files/original/8b668143ca8ff4ec00d38bdaca0e8295.jpeg"><b>Fig. 1</b></a>). The top of <b>Fig. 1</b> shows three Micromo motors and the bottom of the figure, the assembled unit. On the shaft of the motor an eccentric mass is mounted. (Several such masses are shown on the right of <b>Fig. 1</b>). This causes the motor to vibrate in proportion to the motor speed (motor speed is proportional to current). When this motor is rigidly mounted to virtually any portion of a prosthesis, the entire prosthesis will vibrate in turn (<a href="/files/original/3bb0ef66a8d97b487e2406e04dfe528a.jpg"><b>Fig. 2</b></a>). Thus, the entire surface of the skin in contact with the prosthesis receives feedback information. The units installed thus far in patients' below-elbow myoelectric prostheses have been fixed at the distal end of the socket with a hose clamp which has been laminated to the socket (<a href="/files/original/c874cf9cf5f6cd93cbfd7caefebfdb17.jpg"><b>Fig. 3</b></a>).</p> <p>The feedback motor can be installed in virtually any electrically powered prosthesis by putting it in series with the drive motor(s). So that most of the current flows to the drive motor(s) and to avoid overloading the small feedback motor, a resistor of approximately three ohms is placed in parallel with the feedback motor. In order to fine tune the system, it would be convenient to have this resistor be of the variable type.</p> <p>This system has been applied to myoelectric prostheses for seven patients at the Institute of Rehabilitation Medicine, New York University Medical Center. It is being applied explicitly for force feedback. But it appears to serve for position feedback as well, since the prosthetic hand unit and glove offer resistance to the drive motor as the hand opens, i.e., the greater the opening, the higher the vibration frequency. The hardness or, more importantly, brittleness, of objects could also possibly be determined by the sensing of rate of change of vibrations, i.e., vibration rate of change for a hard object like an egg is greater than that for a soft object like a paper cup. There have been no controlled studies as yet to verify these possible benefits.</p> <p>A variation of the principle has been applied in the laboratory to an electric arm orthosis tried by a C-4 lesion quadruplegic patient. The feedback motor is either clipped to the user's lapel (<a href="/files/original/8ae5ce0e382f544320be566569a2f206.jpg"><b>Fig. 4</b></a>) or to the back of his wheelchair.</p> <p>Another orthotic variation of the principle was tried in the laboratory by replacing the feedback motor with a flashlight-type light bulb to provide proportional visual feedback. Brightness of the bulb is proportional to pressure at the desensitized finger tips when used with an electrically-driven prehension orthosis.</p> <em><b>*James A. Reeve, B.S. (in E.E.) </b> Project Engineer, Orthotics &amp;Prosthetics, IRM, NYU Medical Center.</em><br /><br /><em><b>*Warren Frisina, B.E. (in M.E.) </b> Formerly Associate Research Scientist, Orthotics &amp;Prosthetics, Institute of Rehabilitation Medicine, NYU Medical Center</em><br /> <div style="width: 400px;"><br /><br /></div> Page Number(s) 7 - 8 Year 1981 Volume 5 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1981_03_007/1981_03_007-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1981_03_007/1981_03_007-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1981_03_007/1981_03_007-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 4 http://www.oandplibrary.org/cpo/images/1981_03_007/1981_03_007-4.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Feedback For Electrically Powered Prostheses And Orthoses Creator An entity primarily responsible for making the resource Warren Frisina, B.E. (in M.E.) * James A. Reeve, B.S. (in E.E.) * https://staging.drfop.org/files/original/4a1d647a65001ac401d87d1ff0a502dc.pdf be21d355bbb7726b48257560f38ffcc1 https://staging.drfop.org/files/original/ade75bbe682d095fafd8dc98e0bdeebc.jpg cb33bea6982578ca9f1ac897d024b8aa https://staging.drfop.org/files/original/f53916b68ed1a9091e5b7dfd3280019f.jpg e427877188e0e0d0e8f2b3055d5f8df4 https://staging.drfop.org/files/original/1dd8550b2936a7b9cdcc9b23c89e287c.jpg 04f2643b57c264bf37196de0ec256397 https://staging.drfop.org/files/original/e6dab0edff7c7c4249c3192ca924704f.jpg c979896054406fa7bbaa56c9b9bb2d45 https://staging.drfop.org/files/original/3e28fdce00199c50876c4dea728fcd3d.jpg 5fdcfa70023ebdf6bbe368c413721e11 https://staging.drfop.org/files/original/f43c68108152e6a1e1c805a301451b93.jpg 0d3fa2972071447fad21b77828e0dde6 https://staging.drfop.org/files/original/c1607df85b443b92c33b9062283f89f9.jpg ed20251e138d78199b81805f9b773f8e https://staging.drfop.org/files/original/7c2db4f48c70105bc7bf7a49a36f693d.jpg 69d9387960fd1c5c46cf6fd1945e043b https://staging.drfop.org/files/original/a1504fa035cb6baf568bc21f4e6032ae.jpg d2ee96370904fedccfdd586158fc8106 https://staging.drfop.org/files/original/a75b7b94908e32a9a415c6af0859c4d1.jpg 4777a991370a82177c1ba45d1885294f https://staging.drfop.org/files/original/5137c3276e634e3a7a07c361d89615f6.jpg fba588d37b02c32d343d6047401bbf78 https://staging.drfop.org/files/original/2b8e10f3ccd57901d0685024fa54fe16.jpg 4993250f15bf97bab4d79615df1bcda1 https://staging.drfop.org/files/original/0de013a315001679feaee2a5fb2512ec.jpg f62d2caa4a29bf71c555be9f20eeb071 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1966_02_027.pdf Year 1966 Volume 10 Issue 2 Page Number(s) 27 - 38 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/1966_02_027.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1966_02_027.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>Fitting and Training Children with Swivel Walkers</h2> <h5>W. M. Motloch <a style="text-decoration:none;">*</a><br />Jane Elliott <a style="text-decoration:none;">*</a><br /></h5> <p><i>Mobility can be provided fairly successfully for the bilateral hip-disarticulation patient when his arms can be used in connection with crutches and canes, but when the patient cannot use crutches a most difficult problem is presented to the clinic team. The most effective means of treating patients who have complete or essentially complete absence of all four limbs has been to provide them with a socket encasing the pelvic region mounted on a three- or four-wheeled platform (<b>Fig. i</b>), or to provide them with motorized carts with special controls. The unpowered vehicles permit the patient to be upright but generally they must be moved from place to place by an attendant, and the motorized carts are expensive.</i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. i. Three-wheeled cart built by Child Amputee Prosthetics Project, University of California, Los Angeles, for patient with congenital bilateral above-elbow amputations and bilateral lower-extremity amelias. From Blakeslee, Berton, The Limb-Deficient Child. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Experiments at the Child Amputee Prosthetics Project, University of California, Los Angeles, with pylons mounted on rockers, and hinged at a point anterior to the anatomical hip joint, proved to be very disappointing mainly because the effort required in their use exceeded the functional gain (<b>Fig. ii</b>) <a></a>.</i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. ii. Same child who appears in Figure i shown on pylons mounted on rockers and hinged at a point anterior to the anatomical hip joint. Although the child learned to ambulate with this device, her progress was slow and the energy expenditure extremely high. From Blakeslee, Berton, The Limb-Deficient Child. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>To overcome some of the deficiencies presented by previous approaches, Richard E. Spielrein, <a></a> Senior Engineer, Repatriation Department, Commonwealth of Australia, suggested a pylon arrangement to capitalize on side-to-side oscillations of the man-machine combination (<b>Fig. iii</b>) and built a prototype, based on mathematical computations, which was used successfully by a 16-year-old girl.</i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. iii. Swivel walker developed by Richard E. Spielrein, Senior Engineer, Repatriation Department, Commonwealth of Australia. From Spielrein, R. E., A Simple Walking Aid for Legless People. <a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>The Ontario Crippled Children's Centre, Toronto, Canada, has successfully utilized the principles set forth by Spielrein and presents herewith instructions for fabrication and use of the so-called swivel walker (<b>Fig. iv</b>).</i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. iv. Swivel walker developed by the Ontario Crippled Children's Centre, Toronto, Canada. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>Experience has been limited to young children, but the walker should prove successful with older persons. It has been suggested that the principle of the swivel walker might also be applied in the case of paraplegia.</i></p> <p><i>A. Bennett Wilson, Jr.</i><a style="text-decoration:none;">*</a></p> <p>The swivel walker in its simplest form (<b>Fig. 1</b>) consists of two pylons attached in a vertical position to a pelvic socket, and two foot pieces which are attached to the pylons so that each may rotate about the vertical axis of the appropriate pylon. Stops are provided to limit rotation of the feet in each direction, and a spring returns the feet to a neutral position when no force is applied.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Principle of the swivel walker. The child can transfer his weight to one foot by leaning sideways and then swivel forward about this foot, using only the force of gravity. Stops are provided to limit forward or backward swing, with springs returning the foot to the neutral position when it has been returned to the floor. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The soles of the feet are canted in relation to the floor, and the pylons are positioned with their center lines falling posterior to the center of gravity of the patient and prosthesis so that tilting of the body on one side will cause rotation of the socket about the long axis of the pylon on the tilting side. The contralateral pylon is raised initially and swings forward due to gravity until it strikes the floor ahead. Backward motion can be obtained by tilting sideways and leaning backward so that the center of gravity falls posterior to the center lines of the pylons. Of course, to manipulate the swivel walker, the patient must have a mobile trunk.</p> <p>The type of walker suggested for initial use is shown in <b>Fig. 2</b>. Later, a more cosmetic device can be used.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. Basic dimensions of the swivel walker. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The socket is essentially the same as that for a conventional bilateral hip-disarticulation prosthesis <a></a> and is mounted on a platform which, in turn, is mounted on two aluminum tubes. In the bottom end of each pylon is mounted an ankle joint, or rotation unit, which in turn is attached to a foot piece mounted so that the inner edge rests on the floor when the appliance is at rest (<b>Fig. 2</b>). The foot pieces should have rubber soles to prevent slipping.</p> <h3>Measurements</h3> <ul> <li>Measurements that need to be recorded (<b>Fig. 3</b>) are:</li> <li>Crown-rump length Waist width</li> <li>Crest of ilium to ischial tuberosities</li> <li>Distance between ischial tuberosities</li> <li>Maximum distance across pelvis</li> </ul> <p>The "normal" height of the child with pylons on can be estimated by multiplying the crown-rump length by two or a little less.</p> <h3>Taking the Cast</h3> <p>Taking the cast usually requires the services of two people. A length of large-diameter stockinette is sewn closed at one end, with openings for existing limbs if present. Straps or webbing are used to suspend the stockinette from an overhead hook. This arrangement ensures firm contours and supports the child. The lower trunk, excluding the limbs, is then wrapped with plaster bandages up to the rib cage.</p> <p>If the child is not toilet trained, the cast is made over the diapers. If diapers are not worn, the ischial tuberosity, pubic tubercle, crests and anterior spine of the ilium, and the rib cage are marked as shown in <b>Fig. 4</b>. For use in alignment, vertical lines indicating the lateral and sagittal planes are drawn on the cast before it is removed from the patient.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. Modifications of cast. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Fabrication</h3> <h4>Socket</h4> <p>The original socket is usually made so that it extends a little higher than the waist, both front and back, for early training. As ability to balance improves and proficiency increases, the height can be reduced to approximately waist level. It is important that forward, backward, and side-to-side motions of the torso are not restricted.</p> <p>The original socket fabricated for testing the first model of the swivel walker was heat-formed out of acrylic sheet, but all later models have been of polyester laminate. Two complete layers of Dacron felt, two partial layers of Dacron felt, and two partial layers of glass cloth are used, as shown in <b>Fig. 5</b>. The lay-up is completed with four layers of nylon stockinette before impregnation with a mixture of 70 per cent rigid and 30 per cent flexible polyester resin. The laminate should be formed under a vacuum in order to prevent unnecessary bulk.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Recommended socket configuration. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>After curing and removal from the plaster cast, the socket is trimmed approximately as shown in <b>Fig. 5</b> and all edges are rounded and smoothed. Ease of entry and exit is facilitated by an anterior hinge.</p> <p>A plastic hinge with the trade name of Polyhinge is satisfactory and may be fastened with flat-head wood screws. Either polyester or epoxy paste can be applied to the screw heads to prevent corrosion if necessary.</p> <p>Wooden blocks are screwed to the base of the socket to provide a level surface for mounting the socket on top of the pylon walker.</p> <p>The pylons are aluminum tubing, 2-in. outside diameter, 1/16-in. wall thickness. The top ends are fitted with wooden plugs; the bottom ends are fitted over the ankle joints.</p> <p>The dimensions of the pylon and its placement are based on the "normal" height of the child and are indicated in <b>Fig. 3</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. Measurements required for fabrication of the swivel walker. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>An adequate method for fastening the pylons is to slit the ends and use hose clamps (<b>Fig. 6</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. Assembly of the swivel walker. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Ankle Joint</h4> <p>The ankle joint (<b>Fig. 7</b>), mounted between the pylon and the foot piece, permits rotation of the foot piece about a vertical axis to allow forward and backward swing. As can be seen in <b>Fig. 7</b>, the foot piece is returned to a neutral position by a spring-loaded roller. Built-in stops restrict rotation to approximately 39 deg. forward and 11 deg. backward. (It is planned that a simpler, less expensive version of the ankle joint will be available commercially in the near future.)</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The ankle unit. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Foot Pieces</h4> <p>The foot piece (<b>Fig. 2</b> and <b>Fig. 6</b>) consists of a block of wood, a platform sole, and a rubber undersole. The rubber is glued to the wooden platform, which is fastened to the block of wood with glue and screws. The block is bored to receive the lower part of the ankle unit, which is held in place with epoxy resin or paste.</p> <h3>Alignment</h3> <p>The main considerations in alignment are (<b>Fig. 2</b>):</p> <ul> <li>The center lines of the ankle joints should fall approximately 1 1/2 in. behind the center of gravity of the child's body.</li> <li>When the walker is at rest, the pylons should be vertical.</li> <li>The foot platform should tilt about 6 deg. and rest on the medial edge.</li> <li>When viewed from above, the foot pieces are rotated out about 10 deg. (This adjustment is made by reaching down inside the pylon with an extension wrench and slackening off the bolt. This releases a tapered shaft, enabling the foot piece and lower ankle housing to be rotated to the desired position.)</li> </ul> <h3>The Cosmetic Swivel Walker</h3> <p>To improve appearance and to permit the patient to assume a sitting position, the pylons can be replaced with articulated limbs (<b>Fig. 8</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Swivel walker equipped with articulated limbs to permit sitting, and fabricated to improve cosmesis. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The knee joints and hip joints are those used in a Canadian-type hip-disarticulation prosthesis, and they are aligned in a similar manner. For purposes of stability, the hip joints are placed well forward and the knee joints well back. It is imperative that the alignment between the socket and the foot pieces be identical to that used with the pylon type.</p> <p>The lateral straps are 1-in. elastic webbing installed with sufficient tension to prevent hip or knee flexion when the limb is lifted clear of the floor. Each strap is attached to the socket and to the lower limb in such a manner that in the standing position the direction of pull is behind the hip joint and in front of the knee joint. In the sitting position, the straps pass in front of the hip joint and behind the knee joint.</p> <p>The foot is carved from solid wood, bored out to receive the lower housing of the ankle joint. Foot pieces, used for training, are at-</p> <p>tached by screws through the soles of the shoes into the wooden feet. When the child has progressed to a point where foot pieces can be removed, screws are used to secure the soles of the shoes to the wooden feet. The shoe soles should be flat, with the same 6 deg. tilt from the medial edge.</p> <p>The shank sections must be hollow so that a wrench may be inserted from the top to adjust the vertical shank bolt.</p> <h3>Training</h3> <p>It is recommended that training for young children be commenced by using a lateral rocker as shown in <b>Fig. 9</b> to enable the child to establish balance, to learn and practice the sideways rocking motion, and to establish a rhythm. When the child feels secure in this arrangement, he is transferred to the swivel walker with short pylons and encouraged to go through the same rocking motion. At this point it is necessary to demonstrate to the child the forward swing by placing the hands on the trunk and guiding the child through the side-to-side motion coupled with a forward tilt. This support is gradually decreased until the child can manage unaided.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Device for training patient to use the swivel walker. The lateral rocker enables the child to establish balance, to learn and practice the sideways rocking motion, and to establish a rhythm. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>As proficiency in the use of the swivel walker increases, the height of the pylons is raised in 1-in. increments until a "normal" height is attained. The rate of increase will vary according to the child's capability. Experience at the Ontario Crippled Children's Centre has been that the height can be increased one inch about every two days.</p> <p>At low heights body sway above the waist is required to operate the walker. As the height is increased, the child's movement alters to a lateral displacement of the hips such that the body moves sideways while remaining vertical.</p> <p>When patients become proficient in the use of the walker, they do not swing the walker to the limits of the stops.</p> <p>The ability to walk backward is attained with little more difficulty than walking forward, but smaller steps are generally used. One child was able to walk very well in either direction within a period of two weeks. Walking backward is important because it permits the child to back out of corners or similar situations.</p> <p>Great care must be taken with the child during training, since it is possible that a few falls will occur until his sense of balance is perfected. Falls from being pushed by other children are likely to be far greater in number than those resulting from overbalancing. It is recommended that some form of protective head covering (such as an ice hockey head guard) be worn during this stage of training.</p> <p>One child was fitted with the swivel walker shown in <b>Fig. 8</b> after she became proficient with the pylon type. Initially, the foot pieces were larger than the shoes. As proficiency developed, they were gradually trimmed in size and finally removed, leaving the shoes tilted at the same angle.</p> <p>With both types of walker it was found that the children averaged approximately 120 steps per minute, each step being approximately three inches when walking forward.</p> <p>Each child had to be treated individually according to his own temperament. One child was extremely nervous and frightened, and so training had to be carried on more slowly than with another child who accepted alterations readily.</p> <p>From experience gained so far, it is suggested that a child who is nervous and cautious be given a period of at least one week to become used to major adjustments and alignment changes.</p> <p><b>References:</b></p> <ol> <li>Biakeslee, Berton, ed., The limb-deficient child, Universitv of California (Berkeley and Los Angeles), 1963.</li> <li>McLaurin, Colin A., The evolution of the Canadian-type hip-disarticulation prosthesis, Artificial Limbs, Autumn 1957, pp. 22-28.</li> <li>Spielrein, R. E., A simple walking aid for legless people, Journal of the Institution of Engineers, Australia, 35(12): 321-326, December 1963.</li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">McLaurin, Colin A., The evolution of the Canadian-type hip-disarticulation prosthesis, Artificial Limbs, Autumn 1957, pp. 22-28.</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">Executive Director, Committee on Prosthetics Research and Development, National Academy of Sciences-National Research Council, 2101 Constitution Ave., Washington, D. C. 20418.</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">Spielrein, R. E., A simple walking aid for legless people, Journal of the Institution of Engineers, Australia, 35(12): 321-326, December 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Spielrein, R. E., A simple walking aid for legless people, Journal of the Institution of Engineers, Australia, 35(12): 321-326, December 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Biakeslee, Berton, ed., The limb-deficient child, Universitv of California (Berkeley and Los Angeles), 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Biakeslee, Berton, ed., The limb-deficient child, Universitv of California (Berkeley and Los Angeles), 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Biakeslee, Berton, ed., The limb-deficient child, Universitv of California (Berkeley and Los Angeles), 1963.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Jane Elliott </b></td></tr><tr><td class="clsTextSmall">Physiotherapist, Prosthetic Research and Training Unit, Ontario Crippled Children's Centre, 350 Rumsey Rd., Toronto 17, Canada.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>W. M. Motloch </b></td></tr><tr><td class="clsTextSmall">Prosthetist, Prosthetic Research and Training Unit, Ontario Crippled Children's Centre, 350 Rumsey Rd., Toronto 17, Canada.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-01.jpg Figure 2 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-02.jpg Figure 3 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-03.jpg Figure 4 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-04.jpg Figure 5 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-05.jpg Figure 6 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-06.jpg Figure 7 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-08.jpg Figure 8 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-09.jpg Figure 9 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-07.jpg Figure 10 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1966_02_027/aut66-3-13.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Fitting and Training Children with Swivel Walkers Creator An entity primarily responsible for making the resource W. M. Motloch * Jane Elliott * https://staging.drfop.org/files/original/901b570f7984e7d4389bd77bc8b49ab7.pdf 4dc89f03888f81781cc820b1c4281db2 https://staging.drfop.org/files/original/70079561438f68ead76f52fc65dd8527.jpg 9f295a4e4335c10beed8e204bd3902b4 https://staging.drfop.org/files/original/178ecd5991ed2ffe397316d0a4dd0546.jpg 843b4338dc78f6e9769246fa79846425 https://staging.drfop.org/files/original/2b7b51bf9cad86f7ce11a1660d52b387.jpg b0271f700b8d4901edf91d2082d01352 https://staging.drfop.org/files/original/ffaa35ca7b5ac23a6a947d2d3ad255f2.jpg 2fe8351da1a1e6155fb684e2e76de872 https://staging.drfop.org/files/original/f7c3b167230622c735630542cfdca207.jpg 3c649879a171c5ff0e0d93e99308eb76 https://staging.drfop.org/files/original/c4a610256e9b758a37d3623694e2271b.jpg 50f7124cde5cc7ce984f2315ba51fa73 https://staging.drfop.org/files/original/804efb442220a760c2ad6db87361ab61.jpg 373e078a4bb07aaf2eae6726bd391ff6 https://staging.drfop.org/files/original/1e7fab041130f301f034215e0e5b357d.jpg ecae0c1212323fe32a9a5b842bcf28b2 https://staging.drfop.org/files/original/ef3813f645bf9a4a4dd8188a6de82361.jpg 3a0b706d106a04ea3b6e27dcc9b84af6 https://staging.drfop.org/files/original/bb68eabedc0b65835c332efcf81f8201.jpg d34e1f0f082d9b6183dc2c8cee20fa2c https://staging.drfop.org/files/original/ccf65b3120d8051f16e304b8d2ef8f53.jpg 3ef8653b23290da3062586d399ca498b https://staging.drfop.org/files/original/1e94e8303e2979d8bbc043ee1a0e6ee8.jpg abc1ec3d3045264621578c7b7baf7e6e https://staging.drfop.org/files/original/b6daf9f8f83efde86777545189ff48f7.jpg dd96d853a981be0539a39293ad96b1d4 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_04_031.pdf Text Any textual data included in the document <h2>Flex-Frame Sockets in Upper Extremity Prosthetics</h2> <h5>Donald L. Fornuff, CP.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The development of various new plastic materials has brought about a rapid change in the design and fabrication of lower extremity prosthetic sockets. We can now expect most of these revolutionary developments to overflow into other areas of prosthetics and orthotics. The most natural area next to be influenced is upper limb prosthetics.</p> <p>We at Rusk Institute of Rehabilitation Medicine have been trying various socket frame configurations with all levels of upper limb amputees, from wrist disarticulations to above elbows, including the humeral neck amputation.</p> <p>The following is a brief "technical note" describing the technique we use for fabricating the flex-frame socket for the upper limb prosthesis and a sampling of various socket designs.</p> <h3>Below Elbow Socket</h3> <p>When the below elbow socket model has been modified and smoothed, a flexible socket is made by vacuum molding, using Surlyn or Ethalux polypropylene (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-01.jpg"><b>Fig. 1</b></a>). A thin socket is then laminated in the conventional fashion, over the flexible socket (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-02.jpg"><b>Fig. 2</b></a>). This socket will act as a frame for the flexible socket and will allow for the secure attachment of the forearm extension and wrist unit. Upon completion of the thin laminated socket, the P. V. A. sleeve is removed. The socket is then covered, using strips of 1" masking tape (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-03.jpg"><b>Fig. 3</b></a>).</p> <p>The forearm extension form, or mold, holding the wrist unit is mounted to the below elbow socket in the correct alignment, position, and length (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-04.jpg"><b>Fig. 4</b></a>). The wrist unit is taped over to prevent foam from clogging various screw holes. A hole is cut in the forearm extension piece just proximal to the wrist unit. Foam is poured into this hole to form the forearm extension piece. Additional foam may be required to ensure proper shaping of the forearm section. When shaping is completed, the wrist unit is heated slightly and removed. Vaseline® is applied to the remaining foam and socket, and a P.V.A. sleeve is pulled on and tied at both ends (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-05.jpg"><b>Fig. 5</b></a>). The wrist unit is replaced over the P.V.A. sleeve, held in place by the layers of material to be used in the second lamination. The material is tied off in the usual manner.</p> <p>When the forearm has been laminated, it should be completely removed from the below elbow socket and foam extension (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-06.jpg"><b>Fig. 6</b></a>). This removal is relatively easy because of the P.V.A. sleeve applied over the shaped foam forearm section. After the laminated forearm is removed, the foamed forearm section and tape are completely removed from the laminated socket.</p> <p>The laminated and vacuum molded flexible sockets are removed from the model (the model must be broken many times) and the laminated socket frame is cut to its desired shape to allow maximum flexibility of the flexible socket (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-07.jpg"><b>Fig. 7</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-08.jpg"><b>Fig. 8</b></a>).</p> <p>The frame socket is placed into the forearm section and trim lines are established. Both sections are then sealed together. The flexible socket is placed in the frame socket and the trim line is established: 1/8" to 1/4" above the edge of the laminated frame socket to minimize the stiffness gradient and to allow a gradual transition from the flexible socket to the rigid frame (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-09.jpg"><b>Fig. 9</b></a>). Socket designs are many and quite variable (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-10.jpg"><b>Fig. 10</b></a> and <a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-11.jpg"><b>Fig. 11</b></a>).</p> <h3>Above Elbow Socket</h3> <p>All previous steps used in the below elbow prosthesis apply to the above elbow prosthesis until removal of the laminated humeral section with the attached elbow turntable. When the humeral section is removed from the foamed humeral extension, it is set aside (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-12.jpg"><b>Fig. 12</b></a>), while the laminated above elbow socket is cut out to allow maximum flexibility of the flexible socket. The laminated humeral extension holding the turntable is then re-attached to the flex-frame socket with a rigid plastic resin (<a href="http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-13.jpg"><b>Fig. 13</b></a>). Easy removal of the flexible socket will allow for easy access to the elbow friction and attachment nut at the elbow turntable.</p> <p>Again, configurations of both below and above elbow flex-frame sockets are many in design, but must provide attachment areas for harnessing and base plates for proper transition of the cable control system.</p> <h3>Acknowledgments</h3> <p>The author wishes to acknowledge Mr. Steve Szabo's technical assistance.</p> <em><b>*Donald L. Fornuff, CP. </b> Donald L. Fornuff, CP., was formerly Assistant Director of Orthotics and Prosthetics at Rusk Institute of Rehabilitation Medicine, New York, New York. He is presently Director of Medishare Orthotics and Prosthetics Laboratories, Fords, New Jersey.<br /><br /><br /></em> Page Number(s) 31 - 34 Year 1985 Volume 9 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-11.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-12.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1985_04_031/1985_04_031-13.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Flex-Frame Sockets in Upper Extremity Prosthetics Creator An entity primarily responsible for making the resource Donald L. Fornuff, CP. * https://staging.drfop.org/files/original/6f9164852f923d934924fa8fcf1f17fc.pdf 1b58d80ae3b0054e7a4e88d749254638 https://staging.drfop.org/files/original/e16607ccd46c9c7e42dd07751d977682.jpg 8eaff6854b224c7b799187bdded6988d https://staging.drfop.org/files/original/2166b64e7aaf0c784c32236c01c93747.jpg 410b2c45e6cf4b741c28fe03999558fd https://staging.drfop.org/files/original/331bf1cb4de93a9584b33553af58c3f7.jpg f1b22d42a14fec42d03dc4b116e3a685 https://staging.drfop.org/files/original/df476f11eb4ab1fd182da42ae9133165.jpg 18ded7ff78503d7a542bdbb93f7fa5fa https://staging.drfop.org/files/original/18d2e38e612b0c2cbc33f88021561703.jpg 3c1da62f89d9fe83a64335c1b8383f6a https://staging.drfop.org/files/original/c9afab133e1b7a0100fb05064a779272.png 2ba2e902e2ced64b216af2c281388060 https://staging.drfop.org/files/original/55b9142f83521a8a0e523c679963214e.png 6960cb5288eaf7123f81be484479e8d3 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_01_006.pdf Text Any textual data included in the document <h2>Flexible Prosthetic Socket Techniques</h2> <h5>H.R. Lehneis, Ph.D., CPO&nbsp;<a style="text-decoration: none;">*</a><br />Don Sung Chu, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Howard Adelglass, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The continuous development and availability of new materials of various kinds, e.g., elastomers, copolymer thermoplastics, and composite materials have brought a potentially revolutionary development in the design, configuration, and fitting principles of prosthetic sockets, especially for above-knee prostheses. All of this may result in greater patient comfort, physiological, and psychological advantages.</p> <p>Improvements in socket comfort with concomitant physiological and psychological benefits are not only due to the materials themselves, but rather, the inherent characteristics of the various materials used permit socket configurations heretofore not possible. For example, socket fenestrations over selected or entire stump surface areas are now possible. The desirability and principle of permitting greater flexibility over muscular areas than is possible in a rigid, laminated socket were appreciated more than 25 years<a></a> ago in the fitting and design of the "Flexi-cage" socket<a></a> which consisted of nylon cords strung between the proximal brim and the distal end of the socket. McCollough, et al.,<a></a> as early as 1968, attempted fenestrations over selected socket areas. These attempts, however, were not generally successful because of the potential and real problems with window edema and the properties of the material used. These problems now have been overcome through the availability of materials which can be used as elastic or semi-elastic inserts, preventing window edema, yet permitting removal of the outer rigid socket shell in selected areas.<a></a></p> <p>Below are described several approaches allowing flexible or semi-flexible stump containment, while maintaining the essential biomechanical characteristics required for interface stability to transfer body weight through the prosthesis to the ground, and for dynamic and safe control of the prosthesis.</p> <p>Two systems are curently used at the Institute of Rehabilitation Medicine at NYU Medical Center (IRM-NYU) to provide the characteristics described above. The first system consists of an inner socket laminated of Perlon fiber and silicone elastomer contained in a rigid plastic laminated socket (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-1.jpg"><b>Fig. 1</b></a>). The laminated silicone elastomer has nearly perfect memory and permits fenestrations of the rigid outer socket over the posterior area (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-2.jpg"><b>Fig. 2</b></a>), rectus femoris (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-3.jpg"><b>Fig. 3</b></a>) and the adductor group, without causing window edema. This design permits greater muscle expansion than the designs described below because of the elasticity of the silicone material. It also provides enhanced sensory feedback, particularly when sitting, i.e., the patient is able to feel the surface of the chair or seat. The soft liner is also a boon to improved comfort, particularly in geriatric amputees and those with a history of general socket discomfort.</p> <p>The second design utilized at IRM-NYU is a Surlyn® inner socket (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-4.jpg"><b>Fig. 4</b></a>) which permits removal of even more of the hard outer laminated socket (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-5.jpg"><b>Fig. 5</b></a>). The reason larger areas of the hard socket can be removed is the lesser flexibility of Surlyn®. Thus, more rigid material can be eliminated without compromising the integrity of known biomechanical principles (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-6.jpg"><b>Fig. 6</b></a>).</p> <p>A more recent design developed in Iceland and further refined in Sweden and at New York University, known as the ISNY socket, consists of a medical rigid frame only, leaving the rest of the polyethylene socket semi-flexible.</p> <p>For below knee amputations, similar systems have been developed at IRM-NYU and in Belgium by Van Rolleghm of CEBELOR.<a></a> In the IRM-NYU system, a Surlyn® inner socket permits removal of material in the outer laminated socket over bony or pressure sensitive areas (<a href="http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-7.jpg"><b>Fig. 7</b></a>). This permits easy inspection of these areas and ease of adjustment by heating the inner socket to further relieve painful areas.</p> <p>The CEBELOR consists of a silicone laminated soft socket insert for the SP-SC below-knee prosthesis. Thus, it is self-suspending, provides improved comfort, and permits selected fenestration over pressure sensitive areas, e.g., head of the fibula, distal end of the tibia. To prevent slippage and rotation of the inner silicone socket, distal and posterior plugs are laminated as an integral part of the soft socket to fit into female counterparts in the plastic laminated socket.</p> <h3>Summary</h3> <p>While the various systems described above employ different materials and socket configurations, certain characteristics are common to all systems. These are: improved muscle physiology due to greater socket flexibility; enhanced sensory feedback; quicker heat dissipation due to thinness of the flexible stump containment material; and improved comfort, especially in the IRM-NYU and CEBELOR systems with the soft silicone liner.</p> <p>All these are important improvements which were made possible through the use of flexible or semi-flexible materials. Yet, the biomechanical principles of providing stump containment, weight transfer, and control of the prosthetic limb are not compromised. In the ISNY System, however, it is not clear how lateral and anterior/posterior stability of the femur is achieved, since there are no structural components in areas conventionally considered to provide such stability. This question, however, will be addressed in studies to be conducted in the near future.</p> <h3>Acknowledgments</h3> <p>The participation of Donald Fornuff, CP, and Roger Chin, CPO, in the development of the IRM-NYU systems is gratefully acknowledged.</p> <p><b>References:</b></p> <ol> <li>Bach, Johann; Essen, Germany, personal communication, 1958.</li> <li>Fillauer, Carlton; Chattanooga, Tennessee, personal communication, 1983.</li> <li>McCollough, Newton, and Sinclair, William, "Some Considerations in Management of the Above-Knee Geriatric Amputee," Artificial Limbs, 12:2, 28-35, Autumn, 1968.</li> <li>Ockenfels, Peter; Columbus, Ohio, personal communication, 1983.</li> <li>Sabolich, John; Oklahoma City, Oklahoma, personal communication, 1983.</li> <li>Van Rolleghm, Jacques; Brussels, Belgium, personal communication, 1983.</li> </ol> <div style="width: 400px;"><em><b>*Howard Adelglass, M.D. </b> Institute of Rehabilitation Medicine, NYU Medical Center (IRM-NYU).</em><br /><br /><em><b>*Don Sung Chu, M.D. </b>Institute of Rehabilitation Medicine, NYU Medical Center (IRM-NYU). </em><br /><br /></div> <div style="width: 400px;"><em><b>*H.R. Lehneis, Ph.D., CPO </b> Institute of Rehabilitation Medicine, NYU Medical Center (IRM-NYU).</em><br /><br /><br /></div> Page Number(s) 6 - 8 Year 1984 Volume 8 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1984_01_006/1984_01_006-7.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Flexible Prosthetic Socket Techniques Creator An entity primarily responsible for making the resource H.R. Lehneis, Ph.D., CPO * Don Sung Chu, M.D. * Howard Adelglass, M.D. * https://staging.drfop.org/files/original/9fce2f56ec56ccbbaff5166e0706b01f.pdf 5548abda79aee7e1363a542a22e37550 https://staging.drfop.org/files/original/1cc44d2e04b139d764a73a5ec808af6f.jpg 0222f4152435fc260955f32524bbb711 https://staging.drfop.org/files/original/fed0e95cfabfb6b0189e6da15c916a6f.jpg d1dbb049869929f1473972725498c986 https://staging.drfop.org/files/original/9345c2d14d824a077fd7b1f96c118c14.jpg 3bafaaab01346b31406d8d2d21b0be9c https://staging.drfop.org/files/original/de4e477cd3382de1d4516750b81da61d.jpg abf27e1e5360c4d5dfa6da2f7932a611 https://staging.drfop.org/files/original/5ac2dc8211dc6bd0f9079857dd3ca586.jpg 7bc8b46ef73d497018dceb1b1133d3c5 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_04_027.pdf Text Any textual data included in the document <h2>Flexible Socket Systems</h2> <h5>David J. Jendrzejczyk, CP.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Over the past two years there has been impetus towards the use of the flexible socket interface in above knee prosthetics. For our purposes here, it is widely accepted that the flexible socket is of multiple benefit to the patient. We will concentrate on discussing the different systems available.</p> <p>The history of flexible sockets dates back a number of years. The article by Charles Pritham, C.P.O., et. al. "Experience with the Scandinavian Flexible Socket"<a></a> provides a concise summary of this train of development.</p> <p>At the present time, there are numerous flexible socket systems being used in the United States and throughout the world. These sockets differ in design in two major areas: flexible socket interface and the outer hard socket. The flexible socket is currently being used with three types of support mechanisms:</p> <ol> <li> <p>Total hard socket as the support</p> </li> <li> <p>Hard socket with strategic fenestrations</p> </li> <li> <p>True frame design</p> </li> </ol> <p>The prosthesis discussed by R. Volkert in the article, "Frame type Socket for Lower Limb Prosthesis"<a></a> is constructed with a frame outer socket and an elastic stocking interface. This system can accommodate stump volume changes, therefore, it appears to be most useful with early amputees.</p> <p>The TC Couple Socket<a></a> above-knee prosthesis used a polyethylene flexible interface and an external polypropylene socket. There are no fenestrations in the outer socket, so it doesn't have some of the benefits of sensory feedback as a fenestrated outer socket would. The advantage of this system is its light weight polypropylene outer socket.</p> <p>Work done at the Institute of Rehabilitation Medicine, New York University Medical Center, is detailed in "Flexible Prosthetic Socket Technique."<a></a> Two systems are described in the article, both have a hard outer socket with windows cut out in strategic locations (<a href="/files/original/1cc44d2e04b139d764a73a5ec808af6f.jpg"><b>Fig. 1</b></a>). The interface is either of thermo-formed polyethylene or of silicone elastomer lamination.</p> <strong><a href="/files/original/1cc44d2e04b139d764a73a5ec808af6f.jpg">Figure 1</a>. Prosthesis incorporating a flexible Polyethylene socket in a support with fenestrations in selected areas as fitted at the Rusk Institute of Rehabilitation Medicine (Photo courtesy RIRM).</strong><br /> <p>Currently, in the United States, the external frame with the thermoplastic interface seems to be the most commonly used. There are three major fabrication techniques for the frame system described. They are the IPOS System (<a href="/files/original/fed0e95cfabfb6b0189e6da15c916a6f.jpg"><b>Fig. 2</b></a>),<a></a> the ISNY (<a href="/files/original/9345c2d14d824a077fd7b1f96c118c14.jpg"><b>Fig. 3</b></a>),<a></a> and the SFS System (<a href="/files/original/de4e477cd3382de1d4516750b81da61d.jpg"><b>Fig. 4</b></a>)<a></a> (Fillauer Technique).<a></a><a style="text-decoration: none;">*</a></p> <strong><a href="/files/original/fed0e95cfabfb6b0189e6da15c916a6f.jpg">Figure 2</a>. Flexible AK socket as fabricated by IPOS (Photo courtesy IPOS).</strong><br /><br /><strong><a href="/files/original/9345c2d14d824a077fd7b1f96c118c14.jpg">Figure 3</a>. Icelandic Swedish New York (ISNY) flexible socket (Photo courtesy NYU).</strong><br /><br /><strong><a href="/files/original/de4e477cd3382de1d4516750b81da61d.jpg">Figure 4</a>. Scandinavian Flexible Socket (SFS) (Photo courtesy Durr-Fillauer Medical, Inc.).</strong><br /> <p>The intention of this article is to describe the differences and similarities of the above three systems.</p> <h3>Socket Interface</h3> <p>All three systems use a thermoplastic material for their inner socket.</p> <p>IPOS uses ipolen,<a></a> which is a specially formulated polyethylene and which reportedly provides a uniform socket thickness and has little shrinkage. The resulting socket is translucent.</p> <p>The ISNY system prefers polyethylene which has a tendency to shrink. NYU reports that the shrinkage is not a problem. This socket is also translucent.</p> <p>The SFS system recommends Surlyn®, but polyethylene can be used. Surlyn® is a thermo-formable plastic which shrinks little and provides a transparent socket.</p> <p>The thermo-forming method for the interface is basically the same for all three systems. The only difference is that IPOS recommends that you preheat the vacuum forming frame, and they prefer a dry cast. If a wet cast is used, they recommend that an IPOS sheath be pulled over the cast before the thermo-forming. The SFS system recommends a warm, wet mold for Surlyn®. ISNY states no preference.</p> <h3>Frame (Structural Element)</h3> <p>The most variation occurs in the fabrication of the frame. Materials and lay-up have a wide range of variation (<a href="/files/original/5ac2dc8211dc6bd0f9079857dd3ca586.jpg"><b>Table I</b></a>).<br /><img src="/files/original/5ac2dc8211dc6bd0f9079857dd3ca586.jpg" /><br />IPOS laminates on the positive model with the flexible socket in place. Carbonacryl, which has been specially formulated to use with carbon fibers (13-1), is laminated over the appropriate layers of nylon stockinette, carbon-glass stockinette, fiberglass matting, and fiberglass stockinette. Total lay-up is seven layers for the average size patient of 120 to 180 pounds.</p> <p>The ISNY system laminates on the positive model with the flexible socket in place. Their recommendation is for 100 percent rigid polyester, acrylics if desired. A polyester lamination is done over the appropriate layers of nylon stockinette, fiberglass stockinette, and 1" and 2" unidirectional carbon tape. The total layup is 26 layers in both directions. In addition, they recommend adding dacron felt "to insure sufficient thickness in strategic areas."<a></a></p> <p>SFS laminates their frame over the positive model, which has been built up with varying layers of stockinette used as a filler in place of the flexible socket. An acrylic lamination is done over the appropriate layers of nylon stockinette, fiberglass stockinette, and 1" unidirectional carbon tape. Total lay-up at the proximal brim is 25 layers, and 26 layers at the medial brim.</p> <p>In the ISNY and SFS systems care must be taken in the lay-up of the medial/proximal brim where the materials overlay to avoid excessive thickness.</p> <h3>Frame Dimensions</h3> <p>There are some variations in the final trim-lines of the frame. The medial strut on the SFS and ISNY are approximately 2 1/2" and 2 3/4" wide. The medial strut on the IPOS frame extends around the anterior and posterior medial edge by one centimeter.</p> <p>The proximal trimlines on the SFS, anteriorly and posteriorly, are 2/3 the medial/lateral width. The proximal trimlines of the ISNY extend to the anterior and posterior lateral socket corners. The proximal trimlines of the IPOS extend around the anterior and posterior lateral corner by 2 centimeters.</p> <p>In the SFS and IPOS systems, the distal trim-line cups around the lateral distal femur. The ISNY does not. All systems tell you to take care to have an adequate radius on connecting edges between the medial strut and the proximal and distal trimlines.</p> <h3>Comments and Conclusions</h3> <p>The afore-mentioned indicated that there are many questions still unanswered. The varying lay-up design makes for varying flexibility and weight difference in the frames. At Newington, we question why the severe differences in build-up exist and as a result are undertaking a research project with some students at the Engineering Department at the University of Hartford. As a senior research project, they are planning an evaluation of the mechanics and structure of the three strut designs as well as the flexible socket material.</p> <p>It should be noted that if there are severe undercuts on the positive model, removal of the finished strut from the model can cause stress cracks in the frame.</p> <p>Problems have been noted by Newington and</p> <p>others of the flexible socket breaking after delivery to the patient. Care must be taken in fabrication of the socket that all flares are built into the positive mold. This will help reduce the stress in the molding process. Another recommendation to remove the stress from the finished flexible socket is an annealing process. We have yet to evaluate its effectiveness.</p> <p>In conclusion, there has been some confusion as to the different systems. Our purpose here has been to clarify the systems and their differences. As with any new system, questions and confusion are to be expected.</p> <p>It is still a subjective evaluation. As long as the patient benefits, use the system (or combination of systems) with which you are the most comfortable.<br /><br /><b>Footnote</b> Further reference to the SFS system will be as it is fabricated by Durr Fillauer Medical, Inc.<br /><br /><em><b>*David J. Jendrzejczyk, CP. </b> David J. Jendrzejczyk, CP. is with Newington Children's Hospital, 181 East Cedar Street, Newington, Connecticut 06111.<br /></em></p> <p><b>References:</b></p> <ol> <li>Berry, Dale, CP., "Flexible above knee socket made from low-density polyethylene suspended by a weight transmitting frame," IPOS-Composite Materials for Prosthetic Orthotic Application, April 10, 1985.</li> <li>Berry, Dale, CP., IPOS-Flexible Socket, Case Study and Overview, April 10, 1985.</li> <li>Davis, Roy B., Ill, Ph.D., "Comparison of Inter-face Pressure Distributions, Soft Socket (ISNY/SFS) vs. Hard Socket," presented at an American Academy Orthotics and Prosthetics-New England Chapter Meeting, March, 1985.</li> <li>Giannini, Margaret, M.D., "Transfer of Rehabilitation Research and Development Results into Clinical Practice," <i>Clinical Prosthetics and Orthotics</i>, Volume 8, Number 1.</li> <li>Kay, Hector W. and Newman, June D., "Report of workshop on below-knee and above-knee Prostheses," <i>Orthotics and Prosthetics</i>, Volume 27, Number 4, pp. 9-12, 21, December, 1973.</li> <li><a href="poi/1981_03_129.asp">Koike, K.; Ishikura, Y.; Kakurai, S.; Imamura, T., "The TC double socket above-knee prosthesis," <i>Prosthetics and Orthotics International</i>, 1981, pp. 129-134.</a></li> <li>Kristinsson, Ossur, "Flexible Above Knee Socket made from Low Density Polyethylene, Supported by a Weight Transmitting Frame," <i>Orthotics and Prosthetics</i>, Volume 37, Number 2, pp. 22-27.</li> <li>Lehneis, H.R., Ph.D., CPO; Chu, Don Sung, M.D.; Adelglass, Howard, M.D., "Flexible Prosthetic Socket Techniques," <i>Clinical Prosthetics and Orthotics</i>, Volume 8, Number 1, pp. 6-11.</li> <li><a href="al/1968_02_028.asp">McCollough, Newton, C, III, M.D.; Sarmiento, Augusta, M.D.; Williams, Edward M., M.D.; Sinclair, William F., CP., "Some considerations in Management of the Above-Knee Geriatric Amputee," <i>Artificial Limbs</i>, Volume 12, Number 2, pp. 28-35, Autumn, 1968.</a></li> <li>Pritham, Charles H., C.P.O.; Fillauer, Carlton, C.P.O.; Fillauer, Karl, C.P.O., "Experience with the Scandinavian Flexible Socket," <i>Orthotics and Prosthetics</i>, Volume 39, Number 2, July, 1985.</li> <li>Technical Notes, <i>Artificial Limbs</i>, Volume 13, Number 1, pp. 69-71.</li> <li><a href="poi/1982_02_088.asp">Volkert, R., "Frame type socket for lower limb prostheses," <i>Prosthetics and Orthotics International</i>, pp. 6, 88-92, 1982.</a></li> <li>"A Revolutionary Technique in Fitting AK Amputees," <i>IPOS Flexible Socket Fabrication Manual</i>.</li> <li>"Prosthetic and Sensory Aids Service," Department of Medicine and Surgery, Veterans Administration, Washington, D.C., <i>Bulletin of Prosthetics Research</i>, pp. 227-229, Fall, 1972.</li> <li>"Fabrication Procedures for the ISN Y Above Knee Flexible Socket," January, 1984.</li> </ol> Page Number(s) 27 - 31 Year 1985 Volume 9 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1985_04_027/1985_04_027-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_04_027/1985_04_027-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_04_027/1985_04_027-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_04_027/1985_04_027-4.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 5 TABLE I http://www.oandplibrary.org/cpo/images/1985_04_027/1985_04_027-5.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Flexible Socket Systems Creator An entity primarily responsible for making the resource David J. Jendrzejczyk, CP. * https://staging.drfop.org/files/original/c1518335ef3a2c94cc629494297c68ea.jpg 3f31cecd1dbcfea96badbbf1fe4957f9 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 Humanitarian Organizations Subject The topic of the resource Humanitarian organizations serving the worldwide O&P/Rehab community. Humanitarian Organization Humanitarian organizations serving the worldwide O&P/Rehab community. Contact Name/Title Dino M. Scanio CO, LO - Director Address 6215 Spring Oak Ct. City Tampa State/Province Florida Countries Served USA Regions: North America, Central America, Europe, Asia, South AmericaAge Group: Adults, ChildrenFees Charged: Yes Postal Code 33625 Phone 813-477-1219 Email footfoundation2007@yahoo.com Organization Type Including ID and tax status Non-profit Tax ID 26-3302549 Not-for-profit Type 501C-3 Charity Services Provided Prosthetic Fitting, Orthotic Fitting, Education, Prosthetic Fabrication, Orthotic Fabrication, Rehabilitation / TrainingThere is a facility/physical building for patient care at the specified location. Accomodations for volunteers near or at the specified location. Need I Financial Assistance Need II Materials, Components, and Equipment Need III Materials, Components, and Equipment: New, Disassembled, Equipment, Used Additional Info & Comments Please visit www.footfoundation.org for more details! URL https://footfoundation2007.wixsite.com/footfoundation/about_us 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 Florida O&P Outreach Team https://staging.drfop.org/files/original/7b50b9442fee7b3a075030bce26d5247.pdf c642ea8fa545bc78a7515b88282350b9 https://staging.drfop.org/files/original/1bf96f25f8dad3e8a90a0f93f54b53e3.jpg 5be960caa128ae75975d9e0ace0cc9a0 https://staging.drfop.org/files/original/3c801b7d07539462b4ac10842de5efcd.jpg a96f3e7dc9ed31455ba28a3c1da6dfe8 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_03_022.pdf Text Any textual data included in the document <h2>Follow-up Experience with an Orthosis Combining the Supracondylar Knee Orthosis and the Spiral Orthosis</h2> <h5>Thomas A. Marün, CPO&nbsp;<a style="text-decoration: none;">*</a></h5> <p><b>Fig. 1</b>, <b>Fig. 2</b></p> <strong><a href="/files/original/1bf96f25f8dad3e8a90a0f93f54b53e3.jpg">Fig 1</a>. Side view of orthoses similar to that described by Mr. Martin in his article. (The photographs supplied by Mr. Martin proved to be unusable.)</strong><br /><br /><strong><a href="/files/original/3c801b7d07539462b4ac10842de5efcd.jpg">Fig 2.</a> Posterior view of the same orthoses as in Fig. 1. These photos are supplied courtesy of H. Richard Lehneis, Ph.D., CPO.</strong><br /> <p>A seventy-one year old woman, post polio of long duration, presented herself to our facility with a Supracondylar Knee Orthosis<a></a> that had a spiral type AFO<a></a> attached to it over ten years ago. She had fractured the AFO component just proximal to the malleolus, about one year ago. Another facility had attempted to replace the Nyloplex® spiral AFO with polypropylene material. Her ankle was fixed at 120 degrees plantar flexion. Our investigation indicated that her knee went into genu recurvatum despite the SKO, hence the problem-how to attach the spiral unit to the SKO and duplicate the same alignment that she had been comfortable with after all these years. It is noteworthy that the SKO was held in position by a waist strap.</p> <p>It was our opinion that the SKO no longer fit due to laxity within the knee cavity itself. She was quite adamant, however, that her brace system had been working well and it was our job to fix it. She declared that the waist belt was no problem and further stated, in no uncertain terms, that she wanted what she had because it had been of good service for over a decade.</p> <p>Possibly being more persistent than intelligent, we proceeded. We were unsuccessful in our attempts on three separate occasions in reapplying the spiral type AFO. We finally tried #4134-30 percent and #4110-70 percent polyester resin, laminated with four layers of fiberglass and two layers of glass, and used 1/16" polypropylene welding rods that ran the entire length, one inch apart.</p> <p>Using the old holes of the SKO, we were unsuccessful in obtaining satisfactory alignment when attaching the spiral unit. Therefore we were forced to tape the two units together until we had a compatible arrangement. Once the two components were riveted together, she had some problems in gait, especially between heel strike and foot flat, clearly indicating that the SKO was affecting the knee by not allowing it to go into recurvatum.</p> <p>In summary, we feel that in using the resin as opposed to the Nyloplex® (we used the same plaster mold) we may have compromised some flexibility, but gained, through rigidity, a successful duplication of past gait patterns.</p> <p>Presently this woman is walking better than formerly and is quite satisfied with our results.</p> <p><b>References:</b></p> <ol> <li>Dr. H. Richard Lehneis, CPO, "Bio engineering Design and Development of LE Devices, " Institute of Rehabilitation of Medicine, New York University Medical Center, p. 55, October, 1972.</li> <li>ibid., p. 60.</li> </ol> <div style="width: 400px;"><em><b>*Thomas A. Marün, CPO </b> President Baja Orthotic and Prosthetic Services, 205 Church Street, Chula Vista, California 92010<br /><br /><br /></em></div> Page Number(s) 22 - 22 Year 1984 Volume 8 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1984_03_022/1984_03_022-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1984_03_022/1984_03_022-2.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Follow-up Experience with an Orthosis Combining the Supracondylar Knee Orthosis and the Spiral Orthosis Creator An entity primarily responsible for making the resource Thomas A. Marün, CPO *