7 20 371 https://staging.drfop.org/files/original/1e1744490ce5197c6fbbd672bbe0ec51.pdf ae3011da56cde88195a6545638e8ac74 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_010.pdf Text Any textual data included in the document <h2>Follow-up on Endoskeletal Article and Questionnaire: The Manufacturers Reply</h2> <p><i>Summarized results of the survey concerning endoskeletal prostheses appeared in the Summer, 1982 issue of <i>C.P.O.</i> (Vol. 6, No. 3). These compiled results were circulated among the manufacturers of endoskeletal prosthetic systems. The following responses were received.</i></p> <p>In regards to the "g" response in the additional comments section, [questioning whether the cost is justified] I will submit the following: Endoskeletal prosthetics is a poor excuse to charge more money, only when it is the excuse that it is being charged to the patient. I can also understand being afraid of the dollar sign where it prevails as fiscal remuneration for an excuse, rather than the patient's welfare. Endoskeletal prosthetics have consistently proven themselves a useful tool in developing value in the patients themselves, and in the patient's rehabilitation accomplishments .</p> <p style="margin-left: 10%;">Michael T. Wilson, CPO<br />Medical Center Prosthetics, Inc.</p> <p>Manufacturers must keep many things in mind when designing and building a modular system: weight vs. strength, added features vs. weight and strength, and cost to manufacture vs. simplicity. Research and development expenses are subsidized only by sales profits. A good example is that tooling for one simple item may run $80,000, while sales and volume of manufacture does not warrant this expense. In summary, manufacturers do have handicaps.</p> <p>In reviewing question number ten—what changes would you like to see?—we find 19 answers were provided. Eighteen of the 19 have been researched, and four of these are available now. The others will continue to be researched and will be available in the future.</p> <p>The field of prosthetics has come a long way in the past 20 years; let us look at what is available now in manufactured parts as to what was available in 1962. We at United States Manufacturing Company believe there will be even more improvements in the next 20 years compared to the last 20.</p> <p style="margin-left: 10%;">Dan J. Edwards<br />Sales Director<br />United States Manufacturing Co.</p> <p>Otto Bock, along with several other manufacturers of endoskeletal prosthetic systems, was presented with the survey results from the Winter Issue of <i>C.P.O.</i> and was asked for a response. While the total number of endoskeletal prostheses indicated as having been delivered to patients was significant, we must offer our opinion that the total of 27 returned questionnaires is a rather poor response and certainly does not represent a consensus upon which to base any conclusions.</p> <p>Each manufacturer is individually aware of how many endoskeletal units it produces and sells each year, which gives a general idea of market acceptance. Our experience has been that our endoskeletal units sold continue to increase in significant quantities year after year and this trend has shown no sign of reversing. This in itself is an indication to us that endoskeletal systems have attained a definite place in the armamentarium of components available for prosthetic patient management.</p> <p>A great number of people seem to support the belief that endoskeletal prostheses were designed to replace exoskeletal prostheses. It is certainly not our company philosophy that one is intended to replace the other. Both types of systems have their advantages and disadvantages and it ultimately should depend on the professional decision of the prosthetist as to which system will best fit the needs of each individual patient. Perhaps many of the complaints about endoskeletal systems are due to improper patient selection criteria rather than deficiencies in the systems themselves.</p> <p>Another source of trouble with endoskeletal systems is the improper application of fabrication techniques. Recognizing this possibility—and being one of the first manufacturers to offer a complete multiple option endoskeletal system for the lower extremity—we developed a seminar program for instruction in these new techniques. In addition, we have developed Technical Information Bulletins, slide programs and presentations for various technical meetings. Despite these efforts on our part, the sheer numbers of prosthetists in this country and their diverse geographical locations make it nearly impossible to personally instruct every one, even if we could increase the size and frequency of our seminars. Basically, we are able to trace many of the problems to not following technical recommendations. In many cases the problems have been cleared up rather quickly by following instructions.</p> <p>The prosthetist has the choice of using any of several manufacturers' systems, each with its own unique features. If alignment capability in the definitive prosthesis is desired, an IPOS or OTTO BOCK System can be used. If it is felt that this permanent adjustability is detrimental, the USMC or AFP Systems can be used instead. When the Otto Bock foam cover is too difficult or time consuming to shape, or lacking in durability, there are other alternatives. These include the foam-in-place technique offered by Medical Center Prosthetics, and the option of a prefabricated cover. Choices also exist for the prosthetic skin, such as our nylon stocking, USMC's newly developed cover, or a covering of the paint-on variety.</p> <p>The foregoing statements are not meant to give the impression that Otto Bock is insensitive to the needs of the prosthetist or, more importantly, to the desires of patients they serve. We recognize fully the need for improvement of endoskeletal systems. The covers need to be more durable and easier to fabricate. The structural and functional components need to be made lighter and more sophisticated. Unfortunately, many of these things are easier said than done, but our research department is constantly striving to develop new and better systems.</p> <p>We very much appreciate the opportunity to comment on this survey and would encourage a much greater response to such surveys in the future. This type of feedback on a much larger scale could be very helpful to all manufacturers. Along this line, we are wondering what suggestions might be offered for quickly disseminating information on new products or techniques so everyone interested could become qualified to use them for maximum benefit to the patient. If anyone has some workable ideas for accomplishing this objective, we are certain all concerned would benefit greatly.</p> <p style="margin-left: 10%;">Jack Hendrickson, CP<br />Otto Bock</p> <h3>More Endoskeletal Responses Added to Questionnaire Results</h3> <p>Two questionnaire responses were received too late to be included in the compiled results published in the Summer <i>C.P.O.</i> One individual reported that 75% of definitive prostheses fit were of endoskeletal construction and the other reported fitting 150 endoskeletal prostheses (actual numbers, not a percentage). Their responses to questions two through nine were very much in line with the majority of others received. Their written responses are included below:</p> <ol> <li> <p>What changes would you like to see made?</p> <p><i>First respondee:</i></p> <ol> <li> <p>improved covers</p> </li> <li> <p>hydraulic knees</p> </li> </ol> <p><i>Second respondee:</i></p> <ol> <li> <p>Lighter in weight</p> </li> <li> <p>Improvements in the visual, tactile, and sound aspects of prostheses</p> </li> <li> <p>Longer lasting cosmetic covers, internally and externally</p> </li> <li> <p>For H.D./H.P. prostheses, better sitting ability</p> </li> <li> <p>Standardization of tube sizes and connectors to facilitate "intermarriage" of components</p> </li> <li> <p>More instructional courses by prosthetics/orthotics schools or manufacturers to deal with "practical every-day" problems</p> </li> </ol> </li> <li> <p>Additional comments:</p> <p><i>First Respondee:</i></p> <p>The ability to make either major or even subtle changes in a definitive prosthesis, months or even years after initial fitting, has always appealed to me. The more I use the Bock system the more confident I become of it and I find myself fitting a higher percentage [75% last year, Ed.] . . . every year. I find the poor durability of the cover a minor trade off . . . most of my patients agree. I practice in Montana, so you can guess my patients do not always give their prostheses the easiest use. I am a firm believer in the concept.</p> <p><i>Second respondee:</i></p> <p>Our first choice of components for any amputee (re: level of amputation, sex, job or environmental factors) is the endoskeletal prosthesis. My first reason for this is ease of maintenance/replacement of components. This single factor keeps patients coming back knowing they can get things "fixed" quickly. In our present rush society this factor cannot be overlooked.</p> <p>Cosmesis is becoming a more important factor every day, regardless of the patient's sex or age.</p> <p>For too long, we have, as professionals, trained our patients to think: 'functional restoration is your main objective.' Having been involved with many patients who are "prosthetic failures," I have learned a few very important lessons as to why they are on crutches, in wheelchairs, or have empty armsleeves.</p> <p>Consumers in general, today, are more educated and interested in knowing their options. The prosthetist has the responsibility to inform his patient as clearly and completely as possible concerning what is available. He may end up referring the patient to a colleague if he does not have the necessary skills to satisfy his client. A satisfied, happy patient is not a side benefit to our existence. It is a must.</p> <p>Through publications such as this one and many others around the world, we have an obligation to keep up-to-date on new developments as well as contributing our findings in return. It is not necessarily always true that something we are having success with is known to most colleagues. Try and publish articles with photographs and you will be surprised at the response.</p> </li> </ol> Page Number(s) 10 - 11 Year 1982 Volume 6 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Follow-up on Endoskeletal Article and Questionnaire: The Manufacturers Reply https://staging.drfop.org/files/original/a32e7ddca38ac3658b7debb50c742a7d.pdf 94386f89329ed90de7d4de19d32ee144 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1984_01_004.pdf Text Any textual data included in the document <h2>From Research Lab to Consumer: The Manufacturers' Point of View</h2> <h5>Carlton Fillauer, CPO&nbsp;<a style="text-decoration: none;">*</a><br />Charles H. Pritham, CPO&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The matter of transferring new developments from the researcher to the consumer is one that has bedeviled the American prosthetic-orthotic establishment for years. The researcher, the agency that funds the research, the manufacturer, the clinician, and the patient are all, of course, interested in seeing new products brought to market, and all stand to benefit. Financially, the manufacturer is the one who stands to benefit the most from the successful introduction of a new product. Only by such means does a manufacturer expand his base and increase earnings. If the incentives are greatest for a manufacturer, the risks are also proportionately greater. In making a decision to produce a new product, the manufacturer must weigh the risks against the potential benefits and make a decision about committing his resources. It should be obvious that once resources of time, effort, and money are lost backing an unsuccessful product, they are lost forever. What is not so obvious is the fact that the loss is threefold.</p> <p>Potentially, at least, the resources expended for backing a losing product could have been invested in a successful one, turning a loss into a profit. Also, in making the decision to back a new product the manufacturer commits his prestige and credibility. A positive result resounds to his credit, attracting new attention to products currently being produced and assuring a positive reception for future products. A negative result has the opposite effect, tarnishing the image of other items in the manufacturer's product line and damaging his credibility. That the investment in a new product can be a high one should not be discounted, therefore.</p> <p>A small group of highly skilled and motivated individuals (or an inventor working alone) can, with a relatively low investment in machinery, produce complicated prototypes efficiently and with a low rejection rate. When the time comes to produce the same object in large numbers, the factors are fundamentally different. Production workers are seldom so skilled or motivated. Oftentimes, to overcome bottlenecks in production and to achieve consistent results, a product must be redesigned. The cost of this redesign must be borne by the manufacturer. To achieve productivity and consistent results, the manufacturer will develop tools, dies, and molds with which to produce a device. Resorting to such an alternative can enable relatively unskilled personnel using inexpensive materials to produce products of great appeal and excellent quality. While the material costs of such objects can be measured in the cents, the cost of the molds and dies can frequently run in the thousands of dollars each. If it is necessary to produce the device in a range of sizes and in right and left, the cost can be prohibitive. It should also be borne in mind that the researcher or inventor frequently has only partially tested the prototype and further testing and development must precede redesign for production. The direct expense of manufacturing an object, however, is only a portion of the cost.</p> <p>In order to sell a product it must be promoted and advertised. The total expense of attending a convention (often far from home), renting space to exhibit, and obtaining a suitable display is not cheap. Commissioning the art work and copy of an advertisement, and obtaining space for it in a journal are, similarly, of considerable expense.</p> <p>The organization that makes all this possible (research and development, production, and promotion) can frequently be quite large and demand a sizable indirect labor force to administer the resources and personnel involved. The total expense of all factors involved in developing a new product is a figure to be reckoned with and can be justified only if the product has the potential of selling in sufficient quantities to recoup the original investment and earn a favorable rate of return. It is in connection with this that the greatest stumbling block is encountered. Whatever the merits of a design may be, a manufacturer can not afford to devote the resources to its development if it will not sell in a large enough volume to enable him to sell it at a reasonable cost.</p> <p>Despite the optimistic expectations of a developer, the market for his new object is seldom as large as he hopes. All researchers and developers seeking federal research money are asked to project the number of individuals for whom their work will be applicable. As all involved will admit, it is a fundamental fact of the way that health care is funded in the United States and the way that health care statistics are gathered that the best of projections are crude estimates. What statistics are available point to the fact that the total market for any one product is small. This market is rendered smaller because not all members of that market are in the marketplace at one time, or even interested in the new product.</p> <p>A new product must compete for a share of the market with existing products that do the same thing. It should be kept in mind that few, if any, developments are so radically different as to have no potential competiton for market share. The price at which established products are sold limits the price for which a new product can be sold. For a new product to rapidly gain market share, it must be reasonably priced versus the competition, potentially much better than the competition, and current users must be very dissatisfied with the competing product.</p> <p>On a practical level, the people to whom a product must be marketed are not the ultimate consumer, but the prosthetist-orthotist who will render that product into a form suitable for a particular patient, and who must also frequently convince the physician to prescribe the device.</p> <p>At any one time, there are said to be about 2,000 practicing prosthetists-orthotists; that is hardly a mass market. Prosthetists-orthotists as a group are not the easiest group to introduce to a new product. Most of them have experience with one or more products that, despite the manufacturer's best efforts, were released before all the problems were worked out. Like the car buyer who chooses not to buy a car during its first model year, they prefer to wait and see. Others, while interested in trying a new product are "waiting for just the right patient." On the other hand, a disconcerting number are all too ready to rush in without thought.</p> <p>Battling for preeminence in every prosthetist-orthotist's lexicon of adages to live by are the two:</p> <ol> <li> <p>If all else fails, read the instructions.</p> </li> <li> <p>Don't force it, get a bigger hammer.</p> </li> </ol> <p>Every manufacturer can recount instances of practitioners who provided a device to a patient for whom it was specifically contraindicated, or who neglected one or more crucial precautions in fabricating the completed device. This can result in a wave of negative word of mouth publicity despite a manufacturer's best efforts to promote a new product and educate the profession about its proper use. The end result may be passive indifference, or active rejection whatever the positive merits of a new device are when it is properly prescribed and utilized.</p> <p>A developer of a new object has a vested interest in making it work successfully and will go to considerable pains to make it do so. It is a well recognized fact that a product, when transferred to even the best motivated and prepared practitioners, seldom works as well as it does for the developer.</p> <p>In summary, then, the following points can be made:</p> <ol> <li> <p>The following factors are sizable expenses:</p> <ol> <li> <p>Research and development of the original idea to a workable prototype</p> </li> <li> <p>Production design</p> </li> <li> <p>Tooling</p> </li> <li> <p>Manufacturing</p> </li> <li> <p>Quality control and testing</p> </li> <li> <p>Marketing</p> </li> </ol> </li> <li> <p>Considerable uncertainty surrounds the business of gauging market size and reception for a new product.</p> </li> <li> <p>However well an object sells, the field of prosthetics and orthotics can hardly be said to constitute a mass market of sizable proportions.</p> </li> <li> <p>Experience has repeatedly shown that it takes three years to achieve a profitable volume of sales once a new product is introduced.</p> </li> </ol> <p>The result of these facts is that the manufacturers of items for use in the prosthetic and orthotic market are confronted with the need to make sizable initial investments for a rather small market that is oftentimes slow to adopt new products of even the greatest merit. Considerable uncertainty surrounds the decision to make the investment and it can take many years for a return on the investment to be realized and the decision to be vindicated. Given these facts, it is understandable that manufacturers differ from developers and their backers about the utility and acceptability of many developments, and that they are slower to adopt new products than others might wish.</p> <em><b>*Charles H. Pritham, CPO </b> Technical Coordinator, Durr-Fillauer Medical, Inc.</em><br /><br /><em><b>*Carlton Fillauer, CPO </b> Vice President, Durr-Fillauer Medical, Inc., Orthopedic Division, 2710 Amnicola Highway, Chattanooga, Tennessee 37406.<br /><br /></em><br /> <div style="width: 400px;"></div> Page Number(s) 4 - 6 Year 1984 Volume 8 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource From Research Lab to Consumer: The Manufacturers' Point of View Creator An entity primarily responsible for making the resource Carlton Fillauer, CPO * Charles H. Pritham, CPO * https://staging.drfop.org/files/original/fcf5e10ffc3bff3cb89b517eb63ea5a2.pdf 0b8215ed539490f64e8cf75633dbb151 https://staging.drfop.org/files/original/5df5af90029daa1b7947c5ee33d08bc8.jpg 949b68f099a2ded1f6d45b1a93835af6 https://staging.drfop.org/files/original/e885e588918c3f3ed5fed4be446f6515.jpg 9c9edb182b521a4f3c55907aac2c12c4 https://staging.drfop.org/files/original/8ae9ef1f9e51a1ffe5839ee578fde9ec.jpg 3e30a207b5d92d01eaba842dbb9ce17e https://staging.drfop.org/files/original/dc315daacc177135b612f6d9d75dac9f.jpg 80cbacdea646e05d40116aa522d6538c https://staging.drfop.org/files/original/d6a0e71d869fdf811919200fc92af175.jpg 8af7b934c360f7d8be36455e7d27b56d https://staging.drfop.org/files/original/dcd15d5b2cb3600bbb9a16ceee230a8a.jpg b4bee6b427deadb2481ef102215ea90d https://staging.drfop.org/files/original/fbab7c843102fc1a6a56f0387d6474e7.jpg eecb06f6a79e8bf93b309fd4571aa73e https://staging.drfop.org/files/original/a36d8df923391175c131cc2503b2ad4f.jpg f12d7502edc79a9815ea0effa5a61252 https://staging.drfop.org/files/original/65c39b075e4ed74821b311f1425e07fe.jpg 33cdcc9406cbfccab6083b95a496cd32 https://staging.drfop.org/files/original/7ad63a3c7138be2c4aeadf85e67c3352.jpg 7f4f5ea9d217ef6cb6424c830141f675 https://staging.drfop.org/files/original/2c83de4880188f302b29099589602a5f.jpg c8b1c39cf8255f9580c8abf663fd469e https://staging.drfop.org/files/original/ae139375a47c70c260990878a1f0ae09.jpg 9e529d7b3beb3edc4fb97f0b018934f9 https://staging.drfop.org/files/original/dddd1109e0786871b6890b901ad89193.jpg f0c7d156e4cf6e475c16a3ffd9013a96 https://staging.drfop.org/files/original/43b8b6068ae6129c2d30f9f07c50ffce.jpg a10cd2406b8ed3c261645d2669705d61 https://staging.drfop.org/files/original/6fc43a0cc84ce447ae02214678f3688f.jpg f11a6615dd5d7161c615453a358094c1 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_01_035.pdf Year 1955 Volume 2 Issue 1 Page Number(s) 35 - 60 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_01_035.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_01_035.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>Functional Considerations in the Fitting of Above Knee Prostheses</h2> <h5>Charles W. Radcliffe, M.S., M.E. <a style="text-decoration:none;">*</a><br /></h5> <p>In the fitting of any artificial limb, the goal of the prosthetist is simply to restore to the amputee the ability to perform everyday activities in an easy, natural, and comfortable manner. The basic requirements are therefore three in number-comfort, function, and appearance, the latter embracing both cosmetic appearance and appearance in use. Unless a prosthesis is reasonably comfortable, the amputee will be unable to wear it. Unless it performs the necessary functions with reasonable ease and dexterity, the amputee is not apt to find the device very useful. Unless it is reasonably acceptable cosmetically, and unless it can be operated in a natural manner, the limb is likely to be disagreeable both to the wearer and to his friends and associates. But this seemingly simple set of requirements is vastly complicated by the fact that the three are all mutually interrelated. That is to say, the degree of satisfaction attained in one condition is influenced greatly by the situation prevailing with respect to the other two. Cosmetic appearance, for example, is necessarily limited by details of mechanism, and vice versa. No matter how elaborate a prosthetic device may be, it cannot be made to function properly unless it can be manipulated with ease and without discomfort. And conversely, no device can be comfortable in use unless its functional characteristics are properly integrated with the residual biomechanics of the wearer. Any change aimed at improvement in one condition unavoidably affects the other two-sometimes favorably, sometimes unfavorably.</p> <p>In the lower extremity, cosmesis presents no serious problem. Since it is comparatively easy to fashion an artificial leg to an external shape and appearance more or less like that of its normal counterpart, and since in both sexes the lower extremity may be concealed beneath some sort of clothing, the actual cosmetic properties of a lower-extremity prosthesis amount to refinements to be added after all other requirements have been met. More critical in the lower extremity are comfort, function, and appearance in use. The leg prosthesis is in almost constant service, and it must provide both adequate support and a natural-appearing gait with as modest consumption of energy as possible. In fitting an above-knee limb, therefore, correct practices based on established biomechanical principles are mandatory if success is to be had.</p> <p> Because during all activities the suction-socket above-knee leg<a></a> is controlled by the amputee through the use of remaining hip musculature, every effort must be made to ensure that these muscles are used to the fullest possible extent without causing discomfort. The intent here<a style="text-decoration:none;">*</a> is to present the basic concepts that apply to the fitting of all above-knee prostheses, regardless of type of suspension, but which have particular application to the suction-socket above-knee leg. Although the details of fitting must necessarily be modified as dictated by the individual case, the basic features apply to all cases.</p> <h3>The Principles of Above-Knee Alignment</h3> <h4> Mediolateral Stability</h4> <p>When one watches the walk of a typical above-knee amputee, two characteristics of gait often are particularly apparent. First, sidesway, <i>i.e.,</i> lateral movement of the torso from side to side, is exaggerated. Second, the amputee usually walks with his feet farther apart than does a normal individual of similar build. The average individual walks in such a manner that the lateral distance between successive points of heel contact is from 2 to 4 in. In order for the gait of an amputee to appear as normal as possible, therefore, he must walk with a base equally narrow. The amputee with a walking base of from 6 to 12 in. never can achieve a normal gait appearance. If such an amputee is asked why he walks with a wide base, he usually gives as the reason that it is more comfortable or that he feels more secure with his feet farther apart. </p> <p>This circumstance is accounted for by the fact that, as an amputee attempts to walk with his feet closer together, certain functional requirements are placed upon the fit of the socket and upon orientation of the socket in space. In general, these requirements are not fulfilled in a prosthesis aligned for a wide-base gait. If an attempt is made to use such a prosthesis with a gait of narrow base, difficulties arise because certain forces come into play that cannot be accommodated by the stump in a comfortable manner. Although a poorly fitted prosthesis may be reasonably comfortable for many months provided the amputee walks so as to compensate for errors in fit and alignment, the same prosthesis may be very uncomfortable if the wearer attempts to change to a more normal-appearing gait. It is, however, possible to construct for the average above-knee amputee a prosthesis that allows a reasonably normal gait, that is comfortable in all normal activities, and that eliminates common points of stump irritation such as those in the crotch area and near the end of the femoral stump.</p> <h5> <i>The Weight-Bearing Line</i> </h5> <p>One of the most common terms used by the prosthetist in the fitting and alignment of an above-knee prosthesis is the "weight-bearing line." It serves as the guide for many phases of setting up the prosthesis, but its exact position is subject to considerable difference of opinion. One prosthetist may use a weight line drawn from the ischial tuberosity through the center of the ankle joint; a second may select a line falling along the medial side of the foot; and a third may advocate use of a line drawn from the geometric center of the socket at the ischial level to the center of the heel. It is possible to get many other definitions of the weight-bearing line. As a matter of fact, they probably are all equally helpful in the alignment of prostheses. In considering the manner in which the weight-bearing line is used, it becomes apparent immediately that such a line actually serves as a "reference line" or "construction line."</p> <p> In the discussion that follows, the term "weight line" is used to establish a mental picture of a theoretical line in space along which the force of the body weight acts. This concept differs from "weight-bearing line" in that "weight" is due to the gravitational attraction of the earth, whereas "weight-bearing" refers to the transmission of a force through the structural elements of the anatomy and the prosthesis. Although it would appear difficult to establish any one line which accounts for the net effect of the weight of the various and widely separated parts of the anatomy, that can be done in a theoretical, idealized way by defining a point within the body at which the effect of all body weight can be assumed to be concentrated. This point is usually designated as the "center of gravity" of the body as a whole. With all the weight assumed to be concentrated at the center of gravity, the body weight must then always be considered as acting directly downward from this point, as though it were a plumb bob suspended on a string hanging from the center of gravity. The string would represent the body weight line. A short definition of the weight line as shown in Figure <i>A</i> might read as follows: <i>The weight line of the body is a line through the center of gravity along which the body weight can be assumed to act vertically downward at all times.</i> </p> <h5> <i>Variations in Vertical Force</i> </h5> <p>Thus far we have considered only the effect of the body weight acting downward. For either an amputee or a person with two good legs, the body weight must be supported by the contact between foot and floor. For many reasons, the force of contact between foot and floor is very difficult to measure accurately because, for either foot, the contact force is extremely variable over the short time the foot is supporting weight. Shortly after the heel strikes the floor, the leg receives an initial load which, because of the slight reduction in the rate of progression of the body as a whole, quickly increases to a value greater than body weight. During the mid-portion of the stance phase, as the center of gravity of the body is reaching the lowest point in its path of motion, the load on the leg decreases to a value somewhat less than that of body weight. As the body is being elevated and propelled forward into the next step, the load builds up again to a value greater than that of body weight.</p> <h5> <i>Forces in Shear</i> </h5> <p>While all this is occurring, the person also is swaying from side to side and varying in speed slightly as he walks. This condition requires that the contact force must also provide some horizontal frictional forces along the floor, as everyone has realized after slipping on ice or when making a sharp turn. The forces acting on the foot during walking are, then, of two kinds-those acting perpendicular to the floor, which support the body weight, and those acting parallel to the floor, which are necessary to provide resistance to the impetus of the body moving forward, backward, or sideways.</p> <h5> <i>Floor Reaction and Load Line</i> </h5> <p> The total force exerted on the sole of the foot-the combination of all these effects-is known as the "floor reaction." It acts along the same line as does the total force exerted by the amputee on the socket of the prosthesis. The floor-reaction force is the load which the leg, whether normal or prosthetic, must transmit upward from the floor. In general, the line of these forces, known as the "load line" ( <b>Fig. 1</b> <i>B),</i> is not perpendicular to the floor but is directed upward, inward, and forward or backward with an inclination that varies continually during the time either foot is supporting the body. It is very definitely not a line drawn from the center of the hip joint through the knee and ankle joints. A line so drawn should, instead, be designated as the "mechanical axis of the lower extremity." </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 1. Definitions in alignment of the lower-extremity prosthesis. A, The "center of gravity" of the body is a point at which all body weight can be assumed to be concentrated. The effective body weight passes through the center of gravity and acts vertically downward along the "weight line." B, The "load line" is a line along which the force between the foot and the floor acts. In general, it is not perpendicular to the floor surface, since this force has two effects. First, it supports the body weight in a vertical direction, and second, it provides the horizontal forces necessary to cause motion of the body in the forward and medial directions. C, The "support line" is a vertical line along which the effective supporting force exerted between the rim of the socket and the stump of the amputee is assumed to act. In general, the support line does not pass through the center of gravity or through the center of foot pressure.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5> <i>The Support Line</i> </h5> <p> An additional necessary concept is that of the "support line" (<b>Fig. 1</b>). In order to define the support line, it is necessary first to identify a "support point," which may be defined as the center of action of all the vertical supporting forces at the top rim of the socket, including the ischial-bearing force, support in the gluteal region, and support in other weight-bearing areas around the socket rim. Where such a point lies is very difficult to establish, its actual location depending largely upon the individual prosthetist's methods of fitting. In a typical ischial-bearing socket, the support point is probably somewhere anterior and lateral to the point of contact of the socket with the ischial tuberosity. The support line is defined as a vertical or plumb line, passing through the support point, along which the effective supporting force between the socket rim and the stump can be assumed to act. In general, the support line coincides neither with the weight line nor with the load line. </p> <h5> <i>Use of the Hip Abductors</i> </h5> <p> <b>Fig. 2</b> presents a rear view of an above-knee amputee, walking with a narrow base, at an instant during the walking cycle when the full weight is carried on the prosthesis. During the stance phase, the amputee, like the normal individual<a></a>, keeps his pelvis horizontal primarily by action of the hip abductors on the supporting side, as shown by abductor tension in <b>Fig. 1</b>. If, for one reason or another, the hip abductors are unable to exert the necessary force, the pelvis has a tendency to drop toward the unsupported side. When, therefore, the above-knee amputee stands upon his prosthesis, his pelvis may tend to drop toward the normal side owing either to inadequate hip abductors or to inadequate support on the lateral side of the stump-support which is necessary to stabilize the femur and to form a firm base for action of the hip-abductor musculature. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 2. Use of the hill abductors for lateral stabilization of the pelvis.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Dropping of the pelvis toward the normal side generally results in an increase in pressure in the crotch area. It often allows the pubic ramus to come into contact with the medial wall of the socket and .an therefore be extremely uncomfortable. Anticipating this action, the amputee makes appropriate compensation. He maintains his balance either by leaning over the prosthesis, which results in the familiar amputee list, or by walking with a wide base and swaying from side to side. In the alignment of an above-knee prosthesis, then, one of the most important objectives is to construct the prosthesis in such a way that the hip abductors may be used in a normal and comfortable manner to prevent this tendency toward pelvic drop, torso list, or sidesway, and to allow a reasonably normal and comfortable gait.</p> <h5> <i>The Pelvic Lever</i> </h5> <p> As indicated in <b>Fig. 1</b> <i>A</i>, the center of gravity of the body is defined as the point at which the entire weight would have to be concentrated were it to have the same effect on the body as a whole as does the actual weight distribution. On the strength of this concept, the pelvis can be assumed to act as a lever in the stance phase while the amputee supports his weight on the prosthesis <b>Fig. 3</b>. Using the ischium as a supporting pivot or fulcrum, the pelvic lever supports the body weight (which acts vertically downward through the center of gravity and along the weight line) by the balancing action of the hip abductors, the process being similar to normal hip action in which vertical support is through the hip joint. If this lever action is to prevent dropping of the pelvis toward the unsupported side, the tension in the hip abductors must be sufficient to balance the body weight. The abductor muscle force can perform this function only if abduction of the stump is prevented by firm contact against the lateral wall of the socket. Otherwise the muscle action would simply cause abduction of the femoral stump inside the socket. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 3. Lever action of the pelvis in stabilization of the torso.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5> <i>Distribution of Lateral Pressure</i> </h5> <p> The necessary stabilization of the stump against the lateral wall of the socket can be accomplished comfortably if the stabilizing pressure is distributed widely over the lateral side. For a stump of average length, stabilization is achieved by fitting the lateral wall snugly over its entire length. A slight flattening of the lateral wall, with relief near the distal end of the femur, usually ensures that the stabilizing forces are not only comfortable but that they are directed medially as required <b>Fig. 2</b>. If, with the stump improperly supported against the lateral wall, an attempt is made to use the hip abductors for pelvic stabilization, the result may be a gap around the lateral brim and a painful concentration of pressure near the end of the stump. </p> <h5> <i>Considerations of Mechanical Advantage</i> </h5> <p> Two other factors enter into the lateral stabilization of the pelvis by the hip abductors. First, in balancing the body weight on the ischial fulcrum, the tension in the hip abductors has greatest mechanical advantage when the lever arm between the abductor tension and the support point is as long as possible. Support of a substantial portion of the body weight by the ischial seat and of a smaller amount by the gluteal musculature gives the abductor tension sufficient mechanical advantage to balance the body weight with little or no conscious effort on the part of the amputee. The characteristics of this lever system are shown in the schematic diagram of <b>Fig. 3</b> , where the required tension <i>T</i> is reduced by decreasing the distance <i>x</i> and increasing the distance <i>y.</i> </p> <h5> <i>Adduction of the Stump</i> </h5> <p> A second factor in making allowance for normal use of the hip abductors is the degree of stump adduction in the socket. The "rest-length" theory of muscle action<a></a> has shown that the muscles of the body act most efficiently when they are at approximately their normal rest length. To make the action of the hip abductors efficient, the stump, when fitted in the socket, must be adducted in such a manner that the outward movement of the femur within the muscle mass of the stump is anticipated and that the normal pelvic-femoral angle is maintained as closely as possible while the body weight is being supported on the prosthesis. For the average amputee, this requirement can be met in a practical way by aligning the medial wall of the socket perpendicular to the floor, the lateral wall being sloped definitely inward. Although exceptions are necessitated on the basis of stump length, the short stump being aligned with less adduction, every effort should be made to adduct the stump as much as conditions permit. </p> <p> An additional advantage of alignment in adduction becomes apparent immediately. As a result of the accompanying decrease in tension of the adductor musculature, pressure in the crotch area is decreased. As a result of this relaxation, the pressure in the crotch or medial area (<b>Fig. 2</b>) is then predominantly lateral rather than vertical and no longer causes painful pressure on stretched adductor tendons or in the region of the ramus. It should be emphasized here that a socket properly fitted and aligned carries little or no weight on the medial wall. </p> <h5> <i>Foot Position</i> </h5> <p> Alignment of the foot in a medial position, a fundamental consideration if the amputee is to walk without excessive sidesway or torso list, helps to ensure that the body weight will be borne chiefly on the ischial seat. The average amputee walks well with the centerline of the foot located directly below the ischium during the time the prosthesis is supporting the entire body weight. But this rule-of-thumb, illustrated by the reference line shown in <b>Fig. 2</b>, must vary depending upon the capacity of the amputee to use his hip abductors. If an amputee with a very short stump attempts to use it for lateral stabilization, he cannot tolerate the increased and usually localized pressure resulting from the short stump length and the concentration of force in a small area. He must, therefore, walk with more limited use of his hip abductors, and compensation is effected by leaning over the prosthesis to shift the weight line closer to the support line and by walking with a wider base, an expedient which increases lateral stability but leads to excessive sidesway. Because of these factors, and because of the probability in such cases of some degree of abduction contracture, the amputee with a very short stump should have his prosthesis aligned to accommodate a gait of wider base. </p> <h5> <i>Recapitulation</i> </h5> <p>In summary, mediolateral stabilization of the pelvis accompanied by a decrease in the amount of sidesway and list can be achieved by alignment of the foot in a medial position relative to the socket, by fitting the stump in an adducted position where possible, and by providing firm support for the stump against the lateral wall of the socket to allow efficient use of the remaining abductor musculature of the hip.</p> <h4>Knee Control</h4> <h5> <i>Involuntary Control</i> </h5> <p> Generally, the tendency of the articulated knee joint of the above-knee prosthesis to collapse under load is controlled involuntarily through alignment or by mechanical devices which lock or restrain flexion while the body weight is being transferred through the prosthesis.<a></a> Although involuntary control is desirable as an aid in achieving a smooth and natural-appearing gait, a proper balance must be obtained between the amount of involuntary and voluntary control of knee stability, taking into account the amputee's coordination and age and the condition of his stump. </p> <p>Involuntary control of knee stability during weight-bearing is made possible by so placing the knee axis that it is at all times posterior to the load line of the prosthesis<a></a>. A prosthesis with the socket placed well forward on the knee block or aligned in hyperextension and with the knee joint located posterior to the ankle joint is said to have a high degree of "alignment stability." That is to say, under load the knee joint is forced to extend until the extension stop makes contact and prevents further motion. This expedient often is necessary for amputees who have a fear of falling or when it is required because of age, insufficient stump power, excessive weight, or the prevailing terrain. But it has the disadvantage of making the prosthetic knee hard to flex under even a light load and thus results in poor gait and difficulty in negotiating stairs and slopes. </p> <h5> <i>Voluntary Control</i> </h5> <p> An attempt should therefore always be made to minimize the amount of involuntary alignment stability and to provide for a maximum of voluntary knee control by stump action because this type of functioning results in the smoothest and most effortless gait possible. The average above-knee amputee has a reasonable amount of strength remaining in his hip flexors and extensors and is able to extend and flex his stump throughout an appreciable range of motion, and it is important that the fullest use be made of this musculature in voluntary control of knee stability. That this control may be exercised in the most efficient manner possible, the stump should never approach the limits of its motion as the amputee performs normal activities. If, for example, the stump is able to extend a maximum of 20 deg. to the rear, then at push-off any forced extension in excess of the 20 deg. results in a forward rotation of the pelvis. To compensate for such a forward pelvic rotation, the amputee must arch his back, an expedient which leads to the development of lordosis. Alignment of the socket in a position of initial flexion, as shown in <b>Fig. 4</b>, eliminates much of this difficulty. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 4. Influence of alignment on control of knee stability, socket aligned in initial flexion to avoid exces. sive pelvic rotation.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h5> <i>Initial Flexion</i> </h5> <p>When the socket is aligned with initial flexion, several other advantages become apparent. Since the length of the hip extensors is increased by the additional degree of hip flexion, the amputee has greater control of knee stability during the entire stance phase of the walking cycle. Since the extensor muscles are thus elongated slightly, they are able to develop the required tension easily. With much less conscious effort on the part of the amputee, therefore, the stump is able to exert the force necessary to keep the prosthetic knee back against its extension stop.</p> <p> Again, in an amputee with overdeveloped hamstring musculature there often is a tendency, as the stump extends at push-off, for the muscles to force the tuberosity of the ischium off the ischial seat, thereby causing pressure on the hamstring muscle and attachments and against the anterior brim of the socket. Initial flexion of the socket reduces this tendency and allows a portion of the body weight to be borne comfortably upon the hamstring attachments.<a style="text-decoration:none;">*</a> </p> <p>If the same degree of alignment stability is to be maintained, initial flexion of the socket must be accompanied by a shifting of the socket anterior to the knee axis. Merely changing the extension stop to decrease knee extension never can achieve the desired end-results. But less alignment stability is necessary under these conditions because of the increased voluntary control of the knee. Anterior positioning of the socket relative to the knee axis allows the prosthetic knee to be flexed a great deal more easily as weight is transferred from the prosthesis to the normal leg at the end of the stance phase. The result is a smoother gait. Although increased use of the hip extensors owing to their greater working length produces some decrease in the power available in the hip flexors, the loss is not serious since during ordinary activities the hip flexors never approach the limit of their range of flexion and since the force requirements are small as compared with those of the hip extensors.</p> <h5> <i>Ankle Position and Toe Break</i> </h5> <p> Another important factor in achieving the proper amount of knee stability is the fore-aft position of the ankle joint relative to the knee joint. For the active above-knee amputee, it usually is desirable to have the ankle joint directly below or slightly posterior to the knee joint, as shown in <b>Fig. 4</b>. Such an arrangement has several effects. First, as the foot is moved to the rear, the distance out to the toe break decreases to give the foot more of a "rocker" action and to allow the knee to flex easily at the end of the stance phase. Second, the major portion of the weight can be carried on the ball of the foot while standing. And third, the amount of toe clearance during walking is greater for a given angle of knee flexion. To move the ankle joint too far to the rear, however, results in instability at heel contact and excessive shortening of the stride. </p> <p> Many of these advantages can be achieved by use of a double toe break <i>(i.e.,</i> a flexible forefoot), which also gives the foot more of a rocker action and decreases the amount of vaulting over the prosthetic foot. But too much flexibility or too short a distance from ankle to toe break causes the leg to feel too short at the time of push-off. </p> <h3>Dynamic Alignment</h3> <p>For the major part of the time that the amputee is supporting himself on the prosthesis during the stance phase, the motions are relatively smooth, and the forces act on the prosthesis in essentially the same way as if the amputee were standing still with all weight carried on the artificial leg. During the swing phase, however, and during the times of transition from stance to swing and from swing to stance, the behavior of the prosthesis is influenced largely by dynamic forces varying rapidly with time. It is often relatively easy to fit an amputee so that he is comfortable in the stance phase, but in many cases it is more difficult to construct the prosthesis so that the amputee is able to walk with a smooth, natural-appearing, effortless swing-through. The first requirement for a smooth swing phase is a smooth transition from stance to swing, since, if the prosthesis is to swing properly, it must be given a good start.</p> <h5> <i>Knee Stability and Toe Break</i> </h5> <p>Of particular importance during these transition periods are knee stability, as affected by alignment and by the stiffness of dorsi-fiexion and plantar flexion at the ankle, and the combined effect of toe-out and orientation of the toe break in the foot. For security, the knee axis should be positioned far enough behind the hip-ankle line so that the amputee is conscious of a stable knee while standing. The amount of security desired depends upon the particular amputee. If, as the amputee attempts to walk, the knee feels insecure, the dorsiflexion position and stiffness in the ankle should be investigated as a possible additional cause of knee instability.</p> <p>In general, placing a stiff dorsiflexion bumper in the ankle and having the foot plantar-flexed in the neutral position, close to the point where the amputee has the sensation of "walking over a hill," produces the most desirable knee stability and allows smooth flexion of the knee at the start of the swing phase. The amount of toe-out usually is adjusted to the individual amputee. In all cases, however, the toe break should be at right angles to the line of progression to prevent insecurity resulting from the rapid shifting of the center of pressure during push-off.</p> <h5> <i>Whip in the Swing Phase</i> </h5> <p> One of the more obvious indications of poor dynamic alignment is the so-called "whip" of the prosthesis during the swing-through (<b>Fig. 5</b>). This lateral movement of the knee accompanied by medial movement of the foot, or vice versa, usually is caused by an incorrect amount of adduction for the particular socket being fitted, an improper angle of the knee axis with respect to the frontal plane, the natural tendency of the femoral stump to twist inward as it is brought forward, or a combination of these factors. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 5. Common indications of incorrect alignment. A, Whip of the prosthesis during the swing phase. B, Mediolateral instability. C, Rotation at heel contact. For specific causes of these difficulties, see Radcliffe (10).</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>An above-knee prosthesis often is "knocked" at the knee to position the foot laterally for greater stability while standing. Sufficient two-leg standing stability thus can be attained, but a stable, narrow-base gait is not then possible. The tendency of the prosthesis to whip also is aggravated because, as it swings like a pendulum, the leg has a natural tendency to swerve medially after toe-off and then to swerve out again just before heel contact. A prosthesis having the foot aligned medially for a narrow base during the stance phase need only move forward in a straight line from toe-off to heel contact.</p> <h5> <i>Rotation of Knee Axis</i> </h5> <p> Studies of normal human locomotion<a></a> show that the femur rotates an average of 3 to 4 deg. medially as the hip is flexed to bring the knee forward. Medial rotation of the femur causes a lateral displacement of the foot, as can be verified easily by observation of a person standing and flexing the hip while the shank hangs vertically. Accordingly, the knee axis in an above-knee prosthesis usually is rotated laterally to compensate for the tendency of the femur to rotate medially as the hip is flexed.<a style="text-decoration:none;">*</a> When the prosthetic knee axis is aligned in a position laterally rotated with respect to the socket, the foot moves somewhat medially with knee flexion, thus compensating for lateral movement of the foot caused by the medial rotation of the socket during the swing phase and allowing the foot to travel in a straight path. </p> <h5> <i>Ankle Stiffness</i> </h5> <p>The stiffness of plantar flexion at the ankle determines, to a large degree, the stability of the knee at heel contact. A stiff ankle does not allow the foot to rotate forward into the stable flat position and thus tends to cause the knee to buckle forward as the weight is transferred to the prosthesis. An ankle joint with insufficient plantar-flexion stiffness, however, allows the foot to slap at heel contact. A proper balance between these two effects must therefore be attained for the individual amputee. Proper swing-through is achieved by proper dynamic alignment, which, in turn, is effected by a comfortable, stable, and functional prosthesis in the stance phase; a smooth transition from stance to swing phase; proper ankle stiffness; and adjustment of the knee axis in lateral rotation to compensate for medial rotation of the stump during hip flexion.</p> <h4>Socket Shape and Orientation</h4> <p>Considered thus far are the means by which the amputee can make most efficient use of the remaining hip musculature to control body movements and to control the prosthetic knee during the stance and swing phases. There are, however, many functional details of socket shape and fit which make it possible for the amputee to derive these benefits comfortably.</p> <h5> <i>The Lateral Wall</i> </h5> <p>As already indicated, for the amputee having sufficient stump length and power, sidesway and leaning over the prosthesis during the stance phase can be eliminated almost entirely by making provision in the socket for full use of the remaining abductor muscles of the hip, primarily the gluteus medius. This can be achieved in two ways. First, the stump is adducted in the socket so that the lateral wall is sloped downward and inward, the medial wall remaining essentially vertical. Second, a slight flattening of the lateral wall, and undercutting for relief of pressure points where necessary, ensures a comfortable distribution of the pressure directed medially against the stump. The hip abductors then can develop tension as needed because the excursion of the femur is blocked comfortably against the lateral wall of the socket. If, after the fit of the lateral wall is considered satisfactory, the socket is too tight, relief should be provided along the medial wall of the socket to avoid disturbing the fit required to block excursion of the femur.</p> <h5> <i>The Anterior Wall</i> </h5> <p>The lateral pressures, acting with the horizontal counterpressures in the upper portion of the medial wall, tend to maintain the ischium on its seat medially. To hold the ischium in place still more firmly, it is necessary to provide stabilization at the front of the socket. Accordingly, the anterior wall of the socket should fit the stump firmly in the area of Scarpa's triangle, and a very accurate measurement should be made of the distance from the ischial tuberosity to the tendon of the adductor longus so that the anteromedial apex may be fitted snugly around the adductor tendons. The socket brim should be rounded and fitted high on the anterior side. If fitted properly, the anterior brim usually can be brought up to the level of the inguinal crease without producing discomfort when the wearer is seated. The actual height of the anterior brim varies with the individual and is limited by contact with bony prominences. It usually extends from 2 to 2-1/2 in. higher than the ischial seat, but it should extend at least high enough so that the brim will press into the abdominal muscles rather than pinch a roll of flesh near the top of the stump. Distributed over the upper portion of the entire anterior wall of the socket, such anterior counter-pressure easily can prevent the ischium from sliding into the socket and can prevent the discomfort that would result in the crotch area.</p> <h5> <i>The Adductor Region</i> </h5> <p>Incorporation of the proper distance from the adductor tendons to the ischial tuberosity, combined with a well-fitted, high, anterior brim, usually eliminates entirely any unwanted pressure in the crotch area. Some lateral counterstabilization by pressure in the crotch area is unavoidable, but it should be predominantly by lateral rather than by vertical pressure, and it can be tolerated comfortably if distributed over the widest possible area. Flattening the medial wall of the socket is one means of ensuring a comfortable distribution of pressure in the adductor region.</p> <h5> <i>The Anteroposterior Dimension</i> </h5> <p>Weight-bearing in the gluteal region makes it possible to reduce the size of the ischial seat. If the anteroposterior dimension is shortened, the socket may be widened in the mediolateral dimension, a feature having several advantages. First, it allows a greater area for gluteal weight-bearing on the posterior rim of the socket. Second, the ischium is moved laterally, allowing the ramus to be carried within the brim of the socket and thus easing a major source of irritation. Finally, because the ischium bears no weight in the posteromedial apex, there is less tendency for crowding of the adductor and hamstring musculature. Relaxation in this area owing to stump adduction also helps to relieve uncomfortable vertical pressures.</p> <h5> <i>Shape at Ischial Level</i> </h5> <p> As a result of these functional requirements, the socket shape shown in <b>Fig. 6</b> has evolved. When coupled with the proper alignment, it has proved to be extremely beneficial to the average amputee. As with any method of fitting, variations in shape must be made in accordance with the muscular development and condition of the individual stump. The influence of muscular development at the ischial level is shown in (<b>Fig. 7</b>). </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 6. Anatomical features of an above-knee stump in weight-bearing, shown in cross section 1/2 in. below schial level.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 7. Influence of stump muscular development on socket shape at ischial level.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> Entrances of the adductor tendons in the anteromedial apex, shown as <i>A</i> in <b>Fig. 6</b>, can be made more comfortable by a slight flaring of the socket brim in this region. Flaring of the socket brim in the hamstring area <i>B</i> has no function while the amputee is walking, but it contributes remarkably to his comfort while sitting. Many amputees experience a burning sensation while sitting because the hamstring attachments attempt to stretch over an ischial seat located high or medially, especially when the ischial seat has been placed diagonally across the posteromedial apex. The socket shape shown in <b>Fig. 6</b>, however, allows the ischial seat to be placed laterally to provide relief in the hamstring region and does not disturb the functioning of the limb during walking. </p> <h3>Construction of the Socket</h3> <h4>Stump Examination and Measurements</h4> <p>Before construction of an above-knee prosthesis is started, it is essential that a very careful evaluation be made of the amputee and his stump. A prosthesis may thus be planned and constructed to take full advantage of the individual patient's capabilities. Of particular importance is a thorough examination of the stump with regard to its functional characteristics. Answers to the following questions are helpful in planning the prosthesis, and they should be included in the examination data:</p> <ol> <li> What degree of stump flexion contracture is present? </li><li> What degree of stump abduction contracture is present? </li><li> Is the stump musculature soft, average, or hard? </li><li> Is the hamstring group soft, average, hard, or prominent under tension? </li><li> Is the gluteal group soft, average, hard, or prominent with stump extension? </li><li> Is the stump contour along the lateral side convex, concave, or essentially flat? </li><li> Is the rectus femoris muscle prominent with stump flexion? </li><li> Is the adductor longus soft, average, or hard? </li><li> Is the ischium toughened, pressure sensitive, padded with muscle, or prominent? </li><li> Has the amputee been accustomed to ischial-bearing? </li><li> What is the amount and location of redundant tissue? </li><li> What is the extent, location, and adherence of scars? </li><li> Are there areas of prior irritation as shown by blisters, boils, pimples, scars, darkened skin areas, and so forth? </li><li> Are there areas which are sensitive because of bone spurs or other prominences? </li><li> Is there any prior history of edema? </li></ol> <p> In addition to this general information about the condition of the stump, which can be recorded on a form such as <b>Fig. 8</b> <i>8A,</i> the series of measurements indicated in <b>Fig. 8</b> <i>8B</i> should be recorded carefully. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 8A. Form used at the University of California for recording stump characteristics and measurements in above-knee fitting.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Planning the Socket Shape</h4> <p>After the information gathered during the examination is recorded, the limbfitter is ready to begin planning the prosthesis, a phase essential to proper fit. The socket contours and the over-all alignment to be incorporated into any lower-extremity prosthesis depend upon the interrelation of many factors. First, the amputee's general physical condition must be determined. Will the amputee be an active walker? Will ease of walking be more important than knee security, or vice versa? Has the amputee developed gait habits that require corrective training? Second, the stump must be evaluated on a functional basis. In terms of its potential usefulness in control of the prosthesis and of body movements, is it classed as short, medium, or long? Is there a normal range of motion in all directions? Are there any sensitive areas that restrict stump function? The answers to these questions affect the alignment of the prosthesis as well as the fit of the socket.</p> <p> It is important to plan for alignment before the socket contours are considered because the orientation of the socket on the stump and the alignment of the socket on the prosthesis may affect considerably the method of fitting the socket. Shown in <b>Fig. 8B</b> are some general features of alignment based upon the functional capacity of the stump-short, medium, and long. There are exceptions, of course, and these illustrations should serve only as a guide. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Figure 8B.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> After the general type of alignment has been decided upon, the necessary features can be incorporated into the orientation of the socket on the stump, a matter requiring a decision regarding the approximate amount of initial flexion and adduction to be anticipated in the final alignment. The socket contours are determined by reference to the information on stump muscle development recorded during the examination. <b>Fig. 7</b> shows a typical socket shape for an amputee of average musculature and indicates the variations possible with different types of stump muscle development. Undersize patterns for use in roughing out the socket contours are shown actual size in <b>Fig. 9</b> and <b>Fig. 10</b>. The dimensions shown along the medial side of the patterns are typical measurements of the distance from the ischial tuberosity to the anterior aspect of the adductor longus tendon. The perimeter measurements shown correspond to actual stump dimensions. But these patterns may require modification to provide for individual stump characteristics, an example of such a pattern modification being shown in <b>Fig. 11</b>. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 9. Variations in alignment to accommodate stumps of different functional lengths. With the short stump, the slow or hesitant walker, having limited use of the hip abductors and extensors, needs considerable alignment stability. The moderate walker, with stump of medium functional length, has average use of the hip abductors and extensors. Alignment for the long stump is for an active walker having good use of the hip abductors and extensors.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 10. Undersize socket patterns (shown actual size) for stump with soft or average musculature,</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 11. Undersize socket patterns (shown actual size) for stump with firm musculature.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Materials</h4> <p>The primary features required of a material to be used in making a suction socket are ease in forming to the proper shape, adaptability to a surface finish which is nonirritating and easy to keep clean, and ease in making alterations as required by changes in the stump. Wood and plastic laminates have, so far, proved to be the most satisfactory. But major changes in the size of the stump often take place during the first several months of wear. Hence, wood is recommended for the first socket because it is relatively simple to shape and allows alterations to be made as required. After the stump size is stabilized, a socket can be made of plastic laminates, which seem better than wood because of their flexibility, their ability to stand cleansing with soap and hot water, and their greater resistance to the action of perspiration.</p> <h4>Shaping the Wooden Socket</h4> <p> The three stages in shaping a typical socket are shown in <b>Fig. 12</b>. In the first, the posteromedial shelf is cut after laying out the socket pattern on the top of the socket block. The ischiogluteal shelf is cut in such a way as to be horizontal when the socket is oriented vertically in space. For the average socket, the medial wall is parallel to the vertical reference line ( <b>Fig. 2</b> ), and therefore the horizontal ischiogluteal shelf is cut at right angles to the medial wall of the socket. After the ischiogluteal shelf is cut, the missing portion of the socket pattern line is transferred down to the ischial level. </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 12. Modification of socket shape to accommodate individual stump characteristics.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The second construction stage shows the roughed-out socket, where considerable extra wood has been left above the ischial level to allow for the protrusion and flaring of the anterior brim in this area. The finished socket is shown in the third stage with all areas of the socket brim flared and rounded to prevent irritation of the stump, especially important in the anteromedial apex where the adductor longus tendon enters the socket.</p> <p> <b>Fig. 6</b> indicates the principle muscle groups and other anatomical features considered in preparing the patterns used as a guide in the preliminary layout of the socket outline. Because of the atrophy of certain muscle groups in the above-knee stump, and because the cross section shows the stump in the weight-bearing condition, the shape differs slightly from that of the normal. When the stump is bearing weight, it is necessarily compressed slightly in areas of relatively soft tissue which support load, such as the gluteal channel. </p> <h5> <i>The Lateral Wall</i> </h5> <p>The lateral side is always higher than the level of the ischial seat. In most cases, it is possible to extend it over the trochanter. To do so is especially important when the slump is short and when the height of the socket in this region may be required to maintain suction. If the muscular development requires it, the lateral side of the socket is, in some cases, undercut above the ischial level. Examination of the amputee determines the amount of undercut required, and, if it is necessary, it should be done with caution. The lateral wall should taper in acutely below the ischial level to provide adduction and lateral support for the femur upon weight-bearing above the distal end. Because the femur has been established as the body stabilizer during the stance phase, an undercut below the ischial level may distribute the pressure unevenly and thus allow most of the pressure to be taken at the top of the socket and near the distal end of the stump. The lateral wall should be shaped to fit the stump accurately and should, if necessary, be flattened to distribute the lateral-support pressure over a large area so that it can be tolerated comfortably.</p> <h5> <i>The Medial Wall</i> </h5> <p> The length of the crotch-line area that receives the adductor longus, gracilis, and adductor magnus muscles should be determined accurately by skeletal measurements. As indicated in <b>Fig. 11</b>, the measurement from the anterior aspect of the adductor longus tendon to the weight-bearing portion of the ischial tuberosity, less about half an inch, gives the approximate length of the medial side of the socket. In general, the upper third of the medial wall is flattened, and the superior brim is flared to prevent skin irritation. </p> <p>In almost every case, the crotch-line height varies with respect to the level of the ischial seat, but it should always be as high as is tolerable. In the typical socket, the crotch area is from 1/8 to 1/4 in. lower than the ischial seat. A pelvic tilt lowers the ramus of the ischium and may require a lowering of the medial side of the socket. In a properly fitted ischiogluteal weight-bearing socket, little or no weight should be borne on the medial side. From the ramus to the anteromedial apex, the medial brim can be raised as governed by comfort. If a medial adductor roll is present, the socket is enlarged slightly (never lowered) on the medial side to accommodate the excess tissue, which then is pulled into the socket and eventually diminishes.</p> <h5> <i>The Anteromedial Apex</i> </h5> <p> The socket shape at the anteromedial apex (<b>Fig. 6</b>) should conform to the contour of the adductor longus and gracilis muscles. The shape varies in each case, however, because these muscles form a cordlike tendon which must be fitted accurately. Tightness in this region, a common source of irritation in suction sockets, usually is caused by excessive length of the medial side of the socket. This condition allows the ischium to slide forward into the socket and to wedge the stump into the anteromedial apex. If tightness in the anteromedial apex persists, it is apt to be due to inadequate support of the stump across the anterior brim and down the anterior aspect of the adductor group. </p> <h5> <i>The Anterior Wall</i> </h5> <p>The primary function of the anterior brim of the socket is to maintain the ischium in place on the ischial seat so that ischial weight-bearing causes no discomfort. In many cases of amputees who are unable to tolerate ischial weight-bearing, the trouble can be traced to improper contact between ischium and socket. Ischial bearing on the edge of a flat ischial seat is especially uncomfortable. To maintain the ischium in place properly, considerable counterpressure from the front of the socket is required. Since, by and large, the portion of the stump in contact with the region of the anterior brim is soft tissue, some compression of the stump is necessary. This is accomplished by a flattening and inward protrusion of the anterior brim in the area of Scarpa's triangle.</p> <p>The upper portion of the anterior brim is fitted 2 to 2-1/2 in. higher than the ischial seat and with a generous flare along the superior brim. When the socket is fitted with such a "high front," the anterior brim can hold the ischium in place comfortably. The high front does not interfere with sitting or with the amputee's ability to bend over far enough to tie his shoes. As the stump is flexed, the higher brim of the socket is accommodated by the abdominal musculature and does not pinch a roll of flesh on the upper portion of the thigh. The brim should be lowered only as necessary to prevent contact with bony prominences such as the anterosuperior spine. A channel should be provided below the brim for the rectus femoris muscle, which usually becomes prominent with stump flexion.</p> <h5> <i>The Posterior Wall</i> </h5> <p>The back of an ischial-bearing socket deserves particular attention. Channelization for the gluteus maximus muscle depends on the individual, but, in most cases where there has been little atrophy or distortion, this region of the socket should be kept on the same level as the ischial seat with a gradual enlargement in the posterolateral apex. The gluteus muscle should carry a considerable amount of body weight on a flared socket brim.</p> <p>Relief for the adductor muscles or the crotch line often can be made by relieving the gluteus maximus. Too tight a fit over the gluteus maximus can cause crowding of the adductor muscles in the crotch section. If the space for the gluteus muscle is lowered and widened, the ischial tuberosity can be moved posteriorly and laterally on the ischial seat of the socket. Lowering this section, however, increases pressure on the ischial tuberosity and should, therefore, be avoided. Should additional room be needed within the socket, the lateral side of the gluteal region can be made wider. The gluteal area should be widened instead of cut deeper posteriorly because a deeper section forms a hump or radius on which the leg rotates during sitting and thus causes a burning sensation of the skin over the ischial tuberosity.</p> <p>The outside shape of the socket in the posterior region is important to sitting comfort, but no attempt should be made to complete its shaping until the inside has been made comfortable and until the leg has been aligned properly and tested by walking. After these things are done, the back then is flattened for comfort and alignment while sitting.</p> <h5> <i>The Ischial Seat</i> </h5> <p>The ischial seat cannot be overemphasized. It should be located accurately under the ischial tuberosity, and, in the determination of its location, individual variations in anatomy must be taken into account. The seat should be adequate but not so wide as to cause discomfort while sitting. Slipping of the ischial tuberosity either to the inside or to the outside of the seat, conditions which create a great deal of discomfort, can be prevented by shaping the bearing surface in such a way that the seat slopes slightly toward the inside of the socket to render it more comfortable. Sloping increases the radius of the edge of the ischial seat and lessens the burning sensation of the skin in this region.</p> <p>If the ischial seat is too prominent, or if the ischium rides on the edge of the seat, a jabbing sensation or a marked increase in pressure is felt near the end of the stance phase. Lowering the ischial seat allows more weight to be distributed to the gluteal region and, if the ischial tuberosity is located properly on the seat, results in less discomfort and a shorter break-in period.</p> <p>Amputees with highly developed stump muscles may not require a well-defined ischial seat. In some cases, the muscles may push the ischial seat away from the tuberosity of the ischium and cause the weight to be carried by the muscles around the top of the socket. Such a condition is not objectionable, provided that the socket is designed with proper modification of the ischial seat. Indeed, such a design may be necessary in unusual cases, as for example those with end-bearing stumps.</p> <h4>Special Considerations in the Suction Socket</h4> <h5> <i>Tightness of Fit</i> </h5> <p> In the case of the suction socket, better results are obtained by having proper contours than by having a tight fit .<a></a> If, in the course of donning the leg, much difficulty is encountered in removing the sock, the fit is too tight. The superior brim of the socket should fit the contour of the stump while the muscles are tensed, and the fit should be so accurate that the socket can be suspended for short periods by skin friction without the aid of negative pressure <i>(i.e.,</i> without a valve). </p> <h5> <i>Free Space Below the Stump End</i> </h5> <p>The volume of unoccupied space at the lower end of the suction socket is not critical in obtaining sufficient suction. In most cases, it is convenient to have approximately 2 in. of space below the end of the stump to provide room for installation of the valve and for elongation of the soft tissue. In general, the smaller the volume in the end of the socket the less the excursion, but in itself the amount of free volume has no significant effect on the magnitude of the negative pressure.</p> <h5> <i>End Bearing</i> </h5> <p>If it can be tolerated, end-bearing is recommended because it relieves the load on the ischium. Felt or foam-rubber padding placed in the bottom of the socket permits comfortable end-bearing, the thickness of the padding governing the amount of weight carried on the end of the stump. Although little free space remains in the socket, adequate suction and control are not affected. For example, Gritti-Stokes amputations, which are principally end-bearing, have been fitted successfully.</p> <h5> <i>Inside Finish</i> </h5> <p>No single recommendation is made regarding adequate nonirritating finishes. Industrial and perspiration-resistant lacquers common to the limb industry are being used routinely. Some subjects have reported slipping of the socket because of perspiration. In some cases, perspiration also has caused the lacquer finish to deteriorate and to produce a roughness resulting in skin irritation. In general, however, these industrial lacquers have proved satisfactory when applied according to manufacturers' specifications. In cases of excessive perspiration, the socket may have to be refinished every few months. Whenever perspiration creates a severe problem, the amputee should be referred to a dermatologist for possible treatment.</p> <h5> <i>Bottom Seal</i> </h5> <p>The bottom of the socket should be sealed with a piece of hard wood 1/8 in. thick or more, cut so that the surface goes along the grain, and sealed with a waterproof glue. The bottom may be given additional protection by applying a thin coating of one of the thermosetting plastics common to the limb industry.</p> <h5> <i>Control of Negative Pressure</i> </h5> <p>Several different types of valves have been used in suction sockets with good results. A simple type of plug valve with a manual suction release is satisfactory. Automatic expulsion valves permit some change of air in the socket, a beneficial feature during hot weather and at times when the amputee perspires. They have proved successful in all cases and are now in general use.</p> <p>The valve opening should be positioned for ease in removing the fitting sock when the leg is donned and for convenience in operating the manual control, and it should be placed where the distal end of the stump is least likely to touch the inner face of the valve. The optimum location is toward the front on the medial side below the stump end.</p> <p> The magnitude of the negative pressure or suction required to hold a suction socket in place is only slightly greater than the value given by dividing the weight of the prosthesis by the cross-sectional area of the stump near the distal end-in most cases about 1-1/2 lb. per sq. in. With the additional support given by contracting the stump muscles during each step, a negative pressure of 1-1/2 lb- Per sq. in. is sufficient. Some amputees prefer somewhat greater suction, with its accompanying feeling of security, but excessive suction may cause edema. A negative pressure greater than 1-1/2 lb. per sq. in. indicates the presence of forces tending to pull or push the leg off the stump. This action may occur when the stump muscles are contracted, or it may be caused by an improper fit resulting in constriction of the muscles. Use of a gauge for measuring the maximum negative pressure at the time of the rough and the final fittings serves as a check on the quality of fit and is essential to good and consistent results. </p> <p> Accurate records should be made of the variations in pressure inside the suction socket during normal walking. With the automatic expulsion valve now in general use, these records should show a small positive pressure during weight-bearing and a negative pressure when the leg is in the swing phase. ( <b>Fig. 13</b> ) is a record of the pressure variations in a suction socket during two complete walking steps, the valve used during this test permitting automatic exhaust starting at a positive pressure of 1/2 lb. per sq. in.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 13. Three stages in the construction of a wooden socket. A, Block cut to form posteromedial shelf. B, Roughed-out socket. C, Completed socket with inside finished and rawhide covering on outside.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p> The stiffness of the spring in the valve has, in itself, no direct effect on the magnitude of the maximum negative pressure. It does, however, allow a greater or lesser amount of air to be expelled with each step and thereby affects the amount of positive pressure developed during weight-bearing. Fairly high positive pressure within the socket during the stance phase generally is found desirable because it increases the pavex action of the socket on the stump, with consequent benefit to the circulation. High positive pressures help to control edema and to give the amputee a sense of "walking on air." But, as already mentioned, too great a positive pressure in the stance phase may tend to push the leg off or to increase the piston action of the stump in the socket. Springs permitting expulsion at a positive pressure of 1/2 <i>, 1-1/2</i> or 2 lb. per sq. in. now are commercially available. The choice should be based upon individual circumstances. Some leakage generally occurs either in the valve or between the socket wall and the stump. A regulated amount of leakage is, however, desirable because it relieves the suction during periods of inactivity. If the leak rate is too great, the leg may fall off or the piston action may be excessive and cause discomfort. If the leak rate is too small, however, edema may result. A good test for leak rate is to measure the time required for the negative pressure to drop to half its initial value while the prosthesis is suspended on the relaxed stump. If the time is 50 to 80 sec, the leak rate is satisfactory, but if it is greater than 100 sec, the manual release should be used during periods of inactivity. </p> <p>Conclusion In summary, then, it may be restated that, in the construction of an above-knee artificial leg, the objective of the prosthetist is to provide the wearer with optimum security in standing and walking, the best possible walking pattern, a minimum requirement for expenditure of energy in usual activities, and a generally comfortable leg that can be used more or less continuously without injuring the stump and without causing undesirable postural deformities. The above-knee prosthesis is called upon to replace as nearly as possible the functions of the normal leg, but it must do so under the influence of a residual motor mechanism deficient in power and sensory control. The necessary features are therefore to be obtained only by observance of certain functional rules established on the basis of anatomical, physiological, and mechanical considerations.</p> <p>Of first importance is that the prosthetist well understand the mutual interdependence of the details of alignment of the various components and of the fit and orientation of the socket. Since, unlike the normal limb, support in the above-knee prosthesis is not through the shaft of the femur but through some other axis, due cognizance needs to be taken of the new set of musculomechanical relationships and of the influence of these relationships on the static and dynamic characteristics of the artificial replacement. When proper compensation for these factors is made by the limbfitter, undesirable compensation by the amputee is avoided, while the requirements of comfort, function, and acceptable gait are satisfied. In no other way can so much satisfaction be afforded the above knee amputee.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br />Fig. 14. Typical pressure variation in an above-knee suction socket during level walking. Body weight: 145 lbs.</p> </td> </tr> </tbody></table> </td> </tr> </tbody></table> <p><b>References:</b></p> <ol> <li> <p>Buchthal, Fritz, and E. Kaiser, Optimum mechanical conditions for work of skeletal muscle, Acta Psychiat. et Neurol., 24:333 (1949).</p> </li> <li> <p>Eberhart, Howard D., Verne T. Inman, and Boris Bresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</p> </li> <li> <p>Eberhart, Howard D., and Jim C. McKennon, Suction-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</p> </li> <li> <p>Haddan, Chester C, and Atha Thomas, Status of the above-knee suction socket in the United Stales, Artificial Limbs, May 1954. p. 29.</p> </li> <li> <p>Inman, V. T., Functional aspects of the abductor muscles of the hip, J. Bone and Joint Surg., 29:607 (1947).</p> </li> <li> <p>Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</p> </li> <li> <p>Libet, B., H. J. Ralston, and B. Feinstein, Effect of stretch on action potentials in muscle, Biol. Bull., 101:194 (1951).</p> </li> <li> <p>Radcliffe, C. W., Use of the adjustable knee and alignment jig for the alignment of above knee prostheses, University of California (Berkeley), Prosthetic Devices Research Project, Report to the Advisory Committee on Artificial Limbs, National Research Council, August 1951.</p> </li> <li> <p>Radcliffe, Charles W., Mechanical aids for alignment of lower-extremity prostheses, Artificial Limbs, May 1954. p. 23ff.</p> </li> <li> <p>Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</p> </li> <li> <p>Ralston, H. J., Mechanics of voluntary muscle, Am. J. Phys. Med., 32:166 (1953).</p> </li> <li> <p>Ralston, H. J., H. D. Eberhart, V. T. Inman, and M. D. Shaffrath, Length-tension relationships in isolated human voluntary muscle, Proc. 17th Internat. Physiol. Cong., Oxford, 1947. p. 110.</p> </li> <li> <p>Ralston, H. J., V. T. Inman, L. A. Strait, and M. D. Shaffrath, Mechanics of human isolated voluntary muscle, Am. J. Physiol., 151:612 (1947).</p> </li> <li> <p>Ramsey, R. W., and S. F. Street, Isometric length-tension diagram of isolated skeletal muscle fibers of frog, J. Cell. and Comp. Physiol., 15:11 (1940).</p> </li> <li> <p>Schede, Franz, Theorelische Grundlagen fur den Bau von Kunstbeinen; insbesondere fur den Oberschenkelamputierten, Ztschr. f. orthopad. Chir., Supplement 39, Enke, Stuttgart, 1919.</p> </li> <li> <p>Schnur, Julius, Beinbelastungslinie und Schwerlinie, Medizinische-Technik, 5(3):54 (March 1951).</p> </li> <li> <p>Schnur, Julius, Die Aquilibral-Kontakt Prothese, Orthopadie-Technik, 4(2) :36 (February 1952).</p> </li> <li> <p>University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes.</p> </li> <li> <p>University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949.</p> </li> <li> <p>Wagner, Edmond M., and John G. Catranis, New</p> </li> </ol> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall"> Eberhart, Howard D., and Jim C. McKennon, Suction-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">The amount of medial rotation in the stump depends upon the inherent physiological characteristics of the hip joint and upon the loss of muscular function after amputation. Some amputees have even been observed to have lateral rotation of the stump upon hip flexion.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall"> Eberhart, Howard D., Verne T. Inman, and Boris Bresler, The principal elements in human locomotion, Chapter 15 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>18.</b> </td><td class="clsTextSmall"> University of California (Berkeley), Prosthetic Devices Research Project, Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Fundamental studies of human locomotion and other information relating to design of artificial limbs, 1947. Two volumes. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Too much initial flexion results in a decrease in stride length, which may be undesirable in some cases.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall"> Radcliffe, Charles W., Alignment of the above-knee artificial leg, Chapter 21 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall"> Wagner, Edmond M., and John G. Catranis, New </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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"> Buchthal, Fritz, and E. Kaiser, Optimum mechanical conditions for work of skeletal muscle, Acta Psychiat. et Neurol., 24:333 (1949). </td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall"> Inman, Verne T., and H. J. Ralston, The mechanics of voluntary muscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall"> Libet, B., H. J. Ralston, and B. Feinstein, Effect of stretch on action potentials in muscle, Biol. Bull., 101:194 (1951). </td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall"> Ralston, H. J., Mechanics of voluntary muscle, Am. J. Phys. Med., 32:166 (1953). </td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall"> Ralston, H. J., H. D. Eberhart, V. T. Inman, and M. D. Shaffrath, Length-tension relationships in isolated human voluntary muscle, Proc. 17th Internat. Physiol. Cong., Oxford, 1947. p. 110. </td></tr><tr><td class="clsTextSmall"><b> 13.</b> </td><td class="clsTextSmall"> Ralston, H. J., V. T. Inman, L. A. Strait, and M. D. Shaffrath, Mechanics of human isolated voluntary muscle, Am. J. Physiol., 151:612 (1947). </td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall"> Ramsey, R. W., and S. F. Street, Isometric length-tension diagram of isolated skeletal muscle fibers of frog, J. Cell. and Comp. Physiol., 15:11 (1940). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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"> Inman, V. T., Functional aspects of the abductor muscles of the hip, J. Bone and Joint Surg., 29:607 (1947). </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">It should be understood that no new theory of alignment is intended, that the aim is simply to explain logically some of the problems facing prosthetists in the construction of above-knee legs and to provide rational solutions for those problems. The views presented are the combined result of experience gained at the University of California Prosthetic Devices Research Project during limbshop trials of the adjustable leg and alignment duplication jig(8,9,10) of a study of methods presently in use by the artificial-limb industry, and of a survey of information presented in the German literature.(15,16,17)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall"> Eberhart, Howard D., and Jim C. McKennon, Suction-socket suspension of the above-knee prosthesis, Chapter 20 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954. </td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall"> Haddan, Chester C, and Atha Thomas, Status of the above-knee suction socket in the United Stales, Artificial Limbs, May 1954. p. 29. </td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall"> University of California (Berkeley), Prosthetic Devices Research Project, [Report to the] Advisory Committee on Artificial Limbs, National Research Council, The suction socket above-knee artificial leg, 3rd edition, April 1949. </td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Charles W. Radcliffe, M.S., M.E. </b></td></tr><tr><td class="clsTextSmall">Acting Assistant Professor of Engineering Design University of California, Berkeley; member, Technical Committee on Prosthetics, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-22.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-23.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-24.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-25.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-26.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-27.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-28.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-29.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-30.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-31.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-32.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-33.jpg Figure 13 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-34.jpg Figure 14 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-35.jpg Figure 15 http://www.oandplibrary.org/al/images/1955_01_035/1955-JanuaryOCRBatchc-36.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 Functional Considerations in the Fitting of Above Knee Prostheses Creator An entity primarily responsible for making the resource Charles W. Radcliffe, M.S., M.E. * https://staging.drfop.org/files/original/d3d522f214d3d93989e33214af0237cc.png 4573b6d2c49c4fcf47ded16b1c4c04ff 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. URL <a href="https://funprobo.com/home/">Foundation Prosthetics For Bolivia | Funprobo</a> City La Paz Countries Served Bolivia Phone (+591) 2242 6301 Email rotaryboliviaprosthetics@gmail.com infofunprobo@gmail.com Organization Type Including ID and tax status Non-profit Not-for-profit Type Under Bolivian law Services Provided Prosthetic Fitting, Prosthetic Fabrication, Rehabilitation Need I Financial Assistance Need II Volunteers Need III Materials, Components, and Equipment Volunteer Contact <a href="https://funprobo.com/volunteer/" target="_blank" rel="noopener">https://funprobo.com/volunteer/</a><br /><br /><span>volunteer@funprobo.com</span> Patient Contact <a href="https://funprobo.com/contact-us/" target="_blank" rel="noopener">https://funprobo.com/contact-us/</a><br /><br /><span>infofunprobo@gmail.com</span> Facebook Page <a href="https://www.facebook.com/ProstheticsforBolivia/">Prosthetics for Bolivia / Funprobo | La Paz | Facebook</a> Mission Help People Regain Their Lives Address Calle Presbitero Medina 2140 Esq. Luis Lastra State/Province Bolivia 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 Fundacion Protesis para Bolivia Description An account of the resource We are a Bolivian non-profit organization providing prosthetics to people with limited resources who have lost one or both lower extremities. We are a permanent team of specialists who get support from volunteers from all over the world that come to work with us in our centre in La Paz. https://staging.drfop.org/files/original/51486fbf42cc456290b9b952e05db61a.jpg c8aff7f06962712a5421f54a3e2e8fed 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. URL www.gabkulfoundation.org Contact Name/Title Gabriel Talahumbu - Director Address 5425 85th Avenue , Ste 2 City Lanham State/Province Maryland Countries Served USA Regions: AfricaCountries: Congo RDC, Gabon and AngolaSpecific cities, regions, or groups of people: Kinshasa, MasalaAge Group: ChildrenFees Charged: No Postal Code 20706 Phone 240-286-2716 Email gabkulfoundation@yahoo.com Services Provided Prosthetic Fitting, Orthotic Fitting, Medical Equipment / Supplies, Education, Prosthetic Fabrication, Orthotic Fabrication, Medical / Surgical Care, 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 Additional Info & Comments The year of 1998 is very significant in DR Congo history. This year marks the expansion of the worse civil war in the history of DR Congo with millions of fatalities and handicapped left behind. In the same year, a group of Congolese Orthopedists and Doctors were exposed to some of the worse atrocities in the world history. Those people decided to form a Foundation that would help alleviates the situation not only in this trouble country but also in surrounding regions. Consequently, they created.GABKULFOUNDATION. “The Democratic Republic of Congo is a country affected by extreme poverty and where the economy and social structures have collapsed.After the war, the Cities were swamped with handicapped as well as amputated children, victims of mines and other types of weapons. Over million children need as much help as they can get.The quality of life includes hunger and poor or malnutrition causing various illnesses and physical malformations.The statistics shows it as an extremely population, from which at least 50% does not have access to potable water, 60% does not have access to health care and 40% is analphabet…As a result, over 30,000 children die every month from easily preventable and treatable diseases such as diarrhea, malaria; measles, infections disease and malnutrition. Since 1998, GABKUL FOUNDATION has used every minimal resource available to provide following assistance programs:• Locally made orthopedic equipment – shoes, artificial hands and legs- for handicapped and physically challenged; provide wheelchairs, orthopedic braces, walkers and lifts.• Promoting and protecting the interests of deaf and hearing impaired;• Providing medical supplies and pharmaceuticals to orphans, abandoned children and less fortunate people;• Repairing and providing equipment to hospitals, schools, churches, etc • Providing school equipment (including literatures and computers).• Provide each health center with essential drugs, equipment and medical supplies, and clinical and management training and support• Identify most vulnerable persons (widows, orphans, and elderly, handicapped) and provide free health care. Provide medical supplies and training to improve reproductive health services at the health center level. Improve vaccination coverage for pregnant women and children under five.• Support health centers in conducting antenatal consultations, with basic equipment including scales, feotoscopes, measuring tape, gloves.HIV/AIDS prevention. 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 Gabkulfoundation https://staging.drfop.org/files/original/02b69054e99fc08b4b12033c4c735d90.pdf a11820a4a41bad505f07eb0c2b9d0fc9 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_03_017.pdf Text Any textual data included in the document <h2>Gait Analysis</h2> <h5>Ronald F. Altman, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The following series of articles on Gait Analysis were based on a project which was supported by the Newington Children's Hospital Research Fund.</p> <p>The following series of articles all have to do with using gait analysis, in orthotics as well as prosthetics, to improve function. The Gage/Hicks study traces gait analysis in prosthetics from Inman forward, and the individual articles illustrate contemporary laboratory approaches to the objective assessment of gait.</p> <p>Fundamental to optimal lower-extremity prosthetic/orthotic service is an analysis of the gait of the patient. To the extent the method of analysis fails to provide adequate objective or useful information about gait, it allows for the possibility and probability that a less than optimum fit and/or alignment configuration has been or will be achieved.</p> <p>While gait analysis has long been an established procedure of varying objectivity in prosthetics, in orthotics the use of gait analysis has been rather ineffectual in assisting to optimize gait, a process which for the most part fails to go beyond a most rudimentary observation. This is due in part to the rudimentary functional characteristics of most orthoses.</p> <p>Advances in our profession as well as technology and materials can and do result in more functional orthoses. If we are going to provide the optimal orthotic design configuration for any given patient, it is essential that we define gait characteristics more precisely and reliably.</p> <p>Though not yet universally available, the increasing number of gait analysis facilities will soon benefit us all—patients and practitioners alike—as we gain access to the resulting information flow in formats readily usable by orthotists and prosthetists.</p> <em><b>*Ronald F. Altman, C.P.O. </b> Director of Orthotics/Prosthetics Department at Newington Children's Hospital in Newington, Connecticut.<br /><br /></em> Page Number(s) 17 - 17 Year 1985 Volume 9 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Gait Analysis Creator An entity primarily responsible for making the resource Ronald F. Altman, C.P.O. * https://staging.drfop.org/files/original/681729931d4cfc067bfb635d350a0038.pdf 08c883182b90889c54a46553cb7eb012 https://staging.drfop.org/files/original/e3d52b0be7f8bf314487219accc7c636.jpg 533dd7911eac0f2103f63f55a2974f2e https://staging.drfop.org/files/original/88d35e0e098d1d592a33914182995d15.jpg 01b25278628c187bfd931c739f3f8d09 https://staging.drfop.org/files/original/7ea94c7033aad3284d8cc18bffbb2567.jpg 0e95b44fd8762f309bc14b7344472c45 https://staging.drfop.org/files/original/504357506176edb60a65b7ae82059220.jpg 0a53764bf308ba3a7a6cb38844c982d5 https://staging.drfop.org/files/original/4e0d9e4dfe99d6747445d53d6087df2b.jpg d6f074b0d9ad6cb75e44c3c67e36f961 https://staging.drfop.org/files/original/525c5f37bce1e329faedbb78c8ff8a2d.jpg 79827f16dc5d8ac8a0d99d9def75de42 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_03_018.pdf Text Any textual data included in the document <h2>Gait Analysis in Prosthetics</h2> <h5>James R. Gage, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />Ramona Hicks, R.P.T., M.A.&nbsp;<a style="text-decoration: none;">*</a></h5> <h3>Review</h3> <p>Objective measurement systems which quantify locomotion have been in use for the past century. But not until World War II, when thousands of men returned home to the United States with amputations, was technology really applied to the understanding of prosthetic gait.</p> <p>Inman and colleagues<a></a> founded the Biomechanics Laboratory at the University of California to establish fundamental principles of human walking, particularly in relation to problems faced by lower limb amputees. Inman's measurement techniques included motion pictures of coronal and sagittal views, as well as transverse rotations from below using a glass walkway. Using interrupted light photography, the Biomechanics Laboratory team studied the motion of body segments during gait. Force plates measured the subject's ground reaction forces, and muscle activity was recorded using electromyography (EMG), which measures the electrical signals associated with contraction of a muscle. Prior to Inman's fundamental studies prostheses were customized for the individual amputee, without any particular regard to rational structural design. Inman's goal was to provide fundamental data essential for the design of prosthetic limbs. By analyzing normal human walking, he and his colleagues laid the groundwork for biomechanical analysis of amputee gait.<a></a> Since that time, numerous techniques have been developed to study human locomotion,<a></a> and numerous studies have been undertaken to evaluate prosthetic gait.</p> <h3>Research Applications</h3> <p>Eberhart, et al.<a></a> described the locomotor mechanism of the above-knee amputee from kinematic and kinetic data. They compared lateral stick figures of amputees to normal subjects as a means to objectively identify gait deviations in the sagittal plane. Force plate data were used to compare the weight-bearing characteristics of the prosthetic limb and the sound limb. From these comparisons, the authors identified amputees who walked well with their prostheses and those who were less adept. Eberhart believed that ultimately "optimal" patterns of gait could be determined for amputees and used as a reference for evaluating prosthetic gait.</p> <p>Zuniga, et al.<a></a> studied gait in 20 above-knee amputees by using electrogoniometers attached to the knee and foot switches. Their data documented asymmetry in the stance and swing phase times between the prosthetic and sound limb.</p> <p>In similar investigations, James and Oberg<a></a> and Murray, et al.<a></a> studied temporal stride parameters and knee flexion-extension angles, and also examined above-knee gait at various speeds. They confirmed the stance and swing phase asymmetry between the prosthetic and sound limb. They also showed that the asymmetry was present regardless of the speed of walking.</p> <p>The collection of baseline data in above-knee amputees clearly demonstrated some shortcomings in prosthetic gait. One of these, the longer swing time which is required on the prosthetic side, has led to the development of dozens of prosthetic knees. Gait analysis laboratories have been used to evaluate some of these prosthetic designs. Godfrey, et al.,<a></a> in a limited study that compared gait with six cadence-responsive knee units, found no significant differences among them. Murray, et al.<a></a> compared the gait of above-knee amputees with hydraulic knee units versus constant friction knee units. Temporal and kinematic data, which were collected at slow, free, and fast speeds, showed that the hydraulic knees improved the symmetry between the prosthetic limb and the sound limb, especially at the fast and free speeds. This finding was true for both cadence and the amount of knee-flexion at swing phase.</p> <p>Hoy and colleagues,<a></a> in one of the few studies on gait in juvenile amputees, collected kinematic data at various speeds to compare the solid ankle cushioned heel (SACH) foot to a Child Amputee Prosthetic Project (CAPP) experimental foot. The authors found hip range of motion to be closer to normal and significantly less with the CAPP foot than the SACH foot.</p> <p>Hannah and Morrison<a></a> studied the effect of alignment of the below-knee prosthesis on gait. Using electrogoniometers to measure hip and knee joint rotations in the coronal, sagittal, and transverse planes, they found that malalignment of the prosthetic foot was the most crucial for gait symmetry.</p> <p>Grevsten and Stalberg<a></a> used electromyography to compare muscle activity in below-knee amputees walking with patellar tendon-bearing (PTB) and PTB-suction prostheses. Surface electrodes were placed over the tibialis anterior and gastrocnemius muscles which, in normal gait, usually fire at opposite phases. The data showed that these muscles contracted for longer periods when the PTB prosthesis was used than with the PTB-suction prosthesis, suggesting that the suction mechanism improved the adaptation to the prosthesis.</p> <p>Thiele, et al.<a></a> investigated possible neuro-physiological reasons for weakness in above-knee amputees by recording electromyographic activity of the quadriceps during gait. They did not find abnormal recordings and concluded that muscle weakness was secondary to biomechanical, rather than neurophysiological, factors.</p> <h3>Clinical Applications</h3> <p>Until the present, gait analysis has been applied to prosthetics only for research purposes. Routine prosthetic fitting and checkout are still done by means of observational gait analysis. However, observational gait analysis has many disadvantages.</p> <p>In the first place, even normal human walking is extremely complex. With each step, more than 30 major muscles have to contract and/or relax synchronously in each lower extremity. Also, normal human gait is rapid (approximately 105 steps per minute), and the human eye is not fast enough to separate the various components of gait at this speed. Krebs, et al.<a></a> have shown that data vary widely when different examiners have observed a person's gait and that observational analysis is only a moderately reliable technique. The variations between observers may be due to the preconceptions of individual observers, to limitations of human perception, or to problems in transmitting the information or data to colleagues. In light of these findings, it is not surprising that the fit and quality of the limbs fabricated by different prosthetists vary greatly.</p> <p>Technology has now progressed to the point where automated gait laboratories can be built. Their capabilities vary, but most labs monitor one or more of the following parameters:</p> <ol> <li> <p>kinematics or movement measurements through a motion analysis system,</p> </li> <li> <p>evaluation of ground reaction forces via force plates or pressure sensitive switches, and</p> </li> <li> <p>dynamic electromyography (monitoring the electrical activity of contracting muscles).</p> </li> </ol> <p>The advantage of an automated motion measurement system is that automated data entry and rapid processing allow routine clinical use at a reasonable cost. Since the sampling rate of most automated motion systems is in excess of 50 Hz (50 samples/second), all movement in the lower extremities during walking can be examined in detail and with excellent reproducibility.</p> <p>Thus, the analysis of walking becomes objective, rather than subjective, and a record of this objective analysis is produced by the computer in such a fashion that preconceived biases and communication errors between observers are minimized. Furthermore, some of the more modern gait analysis facilities have the ability to compare records, for example, of a patient's gait pre- and post-operatively, or of an amputee's gait with two different prosthetic devices or components. Through comparisons like these, the presence or absence of benefit can be determined objectively.</p> <h3>Kinesiology</h3> <p>The field of prosthetics can make use of the new science of kinesiology, or the study of movement. Kinesiology consists of two major fields:</p> <ol> <li> <p>kinematics, the study of motion exclusive of the influences of mass or forces, i.e., without regard to the underlying cause of the motion; and</p> </li> <li> <p>kinetics, which deals with the forces that produce motion.</p> </li> </ol> <p><i>Kinematic Data</i></p> <p>Kinematic data can be gathered in a variety of ways—through interrupted light photography, cinefilm, video systems, and/or electro-goniometers—and it can be displayed in many ways. Stick figures provide a visual display of the subject walking.</p> <p><a href="/files/original/e3d52b0be7f8bf314487219accc7c636.jpg"><b>Fig. 1</b></a> is a stick figure representation of an 11 year old girl with a right knee disarticulation. The stick figures facilitate the identification of gait deviations, e.g., knee hyperextension on the prosthetic side at stance phase. With observational gait analysis, this gait deviation might be missed, or two examiners might argue about its presence. With objective gait analysis, we can prove the deviation's existence by viewing the stick figures, and we can identify the cause of the deviation by reviewing the graphs that depict motion. These graphs display motions of each joint of the lower extremities in all three planes during a representative gait cycle.</p> <strong><a href="/files/original/e3d52b0be7f8bf314487219accc7c636.jpg">Figure 1.</a> Lateral stick figures of the right gait cycle of an 11-year-old-girl with a right knee disarticulation.</strong><br /> <p><a href="/files/original/88d35e0e098d1d592a33914182995d15.jpg"><b>Fig. 2</b></a> is a graph showing knee flexion-extension of the same child with a knee disarticulation. The child's sagittal knee motion is compared with the mean or average flexion-extension of seven other above-knee amputees.</p> <strong><a href="/files/original/88d35e0e098d1d592a33914182995d15.jpg">Figure 2</a>. Comparison of knee flexion-extension motion in one above-knee amputee with an average composite of knee flexion-extension in seven above-knee amputees.</strong><br /> <p>Although all above-knee amputees hyperextend their knees slightly during stance phase, this patient has 10 degrees more hyperextension than average. Following the gait analysis, it was discovered that the knee extension bumper was too soft, and it was replaced with a suffer one.</p> <p>Kinematic data can also be used to compute temporal data, such as stride length, cadence, and walking velocity. <a href="/files/original/7ea94c7033aad3284d8cc18bffbb2567.jpg"><b>Fig. 3</b></a> compares the temporal data of the child with knee disarticulation with "normal" children the same age. Notice that the stride length is normal but that the walking velocity and cadence are less than normal.</p> <strong><a href="/files/original/7ea94c7033aad3284d8cc18bffbb2567.jpg">Figure 3.</a> Linear measurements of an 11-year-old girl with a knee disarticulation compared with a composite of linear measurements of normal children.</strong><br /> <p><i>Kinetic Data</i></p> <p>The forces that cause movement are usually collected through pressure sensitive switches or paper, or with commercial force plates, which are designed to break down the ground reaction forces into their components (X,Y,Z force, and X,Y,Z moment). The software of a modern gait analysis laboratory is able to combine force plate data with motion analysis data to produce meaningful graphic outputs.</p> <p><a href="/files/original/504357506176edb60a65b7ae82059220.jpg"><b>Fig. 4</b></a> shows the vertical ground reaction force (Z force) for walking barefoot compared with walking with shoes in a 9 year old boy with a Symes prosthesis. Notice the improved symmetry at push-off between the prosthetic and sound limb when shoes are worn.</p> <strong><a href="/files/original/504357506176edb60a65b7ae82059220.jpg">Figure 4.</a> Graphic display of the vertical ground reaction forces in a 9-year-old boy with and without shoes.</strong><br /> <p>Force plates can also be used to compute the location of the center of pressure on the foot. <a href="/files/original/4e0d9e4dfe99d6747445d53d6087df2b.jpg"><b>Fig. 5</b></a> compares the foot force progression pattern of a SACH foot to a multi-axis foot in a 27 year old male with a below-knee amputation. From these data, one can see that the foot force progression pattern is more lateral with the multi-axis foot than with the SACH foot. Also, notice with the SACH foot how the initial forces move from an anterior to posterior direction as the heel compresses. This pattern is not seen in the multi-axis foot.</p> <strong><a href="/files/original/4e0d9e4dfe99d6747445d53d6087df2b.jpg">Figure 5</a>. Path of the center of pressure on the foot in a 27-year-old below-knee amputee with a SACH foot and with a multi-axis foot.</strong><br /> <h3>Dynamic Electromyography</h3> <p>Dynamic electromyography is a valuable tool for measuring the time duration of muscle activity, which is recorded through electrodes, either surface or indwelling. However, since voluntary muscle activity results in an electromyographic recording that increases in magnitude with the tension, other variables can also influence the signal, limiting the accuracy of EMG as a predictor of muscle tension.</p> <p>Electromyographic data can be displayed in several ways. When used to analyze a gait cycle, the data show which muscles are active during each phase of gait. <a href="/files/original/525c5f37bce1e329faedbb78c8ff8a2d.jpg"><b>Fig. 6</b></a> compares muscle activity during gait of the subject walking with the SACH foot compared with the multi-axis foot. The hamstrings and quadriceps muscle groups were sampled and show the same firing patterns regardless of the type of foot that is worn. What is interesting is that the hamstrings are firing just before toe-off when they are usually silent and the quadriceps are inactive at this time when normally they fire to restrain knee flexion and prevent excessive heel rise. As might be expected, this patient walks with exaggerated knee flexion at swing phase.</p> <strong><a href="/files/original/525c5f37bce1e329faedbb78c8ff8a2d.jpg">Figure 6.</a> EMG activity of the hamstrings and quadriceps muscles during gait in a 27-year-old patient with a SACH foot and with a multi-axis foot.<br /></strong><br /> <h3>Summary</h3> <p>Gait analysis is useful in evaluating an amputee's prosthesis by providing objective measurements and a permanent record of the patient's status. Kinematic, kinetic, and EMG data assist the clinician and prosthetist in identifying specific problems encountered by the amputee and in identifying the causes. Gait analysis also allows comparison of different prosthetic designs or different alignments of the same prothesis. Most importantly, however, the record provided allows examiners to objectively discuss the problems and their potential solutions.</p> <h3>Future Applications</h3> <p>The field of prosthetics will begin to change rapidly with the application of kinesiology. Soon, optimal standards of gait will be established for each prosthetic level. With the widespread availability of low-cost motion analysis, kinematic analysis will be routinely incorporated into dynamic alignment of each new prosthesis, helping to insure appropriate alignment and fit. Finally, prosthetic research, using both kinematics and kinetics, will continue as we seek to identify and rectify the problems created by loss of the body's normal limb. The ultimate outcome of this research will be the development of components that will be stronger, lighter in weight, and much more functional than those used now.</p> <div style="width: 400px;"> <div style="width: 400px;"><em><b>*Ramona Hicks, R.P.T., M.A. </b> Kinesiology Laboratory at Newington Children's Hospital in Newington, Connecticut 06111.</em><br /><br /><em><b>*James R. Gage, M.D. </b> Kinesiology Laboratory at Newington Children's Hospital in Newington, Connecticut 06111.</em></div> </div> <div style="width: 400px;"></div> <p><b>References:</b></p> <ol> <li><i>Fundamental Studies of Human Locomotion and Other Information Relating to Design of Artificial Limbs</i>. Subcontractor's Report to the Committee on Artificial Limbs. National Research Council. Prosthetic Devices Research Project, College of Engineering, University of California, Berkeley. Serial No. CAL 5. 2 vols. The Project, Berkeley, 1947.</li> <li>Radcliffe, C.W., "Functional considerations in the fitting of above-knee prostheses," <i>Selected Articles From Artificial Limbs</i>, Huntington, NY, Kreiger Publishing Co, Inc, 1970, p.p. 5-30.</li> <li>Winter, D.A., <i>Biomechanics of Human Movement</i>, New York, John Wiley &amp; Sons, 1979, p.p. 9-46.</li> <li>Eberhart, H.D.; Elftman, H.; and Inman, V.T., "The locomotor mechanism of the amputee," <i>Klopsteg PE, Wilson PD, et al (eds): Human Limbs and Their Substitutes</i>, New York, Hafner Publishing Co, 1968, p.p. 472-480.</li> <li>Zuniga, E.N.; Leavitt, L.A.; Calvert, J.C.; Canzoneri, J.; and Peterson, C.R., "Gait patterns in above-knee amputees," <i>Arch Phys Med Rehabilitation</i>, 53:373-382, 1972.</li> <li>James, U. and Oberg, K., "Prosthetic gait pattern in unilateral above-knee amputees," <i>Scand J Rehabil Med</i>, 5:35-50, 1973.</li> <li>Murrary, M.P.; Sepic, S.B.; Gardner, G.M.; and Mollinger, L.A., "Gait patterns of above-knee amputees using constant-friction knee components," <i>Bull Prosthet Res</i>, 17(2):35-45, 1980.</li> <li>Godfrey, C.M.; Jousse, A.T.; Brett, R.; and Butler, J.F., "A comparison of some gait characteristics with six knee joints," <i>Orthotics and Prosthetics</i>, 29(3):33-38, 1975.</li> <li>Murray, M.P.; Mollinger, L.A.; Sepic, S.B.; Gardner, G.M.; and Linder, M.T., "Gait patterns in above-knee amputee patients: Hydraulic swing control vs constant-friction knee components," <i>Arch Phys Med Rehabil</i>, 64:339-345, 1983.</li> <li>Hoy, M.G.; Whiting, W.C.; and Zernicke, R.F., "Stride kinematics and knee joint kinetics of child amputee gait," <i>Arch Phys Med Rehabilitation</i>, 63:74-82, 1982.</li> <li>Hannah, R.E. and Morrison, J.B., "Prostheses alignment: Effect on gait of persons with below-knee amputations," <i>Arch Phys Med Rehabil</i> 65:159-162, 1984.</li> <li>Grevsten, S. and Stalberg, E., "Electromyographic study of muscular activity in the amputation stump while walking with PTB- and PTB-suction prosthesis," <i>Ups J Med Sci</i>, 80:103-112, 1975.</li> <li>Thiele, B.; James, U.; and Stalberg, E., "Neuro-physiological studies on muscle function in the stump of above-knee amputees," <i>Scand J Rehabil Med</i>, 5:67-70, 1973.</li> <li>Krebs, D.E.; Edelstein, J.E.; and Fishman, S., "Reliability of observational kinematic gait analysis," Accepted for publication in <i>J Phys Ther</i>, 1985.</li> </ol> <div style="width: 400px;"></div> Page Number(s) 18 - 23 Year 1985 Volume 9 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1985_03_018/1985_03_017-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_03_018/1985_03_017-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_03_018/1985_03_017-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_03_018/1985_03_017-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_03_018/1985_03_017-5.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/1985_03_018/1985_03_017-6.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 Gait Analysis in Prosthetics Creator An entity primarily responsible for making the resource James R. Gage, M.D. * Ramona Hicks, R.P.T., M.A. * 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. URL http://www.gefpor.ge Contact Name/Title See Website Address 18-20 Lubliana City Tbilisi Countries Served Georgia Regions: EuropeCountries: GeorgiaAge Group: Adults, ChildrenFees Charged: Sometimes Postal Code 159 Phone (995 32) 522 899 Fax (995 32) 522 899 Email ortho@gefpor.ge Organization Type Including ID and tax status Non-profit Services Provided Prosthetic Fitting, Orthotic Fitting, Medical Equipment / Supplies, Prosthetic Fabrication, Orthotic Fabrication, Rehabilitation / TrainingThere is a facility/physical building for patient care at the specified location. Need I Financial Assistance Need II Materials, Components, and Equipment Need III Materials, Components, and Equipment: New, Disassembled, Equipment, Used, Medical Supplies Additional Info & Comments The GEFPOR was founded in December 2003 on the base of the Orthopaedic Project of the International Committee of the Red Cross (ICRC), which has been successfully implemented in Tbilisi during 1994-2003. The GEFPOR presently is the leader in providing PO services throughout the country.The foundation is staffed by highly qualified orthopaedic technologists, who are awarded ISPO (International Society of prosthetics and Orthotic) II category certificates.Financially the GEFPOR activities still based mainly on international support - the International Committee of the Red Cross is the major donor of the foundation. From the begining of 2006 The GEFPOR has been kindly supported by the Canada Fund and Eurasia Foundation. The GEFPOR takes part in implementation of the Governmental programs assisting disabled persons. 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 Georgian Foundation for Prosthetic Orthopaedic Rehabilitation https://staging.drfop.org/files/original/8c59087dd5defe8f43e0fb7935616737.pdf 8ce43640135a5c2fa157eb5fa345410e DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1957_01_001.pdf Year 1957 Volume 4 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/1957_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1957_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>Getting Down to Cases</h2> <h5>Charles O. Bechtol, M.D. <a style="text-decoration:none;">*</a><br /></h5> <p>It is the common teaching of all experience that even the most carefully planned activities seldom follow the course originally laid out for them. Man tends to play himself through life by ear, as it were, in a series of false starts and fortunate recoveries. In all fields of endeavor, therefore, hindsight is more often than not the quality which, in the long run, keeps people going in the general direction of progress. That such is the way things are is perhaps nowhere more patent than in the evolution of the Artificial Limb Program.</p> <p>When, for example, in 1945, the Committee on Prosthetic Devices (now the Prosthetics Research Board) set out to improve the lot of the amputee population, it chose for itself the seemingly obvious, if also apparently simple, goal the design and development of new and improved artificial limb components. Because of the more or less widely held misconception, even among amputees themselves, that improved devices alone might well raise the level of the art of limb prosthetics to that existing in other fields of science and invention, the Committee established, through arrangements for contract research, a far flung program with principal emphasis on the fundamental investigation of human locomotion, on time and motion studies of the human arm and hand, and on what might by some be called professional gadgeteering.</p> <p>After a few years of organized effort on the part of engineers and prosthetists, with the consequent development of new and supposedly improved models and techniques, and after the application of experimental prostheses to amputees for initial tests of the new equipment, it became perfectly clear that, if genuine improvement in amputee service were to be had, something more would be needed. In retrospect came realization of the circumstance that no single design of prosthesis is ever apt to be superior for all amputees of a given type and, conversely, that every amputee presents in one way or another a special problem not amenable to mass treatment. Put in engineering language, the difficulty was seen to lie in the fact that dealing with the rehabilitation of amputees means dealing with a "nonstandard product," the human being. He comes in all sizes, shapes, and conditions. And his reaction to any given selection of equipment is almost always grossly influenced by his individual personal needs and characteristics—physical and mental—as well as by his activity requirements. Since most of the new devices and new methods were largely untried at the clinical level, there existed no valid criteria either for determining when components had been prescribed and fitted to best advantage in the individual case or for assessing the degree of utilization achieved by a given wearer. In the absence of demonstrable proof of successful application on a relatively broad scale, the limb industry was understandably reluctant to adopt the new ways and means with any ostensible enthusiasm. But at the beginning of the Artificial Limb Program in 1945 no one was in a position to predict such eventualities.</p> <p>Lacking, in brief, was the experience necessary for the construction of a general set of principles of amputee management. In recognition of this state of affairs, and in view of the especially challenging problems prevailing in the upper extremity, there was established in mid 1950, in the Department of Engineering at the University of California at Los Angeles, the so called "Case Study Program," with the purpose of investigating the application of prostheses to a wide variety of amputee types and of developing effective methods for evaluation of amputee service, not only with regard to the quality and applicability of the mechanical equipment but also with concern for the effect of training and of occupational, educational, recreational, and other personal factors on the final success of prescription and fitting. Intended to bridge the gap between fundamental work in the laboratory and practice in the field, and with excellent industry participation, the work continued until 1953. Analysis of the data thus accumulated continued until late in 1956.</p> <p>So fruitful was the case study work in upper extremities at UCLA that in the spring of 1953 there was organized at the University of California at Berkeley a similar investigation into the problems of the leg amputee, especially the above knee case, a matter that had already been the subject of fundamental research and engineering design at that institution since the beginning of the Artificial Limb Program eight years earlier. Again with the wholehearted cooperation of the limb industry, the so called "Clinical Study" in lower extremities has, like the UCLA Case Study, now garnered much valuable information on which to base some general principles.</p> <p>Because the experience gained at UCLA and at Berkeley represents the most reliable data available on what now constitutes good practice in limb prosthetics, the bulk of this issue of <i>Artificial Limbs</i> is devoted to a presentation of selected case histories, predominantly the histories of typical problem cases as contrasted with cases that responded readily and well to routine fitting. The balance is given over to a discussion, by one of the world's best known leaders in hand surgery, of the possibilities for surgical reconstruction of damaged hands and of the application of prostheses for the partial hand, an area which offers, if anything, even more highly specialized individual cases and which therefore has not yet been the subject of any major investigation within the Artificial Limb Program. Bunnell's contribution fills admirably what would otherwise be a noticeable gap in the coverage.</p> <p>As regards the broad implications of the case material, it is worth observing how many and diverse are the ways in which the problem of amputee rehabilitation must be attacked and how wide is the variety of skills necessarily brought to bear. In pursuit of clinical work it was found essential to enlist the participation of numerous specialists, each with his own particular interests and abilities. Functioning together, these people not only aided materially several hundred cooperating amputee subjects but at the same time contributed to their own self development and hence to the growth of techniques suitable for widespread dissemination to practicing clinic teams. Thus, in a larger sense, they laid the basis for the nationwide program of prosthetics education now so well under way. Because, in turn, the education program resulted in a vast increase in the number of available clinic teams, amputees in the United States are today reaping benefits that could scarcely have been visualized seven or eight years ago. Here then, in the results of the case studies, lies the key to continued advancement in the mastery of limb prosthetics.</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>Charles O. Bechtol, M.D. </b></td></tr><tr><td class="clsTextSmall">Associate Professor of Surgery and Chief of the Division of Orthopedic Surgery, Yale University; Orthopedic Consultant, Veterans Administration Hospital, West Haven, Conn.; formerly Assistant Clinical Professor of Orthopedic Surgery, University of California, and Western Area Consultant for Orthopedic and Prosthetic Appliance Clinic Teams, Veterans Administration; member, Committee on Prosthetics Research and Development, PRB, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Getting Down to Cases Creator An entity primarily responsible for making the resource Charles O. Bechtol, M.D. * https://staging.drfop.org/files/original/b55c999f394c95f22da4376f0a7fd130.pdf 5101740961929f47b6d05aa1fc10398e Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1980_01_002.pdf Text Any textual data included in the document <h2>Guest Editorial: Of Prosthetics And 1980</h2> <h5>Anthony Staros&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The survey of prosthetics components shown in this issue yields conclusions mostly related to above-knee amputees, as indicated in the text associated with Tables I and II. Fortunately more lower-limb amputations today are below-knee, so one really cannot tell much about trends in prosthetics practice from these data except to note that the SACH foot is indeed a success. This however should not make us complacent about this design, for we should never be happy with anything that we have in prosthetics. Our objective should always be constant improvement.</p> <p>As suggested, data are needed on below-knee fittings to give us a better impression of the state of lower-limb prosthetics today. Surveys of suppliers will show little; needed are data from the fitters of the country.</p> <p>Many of you know that the support of the VA Research Program of the University of California at Berkeley and San Francisco many years ago yielded the crucial bio-mechanical parameters in lower-limb amputee prosthetic service associated with fit and alignment. But never to be overlooked as very significant to service is the "tender loving care" and the training provided to the patient by the emphatic prosthetist. In any case, components although secondary are still important. But clearly recognized is the need to get the prosthesis properly interfaced and the amputee motivated. Perhaps a survey covering rotators might produce helpful data about how these have been used to reduce fitting problems by the diminution in shear stresses.</p> <p>The post-World War II education program has been primarily based on the teaching of the biomechanics and techniques of fit, those of alignment and to some extent but a lesser one, teaching about components. Even though these are of lesser importance, have we overlooked some essentials?</p> <h3>On Prosthetic Knees.</h3> <p>We really don't fault the survey, but recognize its limitations. It nevertheless does show that for above-knee knee joints at least there may be some lapses in the teaching of prosthetists, in the teaching of other members of the clinic team and most importantly, in orienting the administrators representing third party payers. Perhaps the low number of hydraulic knees (as a %) can be attributed to the larger percentage of amputees who are geriatric. But aren't these supposed to be mostly below-knee amputees these days?</p> <p>Not to be overlooked is the value of properly selected hydraulic knee mechanisms for certain cases. The selection of large numbers of "safety" knees is noted; but isn't it that clinic teams seem to get hooked on these, not trying others, or perhaps they have become disillusioned with price or maintenance burdens?</p> <p>Today, the safety knee is the unit of choice but we wonder whether even these are being used properly. For example, are they in fact being used to exploit the value of the stance phase characteristics in initiation of swing phase? Are the alignments such that one provides more "trigger" for initiation of knee flexion?</p> <p>The low numbers for polycentric knees bother us. If properly understood, some of the polycentric knee systems can be very beneficial in providing improved function to amputees with very short above-knee residual limbs and those with very weak hip musculature. How about their use in geriatrics?</p> <p>Are indeed the polycentrics really understood? Are those that are being used being fitted and aligned properly? Do clinicians really understand the real values of the polycentric systems?</p> <p>The system developed at the Orthopaedic Hospital, Copenhagen for example, can be used not only for end-bearing above-knee amputees but can also be applied for shorter amputation levels. The University of California at Berkeley is now developing other improvements in polycentric systems; we hope to see some of those soon presented through manufacturers.</p> <p>Unfortunately we sense that clinics tend to adopt particular "pet" knee mechanisms or pet prescriptions. We worry that for various reasons (valid?) the full range of knee mechanisms has not been given a complete trial. Our publications have tried to get the information across about the pros and cons of each system. Perhaps we have failed.</p> <p>For example, some of the rehabilitation achievements we have been able to make in our own clinic with the hydraulic knees are in fact extraordinary. Alongside the other important factors, the Mauch SNS in particular has been a boon to many of our above-knee amputees, particularly bilateral cases we have had from the Viet-Nam conflict and some Israeli cases from the October (Yom Kippur) War which were referred to us.</p> <h3>A Case in Point</h3> <p>One interesting case from Viet-Nam, a bilateral above-knee amputee, not only now sky dives but snow skis and disco dances on his above-knee prostheses, both with SNSs. This gentlemen has personal drive and motivation; he was an athlete before he was wounded, but now and this is important, he has been given the "tools" in those knee mechanisms: tools which can be used by him to achieve activity levels to which some of us nonamputees could aspire. Here, the SNS provided the wherewithal; matching these with the man's motivation and well-fitted sockets properly aligned, we were able to provide what can be considered a maximum degree of rehabilitation.</p> <p>This is not an isolated case. There have been many people fitted with the SNS and with others that are spin-offs of this design. We in the Veterans Administration put money into these developments, and we continue to purchase them because we have confidence in them. And our patients do. The problem is that others don't. Perhaps primary cost and maintenance experiences detract. But more so, other third party payers do not or cannot value these units as we do for our service-connected amputees who we believe deserve no less.</p> <h3>How about Modular Systems?</h3> <p>We are concerned about the low percentage of modular systems used. Less than one in four are shown. But these, in this survey, are directly linked to above-knee and higher amputations. Again, the geriatric amputee experiences and thus the more common below-knee amputation levels are not reflected. For these, modular or endoskeletal systems may be used most commonly, more than the rugged, heavier crustacean systems of wood and the like. We hope at least that more and more lightweight below-knee prostheses either using endoskeletal systems or polypropylene would be used to the benefit of this group of amputees.</p> <h3>Finally, on Research and Development</h3> <p>The component survey also doesn't really indicate anything about the needs for research and development. Inferred are some gaps in our link with the prosthetist and the clinic team mainly in the channels of information flow about all kinds of hardware. But one cannot draw too many conclusions.</p> <p>We are pleased to inform you that the National Amputation Foundation with the assistance of Dr. Jerome Siller of New York University has now nearly completed for the VA Prosthetics Center a nation-wide survey of 900 service-connected veteran amputees. Provided from this survey will be data about prosthetic, medical, surgical, employment and psychosocial experiences and statuses of veterans from all wars since and including World War II. We expect the investigators to give a report at the 1980 World Congress of ISPO to be held in Bologna, Italy. From this, we expect to have some significant directions for research and development.</p> <p>On this matter of research and development, it seems to us that as soon as you become extremely successful with a particular item you might look at it again to see what you can do to improve on it. Besides more durable SACH feet more functional types of foot-ankle systems seem needed. Are there ways, for example of achieving the same function with less complexity than presented in the current "universal" ankle joints?</p> <p>There appears to be no need to focus again on knee joint development; we would seriously worry about a further proliferation of new knee mechanisms. A few research groups are working on EMG control of valves on hydraulic knees, to produce voluntary control of knee function. This we can accept as long-range.</p> <p>You should also know that Federal support of research and development in prosthetics and orthotics (our own Center's deemphasis is an example) has been decreased to some extent. We do assist in evaluations; we do a little bit of development, primarily as a result of case presentations in our clinics, but we offer no great effort in prosthetics and orthotics development at this time; we have diverted scarce resources to attack the problems of the very severely handicapped: the spinal cord injured, the blind, the non-vocal, and the cumbersome complexities of the debilitated aged.</p> <p>So there'll be no mistake, know that we're still involved in prosthetics and orthotics, but we honestly believe that prosthetics and orthotics development has come a long way. We in the VA believe we have done much to contribute to this process, especially in funding projects around the country. We have also had our own laboratories involved. But now with a mature profession in place, these responsibilities can be carried primarily by the professional with the Government only assisting when necessary. The manufacturers as a group are certainly participating in development, evaluation, and even in training. Outstanding examples are several in the United States and those from Europe who have done an extremely good job in making the quality and function of components of high quality. And the competition among them has been welcomed by us.</p> <p>We think that the prosthetics (and orthotics) professional especially when it comes to process and device development is contributing enormously. Therefore the Government can turn its attention to that which the private sector cannot economically handle. But we always will be ready to help.<br /><br />*<em><strong>Anthony Staros</strong></em><br /><em>Director, VA Prosthetics Center</em><br /><em>New York, N.Y. 10001</em></p> Page Number(s) 2 - 4 Year 1980 Volume 4 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Needs Revision- See Trello 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 Guest Editorial: Of Prosthetics And 1980 Creator An entity primarily responsible for making the resource Anthony Staros * https://staging.drfop.org/files/original/54dae95f148a182054379dab02968d3b.pdf 8910c8603388bad0090b5916a7fc8ef7 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/1979_03_002.pdf Text Any textual data included in the document <h2>Guest Editorial: Thoughts On The Amputee Clinic Team</h2> <h5>Newton C. McCollough, III, M.D.&nbsp;</h5> <p>The Amputee Clinic team as we know it today, evolved during World War II when the Surgeon General of the Army established a number of Amputee Centers within Army Hospitals to upgrade the management of these patients. Impetus to this multidisciplinary approach was given by the Veterans Administration in 1948 when suction suspension was introduced for the above knee amputee and a protocol was developed establishing the Amputee Clinic Team which initially comprised the physician, the prosthetist and the therapist.</p> <p>Since that time as a more holistic approach to disability developed the team has been enlarged in most clinics to include the occupational therapist, social worker and vocational specialists among other disciplines.</p> <p>The clinic team approach is comprehensive and unquestionably has resulted in superior management of patients with limb loss over the past thirty years. However, recently questions have been raised regarding the efficiency of such a clinic and whether or not a more streamlined approach is desirable from the standpoint of the logistical management of relatively large numbers of patients. The impersonal nature of such a clinic has also been impugned in recent years, and some have felt that the patient may actually be intimidated by such a host of professional personnel.</p> <p>Several years ago, at the University of Miami, a compromise approach to amputee management was undertaken. All new patients and patients with identifiable medical problems (including skin breakdown) were seen in the traditional setting with the physician as the amputee team leader in clinic. Routine follow-up visits and problems which were purely prosthetic in nature were seen in "prosthetic clinic" by the prosthetist and therapist with a prosthetist as the team leader or clinic chief. Other clinic personnel including physicians were available for these clinics but were not necessarily in attendance. This approach was far more efficient in terms of man hours and in many ways more practical than imposing the traditional approach upon all patients at every clinic visit.</p> <p>Two major drawbacks to this system of care slowly became apparent and currently we have resumed the traditional approach to all patients. The first difficulty encountered was that many routine prosthetic visits were also accompanied by concurrent medical problems which could not be identified before the patient was actually seen. Of course, the patient could be referred to the next "full team clinic" but this resulted in undue delay of treatment. Psychological or vocational problems though less frequent were also concurrent in some patients. Secondly, in a major teaching hospital, the education of residents, interns and students suffered from this approach. The critical analysis of prosthetic problems in relation to alignment, gait, suspension, etc. was lost upon students in the absence of interchange between prosthetist, physician and therapist. Additionally, innovative techniques in prosthetic management not infrequently result from discussions involving the prosthetist and physician and the presence of all team members in clinic greatly enhances this aspect of the amputee program.</p> <p>In conclusion, I now feel that the multidisciplinary clinic team approach is sound and has no equal in the educational sphere. Spinoffs from the dialogue created may enhance prosthetic research and thus ultimately patient care. Efficiency in this sytem is less than ideal, but the benefits are greater in the long run. Suitable precautions must be taken to avoid "depersonalization" of the amputee in the multi-disciplinary environment and it is encumbent upon each team member to insure that the clinic experience is a rewarding one for the patient.</p> Page Number(s) 2 - 3 Year 1979 Volume 3 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 Guest Editorial: Thoughts On The Amputee Clinic Team Creator An entity primarily responsible for making the resource Newton C. McCollough, III, M.D.  https://staging.drfop.org/files/original/cbb59f624095eeea4e52f449b842e384.png 5443f94a521468d78a977128a3a54922 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. URL https://www.htflive.org/ Contact Name/Title Danette Miller Executive Director dmiller@htflive.org Address HAITIAN TIMOUN FOUNDATION, 101 SOUTH LEBANON ROAD City Loveland State/Province Ohio Countries Served Haiti Postal Code 45140 Phone 513-683-5950 Services Provided HTF invests in centers that are intentional about empowering children from places of extreme pain. We are committed to eradicating the root causes of poverty by providing education and economic development programs for Haitian women. HTF’s is dedicated to empowering women with the tools they need to break out of poverty and pursue their dreams. Need I Financial Assistance https://app.etapestry.com/onlineforms/HaitianTimounFoundation/onlinegiving.html Need II Sponsor a child: https://www.htflive.org/sponsorship Need III Volunteers https://www.htflive.org/get-involved Mission Since HTF was founded in 2000, we’ve been working toward one specific goal: eradicating dehumanizing poverty in Haiti. While the challenges facing Haitians are unjust, we are hopeful. We know how to invest strategically, and we make progress every day thanks to the work of indigenous partners and generous donors. Facebook Page https://www.facebook.com/HaitianTimounFoundation?ref=hl 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 Haitian Timoun Foundation Description An account of the resource Life-giving impact for Haiti's poor https://staging.drfop.org/files/original/4466dc9f88049d40488d6be216fd66d6.pdf df7dcc4340714709da0ed7b7c1699d85 https://staging.drfop.org/files/original/53b5a7a21d9da4b70e22698b5a760aaa.jpg 580a52b9ef39dda90026098898a6a1ce https://staging.drfop.org/files/original/a0eb985726680bed7cd45922e2034e1d.jpg c4a800fceb94238c2677ac1353245ed1 https://staging.drfop.org/files/original/67e644fd9e00ecd25e6e49a71794f407.jpg 60eaf7d0437847d9e266dcd9fbc1c939 https://staging.drfop.org/files/original/589ba45ffbb62595ca1df05cfeb159c0.jpg 8566b117423ddacb7a5d4153e234f8a8 https://staging.drfop.org/files/original/36ba8f4a7fa3b03421d6f86028269823.jpg 1abb24b7a318ac3b59305fe354af6d54 https://staging.drfop.org/files/original/073598b3381e4a6ac1c6962280a87675.jpg 5b5ae92ad35825fadc4a43eca508978b https://staging.drfop.org/files/original/720a349f49e9cd4af439cb42bebb620b.jpg 10091d4c9cdda7e591209ada36971ae1 https://staging.drfop.org/files/original/f376141812a404af3010dfdf6dbedf29.jpg da6eec89495628a12e65102fc753e2b6 https://staging.drfop.org/files/original/206ae750fa9a0a06275a4a9cc9a4dce8.jpg 724c967272fa84216d1830d4dd4d9548 https://staging.drfop.org/files/original/73d9f7175d3a09f5fd09ba00e95cca0e.jpg 394abd72058740013c9e1f4ea0d5011f https://staging.drfop.org/files/original/a44144b9c6d5a256cd7da054cf8621d2.jpg 418b6d99ee67aedca58cceff52f4205e https://staging.drfop.org/files/original/a716afbeccd1b0841e1ff0e4c66fc23d.jpg e9abb6131a86c67ffdd79c69428ff2a8 https://staging.drfop.org/files/original/eb429fccd53602c04c0a0d04864cad6f.jpg 99826548df6f19c657326b20ba9434f3 https://staging.drfop.org/files/original/16212ba76062ab46774d405e1c0d6dbb.jpg 10231e0bc58bc0d853c27072bd4f19fd https://staging.drfop.org/files/original/8eb0c9a2760981415e2d2ac1a225b498.jpg 1078787fef23aa145c6f4ba544fa286b https://staging.drfop.org/files/original/c7712445845a41b936dc9aeb5cf902d3.jpg 18d9adab9f4fb258d754543b62f65721 https://staging.drfop.org/files/original/067afcb3523416f2f0455fb4e8973fd5.jpg 6b11e8017d8bf6ffd5e528d796afc842 https://staging.drfop.org/files/original/05def91a2bbdd073ada3f01fe3651289.jpg e36c49e73001acd8cb53a05c873baf00 https://staging.drfop.org/files/original/30f0645250433050bcfeab5015060e2d.jpg e054259f8d752d7f0859d67bd239c669 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_03_026.pdf Year 1955 Volume 2 Issue 3 Page Number(s) 26 - 60 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_03_026.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_03_026.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>Harness Patterns for Upper-Extremity Prostheses</h2> <h5>Robert J. Pursley, Lt., USA (MSC) <a style="text-decoration:none;">*</a><br /></h5> <p>The comparatively recent development of more functional components for artificial arms has made it necessary to analyze in greater detail the requirements of harnessing the power needed for effective operation. Just as an automobile is helpless without a well-designed and well-built engine and transmission system, so an arm prosthesis is helpless without a well-designed and well-constructed harness. To build a successful harness system requires not a knowledge of some long-lost art but, instead, a careful appraisal of the wearer, of the device to be worn, and of the available tools to be put to work. Since the modern body harness constitutes a dynamic coupling between a human being and a mechanism designed to replace a living extremity, the problem of devising it is also one of dynamics and of what some call "human engineering."</p> <p>Many illustrations of typical harness patterns are presented later in this article. But it is not enough for the harnessmaker simply to reproduce what is shown in these drawings of typical patterns or to superimpose on an individual amputee a generalized harness pattern of any particular type. He must first understand the purpose of the harness, the requirements of the particular prosthesis involved, and the body motions available, and he must then apply his own skill and judgment in making appropriate modifications to suit the individual case. It is, of course, far more important to produce a harness that will give the desired functional results than it is to produce one that looks exactly like any one of the drawings. The illustrations are therefore intended as general guides only, not as a detailed description applicable to every case of amputation at the indicated level. When planning and making any harness, the prosthe-tist should examine the location of each element to ensure proper function with the expenditure of minimum effort on the part of the particular wearer concerned.</p> <p>The first and most simple requirement of any harness is that it must hold the prosthesis securely on the stump. The second is that it must be comfortable to the amputee. Generally, suspension, as such, is easily obtained, but to suspend the prosthesis properly and at the same time to assure maximum comfort for its wearer is more difficult. If either of these requirements becomes a matter of choice, then comfort must be the more important consideration. If the harness is not comfortable, or at least tolerable, the person for whom it was intended will soon hang it politely on a suitable nail. Since almost no harness can be constructed satisfactorily without a few compromises at first, it is unwise to promise complete success on the first try.</p> <p>The third and all-important requirement of functional body harness is that it must supply a source of power for the operating components of the prosthesis. This means simply that residual body motions must be harnessed to replace lost functions of the natural member, but to provide controls that are operable in an effective and yet inconspicuous manner poses a complex problem. It requires an examination of the body motions that can be utilized by the harness without detracting from the usefulness of the remaining normal hand and without introducing unduly awkward gyrations of parts of the anatomy not ordinarily involved in arm activity. The higher the level of amputation, the greater the control requirements but the fewer the sources of control. The problem is further complicated by the need to maintain the proper balance between adequate suspension, acceptable comfort, and worthwhile function, for each of these needs is often satisfied only at the expense of the other two. A look at the background of harnessing for upper-extremity prostheses <a></a> reveals that, when devices were generally passive in nature, so was the harness. As devices have increased in function, so has the harness also. Today the development of devices has in general surpassed the art of harnessing them. With the proper approach, however, and using a common-sense analysis both of the amputee's capabilities and of the requirements of the prosthesis, an accomplished limbfitter can in almost every case turn out a very acceptable harness that will meet functional needs to a surprising degree.</p> <h4>Harnessing for the Below-Elbow Cases</h4> <p>The prosthesis for the unilateral below-elbow case is unquestionably the simplest to harness. For the reason that the below-elbow amputee retains his own elbow, and therefore usually requires replacement of prehension only, he can almost without exception be harnessed successfully. At least three feasible control motions are to be had. In order of decreasing usefulness, they are arm flexion on the amputated side, shoulder depression on the amputated side, and scapular abduction. The choice and extent of use of these three motions, singly or in combination, is largely a matter of personal preference depending on the area in which the terminal device is required to operate. With the elbow flexed to 90 deg. and with the terminal device located slightly above the level of the head, for example, arm flexion is almost completely spent. Using scapular abduction under the same circumstances, however, the below-elbow amputee can still operate the terminal device satisfactorily. Successful wearers of below-elbow prostheses develop their own individual patterns of operation and subconsciously learn to operate the device in all areas in which it is called upon.</p> <p>The problem of transmitting the force and excursion of body motions from the source to the point of use has in the past involved a wide variety of materials. Rawhide thongs and leather laces are only two of many that have been used, even as late as only a decade ago.<a></a> The flexible metal cable and wrapped-wire housing adopted from the aircraft industry is currently the most widely used and is the most satisfactory available today. It is based on the Bowden principle (<b>Fig. 1</b>), which makes it possible to transmit force and excursion from the body to the terminal device regardless of elbow angle.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. The principle of the Bowden cable for transmitting tension forces applied at one end. Although point <i>C </i>is brought closer to point <i>A </i>when rotation occurs about <i>B, </i>the housing <i>D </i>prevents slack in cable <i>E </i>by preserving the <i>effective </i>path length <i>A </i>to C. A counter-force is required at the opposite end to return the flexible cable to its original position. Other types of Bowden cables are based on the torque principle, as used in speedometer cables, or the push-pull principle, as used in the temperature controls of the automobile heater. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Utilizing any or all of the three useful body motions, together with the Bowden-cable transmission system in every case, two alternate harness patterns are available for the below-elbow amputee with a stump of medium length. The first is known as the "figure-eight" harness, the second as the "chest-strap" harness. In addition, there are two special modifications, one for the very long and another for the very short below-elbow stump. These are, respectively, the "double-axilla-loop" harness and the "dual-control" harness. Finally, there is the special harnessing arrangement using the biceps cineplastic muscle tunnel to provide force and excursion.</p> <h4>The Below-Elbow Figure-Eight Harness</h4> <p><i>The Harness Pattern</i></p> <p>The figure-eight pattern, of which <b>Fig. 2</b> presents a typical example, is the harness most commonly used in the unilateral below-elbow case, the axilla on the sound side being the site of anchor for capturing the relative motion. The front view of <b>Fig. 2</b> shows the suspension portion of the harness. The front harness strap, passing over the shoulder at the pectoral interval on the amputated side, buckles to the inverted Y-strap supporting the leather triceps pad, which in turn supports the socket through the flexible elbow hinges. The back view shows the transmission system from harness to terminal device. The general path of the control cable is such that sharp bends and curves of small radius are avoided as much as possible.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 2. The below-elbow figure-eight harness. A simple webbing loop passes around the sound shoulder, the front portion being used for suspension, the back for attachment of the control cable. The inverted Y-suspensor. triceps pad, and flexible elbow hinges are constructed of 4 to 6-oz. strap leather and lined with 4-oz. pearl horse-hide or equivalent. The proximal retainer on the triceps pad is of the flexible leather type to improve cable life. The three circled inserts show possible variations in individual cases. Circle <i>A </i>illustrates the leather half-cuff as used in combination with rigid elbow hinges and a single billet. Circle <i>B </i>shows a hall-cuff with two billets, again in combination with rigid elbow hinges. Circle <i>C </i>shows the inverted Y-strap as made from fabric instead of leather. Any of the combinations shown may be used as required to furnish the necessary stability depending upon occupational needs, level of amputation, and other factors. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The chief purpose of the control system is to transmit force and excursion to the terminal device. When, however, the amputee must pick up loads with forearm extended, the cable is expected to assist in support whenever the load is of any appreciable magnitude. This, then, is an example of what is meant by the proper balance of forces that is needed to meet amputee requirements. Both suspension and control system should be so constructed and adjusted as to be comfortable and yet be able to meet a reasonable load-support requirement without unnecessary displacement of the prosthesis. Tests for determining allowable displacements and other important factors have been set forth by Carlyle.<a></a></p> <p>As shown in <b>Fig. 2</b>, the harness is padded and protected under the axilla, and the control cable is so adjusted that it cannot come into contact with the amputee's back. For maximum excursion, the cross of the harness should be below the cervical vertebrae and not more than 1 in. toward the sound side of the vertebral spine. The control attachment strap <i>(i.e., </i>the strap attached to the flexible control cable) should lie at the midscapular level. In the course of constructing the harness, visual observations of all these details should be made while the wearer goes through the movements to be expected in normal use.</p> <p>Because of the simplicity of the figure-eight harness, minor deviations usually are not serious. Occasionally, indeed, exceptions to the normal placement of the harness cross are necessary and desirable to improve comfort. The figure-eight harness can be worn successfully by the majority of below-elbow amputees with ordinary duties, it is easy to construct and there is little chance for error, and it is functional and comfortable in most cases. Together these advantages generally represent the reason why it is so widely used. It readily adapts itself to vocations that are clerical in nature and to individuals requiring medium duty, such, for example, as the lifting that might be required of a stockroom worker.</p> <p><i>Below-Elbow Cliffs, Pads, and Hinges</i></p> <p>To furnish suspension and socket stability, three types of cuffs and pads, with and without fillers, are available, and any of several types of hinges, some flexible and some rigid, may be used. The circled inserts <i>A </i>and <i>B </i>of <b>Fig. 2</b> show some of the variations giving greater and greater stability as needed in the individual case. The choice of cuff and hinge combination is strictly a consideration for the prescription team, the rule being to provide maximum stability with the absolute minimum of harness. Prescription criteria and suitable templates for cuffs are described in considerable detail in Section 5.6 of the <i>Manual of Upper Extremity Prosthetics.</i><a></a> It should be remembered that many combinations of hinges and cuffs are available and that no one cuff must necessarily be accompanied by any particular type of hinge. Moreover, the prescription for any given amputee should take into account his own individual requirements and personal preferences.</p> <p>There are at least two ways of making cuff suspension systems, material selection being the principal distinguishing factor. The preference of the limbmaker may enter into the choice of technique largely because of the fabrication facilities that happen to be available. Leather has long been used in the limb industry, and it is readily adaptable because of its molding characteristics. Although the ability of leather to conform readily to the shape of the arm represents something of an advantage over webbing straps (circled insert <i>C </i>of <b>Fig. 2</b>), its tendency to absorb perspiration and thus to deteriorate, as well as to acquire unpleasant odors, is considered by many to be a distinct argument against its use in arm cuffs. The webbing strap, while perhaps less stable, offers the advantage of being easily washed and quickly replaced. Modern synthetic fabrics now available commercially can be laundered without undue shrinkage and may be reapplied without stretching under load.</p> <p>The below-elbow cuffs and pads usually are made of 4- to 6-oz. strap leather and are lined with horsehide or similar material. The fabrication of this component calls for the cutting, sewing, and fitting skills of the limbmaker. To make the Y-shaped leather suspension strap, a paper pattern is first cut to conform to the amputee's arm. When the template lies smoothly against the arm above the bulge of the biceps and will reach properly from the triceps pad or cuff to the webbing suspension strap passing over the shoulder at the pectoral interval, its shape is reproduced in 4- to 6-oz. strap leather or equivalent. The lower legs of the leather suspension strap are then riveted to the cuff or pad in such a position that the "V" lies smoothly against the arm and will support axial loads.</p> <p>The webbing inverted Y-suspensor is prepared by folding a piece of 1/2-in. webbing back on itself in such a way as to form a "V." The apex of the "V" is then sewed directly to the front suspensor strap of the harness at such a level as to give a smooth transition from the harness to the cuff or pad. The lower attachments to the cuff or pad are made by means of 1/2-in. buckles.</p> <p>Again, material selection is the chief factor determining technique. When leather is used, it is hard to determine the proper length of the legs of the "V" and to assure proper alignment without later adjustments. Moreover, unless leather components are coated with nylon <a></a> or similar material, the effects of perspiration will soon become apparent. Conversely, the webbing Y-suspensor offers easy adjustment of alignment and also resistance to perspiration by virtue of its washability. When fitted properly, both systems are acceptable, and hence personal preference is an influencing factor.</p> <h4>The Below-Elbow Chest-Strap Harness</h4> <p>Although the figure-eight harness is suitable for most below-elbow cases, it does not meet all vocational requirements. Heavy-duty activities, such as those of a farmer, requiring frequent lifting of loads greater than 50 lb., can best be accommodated by a below-elbow chest-strap harness. <b>Fig. 3</b> shows a typical example. By the addition of the shoulder saddle to reduce unit stresses on the shoulder and opposite axilla, the load-supporting capabilities and amputee comfort can be greatly improved, but to obtain a satisfactory result with the chest-type harness presents a greater challenge to the harnessmaker.<a></a></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 3. The below-elbow chest-strap harness The two suspensor straps running through D-rings are attached to a leather shoulder saddle Improved stability and reduced unit stresses over the shoulder offer greater ability to lift axial loads. Normally, the below-elbow chest-strap harness, used on amputees requiring heavy-duty service. is constructed in combination with half-cuff and rigid elbow hinges. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><a></a> It has been said that some limbmakers construct the chest-strap harness simply because they do not know how to make the figure-eight design. There ap pears to be no real evidence to prove which type really is the older, but it is generally accepted that the chest strap was the forerunner of the figure-eight. Regardless of priority, both patterns are acceptable, and each offers advantages and disadvantages.</p> <p>As shown in <b>Fig. 3</b>, there are basically three elements in the below-elbow chest-strap harnessâ€"the chest strap to hold the harness on, the shoulder saddle to serve as an anchor for suspending the prosthesis, and the control attachment strap for operating the terminal device. To connect the shoulder saddle and to suspend the prosthesis, two lengths of 1/2-in. leather or webbing are used. They originate on the back of the shoulder saddle, thread through D-rings on the cuff, and then buckle to the front of the saddle. This arrangement distributes the load on four points of the saddle and two points of the cuff and offers the inherent self-equalizing effect by virtue of the D-rings.</p> <p>The control attachment strap is connected to the chest strap and utilizes arm flexion and scapular abduction on the amputated side. Since no definite anchor is involved, neither scapular abduction nor shoulder flexion on the sound side can be harnessed, so that, unlike the case with the figure-eight harness, in the chest-strap design these body motions cannot be used as a source of reserve excursion. Although this basic difference is responsible for the improved comfort of the chest-strap harness, lack of a positive anchor not only robs the amputee of a third control motion but actually permits the harness to rotate upon the chest when excessive forces are applied to the control cable.</p> <p>The indications for and advantages of the chest-strap harness lie in its improved comfort and greater lifting capacity. The chief reasons for its selection over the figure-eight arrangement are concerned with vocational considerations, relief of unavoidable discomfort in the opposite axilla, and amputee preference based on his past experience. Both the figure-eight and the chest-strap harness may be used with almost any combination of hinges and cuffs. It may not be desirable to use a triceps pad and a shoulder saddle in combination, but there is no law against this possibility. The rule, as always, is to try for maximum stability with a minimum amount of harness. This being the case, the figure-eight harness should be tried first.<a style="text-decoration:none;">*</a> If it is not satisfactory, then the more complicated chest-strap harness may be resorted to. For detailed discussions of fabrication techniques for both harnesses, reference may be had to Section 5.0 of the <i>Manual of Upper Extremity Prosthetics .</i><a></a> </p> <h4>The Double-Axilla-Loop Harness</h4> <p>The increased frequency of successfully fitted wrist-disarticulation cases has led in such instances to a departure from the typical below-elbow harness pattern. A very simple and useful harness has been reported by the Naval Prosthetics Research Laboratory<a></a> for use with transcarpometacarpal cases, and the technique is also adaptable to wrist-disarticulation cases. As shown in <b>Fig. 4</b>, a double axilla loop originates the initial body motion on the sound side and provides its own reaction point on the amputated side. A solid piece of Bowden cable extends from the proximal reaction point located on the axilla loop on the amputated side to the distal reaction point located on the arm socket. The cable housing is covered with a piece of plastic tubing to prevent pinching of flesh and pulling of hair on the subject's arm.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 4. The double-axilla-loop harness for wrist disarticulations and transcarpometacarpal amputations. The loop on the amputated side serves as the reaction point, relative motion being produced when the sound shoulder is flexed. The control cable continues to the distal reaction point on the arm socket ([link5]) The auxiliary elastic strap indicated by dotted lines may or may not be needed. <i>Courtesy U S Naval Hospital, Oakland, Calif. .</i><a></a> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>It should be pointed out that the double-axilla-loop harness is only a means of supplying terminal-device operation. Suspension must be inherent in a well-fitted socket, which usually must be split to facilitate donning, the condyles of the wrist being the principal means of retaining the socket on the stump (<b>Fig. 5</b>). Wrist disarticulations can be fitted by this technique at first. If it proves to be unsuccessful for any reason, the harness may easily be replaced with a conventional below-elbow figure-eight harness.<a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 5. Wrist-disarticulation socket for use with the double-axilla-loop harness. Control cable extends to the proximal reaction point located on the axilla loop on the amputated side ([link4]). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>The Below-Elbow Dual-Control System</h4> <p>As opposed to the problem of fitting the wrist disarticulation and other long below-elbow stumps, there is the one involving the fitting and harnessing of the very short below-elbow slump. Use of the split-socket type of prosthesis furnishes a means of increasing the range of elbow flexion through a mechanical step-up. Thia expedient greatly improves the versatility of the below-elbow prosthesis and in the majority of cases proves to be very satisfactory when using the below-elbow figure-eight harness based on the single-control principle.</p> <p>For marginal cases with insufficient torque about the elbow to lift the prosthetic forearm, another departure has been made from the usual pattern of control. The below-elbow dual-control system, shown in <b>Fig. 6</b>, uses a forearm lever loop and a split-housing cable system. Since in this case the cable housing is in two separate pieces, the effective distance between the reaction point on the arm cuff and that constituted by the lever loop on the forearm shell is no longer independent of elbow angle, so that arm flexion produces forearm flexion. When used with the very short below-elbow stump, the dual-control system thus provides an assistive lift for forearm flexion, sometimes especially needed when forearm flexion is begun from full forearm extension. Ordinarily the short below-elbow case has enough torque about the elbow to stabilize the forearm, so that no elbow lock is required. When the forearm socket is stabilized by the stump, the force from the harness is transmitted to the terminal device.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 6. The below-elbow dual control using the split-socket type of prosthesis for the short below-elbow case. Since the cable housing is in two pieces, arm flexion assists in lifting the prosthetic forearm. The stump is then used to stabilize the elbow for terminal-device operation, no elbow lock being needed. The design of the step-up elbow hinges has been discussed in detail by Alldredge and Murphy (<i>1</i>). </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The familiar rule of first trying the less complicated harness should be applied at this level also. If the forearm cannot be flexed by the stump without unnecessary fatigue, or if forearm flexion is painful, then the dual system is indicated. Amputees fitted with the dual control should be checked periodically to see whether the residual muscles have hy-pertrophied enough to be adequate for unassisted forearm flexion, in which event the single control may be substituted. No harm is done by using the below-elbow dual-control harness when its necessity is questionable, but again the usual desirability of simplicity of harness would suggest discard of the assist lift when adequate function can be obtained without it.</p> <h4>The Below-Elbow Biceps-Cineplasty System</h4> <p><i>The Case for Cineplasty in General</i></p> <p>Since World War II, there has been, especially in the United States, a considerable revival of cineplastic surgery <a></a> to produce muscle tunnels capable of harnessing for the operation of artificial arms. Practically all available muscles of the arm and two major muscles of the chest (the pectoralis major and minor) have been harnessed by various means to operate arm prostheses. Two basic philosophies have developed in the use of the cineplastic muscle tunnel. First established was the idea of using the muscle motor to power the terminal device. The advantages of this means of independent terminal-device operation, without relying upon body motions, were readily apparent, to say nothing of the possibility of eliminating body harness completely in some cases.</p> <p>Some authors, for example Mount and Bernberg,<a></a> discuss the advantages of an increased sense of pressure and generally improved sense of perception when a muscle motor is harnessed to a terminal device. Mount and Bernberg say "The results generally indicate that the two Ss [subjects] using cine-plastic prosthesis distinguished, compared and recognized given objects with greater skill and precision than the Ss [subjects] using prosthesis of the harness type." Although further scientific tests to support this observation have not been conducted, subjects successfully fitted with both a conventional and a cineplastic prosthesis indicate that they have a better sense of pressure or feel with the latter.</p> <p>In the second philosophy developed, the pectoral tunnel is used to operate the elbow lock in the shoulder-disarticulation case. Obviously, the advantage in this case lies in the provision of the additional source of control.</p> <p>It may be stated, without reservation, that of all the possible arrangements involving cineplasty, the greatest degree of success has been obtained using the biceps muscle tunnel to power terminal-device operation in the below-elbow case. This does not mean that the combination of other muscle tunnels and other levels of amputation may not be successful in individual cases. Spittler and Fletcher,<a></a> Kessler , <a></a> Alldredge <i>et al., </i><a></a> and Taylor<a></a> report other muscles and other levels of amputation successfully fitted with cineplastic prostheses. Because, however, the other cases have not yet been proven clinically in the general sense, the discussion of the fitting of cineplasty is here restricted to the below-elbow biceps system.</p> <p>In the below-elbow biceps case, fitting is greatly simplified because the muscle tunnel is above the first sound joint in the amputated stump. The socket may thus be made to harness residual pronation and supination, and it does not require window-type construction <a></a> since the tunnel is once removed in the upper arm.</p> <p>Because the biceps tunnel in the below-elbow case is able to avail itself of the physiological characteristics of muscle, <a></a> adequate force and excursion are to be had. Since normally muscles are contracted to produce prehension, contraction of the biceps muscle tunnel should effect closing of the terminal device. For this reason it is generally accepted that a voluntary-closing device is most desirable for use with cineplastic amputees. Of course if the improved sense of pressure is to be had, then it may be best to use the voluntary-closing terminal device. Regardless of all data presented here and elsewhere, however, many biceps tunnels have been successfully harnessed in the below-elbow case with the voluntary-opening terminal device.<a style="text-decoration:none;">*</a> This circumstance can only suggest that the prescription of the terminal device in cineplasty is largely in the same area as is the prescription of the terminal device in the conventional case using body harness.</p> <p>The back-and-forth discussion of these factors is endless. It is therefore useful to have a look at the indications for cineplasty as seen from the point of view of the amputee. Needless to say that, in the growth of prosthetics clinic teams, new amputees are seeing more and more the types of prostheses worn by other amputees. Usually when the wearer of a conventional arm prosthesis sees a cineplastic type he feels that a "Cadillac" version of an artificial arm is available for him. No doubt personal choice, or the individual desire for a cineplastic type of prosthesis, is the major consideration. Amputees who were not too favorable at the time of discussing the cineplasty procedure have not obtained the same degree of success and training as have those who indicated their preference for cineplasty from the beginning.</p> <p>Another important factor relates to vocation. If a below-elbow amputee desires to do, for example, mechanical work on an automobile, he often finds himself lying on his back on a dolly. In this position, he is quite restricted in body motions for using a shoulder-harness prosthesis. For the wearer of a conventional prosthesis to operate his terminal device in this position involves the use of many body motions other than those ordinarily involved.</p> <p>Although no real criterion has yet been developed for the selection of individuals for the cineplasty type of prosthesis, it can be stated categorically that the personal preference of the individual and the vocational considerations are of prime importance and should therefore be discussed thoroughly with the patient before reaching a decision.</p> <p><i>The Two Established Systems</i></p> <p>Prosthetic fitting and socket construction for a biceps-cineplasty below-elbow prosthesis are very similar to the conventional techniques. The socket must provide stability and a means of attaching a terminal device. Suspension of the prosthesis may be handled in various ways. Two power-transmission systems have been developed, one at the University of California at Los Angeles and the other at the Army Prosthetics Research Laboratory. A comparison of the efficiencies of the two systems has revealed that they have quite similar characteristics.<a></a></p> <p><i>The UCLA Below-Elbow Biceps-Cineplasly System. </i></p> <p>The power-transmission system of UCLA consists of a muscle-tunnel pin, a dual-cable power-transmission system, and a twin cable mounting harnessed to the terminal device. All parts of this system, shown in <b>Fig. 7</b>, have been available commercially for some time, and the arrangement has received wide use in the field. Three types of cuffs are available for suspension in the UCLA system. The epicondyle cuff (<b>Fig. 8</b> and <b>Fig. 9</b>), the epicondyle clip (<b>Fig. 10</b>), and the epicondyle strap (<b>Fig. 11</b>) may be used with any selection of either flexible or metal double- or single-axis elbow hinges. The method of installing the UCLA system is described in detail in Section 10.0 of the <i>Manual of Upper Extremity Prosthetics.</i><a></a> </p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 7. The UCLA below-elbow biceps-cineplasty system with epicondyle cuff and rigid elbow hinges. The twin cable mounting is connected to the yoke to allow positioning for adequate operating excursion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 8. Pattern for the UCLA epicondyle cuff. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 9. Alternative design of the UCLA epicondyle cuff, constructed of stainless steel and covered with horsehide, the rigid hinges being attached to the cuff before covering. The cross strap at the top helps to stabilize the cuff on the arm. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 10. The UCLA epicondyle clip, constructed of stainless steel and covered with horsehide. Conventional baseplates are attached to be used as the proximal retainers for the dual cable system. The clip can be used with or without the auxiliary elastic strap as needed to maintain the clip in position when the arm is flexed. The epicondyle clip has also been constructed of a semirigid plastic such as Royalite. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 11. Typical pattern for the APRL epicondyle strap, reduced to exactly half the size needed to produce a strap for an arm with a circumference of 10 1/2 in. Placed as drawn on the grain side of the selected leather, this template makes a left or a right strap depending on whether the amputee prefers to have the strap buckle toward the medial or toward the lateral side of the arm. To produce a strap buckling in the reverse directions, the template is turned over and placed on the grain side of the leather. The dotted lines indicate a modification to accommodate a biceps tunnel located low on the upper arm when it is desirable to save space in the anterior fold of the elbow. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The UCLA system is quite adequate and very simple to harness and provides easy pre-positioning and ready adjustment of effective cable length. It has met with a very large degree of success throughout. Compared to the APRL system,<a></a> it offers the advantage of being applicable to a wider selection of terminal devices inasmuch as the control system may be mounted either on the top or on the bottom of the arm socket (<b>Fig. 12</b>). It offers also the advantage of allowing pre-positioning of terminal devices with less friction throughout the cable system.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 12. Alternate locations of the twin cable mounting for various terminal devices in the UCLA below-elbow biceps-cineplasty system. If it is desirable to interchange between the voluntary-opening hook and the voluntary-closing hand, two snap portions of the twin cable mounting may be used, one toward the lower side and another on the top side of the socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p><i>The APRL Below-Elbow Biceps-Cineplasty System. </i>The APRL system, as it appears in the <i>Manual of Upper Extremity Prosthetics</i><a></a>has been revised to improve function. The principal modifications (<b>Fig. 13</b>) have been to adopt flexible leather hinges and to discard the so-called "transit elbow hinges." Since these changes,<a></a> indications have pointed to a greater degree of success when the biceps tunnel is used with a voluntary-closing terminal device.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 13. Completed installation of the APRL below-elbow biceps-cineplasty system. The epicondyle strap is used in conjunction with flexible leather hinges, the hinges being adjustable by means of strap-type buckles placed at the points of attachment on the arm socket. The ox-bow tunnel pin, fitted with "Dot Fasteners" for joining to the sheave-type cable equalizer, is recommended for use with the APRL system. A flat cable-extensor mechanism is used to allow cable adjustment within the system and to permit interchangeability of terminal devices. Insert shows a variation in pin design that is available commercially. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although both the voluntary-closing and voluntary-opening hands and hooks are recommended routinely for use with biceps tunnels in below-elbow amputees, experience has shown that voluntary-closing devices have offered a number of special advantages. The available excursion can be increased by utilizing spring forces in the terminal device to recover excursion, thereby stretching the biceps tunnel into pre-tension beyond the rest length of the muscle.<a></a> Moreover, the improved ability to select prehensile forces at the finger tips makes it possible for amputees to handle, say, an ice-cream cone without crushing it or to wield a hammer or other heavy object without dropping it. Expressed amputee reaction seems to indicate, furthermore, that a considerable amount of pressure appreciation is realized through the use of the voluntary-closing terminal device, where the biceps is contracted for gripping an object. Of course, some pressure appreciation is lost when the voluntary-opening device is used, for then the biceps is contracted to open the device against the tension of the spring or rubber band, and the grasping force is exerted by the spring or rubber band upon relaxation of the muscle. Although no published data are available to support the claim of improved pressure appreciation with the voluntary-closing device, there are sound indications from active users that such a cue to the pressure exerted is of definite advantage.</p> <p>Since no published instructions for installing the APRL below-elbow biceps-cineplasty system are available, a simplified set is included here. The first step is to cut and check a paper template for the epicondyle strap in order to assure proper size and shape before proceeding to make the finished strap. The typical size and shape are indicated in <b>Fig. 11</b>. The pattern should be placed around the arm and examined for comfort, both with the patient's elbow extended and in maximum flexion (<b>Fig. 14</b>). If the biceps tunnel is located low on the arm, the template should be shaped as indicated by the dotted lines in <b>Fig. 11</b> to allow for maximum passive stretch. By thus lowering the front portion of the epicondyle strap, comfort, as well as excursion, is improved.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 14. Procedure for checking the paper template when making the epicondyle strap. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>With the epicondyle strap fastened in place, the normal elbow center is marked on the projecting hinge tabs. Standard baseplates are located as close to these points as possible and are held in place with a clamp on the upper edge (<b>Fig. 15</b>). They are then so aligned that the cable housings will follow smooth curves from the tunnel pin through the elbow center to the two distal retainers on the arm socket. Notation should be made of the approximate angles shown in <b>Fig. 11</b>.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 15. Placement of the baseplates on the epicondyle strap. They should be so positioned that the cable housings pass through gentle curves from the muscle tunnel to the distal baseplates on the arm socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The extending ears adjacent to the rivet holes on the two proximal baseplates should now be bent, as shown in <b>Fig. 16</b>, to follow the contour of the epicondyles, thus giving greatly improved comfort as well as added stability in supporting axial loads. The baseplates are then riveted to the epicondyle strap by means of the top rivets only.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 16. Bending the ears of the proximal baseplates to conform to the contour of the epicondyles. This detail gives added stability in supporting axial loads and improves amputee comfort. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Two pieces of 4-oz. strap leather 5/8 in. wide are now cut long enough to connect the epicondyle strap to the arm socket. A piece of nylon or vinyon strap is attached by rubber cement to the inside of the leather straps, and the whole is stitched along each side. One end of each of these two flexible hinges is then laid under one of the lower ears of the proximal baseplates and the lower rivets are driven in.</p> <p>With the epicondyle strap fastened in position, the arm socket is placed on the patient, and the proper length of the flexible hinges is determined. Finally, the positions of the distal hinge attachments are marked, and the hinges are riveted to the socket, adjustment being provided for by the two buckles.</p> <p>The arm socket and epicondyle strap are now put in place, the cable-housing retainers are attached to the baseplates on the epicondyle strap, and the cable housings are continued through the elbow center in such a way as to maintain a gentle wave to a point approximately 2 in. below the top of the arm socket (<b>Fig. 13</b>). The arm is then removed from the patient, and the baseplates are riveted in position on the socket. The male end of the cable lengthener is now attached to the terminal device, the lengthener is extended to the full-open position, and the other end of the lengthener is attached to the sheave equalizer.</p> <p>Next the cable housings are installed and adjusted to obtain maximum elbow flexion and extension without compression or stretch of the housings. The ends of the housings are trimmed so that, when the ferrules are installed, the housings will terminate flush with the rivets on the baseplates. The ferrules are then pinched slightly with a diagonal cutter.</p> <p>A female snap-on attachment is now fastened to one end of a length of cable, and the attachment is snapped to the pin. The free end of the cable is fed through one cable housing, down through and around the sheave, and back up through the other cable housing. The terminal device is opened, the muscle tunnel is pulled into passive stretch, and the cable length is measured. The cap fitting is installed according to manufacturer's instructions. Normally, the cable will be a little too long. Adjustment may be made by taking up on the cable-length adjuster.</p> <p>After a period of use of the prosthesis, the amputee may find that the adjuster can no longer remove slack from the system. This development can be expected in some cases. It is only an indication that the tunnel has stretched with use. In this event, the control cable should be detached, shortened, and reattached as in initial cable installation.</p> <p>The APRL system as described here has been used experimentally with a great deal of success, but the lack of commercial availability of components in the past has limited its use in the field. It is designed primarily to be used with the voluntary-closing type of terminal device. Furthermore, the frictional losses in pre-positioning are greater than in the UCLA system, and unless the sheave equalizer is placed on the top of the socket use is limited to voluntary-closing terminal devices. This circumstance makes interchange-ability of a voluntary-closing hand and a voluntary-opening hook quite impractical. The APRL system is primarily recommended for use with the epicondyle strap, which normally gives ample support for axial loads without appreciable displacement of the socket.</p> <p>A distinct advantage of the APRL system over that of UCLA is that the effective cable links between the equalizer and the muscle tunnel may be adjusted while at the same time maintaining equalized forces. To adjust the effective cable links between the twin cable mounting and the muscle tunnel in the UCLA system requires a turnbuckle, which in effect changes the links of the cable housing, thus increasing frictionai losses within the system.</p> <h4>Harnessing for the Above-Elbow Cases</h4> <p>Basically, two functional requirements must be met in above-elbow cases. Not only must prehension be provided for but it must be usable at various degrees of forearm flexion. Experience has shown that satisfactory prehension can best be obtained through a normal range of forearm flexion when provision is made for stabilizing the forearm at the selected level of operation. Thus, to the two basic functions there must be added the requirement of elbow lock. The body motions easily accessible and available for controlling these three functions in the above-elbow prosthesis are arm flexion, arm extension, and scapular abduction.<a style="text-decoration:none;">*</a></p> <p>At present there are three satisfactory harness patterns for the above-elbow case, two based on the so-called "dual control" and the third based on "triple control." The two dual-control systemsâ€"the above-elbow figure-eight harness and the above-elbow chest-strap harnessâ€"utilize arm flexion for forearm flexion and terminal-device operation, elbow lock being effected by arm extension. In the triple-control harness, arm flexion is used to produce forearm flexion, arm extension gives elbow lock, and terminal-device operation is obtained by shrug of the sound shoulder. Each of the three systems has its own advantages and disadvantages, and each therefore has indications and contraindications in individual cases.</p> <h4>The Above-Elbow Figure-Eight Harness</h4> <p>From the wearer's point of view, the above-elbow figure-eight harness (<b>Fig. 17</b>) constitutes the easiest way of meeting the requirements of the above-elbow case. It is simply a modified below-elbow figure-eight design with provisions for the added functional requirements. Although in the below-elbow case it is essential mechanically to maintain a constant effective distance between the proximal and distal reaction points of the terminal-device control cable (Bowden principle), in the above-elbow case two functions may be obtained from a single cable by splitting the cable housing and substituting for the distal reaction point a lift lever on the forearm shell.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 17. The above-elbow figure-eight harness. The basic structure consists of a loop about the opposite axilla, the front portion supporting the arm and the rear portion attaching to the control cable so that arm flexion gives forearm flexion and terminal-device operation. The piece of elastic inserted in the front portion provides for relative motion for elbow locking by arm extension, the elbow-lock control being attached to the nonelastic portion. Suspension is improved by the lateral support strap and indicated auxiliary straps when necessary. As in the below-elbow dual control ([link6]), the cable housing is split so that arm flexion gives forearm lift when the elbow is unlocked, the leather lift loop on the forearm shell serving as the distal reaction point. If it is difficult to start the forearm into initial flexion, two baseplates may be used on the arm socket. The length of the leather lift loop on the forearm shell should be such that, when the forearm is extended, the distance from the center of the cable to the center of the elbow is equal to the distance from the center ot the forearm to the center of the cable housing. This arrangement reduces the amount of force needed to start the forearm into initial flexion without increasing the excursion required for full forearm flexion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>This arrangement couples forearm flexion and terminal-device operation to produce the dual control as used in the case of the very short below-elbow stump. Motion in the control source elicits terminal-device operation or forearm flexion depending on whether the elbow is locked or unlocked.</p> <p>In the dual-control system, arm flexion is used as the source of control for forearm flexion and terminal-device operation, sometimes augmented by scapular abduction at large elbow angles, such as when the terminal device is near the mouth. A piece of elastic-webbing is substituted for the nonelastic front attachment strap of the below-elbow figure-eight harness. It is attached at the level of the clavicle and extends to the adjustable buckle on the arm socket, a minimum of 6 in. being desirable for easy operation of the elbow lock. The elbow-lock control cable is attached to</p> <p>the nonelastic portion of (he front attachment strap by means of a piece of 1/2-in. webbing bearing a 1/2-in. adjustment buckle. Arm extension thus produces relative motion between the elastic webbing and the nonelastic control strap in such a way as to induce elbow locking. Thereafter arm flexion controls terminal-device operation. With proper training and practice the amputee can become very adept in effecting smooth operation of all three prosthetic controls.</p> <p>Suspension is improved by adding a connecting strap, known as the "lateral support strap," above the cross on the amputee's back. It extends laterally across the shoulder to a buckle on the lateral side of the arm socket. Proper adjustment of the lateral support strap controls alignment in the abduction-adduction plane. With these modifications, the below-elbow figure-eight harness is adapted to become the figure-eight for the above-elbow case. In summary, the alterations include insertion of the elastic webbing in the front to help suspend the socket and to provide for relative motion for elbow-lock control, addition of the lateral support strap over the shoulder to contribute to socket stability, and the use of the two-piece cable housing to give forearm flexion when the elbow is unlocked.</p> <p>The two optional straps indicated in <b>Fig. 17</b> together improve suspension, increase the available excursion, and assist in maintaining the control attachment strap on the shoulder when the arm is raised. The over-the-shoulder strap forms a webbing network to support axial loads and to stabilize the lateral support strap and front attachment strap on the shoulder. The cross-back elastic strap not only gives greater excursion both in scapular abduction and in arm flexion but it helps to prevent the control attachment strap from riding over the shoulder during extreme arm flexion, such as when the amputee is working in areas over his head. But again, following the rule of simplicity whenever possible, the above-elbow figure-eight harness should be tried first without the two optional straps. If that proves unsatisfactory, then the extra straps may be added.</p> <p>For a detailed description of the technique of fabricating the above-elbow figure-eight harness, reference may be had to Section 6.7 of the <i>Manual of Upper Extremity Prosthetics </i><a></a> or to the report of the NYU Committee on Above-Elbow Harness.<a></a> It will suffice here to describe some of the common errors often leading to difficulties. Careful observation should always be made to be certain that the elastic straps are not too short and that the proximal end and distal buckle of the front suspensor strap are properly positioned. A minimum of 6 in. of elastic is required to give sufficient excursion for operation of the elbow lock and to provide adequate length for adjustment of tension in the strap.</p> <p>Placement of the proximal end of the elastic suspensor not lower than the clavicle enables the amputee to feel the elastic stretching over the deltopectoral interval during the elbow-lock operation, thus furnishing an additional cue to ensure reliable elbow function, and it permits the minimum of 6 in. of elastic to be used without bringing the attachment too far down on the socket. Normally the harness cross should lie approximately 1 in. toward the sound side of the vertebral spine. Crossing the harness at this point usually brings the control attachment strap over the lower third of the scapula, where maximum excursion may be utilized. The cross should be below the seventh cervical vertebra, thus avoiding the discomfort caused when the harness rides up. If the cross is more than 1 in. toward the sound side, the axilla loop is unduly decreased in size, with consequent increase in discomfort at the axilla.</p> <p>The control attachment strap should not fall so low as to prevent arm abduction, and the lateral support strap should not ride too high on the neck. If the cross is farther to the amputated side, the control attachment strap may ride too high. Placement of the lateral support strap 1/2 in. forward of the acromion is found to result in optimal stabilization of the prosthesis on the stump without causing rotation. Attachment of the lateral support strap should be 2 in. below the acromion. When it is attached at a lower point, the strap rolls back and forth over the shoulder, and higher attachment results in poor cosmesis because of the interference of the buckle with the shoulder pad of clothing. Placement of an adjustable buckle at the junction of the front support strap and elastic suspensor provides optimal position for adjustment of the elbow-lock control cable.</p> <p>The placement of the elastic suspensor strap markedly influences the effectiveness of the elbow-lock control motion. If excess slack is left in the elbow control cable, it must be taken up by the control motion before the lock will operate, and consequently the total excursion will then be greater than necessary. At the same time, there must be sufficient slack in the cable to permit relaxation of tension for resetting the elbow-lock mechanism.</p> <h4>The Above-Elbow Chest-Strap Harness</h4> <p>The chief advantages of the above-elbow figure-eight harness are that it is functional and simple and will satisfy the needs of most vocational activities. As in the below-elbow case, however, if there is a requirement for the harness to lift heavy loads, then another type is indicated. Again as in the below-elbow case, the chest-strap harness (<b>Fig. 18</b>) is recommended for the above-elbow amputee whose activities commonly involve heavy-duty work. By supplying a shoulder saddle and thus reducing the unit stresses over the shoulder, the above-elbow chest-strap harness provides greater comfort, and hence greater loads can be accommodated.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 18. The above-elbow chest-strap harness using for suspension a leather strap threaded through a D-ring on the lateral wall of the socket and attached to a leather shoulder saddle at two points, The strap for the control cable may be attached either to the shoulder saddle, as shown, or to the chest strap at the midspine position. As in the below-elbow case, this type of harness improves lifting ability and reduces unit stresses over the shoulder on the amputated side. The elbow-lock control cable is attached to the front of the shoulder saddle, and again a piece of elastic is used as the front suspensor between shoulder saddle and arm socket. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The shoulder saddle has taken two forms, the leather type and the webbing type. The leather type is precisely like that used in the below-elbow chest-strap harness. <b>Fig. 19</b> and <b>Fig. 20</b> illustrate webbing-type shoulder saddles that furnish adequate suspension on the lateral side of the arm socket and provide for the relative motion needed for elbow lock and for dual control. The operational pattern of body motions is identical to that used with the above-elbow figure-eight pattern. Arm flexion manages dual control <i>(i.e., </i>forearm flexion and terminal-device operation), and arm extension controls the elbow lock.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 19. The above-elbow chest-strap harness with webbing shoulder saddle. The functional arrangement is identical to that in the above-elbow chest-strap harness with leather shoulder saddle ([link18]). The leather has simply been replaced with a webbing saddle designed to give the same function. The technique is best used on individuals who perspire freely but who nevertheless need the chest-strap type of harness for heavy lifting. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 20. An alternative construction of the webbing shoulder saddle for use with the above-elbow chest-strap harness. Beginning at the point of attachment on the front of the arm socket, the principal strap passes over the shoulder on the amputated side, continues across the amputees back, goes under the opposite arm, crosses the chest, again passes over the shoulder on the amputated side, and buckles to the rear portion of the socket. This arrangement equalizes the forces when axial loads are encountered. A Y-type construction is used to connect the control cable to the chest strap at the midspine position and at the point where the chest strap crosses the shoulder. A similar construction is used in front, the lower leg of the Y" being made of elastic to permit the relative motion needed for elbow-lock control. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The above-elbow chest-strap harness has as its chief advantage the ability to lift axial loads with lower unit stresses over the shoulder. Its primary disadvantage lies in its characteristic tendency to rotate about the chest owing to lack of a positive anchor. Again as in the below-elbow case, the simpler figure-eight design should be applied to the above-elbow case whenever it can be made to serve the amputee satisfactorily. The above-elbow chest-strap harness should be adopted only when the simpler figure-eight harness proves to be inadequate in any given case.</p> <h4>The Above-Elbow Triple Ccontrol</h4> <p>In the above-elbow triple-control harness (<b>Fig. 21</b>), arm flexion produces flexion of the forearm, arm extension provides elbow-lock control, and extreme flexion of the sound shoulder (shrug) gives terminal-device operation. Although the control system is quite simple, it requires the amputee to distinguish between arm flexion on the amputated side and extreme flexion of the shoulder on the opposite side to yield two separate controls. Above-elbow amputees with long stumps can usually make this distinction readily enough; those with medium to short stumps find it very difficult.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 21. The above-elbow triple-control harness. It differs from the dual-control pattern in that three body motions are required. The axilla loop uses shrug of the opposite shoulder to operate the terminal device, so that in this case the chest strap is separated at approximately the midspine position. Relative motion takes place between the axilla loop on the sound side and the reaction point located on the portion of the harness on the amputated side. A supporting shoulder saddle is constructed of a webbing network, and the control attachment strap for forearm flexion is attached at a point over the superior spine of the scapula on the amputated side. Arm flexion then lifts the forearm. Arm extension is harnessed as usual, a piece of elastic being used as the front suspensor strap to provide for the necessary relative motion. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The advantage of triple control lies in the possibility of operating the terminal device without first locking the elbow. But the complexity of fabricating the triple-control system has been a major disadvantage and has discouraged its use. It is recommended for amputees requiring versatility in the use of the prosthesis, but it should be approached cautiously by the harnessmaker.</p> <h4>Harnessing for the Shoulder-Disarticulation Cases</h4> <p>To provide adequate functional harness for the shoulder-disarticulation amputee has always been especially difficult because of the lack of the control source otherwise available from humeral motion. In the absence of an arm stump, it has been to date, for all practical purposes, impossible to provide any satisfactory voluntary motion of the prosthetic arm about the shoulder, and consequently a substitute must be sought for arm extension, the control source commonly used by the above-elbow amputee for operation of the elbow lock. The alternatives are to use manual operation of the lock by the sound hand or else to harness some residual control source ordinarily remote from arm function.</p> <p>Since in any case manual control is undesirable because it interrupts two-handed activities, the trend has been to utilize other body motions such as those of the head or shoulders. The nudge control,<a></a> with the operating button located on the shoulder cap of the prosthesis, was designed to be operated by pressure from the chin. But this system leads to such awkward appearance in use that it has since been more or less superseded by harness designs utilizing shoulder motions. The perineal strap, with function based on relative displacement between shoulders and pelvis, is disliked by most amputees and therefore has been used less and less except where special complications prohibit other arrangements. The most practical system worked out to date involves use of a waist band or equivalent. At the present time, there are four satisfactory harness patterns for the male shoulder-disarticulation case and two suitable for the female. For the male, there are three dual-control systems, all operated by scapular abduction, elbow lock being accomplished in the first case by shoulder elevation on the amputated side, in the second by flexion of the opposite shoulder, and in the third by shoulder extension on the amputated side. The fourth system for the male utilizes the triple-control principleâ€"scapular abduction to provide forearm flexion, elevation of the shoulder on the amputated side to give elbow lock, and shrug of the opposite shoulder to operate the terminal device. Since all four of these systems involve a chest strap unsuited to the female, two special arrangements have been worked out for women. Both are built around a brassiere, and both utilize dual control, in the one case operated by scapular abduction, in the other by motion of the opposite shoulder. In both cases, elbow lock is effected by elevation of the shoulder on the amputated side.</p> <h4>Harness Patterns for Men</h4> <p><i>Dual Control with Shoulder-Elevation Elbow Lock</i></p> <p>Of the four shoulder-disarticulation harness systems for males, the one most often used with the least trouble involves scapular abduction for dual control of forearm flexion and terminal-device operation, elbow lock being managed by elevation of the shoulder on the amputated side. As in all dual-control systems, excursion of the control source, in this case bilateral abduction of the scapulae, produces either terminal-device operation or forearm flexion depending on whether the elbow is locked or unlocked.</p> <p><b>Fig. 22</b> presents the basic details of this harness pattern. A webbing chest strap attaches to the front of the shoulder cap, passes under the axilla on the sound side, crosses the back at the midscapular level so as to utilize the maximum available excursion, and attaches to the control cable positioned on the back of the shoulder cap. An elastic suspensor strap extends from the top of the shoulder cap, diagonally across the back, and attaches to the chest strap at a point just toward the sound side of the vertebral spine. The length of the chest strap is so adjusted as to permit full terminal-device operation without bringing the cable into contact with the skin.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 22. Shoulder-disarticulation harness using scapular abduction for dual control, elbow lock being operated by shoulder elevation on the amputated side. After Pursley <i>, </i><a></a> by permission of <i>Orthopedic and Prosthetic Appliance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Elbow-lock operation by shoulder elevation is provided for by linking the elbow control cable to a waist strap encircling the trunk below the thoracic cage, thus establishing an anchor to oppose shoulder elevation. Although adequate force for elbow locking is usually available, care is taken to position the cable reaction points in such a way as to eliminate as much frictional resistance as possible.</p> <p>This system offers several distinct advantages over other methods of harnessing the shoulder-disarticulation case. It involves the minimum amount of harness needed to operate the three basic controls, and it has the inherent advantage of avoiding any possibility of interference between elbow locking and the other two functions. Thus training is simplified considerably, and the success of the individual harness may be determined at the time of fitting.</p> <p><i>Dual Control with Opposite-Shoulder Elbow Lock</i></p> <p>A second shoulder-disarticulation harness system seen frequently also uses scapular abduction for dual control of forearm flexion and terminal-device operation, but elbow lock is effected by a forward rotation of the sound shoulder. The arrangement for dual control is precisely like that just described, the difference in the harness as a whole being concerned with the method of elbow locking (<b>Fig. 23</b>). In addition to the chest strap and the elastic suspensor strap, there is provided for the sound shoulder a webbing saddle, the cross-back extension being attached to the elbow control cable near the point of stabilization on the back of the shoulder cap. Again the lengths of the straps are so adjusted as to permit adequate excursion without the cables touching the flesh.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 23. Shoulder-disarticulation harness using scapular abduction for dual control, elbow lock being operated by flexion of the shoulder on the sound side. After Pursley,<a></a> by permission of <i>Orthopedic and Prosthetic Appli~ ance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although this system eliminates the need for the waist strap, it obviously introduces more complicated harness about the shoulders, and it offers the inherent disadvantage of the possibility of inadvertent locking or unlocking of the elbow in the course of forearm flexion or terminal-device operation. If, however, care is taken to keep the chest strap at the mid-scapular level while making the opposite-shoulder loop as high as possible, and if the amputee is thoroughly trained, the two operating body motions can usually be separated satisfactorily.</p> <p>Because in this system the elbow-lock control cable traverses a comparatively long path, and also because the associated harness moves across the entire surface of the back, the frictional forces involved are sometimes such that the alternator spring in the elbow is not strong enough to return the control cable to the relaxed position. When this is the case, an additional spring may be added on the inside of the arm section (<b>Fig. 24</b>). Since this extra spring force makes the elbow lock more difficult to operate, it has the incidental advantage of making it easier for the amputee to separate opposite-shoulder shrug from scapular abduction, thus helping to avoid inadvertent elbow action. If difficulty is still encountered, separation of controls is sometimes made easier if the opposite-shoulder loop is adjusted to require an extreme flexion of the sound shoulder before elbow locking is induced.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 24. Installation of the elbow-lock cable, showing arrangement when auxiliary spring is needed to return cable to relaxed position. The additional spring force makes it easier to separate the elbow-lock control motion from scapular abduction. After Pursley,<a></a> by permission of <i>Orthopedic and Prosthetic Appliance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>In any event, a considerable period of practice is usually required before the average amputee can manage separation of controls systematically and with the necessary confidence. Training is thus more prolonged than is the case with the shoulder-elevation elbow lock, and consequently the dual-control harness using opposite-shoulder lock offers the further disadvantage that the ultimate success in any given case is difficult to determine at the time of initial fitting.</p> <p><i>Dual Control with Shoulder-Extension Elbow Lock</i></p> <p><b>Fig. 25</b> presents the dual-control shoulder-disarticulation harness utilizing shoulder extension to lock and unlock the elbow. The lower leg of the front attachment strap contains a piece of 1-in. elastic, the front elbow-lock control being connected to the nonelastic part of the chest strap. Thus shoulder extension produces a relative motion for elbow locking.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 25. Shoulder-disarticulalion harness using scapular-abduction dual control, elbow lock being operated by extension of the shoulder on the amputated side The chest strap terminates in front in a forked arrangement for attachment to the socket. A piece of 1-in. elastic is inserted in the lower leg of the fork, and the elbow-lock control cable is attached to the base portion of the chest strap just beyond the elastic, thus providing for relative motion upon extension of the shoulder on the amputated side. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>To operate the prosthesis starting with forearm extended, scapular abduction is used to produce forearm flexion. While maintaining enough force on the lift cable to hold the forearm in the desired position, the amputee extends his shoulder on the amputated side to lock the elbow. Thereafter scapular abduction operates the terminal device.</p> <p>Although this system may be used on any shoulder-disarticulation case, amputees retaining the humeral neck are the most successful. Patients without the humeral neck experience difficulty in coordinating the two body motions. In any event, the length of the elastic and the position of the wide attachment are both critical. Normally a piece of 1-in. elastic 1 1/2 in. long is used as a start. If the elbow is difficult to operate, the elastic portion is made longer. If the elbow operates inadvertently, the elastic is shortened so as to require more definite shoulder extension to lock and unlock. Although this type of shoulder harness is quite new, experience to date would suggest consideration of new elbow mechanisms especially designed for use with it. An obvious advantage is elimination of the waist band and opposite-shoulder loop used respectively in the other two dual-control systems.</p> <p><i>Triple Control</i></p> <p>In the triple-control system for shoulder disarticulation, as in the triple control for above-elbow cases, the three necessary functions are provided by three control sources, one for each. The usual and generally most successful pattern utilizes scapular abduction for forearm flexion, shrug of the sound shoulder for terminal-device operation, and elevation of the shoulder on the amputated side for control of the elbow lock. The basic pattern (<b>Fig. 26</b>) involves a minor modification of the chest strap seen in <b>Fig. 22</b> and <b>Fig. 23</b>, an elastic suspensor strap also similar to that seen in <b>Fig. 22</b> and <b>Fig. 23</b>, an opposite-shoulder loop with an extension passing over the seventh cervical vertebra or slightly below it, and a linkage between elbow control cable and waist band.<a style="text-decoration:none;">*</a>Although the triple control requires more harness than do the other three patterns for shoulder disarticulation, it offers certain advantages not to be had from dual control. Separation of terminal-device operation from forearm flexion offers improved control over prehension, since during forearm flexion no force or excursion is introduced affecting the terminal device. Likewise, as in the case of the dual control with shoulder-elevation elbow lock, the triple-control system overcomes the difficulty of separating elbow lock from the other two functions, so that inadvertent elbow locking or unlocking is avoided. The result is, again, simplified training and the possibility of determining the success of the harness at the time of initial fitting.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 26. Shoulder-disarticulation harness utilizing triple control. Scapular abduction provides forearm flexion; shoulder on sound side operates terminal device; elbow lock is operated by shoulder elevation on the amputated side. After Pursley,<a></a> by permission of <i>Orthopedic and Prosthetic Appliance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Harness Patterns For Women</h4> <p>Since the chest strap, common to all four harness patterns for male shoulder-disarticulation cases, is unsuited for most women, harness designs for female shoulder-disarticu-lation amputees are best based on some other principle. The most satisfactory method found to date for eliminating the chest strap is to utilize as part of the harness a brassiere made of sturdy material.<a style="text-decoration:none;">*</a> As shown in <b>Fig. 27</b>, a strip of 1-in. webbing is sewed around the lower edge of the brassiere known to bra designers as the "diaphragm band." The shoulder cap is so designed as to project in front below the breast on the amputated side to provide an anchor point <i>(B) </i>to which the diaphragm band is attached. An elastic sus-pensor strap attaches to the top of the shoulder cap at <i>A</i>, passes diagonally down the back, and is sewed to the diaphragm band at <i>C </i>somewhat toward the sound side of the vertebral spine. For ease in adjustment and to provide for ready laundering, a buckle is used at <i>D, </i>a clip-type disconnect is installed at <i>E, </i>and attachments at <i>B </i>and <i>A </i>are made with snap fasteners. The arrangement for control of the elbow lock utilizes the waist band<a style="text-decoration:none;">*</a> in the same way as in the corresponding pattern for the male (<b>Fig. 22</b>).</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 27. Harness for female shoulder-disarticulation cases, made integral with bra but detachable from arm socket for laundering. Scapular abduction provides dual control of forearm lift and terminal-device operation, while elbow lock is effected by shoulder elevation on the amputated side. After Pursley, <a></a> by permission of <i>Orthopedic and Prosthetic Appliance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although in this harness design the diaphragm band crosses the back somewhat lower than the midscapular level desired with the chest strap, adequate excursion is usually available from biscapular abduction, which, as in the male patterns of <b>Fig. 22</b>, <b>Fig. 23</b> and <b>Fig. 25</b>, provides dual control of forearm flexion and terminal-device operation. Shoulder elevation provides control of elbow locking.</p> <p>A problem encountered with the design shown in <b>Fig. 27</b> is that in flat-chested persons or in those with comparatively small breasts it is sometimes difficult to get adequate stability, so that operation of the dual control causes the brassiere to rotate upon the chest. When such a situation prevails, use may be made of the modification shown in <b>Fig. 28</b>, where the brassiere is called upon to provide suspension only, the loop about the sound shoulder furnishing the dual control. Here, as in Figure 27, attachments <i>A, B, </i>and <i>D </i>are made with snap fasteners so that the entire harness can be removed from the arm socket for laundering, the elastic suspensor being sewed to the diaphragm band at <i>C.</i></p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 28. Alternative harness for female shoulder-disarticulation cases in which the simpler arrangement of Figure 27 proves too unstable. Here the bra is used for suspension only. The loop over the sound shoulder provides dual control of forearm lift and terminal-device operation, while elbow lock is effected by shoulder elevation on the amputated side After Pursley,<a></a> by permission of <i>Orthopedic and Prosthetic A ppliance Journal</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h4>Some Special Cconsiderations</h4> <p>A distinguishing characteristic of the shoulder-disarticulation amputee is that the available control sources are for the most part of comparatively high force but of low excursion. Most commercially available terminal devices require an average of 1 3/4 in. of excursion for full operation, and normally 2 to 3 in. of excursion are needed to produce full forearm flexion of 135 deg. Generally, the total exceeds the excursion available from scapular abduction. This means that if, in a dual-control system with a voluntary-opening hook, where the excursions for forearm flexion and for terminal-device operation are additive, the amputee is to be able to open the hook at the mouth, some means must be found for obtaining the extra excursion. The only other alternatives are to use a voluntary-closing hook, in which case the excursion used in forearm flexion is regained for hook operation, or to use triple control, in which case forearm flexion and terminal-device operation are obtained from two separate sources. But many shoulder-disarticulation amputees do not care for voluntary-closing terminal devices, and others, for this reason or that, are not always able to manage the triple control. Since in general the force available from scapular abduction far exceeds that needed for forearm lift and prehension, some of the force may be sacrificed in the interest of obtaining an increase in excursion. The "block-and-tackle" cable system shown in <b>Fig. 29</b> and <b>Fig. 30</b> provides a two-to-one step-up in excursion at the expense of surplus force. It may be used with any of the six harness systems whenever added excursion is needed either for forearm flexion or for terminal-device operation. In <b>Fig. 23</b>, for example, it is applied to the dual control. In [link26], it is used to step up forearm flexion in the triple control. It could equally well be installed in the system of <b>Fig. 22</b>, should that prove to be necessary in any given case. Conversely, when excursion step-up is not required for the patterns of <b>Fig. 23</b> and [link26], an external cable routing may be used, as in <b>Fig. 22</b>. In any case, careful analysis of the excursion available and of that required for the terminal device prescribed forms the basis of judgment as to whether the step-up system is indicated or not.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 29. Cable system for reducing the amount of excursion needed in the shoulder-disarticula-tion dual control. After Pursley,<a></a> by permission of <i>Orthopedic and Prosthetic Appliance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /><table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 30. Installation of the excursion-reducing cable system shown in Figure 29. After Pursley <a></a>, by permission of <i>Orthopedic and Prosthetic Appliance Journal.</i> </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Although the six harness patterns described here represent the most generally successful designs now in common use for the shoulder-disarticulation case, no one of them provides a voluntary control source for motion of the upper arm about the shoulder. This deficiency, of course, imposes upon the shoulder-dis-articulation amputee a rather serious limitation not characteristic of the normal arm. Some provision for arm flexion-extension is possible by making the arm socket in two pieces, a humeral section and a shoulder cap, and using the so-called "sectional plates" .<a></a> But this arrangement is intended for manual pre-position only. Recently<a></a> a shoulder-disarticulation arm has been designed with a shoulder joint giving a combination of flexion and abduction to permit comfortable sitting at a table or desk, but again arm lift is manual, there being no satisfactory control source for voluntary flexion-abduction about the shoulder cap. Development of an additional voluntary control source to simulate the motion of the normal glenohumeral joint is now perhaps the most pressing need of the shoulder-disartic-ulation amputee.</p> <h4>Harnessing for Bilateral Arm Amputees</h4> <p>As compared to the unilateral case, the prosthetic requirements of bilateral arm amputees are magnified many fold. Experience shows that the unilateral subject uses his prosthesis chiefly to hold, carry, or assist in activities requiring two hands. Bilat-erals, on the contrary, are required to rely wholly on their arm substitutes for both one-handed and two-handed activities. The prescription criteria and techniques of fitting are therefore modified for the bilateral in an attempt to provide general operation in areas where the unilateral uses his normal hand. Bilateral arm amputees must, for example, have access to the pockets, both shirt pockets and side and hip trouser pockets if possible. They must be able to brush the teeth, comb the hair, use a buttonhook to manage button closures, and perform a great variety of other essential activities in the course of daily living. In general, all of these functions require action close to the body, behind the back at waist level, or at face, neck, or above the head. The prescription criteria for bilaterals therefore require special attention to personal as well as vocational needs, and consideration must be given to such special items as easily operable wrist disconnects and wrist-flexion units. Fabrication techniques are altered to provide for greater strength, and socket margins must be carefully determined in order to assure maximum socket stability for improved control.</p> <p>In below-elbow cases, residual pronation and supination is, of course, priceless. In every step of amputee care, every effort should be made to maintain forearm rotation. Attention should be paid this matter from the time of the original amputation and should continue through prescription, socket fitting, and fabrication of the harness.</p> <p>A matter of the greatest importance to the bilateral arm amputee is that of being able to get the harness and prostheses on and off without help from others. Bilateral above-elbow and shoulder-disarticulation amputees can almost always manage to get their prostheses off without help, but they sometimes require assistance in putting the arms on. Special brackets mounted on a wall in a bedroom are often needed to help amputees otherwise unable to perform independent donning. If, for example, a bilateral with short above-elbow stumps cannot control his prostheses while reaching for the harness cross on his back to remove the harness by pulling it over his head ("skinning-the-cat"), he hangs the cross over the wall hook by simply backing up to it. He then bends his knees to lift the straps over his head. Leaving the harness cross on the hook, he then removes the prostheses by holding the terminal devices, one at a time, each with the opposite foot. Thus the arms are left hanging in such position that the stumps can again be inserted into the sockets and the harness slipped back over the head.</p> <p>Control in the bilateral amputee is at best difficult. Because the number of controls required is doubled, less effective control motions must be brought into use, and independence of control becomes a problem. At present, six control functions, three for each arm, are about all that can be manipulated conveniently and efficiently. Even so, interaction between controls is noticeable.</p> <h4>The Bilateral Below-Elbow Harness</h4> <p>The easiest way to describe a bilateral below-elbow harness (<b>Fig. 31</b>) is to start by supposing that a unilateral below-elbow amputee has lost his remaining good arm below the elbow and has asked that his old figure-eight harness be used to make the new bilateral harness. The first step would be to cut the axilla loop on what was formerly the sound side. The front portion of the cut strap would then be attached to the inverted Y-suspensor of the new prosthesis. The back portion of the cut strap would be turned back upon itself and attached to a buckle. It thus would become the control attachment strap for the new prosthesis.<a style="text-decoration:none;">*</a> Arm flexion on either side then gives terminal-device operation.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 31. The bilateral below-elbow figure-eight harness. A webbing inverted Y-suspcnsor with triceps pad and flexible leather hinges is shown on the right side, while a leather inverted Y-suspensor with full cuff and rigid hinges is shown on the left. Similarly, one type of hook is shown on one side and another type on the other. In the bilateral case, prescriptions should be written independently for the two sides with a view toward providing as much utility as possible. As in the corresponding unilateral cases, the choice of cuffs, pads, hinges, terminal devices, and other details is made on the basis of the individual characteristics of the stump for which the prosthesis is intended. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>The cross on the back may be lowered by loosening the inverted Y-straps in front and taking up the slack in the control attachment straps. The reverse procedure moves the cross up. Should the cross be too far to one side, it may be moved horizontally by loosening the inverted Y-strap and control attachment strap on that side and taking up the slack on the opposite side.</p> <p>An important consideration is the choice of materials best suited to the individual case. In <b>Fig. 31</b>, the right Y-suspensor is made of vinyon, while the left is made of leather. If the amputee finds that getting the harness on and off is a major problem, then the tendency of leather to maintain its shape makes it easier to slip the stumps through the suspensors. If excessive perspiration is a problem, then vinyon tape may be more suitable.</p> <p>Although the combination of one leather and one vinyon Y-suspensor is shown in <b>Fig. 31</b> primarily to suggest the two possibilities, it is not inconceivable to consider the arrangement for actual use. In the bilateral below-elbow cases, the choice of cuffs and hinges is made independently for each side on the basis of such factors as stump length, muscular tone, and elbow mobility. In some cases, it might be well to consider using flexible hinges on one side to encourage the use of residual pronation-supination while applying full cuff and rigid hinges on the other to provide stability. A bilateral so fitted would thus have the added versatility provided by an enhanced function of one kind in one arm and an enhanced function of a different kind in the other.</p> <p>In <b>Fig. 31</b>, a wrist-flexion unit is installed on the left prosthesis. Although in exceptional cases the bilateral fitting of wrist-flexion units might be desirable, ordinarily only one flexion device is necessary. When only one wrist-flexion unit is used, amputee preference, or simply prosthetic dominance of one extremity over the other, is probably the best criterion for determining the side to which wrist flexion should be applied.</p> <h4>The Bilateral Above-Elbow Harness</h4> <p>The unilateral below-elbow figure-eight harness has been adapted for bilateral above-elbow cases as well as for the bilateral belowelbow amputee. It is essentially the same as for the below-elbow cases but with added suspensory harness and means of operating the elbow locks. A typical pattern is illustrated in <b>Fig. 32</b>. If allowance is made for the increased need for function in the bilateral case, then fabrication of the bilateral above-elbow harness is similar to that of the unilateral above-elbow figure-eight pattern. Use is made of the same methods of harness adjustment as in adjusting the harness for the below-elbow bilateral.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 32. The bilateral above-elbow figure-eight harness. As in the bilateral below-elbow case, here too the choice of components for the two sides is made independently with regard for individual stump characteristics and with the intention of providing as much useful function as possible. </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Before attempting the fabrication of the bilateral above-elbow harness, the harness-maker must understand the above-elbow figure-eight harness for unilaterals. He should then discuss with his patient any special vocational or personal activities requiring modification of harness design. When the harness is completed, the prosthetist should make it a point to follow up progress in training to make sure that the bilateral amputee can soon become self-sufficient in all necessary activities. If attention is paid to these few details, and if each bilateral amputee is treated as an individual problem, surprisingly good results may be obtained in practically all bilateral cases.</p> <h4>The Bilateral Shoulder-Disarticulation Harness</h4> <p>Because the bilateral shoulder disarticulation and the bilateral above-elbow/shoulder combination represent comparatively rare and highly specialized instances of upper-extremity amputation, it has thus far not been possible to establish any set harness pattern for these cases. Although in general the bilateral shoulder-disarticulation harness is a sort of combination of two shoulder-disarticulation harnesses for the unilateral, every amputee requiring such harness must have meticulous attention to details in the individual case. In any event, it is obvious that, in the bilateral shoulder-disarticulation amputee, the goal of the prosthetist is to obtain as much function as possible regardless of necessary deviations from ordinary practice. Although experience with extreme cases of this kind has to date been limited, the Case Study at the University of California at Los Angeles (page 61) has accumulated some useful information. At present, the knowledge gained at UCLA probably offers the most important guide for management of the individual bilateral shoulder-disarticulation case.</p> <h3>Conclusion</h3> <p>To the student of the art of harnessing upper-extremity prostheses, it will now have become perfectly plain that here, as in almost every other published source, the harness designs presented are principally those applicable to the comparatively young, healthy, adult male amputee. Included, furthermore, are only those systems for which there has been accumulated enough clinical evidence to prove their validity for use with presently available arm components. Noticeably missing are special patterns and fabrication techniques for the very young, for the very old, for the debilitated, for the special cases involving other complicating handicaps, and, with two exceptions, for the female.</p> <p>The reason for this situation lies in the fact that, inspired as it was by the desire to aid the veteran returning from the wars, the Artificial Limb Program, sponsored by the Veterans Administration and the Department of Defense, has quite naturally placed emphasis upon the type of amputee to be expected from the battlefield. But it is not fully appreciated by the general public that there are produced annually from disease or accidentsâ€"in the home, on the highway, in the factoryâ€"many, many more amputees than are ever produced in military campaigns. Such causes of amputation play no favorites with age or sex.</p> <p>Fortunately, the basic principles involved in the harnessing of the adult male are more or less fully applicable to the juvenile amputee. Recently, for example, an armamentarium chart defining child amputee types and offering suggestions for prescription for children of age three and a half to ten years has been prepared under the auspices of the Michigan Crippled Children Commission.<a></a> Two columns of this reference document are devoted to "harness type" and "control type" respectively. Except for the omission of the below-elbow dual control and of the above-elbow and shoul-der-disarticulation triple controls, at every level of arm amputation in the child the recommended harness and control systems are identical with those used for the corresponding level in the adult male. The only significant modifications are concerned with the use of 1/2-in. instead of 1-in. webbing, according to the size of the child, and with the twofold recommendation that the harness be worn over a T-shirt and that the younger children be provided with two harnesses, one to be worn while the other is laundered. Since in general young children do not possess harnessable forces as large as are usually to be had in the adult, the unit stresses produced by the narrower webbing are acceptable to the small child, and hence, following the rule of minimum permissible harness in all cases, it is obviously advisable to use the 1/2-in. material whenever it can serve the small fry satisfactorily. The need of children generally for a frequent change of clothing deserves no further comment here.</p> <p>In any event, it will be recalled that some twelve-year-olds are actually larger and stronger than some adults, and consequently the determining factor in any given child is his own particular size, which in turn determines whether 1/2-in. or 1-in. material will provide the more comfort. Other features of harness fabrication for children are essentially the same as for adult harnessing.</p> <p>As for the adult female, generally the harness for the adult male is applicable, with the exceptions that the chest-strap designs usually are not desirable and that commonly more emphasis is placed on cosmesis. Most women, for example, prefer to have a choice of wearing "V" necklines instead of being restricted to Peter Pan collars or other high necklines. The figure-eight harness pattern is adequate for both above- and below-elbow female amputees. In high-above-elbow cases and shoulder disarticulations, the patterns of <b>Fig. 27</b> and <b>Fig. 28</b> usually serve satisfactorily.</p> <p>Elderly amputees, amputees with multiple limb losses, and those with additional complications such as blindness or deafness all present such highly specialized problems that no single harness pattern can be more than partially satisfactory in all cases. Some evidence seems to indicate that there may even be an age limit beyond which most individuals begin to feel that bothering with an artificial arm at all is no longer worth the effort. But no really scientific evaluation has yet been made of the needs of the aged amputee. Circumstances in the individual case must therefore dictate the course to be taken. As in the case of children, some geriatric patients are healthy, strong. and dynamic; others are ailing, feeble, or lethargic. In the elderly amputee, therefore, as in all special cases, personal factors prevent the recommendation of any generalized harnessing system.</p> <p>In the two illustrations of typical harnessing for bilateral arm amputees (<b>Fig. 31</b> and <b>Fig. 32</b>), the subjects are shown as having amputations at approximately the same level on the two sides. In actual clinical practice, of course, bilateral arm cases present all possible combinations of above- and below-elbow amputations. In all such cases, the problem of devising suitable harnessing combinations presents a special challenge to the prosthetics clinic team. Similarly, in the case of amputations complicated by other mental or physical handicaps, special assessment of the individual patient must be made to determine, first of all, whether use of a prosthesis is actually feasible and, if so, what if any departures from conventional harness patterns are indicated. In all such unusual instances, the considered judgment of the clinic team is indispensable in the development of a specialized harness pattern suited to the needs and abilities of the individual concerned,</p> <p>It may now be reiterated that, even in the so-called "standard" cases, it does not suffice to supply a "standard" harness. The reference chart of <b>Table 1</b> is appended here only for the convenience of the clinic team in selecting the basic kind of harness applicable to any given case. It is, in the end, the responsibility of the prosthetist to see that the details are properly custom-matched to the wearer and that, after adequate amputee training, the harness chosen actually fulfills satisfactorily the needs of the wearer for whom it was intended. Less meticulous avenues of approach lead ultimately to failure.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Table 1. (For a larger image of this table, please refer to the PDF link at the top of the page.) </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <p>Finally, cognizance should be taken of the understandable circumstance that the harness patterns presented here have all been developed specifically for use with existing mechanical devices. The above-elbow and shoulder-disarticulation systemsâ€"the dual-control figure-eight, the dual-control chest-strap, and the triple-control patternsâ€"have, for example, all been designed around existing elbows. Because heretofore the art of harnessing has lagged behind the development of arm components, it has been necessary in recent years to design the harness systems to fit the mechanical parts rather than vice versa. A more logical arrangement would have been first to analyze the available body control motions, to design the harness for maximum utilization of these motions in the least awkward way, and then to design the other parts of the prosthesis in such a manner as to be operable by control patterns best suited to amputee characteristics. Future research in harnessing can be expected to influence redesign of desirable operational characteristics of the mechanical devices now available and to encourage the development of wholly new and improved arm components.</p> <h4>Acknowledgment</h4> <p>With the exception of the photographs and of <b>Fig. 12</b>, the illustrations appearing in this article are the work of George Rybczynski, free-lance artist of Washington, D. C.</p> <p><b>References:</b></p> <ol> <li>Alldredge, Rufus H., and Eugene F. Murphy,<i>Prosthetics research and the amputation surgeon, </i>Artificial Limbs, 1(3):4 (September 1954).</li> <li>Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, <i>The techniques of cineplasty,</i>, Chapter 3 in Klopsteg and Wilson's <i>Human limbs and their substitutes. </i>McGraw-Hill, New York, 1954.</li> <li>Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Technical Report 5424, <i>Comparison of UCLA and APRL cable transmission systems for B.E. biceps cineplasty arm, </i>21 June 1954.</li> <li>Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Technical Report 5526, <i>Shop instructions for cable and sheave equalizer systems (below-elbow cineplasty APRL), </i>8 August 1955.</li> <li>Carlyle, Lester, <i>Artificial arm checkout procedures,</i>Artificial Limbs, January 1954. p. 25.</li> <li>Carlyle, Lester, <i>Fitting the artificial arm, </i>Chapter 19 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Carnes, W. T., U. S. Patent 1,046,966, December, 1912.</li> <li>Carnes, W. T., U. S. Patent 1,046,967, December, 1912.</li> <li>Carnes, W. T, U. S. Patent 1,402,476, January, 1922.</li> <li>DeFries, Myron G., and Fred Leonard, <i>Bacterio-static nylon films, </i>Applied Microbiology, 3(4):238 (1955).</li> <li>Fletcher, Maurice J., and A. Bennett Wilson, Jr.,<i>New developments in artificial arms, </i>Chapter 10 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Hitchcock, William E., <i>Abduction for shoulder disarticulation prosthesis, </i>Orthop, Pros. Appl. J., September 1955. p. 23.</li> <li>Inman, Verne T., and H. J. Ralston, <i>The mechanics of voluntary miscle, </i>Chapter 11 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Kessler, Henry H., <i>Cineplasty, </i>Charles C Thomas,Springfield, Ill., 1947.</li> <li>Langdale-Kelham, R D., and George Perkins,<i>Amputations and artificial limbs, </i>Oxford University Press, London: Humphrey Milford, 1944.</li> <li>Leonard, Fred, T. B. Blevins, W S. Wright, and M. G. DeFries, <i>Nylon-coated leather, </i>Ind Eng. Chem., 45:773 (1953).</li> <li>Marks, George E., <i>A treatise on Marks' patent artificial limbs with rubber hands and feet, </i>A. A. Marks, New York, 1889.</li> <li>Mary Free Bed Children's Hospital and Orthopedic Center, Grand Rapids, Mich., <i>Child amputee types and suggestions for prosthetic prescription, 3 1/2 years to 10 years </i>(a chart), 1955.</li> <li>Mount, George E., and Raymond E. Bernberg,<i>A preliminary comparison of perception undet cineplastic and harness prostheses, </i>Am. J. Psychol., LXII(1):106(1949).</li> <li>New York University, Prosthetic Devices Study, Committee on Above-Elbow Harness [Hector Kay, Chairman], Report of conference, <i>The above-elbow figure-eight harness a guide to procedures and principles, </i>September 23, 1954.</li> <li>Northrop Aircraft, Inc., Hawthorne, Calif., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>Artificial arm and leg research and development, </i>February 1951. Sections 1.6.1 and 1.6.1.1, p. 92.</li> <li>Northwestern Technological Institute, Evanston,Ill., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, <i>A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, </i>1947.</li> <li>Pursley, Robert J., <i>Harness for shoulder disarticulation amputees, </i>Orthop. &amp; Pros. Appl. J., March 1955. p. 15.</li> <li>Spittler, August W., and Maurice J. Fletcher,<i>Technique of cineplastic surgery and prosthetic appliances for cineplasty, </i>Am. Acad. Orthopaedic Surgeons Instructional Course Lectures, Volume X, Edwards, Ann Arbor, Mich., 1953.</li> <li>Taylor, Craig L., <i>The biomechanics of the normal and of the amputated upper extremity, </i>Chapter 7 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>Taylor, Craig L., <i>Control design and prosthetic adaptations to biceps and pectoral cineplasty, </i>Chapter 12 in Klopsteg and Wilson's <i>Human limbs and their substitutes, </i>McGraw-Hill, New York, 1954.</li> <li>University of California (Los Angeles), Department of Engineering, <i>Manual of upper extremity prosthetics, </i>R. Deane Aylesworth, ed., 1952.</li> <li>U. S. Naval Hospital, Oakland, Calif., Artificial Limb Department, Blueprint 811, <i>Carpometacarpal {harness controlled) prosthesis, </i>September 22, 1952.</li> <li>Wilson, A. Bennett, Jr., and Robert J. Pursley,<i>Fitting the wrist disarticulation case, </i>Orthop. &amp; Pros. Appl. J., September 1952. p. 17.</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>18.</b> </td><td class="clsTextSmall">Mary Free Bed Children's Hospital and Orthopedic Center, Grand Rapids, Mich., Child amputee types and suggestions for prosthetic prescription, 3 1/2 years to 10 years (a chart), 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">While this hypothetical case suffices to describe the harness, it carries the faulty implication that the bilateral harness is simply two unilateral harnesses. No such implication is justified, for, as already pointed out, the functional requirement is magnified many fold, there is the complication of effecting separation of controls, and in addition there is the problem of getting into and out of the harness.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>12.</b> </td><td class="clsTextSmall">Hitchcock, William E., Abduction for shoulder disarticulation prosthesis, Orthop, Pros. Appl. J., September 1955. p. 23.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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>25.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 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>Footnote</b></td></tr><tr><td class="clsTextSmall">When the waist band is disliked by the female amputee, the elbow control strap may be anchored to a girdle or pantie girdle, just as it may be anchored to the trousers in the male.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Not chiffon or lace!</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 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>Footnote</b></td></tr><tr><td class="clsTextSmall">Use of the waist band, as in Figure 22, is largely a matter of personal preference. Some amputees like it, some do not. When the amputee wishes to dispense with the extra waist strap, the elbow control may be anchored to an item of clothing such as a button at the top of the trousers near the fly, as in Figure 26. The control strap then passes out of the shirt between buttons, so that no special opening is needed. But of course when this arrangement is used, the prosthesis is inoperable when the wearer is unclothed.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 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>Reference</b></td></tr><tr><td class="clsTextSmall"><b>23.</b> </td><td class="clsTextSmall">Pursley, Robert J., Harness for shoulder disarticulation amputees, Orthop. &amp;Pros. Appl. J., March 1955. p. 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>References</b></td></tr><tr><td class="clsTextSmall"><b>11.</b> </td><td class="clsTextSmall">Fletcher, Maurice J., and A. Bennett Wilson, Jr.,New developments in artificial arms, Chapter 10 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b> 25.</b> </td><td class="clsTextSmall">Taylor, Craig L., The biomechanics of the normal and of the amputated upper extremity, Chapter 7 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b> 27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>20.</b> </td><td class="clsTextSmall">New York University, Prosthetic Devices Study, Committee on Above-Elbow Harness [Hector Kay, Chairman], Report of conference, The above-elbow figure-eight harness a guide to procedures and principles, September 23, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">It may be noted that the techniques for harnessing the above-elbow amputee can be applied equally well to articulated braces for flail arms.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary miscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>4.</b> </td><td class="clsTextSmall">Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Technical Report 5526, Shop instructions for cable and sheave equalizer systems (below-elbow cineplasty APRL), 8 August 1955.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Technical Report 5424, Comparison of UCLA and APRL cable transmission systems for B.E. biceps cineplasty arm, 21 June 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>3.</b> </td><td class="clsTextSmall">Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Technical Report 5424, Comparison of UCLA and APRL cable transmission systems for B.E. biceps cineplasty arm, 21 June 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Although common-sense logic might lead one to suppose that improvement in pressure appreciation would be obtainable only were the terminal device voluntary-closing, it turns out that considerable improvement is to be had also from muscle tunnels harnessed to voluntary-opening devices. The tests conducted by Mount and Bernberg were, for example, all made with amputees wearing voluntary-opening hooks. How does the amputee so fitted estimate the amount of force being exerted at the hook fingers? He measures holdback and subtracts it mentally from the known total force exerted by the hook when no restraint is applied. (Ed)</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>13.</b> </td><td class="clsTextSmall">Inman, Verne T., and H. J. Ralston, The mechanics of voluntary miscle, Chapter 11 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty,, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes. McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Kessler, Henry H., Cineplasty, Charles C Thomas,Springfield, Ill., 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Spittler, August W., and Maurice J. Fletcher,Technique of cineplastic surgery and prosthetic appliances for cineplasty, Am. Acad. Orthopaedic Surgeons Instructional Course Lectures, Volume X, Edwards, Ann Arbor, Mich., 1953.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>19.</b> </td><td class="clsTextSmall">Mount, George E., and Raymond E. Bernberg,A preliminary comparison of perception undet cineplastic and harness prostheses, Am. J. Psychol., LXII(1):106(1949).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty,, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes. McGraw-Hill, New York, 1954.</td></tr><tr><td class="clsTextSmall"><b>14.</b> </td><td class="clsTextSmall">Kessler, Henry H., Cineplasty, Charles C Thomas,Springfield, Ill., 1947.</td></tr><tr><td class="clsTextSmall"><b>24.</b> </td><td class="clsTextSmall">Spittler, August W., and Maurice J. Fletcher,Technique of cineplastic surgery and prosthetic appliances for cineplasty, Am. Acad. Orthopaedic Surgeons Instructional Course Lectures, Volume X, Edwards, Ann Arbor, Mich., 1953.</td></tr><tr><td class="clsTextSmall"><b>26.</b> </td><td class="clsTextSmall">Taylor, Craig L., Control design and prosthetic adaptations to biceps and pectoral cineplasty, Chapter 12 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>29.</b> </td><td class="clsTextSmall">Wilson, A. Bennett, Jr., and Robert J. Pursley,Fitting the wrist disarticulation case, Orthop. &amp;Pros. Appl. J., September 1952. p. 17.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">U. S. Naval Hospital, Oakland, Calif., Artificial Limb Department, Blueprint 811, Carpometacarpal {harness controlled) prosthesis, September 22, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>28.</b> </td><td class="clsTextSmall">U. S. Naval Hospital, Oakland, Calif., Artificial Limb Department, Blueprint 811, Carpometacarpal {harness controlled) prosthesis, September 22, 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">Except, of course, in those cases where extremely heavy duty is a requirement from the beginning.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><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">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty,, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes. McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>2.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., Verne T. Inman, Hyman Jampol, Eugene F. Murphy, and August W. Spittler, The techniques of cineplasty,, Chapter 3 in Klopsteg and Wilson's Human limbs and their substitutes. McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>10.</b> </td><td class="clsTextSmall">DeFries, Myron G., and Fred Leonard, Bacterio-static nylon films, Applied Microbiology, 3(4):238 (1955).</td></tr><tr><td class="clsTextSmall"><b>16.</b> </td><td class="clsTextSmall">Leonard, Fred, T. B. Blevins, W S. Wright, and M. G. DeFries, Nylon-coated leather, Ind Eng. Chem., 45:773 (1953).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>27.</b> </td><td class="clsTextSmall">University of California (Los Angeles), Department of Engineering, Manual of upper extremity prosthetics, R. Deane Aylesworth, ed., 1952.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>5.</b> </td><td class="clsTextSmall">Carlyle, Lester, Artificial arm checkout procedures,Artificial Limbs, January 1954. p. 25.</td></tr><tr><td class="clsTextSmall"><b>6.</b> </td><td class="clsTextSmall">Carlyle, Lester, Fitting the artificial arm, Chapter 19 in Klopsteg and Wilson's Human limbs and their substitutes, McGraw-Hill, New York, 1954.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>21.</b> </td><td class="clsTextSmall">Northrop Aircraft, Inc., Hawthorne, Calif., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, Artificial arm and leg research and development, February 1951. Sections 1.6.1 and 1.6.1.1, p. 92.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Reference</b></td></tr><tr><td class="clsTextSmall"><b>1.</b> </td><td class="clsTextSmall">Alldredge, Rufus H., and Eugene F. Murphy,Prosthetics research and the amputation surgeon, Artificial Limbs, 1(3):4 (September 1954).</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>References</b></td></tr><tr><td class="clsTextSmall"><b>7.</b> </td><td class="clsTextSmall">Carnes, W. T., U. S. Patent 1,046,966, December, 1912.</td></tr><tr><td class="clsTextSmall"><b>8.</b> </td><td class="clsTextSmall">Carnes, W. T., U. S. Patent 1,046,967, December, 1912.</td></tr><tr><td class="clsTextSmall"><b>9.</b> </td><td class="clsTextSmall">Carnes, W. T, U. S. Patent 1,402,476, January, 1922.</td></tr><tr><td class="clsTextSmall"><b>15.</b> </td><td class="clsTextSmall">Langdale-Kelham, R D., and George Perkins,Amputations and artificial limbs, Oxford University Press, London: Humphrey Milford, 1944.</td></tr><tr><td class="clsTextSmall"><b>17.</b> </td><td class="clsTextSmall">Marks, George E., A treatise on Marks' patent artificial limbs with rubber hands and feet, A. A. Marks, New York, 1889.</td></tr><tr><td class="clsTextSmall"><b>22.</b> </td><td class="clsTextSmall">Northwestern Technological Institute, Evanston,Ill., Subcontractor's Final Report to the Committee on Artificial Limbs, National Research Council, A review of the literature, patents, and manufactured items concerned with artificial legs, arm harnesses, hand, and hook; mechanical testing of artificial legs, 1947.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Robert J. Pursley, Lt., USA (MSC) </b></td></tr><tr><td class="clsTextSmall">Chief, Research Limb Section, Army Prosthetics Research Laboratory, Walter Reed Army Medical Center, Washington, D. C.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-1.jpg Figure 2 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-2.jpg Figure 3 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-3.jpg Figure 4 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-4.jpg Figure 5 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-5.jpg Figure 6 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-6.jpg Figure 7 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-7.jpg Figure 8 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-8.jpg Figure 9 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-9.jpg Figure 10 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-10.jpg Figure 11 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-11.jpg Figure 12 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-12.jpg Figure 13 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-13.jpg Figure 14 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-14.jpg Figure 15 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-15.jpg Figure 16 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-16.jpg Figure 17 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-17.jpg Figure 18 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-18.jpg Figure 19 http://www.oandplibrary.org/al/images/1955_03_026/tmp48A-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Harness Patterns for Upper-Extremity Prostheses Creator An entity primarily responsible for making the resource Robert J. Pursley, Lt., USA (MSC) * https://staging.drfop.org/files/original/e35faf467e1ea9e763ac08ddcf0dbfd3.pdf 1f9fe1e89568efceb15d185fd6f39011 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1955_03_001.pdf Year 1955 Volume 2 Issue 3 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1955_03_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1955_03_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>Harnessing- Here and Hereafter</h2> <h5>John Lyman, PhD <a style="text-decoration:none;">*</a><br /></h5> <p>However well designed the other parts of an artificial arm may be, the functional success of the upper-extremity prosthesis must ultimately depend upon the adequacy of the coupling between the human being and the inanimate mechanism. Since this man-machine linkage is intended to hold the arm on the stump and to secure from residual body sources the mechanical power necessary for operation and control of the prosthesis, the technique of constructing it has come to be known simply as "harnessing." Because body harness is such ah intimate piece of apparel, and because arm amputees exhibit the same kinds of individual differences as characterize the rest of the population, it seems likely that proper harnessing will long remain a tribute to the personal skill of the prosthetist, despite all advances in prefabricated components. Although the clinic team may prescribe the specifications for a prosthesis within the existing framework of medical and engineering knowledge, the final result depends largely upon the prosthetist's talent for constructing and fitting the harness in such a way as to meet anatomical, physiological, and functional requirements.</p> <p>Functionally, the harness may serve one or more of three purposes: it may hold the prosthesis in place; it may transmit power and excursion to produce force and movement in operating components; it may convey to the wearer the intelligence needed for arm control. In conventional construction of upper-extremity prostheses, it has been customary to rely upon the harness for the performance of all three of these services and, further, to obtain them all from a single harness system. Such an arrangement is of course grossly unlike that of the normal limb, where the control function, mediated by the nervous system, is clearly separated from the functions of suspension and of power transmission. Only in externally powered prostheses, as for examples the TBM Electric Arm and the Vaduz hand, has an attempt been made to separate the control function from the power and suspensory functions. Although to date such devices have not proved to be as useful or reliable as simpler ones, they are representative of an approach which may, in the long run, lead to far more refined limb substitutes than can be contemplated by further development of a harnessing philosophy which stresses the combining of suspension, power transmission, and control.</p> <p>The use of body power for operating an artificial arm forms an inherent control link between the neuromuscular system and the prosthesis. To the extent that a "closed loop" is effected via the sensory feedback available to the power-producing muscles, control of force and excursion through the power-transmission system is possible without the aid of external sensory-feedback loops such as vision and hearing. While the latter cues are generally present, they can at best serve only in an auxiliary capacity. The rich sensations of touch, pressure, pain, and temperature, which have been lost with the natural limb, have no substitute beyond their dim reflection in the signals from harness strap or cineplasty muscle pin of present-day prosthetics technology.</p> <p>One can argue, with considerable sustaining evidence, that the modern arm prosthesis is quite functionally adequate in most respects and that the addition of refinements in the form of further sensory cues for improved control would only complicate harnessing unnecessarily. But to take this viewpoint is paying tribute to the adaptability of the human mechanism rather than to the adequacy of today's prosthetics research and development. As facts currently stand, it appears that no clear-cut assessment has been made of the importance of sensory losses to the amputee. The effort has been to achieve prosthetic replacement of motor function, and it still is not generally recognized that this goal has been approached with the present degree of success only because sensory control loops are established incidentally in the course of harnessing for power transmission. The major inadequacies leading to failure in externally powered prostheses can be traced directly to shortcomings in the design of control loops-loops which are intrinsic even in the crudest of body-powered prostheses.</p> <p>Since in the present state of the art the optimum connection between the amputee and the operating mechanism is still so indispensable to the proper functioning of the upper-extremity prosthesis, this issue of Artificial Limbs is devoted to a summary of current harnessing technology as developed under the auspices of the Advisory Committee on Artificial Limbs. Although progress in the improvement of body harness has been substantial since World War II, even the latest techniques fall far short of duplicating the neuromuscular mechanism of the normal arm. And consequently there is still a great deal of forward-looking to be done in the research, development, and production phases of upper-extremity prosthetics.</p> <p>Where will the technology come from that may make possible "sensory prostheses" with attendant refinements in the present "motor prostheses"? Probably not directly from current trends in artificial-limb research. As is common knowledge, a very real and dynamic revolution is under way in the modern engineering sciences. It is accompanied by a plethora of popular terms like"cybernetics," "servomechanisms," "information theory," "digital and analogue computers," and "automation," to name a few. From the developments that are taking place, many new materials and processes are becoming available. Just as the aircraft industry, through the Northrop design studies, has contributed the present lightweight plastic artificial arm and the Bowden-cable transmission system, so it may be anticipated that within a relatively few years the electronics and missile industries may make even greater contributions. Compact, reliable, and lightweight items like the famed transistor may become as commonplace in the control systems for artificial arms as is presently the case in hearing aids. New products from metallurgy and chemistry may eventually make it possible to realize direct attachment of prosthetic devices to remaining skeletal members of the body through the skin and surrounding tissue, with consequent elimination of the socket and of the suspensory elements of harness. Much of the theory and much of the methodology for accomplishing the direct coupling of man to mechanism, including the all-important link to the nervous system for control, are either available already or else are promised within the foreseeable future.</p> <p>Because in the field of amputee rehabilitation there are never apt to be available the amounts of research money now characteristic of other fields of science and invention, it is fortunate that a systematic plan for the advancement of limb prosthetics has become so well established in the decade since World War II. The Artificial Limb Program furnishes an organized means of following progress in other areas and of adapting to limb substitutes new approaches and new techniques that would otherwise lie far beyond the purse of prosthetics research itself. The future in design of limb replacements is thus perhaps now greater than ever before. Even so, no matter how sophisticated upper-extremity prostheses may become, the actual utility of any given artificial arm will continue to reside largely in the degree to which the fitter can attain the optimum sensory-motor association through accomplished harnessmaking. In no other known way can so much satisfaction be afforded the individual arm amputee.</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>John Lyman, PhD </b></td></tr><tr><td class="clsTextSmall">Assistant Professor of Engineering, University of California, Los Angeles.</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 Harnessing- Here and Hereafter Creator An entity primarily responsible for making the resource John Lyman, PhD * https://staging.drfop.org/files/original/0823b143e61ae1f812944fe0bbac32d8.jpg 36028c2e9c03cca681965702d92c63bf 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. URL www.healinghandsforhaiti.org Contact Name/Title Phillippe R. Armand - President and Acting Executive Director Address P.O. Box 521800 City Salt Lake City State/Province Utah Countries Served Haiti Postal Code 84152-1800 Phone 801408-5401 Fax 801 408 5610 Email philippearmand@healinghandsforhaiti.org evelynebernard@healinghandsforhaiti.org Organization Type Including ID and tax status Non-profit Not-for-profit Type 501C-3 Services Provided -Rehabilitation education and training -Clinical treatment -Disability prevention -Increasing public awareness of disabilities and rehabilitation -Rehabilitation Medical and Therapy Clinic -Spinal Cord Injury Care Need I Financial Assistance Need II Volunteers: Rehabilitation specialists (PM&R physicians, rehabilitation nurses, physical, occupational and speech therapists, certified prosthetists and orthotists) We have opportunities for non-rehab medical and non-medical volunteers. Need III Materials, Components, and Equipment: Physicians for Peace, in partnership with Hanger Prosthetics and Orthotics, is accepting new and used prosthetics at more than 670 Hanger locations across the United States. Please use their locator to find the drop-off site nearest you. Other donations (crutches, canes, etc) should be shipped to them at: Physicians for Peace Warehouse 2117 Springfield Avenue Norfolk, VA 23523 Mission To deliver quality, sustainable physical medicine and rehabilitation education, training and care for the people of Haiti. Volunteer Contact http://healinghandsforhaiti.org/WaystoHelp/Volunteer/tabid/77/language/en-US/Default.aspx gailbuck@healinghandsforhaiti.org Patient Contact Headquarters and Kay Kapab Klinik #9 Interior, Rue Dalencourt Bourdon, Port-au-Prince, Haiti Tel: 011 509 2813 0434 Tel: 011 509 2813 0433 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 Healing Hands for Haiti International Foundation, Inc. Description An account of the resource We are a secular, non-profit, non-governmental organization (NGO) dedicated to delivering quality, sustainable physical medicine and rehabilitation education, training and care for adults and children with physical disabilities in Haiti. We believe the best way to serve the people of Haiti is to empower them to help themselves. 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. URL http://www.healthwrights.org Contact Name/Title David Werner or Jason Weston Address 3897 Hendricks Road City Lakeport State/Province California Countries Served USA, Mexico Postal Code 95453 Email info@healthwrghts.org Organization Type Including ID and tax status Non-profit Not-for-profit Type 501C-3 Services Provided Prosthetic Fitting, Orthotic Fitting, Medical Equipment / Supplies, 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 - donate@healthwrights.org Need II Volunteers: We need folks skilled in graphic arts, accounting, page layout, writing and editing, publication, website administration, website development, fundraising, web programming and more. Mission HealthWrights is a 501(c)3 non-profit organization committed to advancing the health, basic rights, social equality, and self-determination of disadvantaged persons and groups. We believe that health for all people is only possible in a global society where the guiding principles are sharing, mutual assistance, and respect for cultural and individual differences. Volunteer Contact volunteer@healthwrights.org 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 HealthWrights Description An account of the resource HealthWrights is a 501(c)3 non-profit organization committed to advancing the health, basic rights, social equality, and self-determination of disadvantaged persons and groups. 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. URL https://www1.hhrd.org/ Address Michigan - Head Office 21199 Hilltop St City Southfield State/Province MI Countries Served Pakistan, Afghanistan, Bangladesh, Burma, Indonesia, India, Jordan, Lebanon, Sri Lanka, Thailand, Cambodia, Philippines, Nepal, Yemen, Tunisia, Kenya, Somalia, Sierra Leone, Tanzania, Uganda, Haiti, Mexico, Peru, Venezuela Postal Code 48033 Phone (313) 279-5378 Email info@hhrd.org Organization Type Including ID and tax status Non-profit Services Provided Equipment and supplies with In Kind Medial Containers Physical, Occupational, Psycho, and Speech Therapy Orthotics – Prosthetics Wheelchairs Audiology 5-Years Doctorate Degree 2-Years Diploma in Physiotherapy Children with Disabilities Program Need I Financial Assistance - Donations Need II Volunteers Need III Materials, Components, and Equipment Additional Info & Comments Physical Rehabilitation Department https://www1.hhrd.org/Programs/Physical-Rehabilitation Mission HHRD is a global humanitarian relief and development organization responding to human sufferings in emergency and disaster situations around the world. 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Title A name given to the resource Helping Hand for Relief and Development Description An account of the resource HHRD is committed to serve humanity by integrating resources for people in need. https://staging.drfop.org/files/original/d634f72b53fee3270263d6b02eee78a9.pdf 081468a627be053883d0d2c0f57e0d81 https://staging.drfop.org/files/original/47c2da3bfe365d19dab934e665f66a7e.jpg c6870a13ba528d9a08b712870f181aef https://staging.drfop.org/files/original/021188ebcef7da90fd31f98828fa6492.jpg 219db07046fc7f9d39d4657d7c82b990 https://staging.drfop.org/files/original/33a23ce6e5de3913d0478c534f7aba36.jpg 3883d5d385c53d064fdf6a5ccd89ca18 https://staging.drfop.org/files/original/603316446d9d314a4586a444cf9f0a22.jpg 4ba8c8779644110430c42c63360db0e7 https://staging.drfop.org/files/original/18b9b43af4d8e97b8ba3e0f2828c3ef6.jpg bd974c771438f676134eb68427186558 https://staging.drfop.org/files/original/105098f81ea7edb2a091dcd0415eed6a.jpg 2f4c92856ae0e6562aebe32d5d1bf29c https://staging.drfop.org/files/original/dedd8fa68f49c7b3bcc8c3e82b8efa92.jpg a5d2d0752fc526c58c0bc3a2c08f9417 https://staging.drfop.org/files/original/e592dc5785c3e7b7ec28c9077eaa7fef.jpg 07a87e00f96d255cf1334360f01727ca https://staging.drfop.org/files/original/a8cce387b55b45e6a667c49df89ae308.jpg 5bb5287ac69b8ef9966416fdcca3aab3 https://staging.drfop.org/files/original/ca2b3ffb8c94001e703bdd917b139e04.jpg 69f9c2b5942f12823da5914a0873a1b3 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_002.pdf Text Any textual data included in the document <h2>Historical Aspects of Powered Limb Prostheses</h2> <h5>Dudley S. Childress, Ph.D.&nbsp;<a style="text-decoration: none;">*<br /><br /></a></h5> <h3>Introduction</h3> <p>People involved in work on powered limb prostheses may wonder if the history of this field is important. My answer is that one can learn a lot from history. Nevertheless, Hegel has said, "What history teaches us is that men never learned anything from it." Unfortunately, it sometimes does seem true in prosthetics that we have not always profited from past experiences. Too many aspects of the work are never published, and the multidisciplinary nature of the field produces papers in a broad spectrum of journals that are difficult to track. Books on the field are, unfortunately, not numerous.</p> <p>The brief history that follows is by no means complete, and since some of it involves years that are within readers' memories, I apologize in advance for omissions that anyone may consider significant. The history is intended to entice readers to look more deeply into historical issues. It is also intended to give some perspective on the field and to dispel notions that powered prostheses are only recent developments of "bionic man" research. Wilson<a></a> has written a brief history on external power of limb prostheses and the handbook by Spaeth<a></a> contains an introductory chapter on this subject. Brief surveys are included in papers (e.g. Childress<a></a> or Bottomley et al.<a></a>)</p> <p>Powered limbs have existed for some seventy years. This roughly corresponds with the history of powered hand tools and other powered technical devices used so widely in modern society (e.g. airplanes, automobiles, etc.). This is not surprising since technology in most fields tends to mirror the state of technology generally. The history of powered limbs is also comparable in length with the history of an identifiable field known as "limb prosthetics."</p> <p>I have chosen to consider the history of powered prostheses from a hardware viewpoint and from the viewpoint of important meetings and events. Control approaches, another viewpoint, are considered but not emphasized. Also, the perspective is from America.</p> <h3>Prologue (1915-1945)</h3> <p>The first powered prosthesis, of which I am aware, was a pneumatic hand patented in Germany in 1915.<a></a> A drawing of an early pneumatic hand is shown in <a href="/files/original/47c2da3bfe365d19dab934e665f66a7e.jpg"><b>Fig. 1</b></a>. <a href="/files/original/021188ebcef7da90fd31f98828fa6492.jpg"><b>Fig. 2</b></a> shows a drawing of what I believe to be the first electric powered hand. These drawings were published in 1919 in <i>Ersatzglieder und Arbeitshilfen</i> (Substitute Limbs and Work Aids).<a></a> This German publication illustrates the importance of history in prosthetics, containing ideas that are still being discovered today. Although the book <i>Treatise on Artificial Limbs</i> by A.A. Marks, published in 1901, does not contain anything about powered limbs, it too illustrates the importance of history in the field because many ideas put forward in it are also quite modern.</p> <strong><a href="/files/original/47c2da3bfe365d19dab934e665f66a7e.jpg">Figure 1</a>. Early compressed-gas powered hand (Perhaps the first powered prosthesis component). From Ersatzglieder under Arbeitshilfen (Limb Substitutes and Work Aids) 1919.</strong><br /><br /><strong><a href="/files/original/021188ebcef7da90fd31f98828fa6492.jpg">Figure 2.</a> Early electric hand component (Perhaps the first electric hand mechanism). From Ersatzglieder und Arbeitshilfen (Limb Substitutes and Work Aids) 1919.</strong><br /> <p>Powered limbs were probably not used to any significant extent between the World Wars, but CO₂ powered limbs were used by Weil as early as 1948.<a></a> Development work continued at Heidelberg during the 1950's under Marquardt,<a></a> and the Otto Bock Company became involved with the work about 1962. Laboratories at Munster and Hannover were also involved in this early work that led to clinical applications of gas powered prostheses. Part of Germany's prominent position in the prosthetics field can be traced to their early commitment to development work in the entire field of prosthetics.</p> <p>Kiessling<a></a> was the major U.S. investigator involved with CO₂ powered limbs. Of course, the McKibben muscle<a></a> was developed in the U.S., but has been used mainly in orthotics.</p> <p>The first, as far as we know, myoelectric prosthesis was developed during the early 40's by Reinhold Reiter, a physicist working with the Bavarian Red Cross. He published his work in 1948<a></a> but it was not widely known and myoelectric control was destined to be "rediscovered" in England, in the Soviet Union, and perhaps other places during the 1950's. Economic conditions in Germany after World War II prevented the work on myoelectric control from being continued there. <a href="/files/original/33a23ce6e5de3913d0478c534f7aba36.jpg"><b>Fig. 3</b></a> shows a picture of the first myoelectric hand prosthesis which was probably used around 1943. The system was controlled by a vacuum tube amplifier and was not portable. The hand was a modified Hüfner Hand that continued a control electro-magnet. The system was heavy, large, and not battery operated; the idea was to use it as a special prosthesis at a work station. Reiter hoped that further development could make it portable.</p> <strong><a href="/files/original/33a23ce6e5de3913d0478c534f7aba36.jpg">Figure 3.</a> Electric powered hand used by Reiter in development of first myoelectric prosthesis (Circa 1943). It consists of a Hüfner Hand in which a control magnet has been built. From Grenzgebiete der Medizin (Frontiers of Medicine) 1948.</strong><br /> <p>It is an interesting coincidence that the results of the first experiments with myoelectric control were published in 1948, the same year in which the development of the transistor was announced. Practical myoelectrically controlled prostheses required the transistor and its subsequent refinements.</p> <p>Although Reiter conceived and developed the idea of myoelectric control in the early 1940's, others had the same idea later and apparently independently. The late Professor Norbert Weiner of Massachusetts Institute of Technology is reported to have suggested the concept around 1947. Berger &amp; Huppert<a></a> presented the idea in 1952. Battye, Nightingale, and Whillis<a></a> at Guy's Hospital in London developed a myoelectric control system for a powered prosthesis in 1955 in what was for many years thought to be the first demonstration of this principle. That they were not first in no way detracts from their accomplishment. Soviet scientists were apparently the first to use transistors in a myoelectrically controlled prosthesis. The so-called Russian Hand<a></a> was the first semi-practical myo-electrical limb to be used clinically and was sold (although not widely used) on a license basis for application in Great Britain and in Canada.</p> <h3>The Early Years (1945-1967)</h3> <p>As far as the United States is concerned, the year 1945 was a turning point in prosthetics. In January 1945, military personnel, surgeons, prosthetists, and engineers met in Chicago (Thorne Hall, Northwestern University) to consider what should be done about limb prosthetics. This meeting is recognized as the beginning of the prosthetics research and development program by the U.S. government. This program ultimately resulted in the establishment of the Committee on Prosthetics Research and Development (CPRD) of the National Research Council which guided work in the field for over twenty-five years. The post-war years saw tremendous advances in limb prosthetics in general, although powered prosthesis development was slow. During the period 1946-1952, Alder-son, with the support of IBM and the Veterans Administration, developed several electric-powered limbs.<a></a> These IBM arms were impressive engineering achievements for the time, but they were somewhat difficult for amputees to use.</p> <p>The Vaduz hand, developed during the early post-war period, appears to have been a prosthesis ahead of its time and one that contained antecedents of today's electric hands. A German team headed by Dr. Edmund Wilms settled in Vaduz, Lichtenstein after World War II to continue their prosthetic hand development work. They wanted to create a hand controlled by the muscles of prehension, which would operate on a portable power source. The hand they created is shown in <a href="/files/original/603316446d9d314a4586a444cf9f0a22.jpg"><b>Fig. 4</b></a>. It has been described by Wilms.<a></a> This hand had a gear shifting mechanism to enable it to obtain high gripping force from an electric motor while also having reasonable finger velocity. This is a principle used in current Otto Bock hands. The hand used a unique controller in which a pneumatic bag inside the socket detected muscle bulge through pneumatic pressure, which in turn operated a switch-activated position servomechanism to close the voluntary-closing electric hand. This principle foreshadows the concept of extended physiological proprioception (EPP) introduced by Simpson<a></a> (<a href="/files/original/18b9b43af4d8e97b8ba3e0f2828c3ef6.jpg"><b>Fig. 5</b></a>). The complete system is shown in <a href="/files/original/105098f81ea7edb2a091dcd0415eed6a.jpg"><b>Fig. 6</b></a>.</p> <strong><a href="/files/original/603316446d9d314a4586a444cf9f0a22.jpg">Figures 4a and 4b.</a> Two views of the mechanics of the Vaduz Hand. Note position and force feedback links that connect to the inner transducer. This connects to an outer transducer (a bladder) adjacent to the residual limb in the socket. This voluntary-closing hand was activated by muscle bulge. It operated as a position servomechanism. It contained a gear shifting mechanism and a current cut-off mechanism. From Bulletin of Prosthetics Research, BPR 10-6, 1966.</strong><br /><br /><strong><a href="/files/original/18b9b43af4d8e97b8ba3e0f2828c3ef6.jpg">Figure 5.</a>&nbsp;Diagram of control circuit for Vaduz Hand. Muscle bulge compresses the outer transducer, which causes expansion of the inner transducer, moving the spindle upward. This activates the switches that close the hand. A link with the output moves the switch assembly along so that the hand stops when the link movement corresponds with spindle movement. Force feedback opens the closing limit switch at some force level when the hand meets an object. This conserves battery power. From Bulletin of Prosthetics Research, BPR 10-6, 1966.</strong><br /><br /><strong><a href="/files/original/105098f81ea7edb2a091dcd0415eed6a.jpg">Figure 6.</a> View of complete Vaduz system. Note similarity of myoelectric systems. From Bulletin of Prosthetics Research, BPR 10-6, 1966.</strong><br /> <p>Lucaccini, Kaiser &amp; Lyman<a></a> evaluated the Vaduz Hand. The center at the University of California at Los Angeles, under Lyman's direction, also evaluated the Alderson-IBM arm, the Heidelburg Pneumatic Prosthesis, and other externally powered systems, as well as conducting many control studies of their own.</p> <p>After 1953, the Vaduz Hand was marketed from Paris and consequently was sometimes called the French Hand. It apparently was difficult to keep in optimal mechanical adjustment, but it must be considered as one of the most important ancestors of today's electric hands, and a hand that contained many novel and intriguing concepts. It was available through the mid-sixties.</p> <p>The Russian Hand and Vaduz Hand were followed by an English Hand developed around 1965 by Bottomley.<a></a> This was the first myo-electrically controlled hand that exhibited proportional control (<a href="/files/original/dedd8fa68f49c7b3bcc8c3e82b8efa92.jpg"><b>Fig. 7</b></a>). This prosthesis also contained several novel features for that period of time, such as internal force and velocity feedback and a unique myoelectric signal smoothing principle called "autogenic backlash," which produced a more or less consistent direct current (DC) output from the fluctuating myoelectric signal while not sacrificing time response.</p> <strong><a href="/files/original/dedd8fa68f49c7b3bcc8c3e82b8efa92.jpg">Figure 7.</a> View of myoelectric hand developed by Bottom-ley in England. Note the two external packages on the table, battery on left and electronics on right. This was the first myoelectrically controlled hand that had proportional control. From Science Journal article by R.N. Scott, March 1966.</strong><br /> <p>The Russian Hand (<a href="/files/original/e592dc5785c3e7b7ec28c9077eaa7fef.jpg"><b>Fig. 8</b></a>), Vaduz Hand, and Bottomley Hand were single-function devices and non-adaptive. During the early 1960's Tomovic suggested an adaptive, multi-articulated hand with rudimentary sensory qualities. This resulted in the Belgrade Hand.<a></a> Although this hand was not used clinically to any great extent, it was used extensively in research laboratories and has had influence on robotic hand developments. In 1965, a Swedish research group began work on an electric hand which was adaptive and which had multiple functions (two types of grasp, wrist flexion-extension, and supination-pronation). This became known as the SVEN-Hand<a></a> (<a href="/files/original/a8cce387b55b45e6a667c49df89ae308.jpg"><b>Fig. 9</b></a>). It also has been used extensively in research, particularly regarding multi-function control<a></a> and concepts employed in it are utilized today in Swedish developments.</p> <strong><a href="/files/original/e592dc5785c3e7b7ec28c9077eaa7fef.jpg">Figure 8.</a> Photograph of Russian Hand. This was the first myoelectric hand that was transistorized and portable (Circa 1959). The external battery pack is shown in the center of the photograph. The electronic package is beneath the battery. The battery charger is at left. Note the long electrode wires and the prosthesis suspension straps. From Science Journal article by R.N. Scott, March 1966.</strong><br /><br /><strong><a href="/files/original/a8cce387b55b45e6a667c49df89ae308.jpg">Figure 9.</a> Photograph of the SVEN-Hand. This was one of the first multifunctional, adaptive, myoelectrically controlled hand prostheses.</strong><br /> <p>Congenital amputations caused by the drug Thalidomide resulted in expanded interest in powered prostheses in the 1960's. Pneumatic systems by Otto Bock (hand, hooks, wrist rotators, and elbows) were fitted successfully, particularly in Germany by Marquardt,<a></a> to many children born without limbs. However, pneumatic systems never caught on well in the U.S. probably because of difficulties with the compressed gas. Cannisters of gas were expensive and difficult to maintain and distribute in the U.S. American laws also required steel cannisters, which added to weight. Pneumatic systems have low energy storage densities and this meant that multiple cannisters were required, particularly to supply the energy needs of adult prostheses. On the other hand, these systems have actuators that are light in weight, which are easily controlled, and which have natural compliance properties that keep them from being rigid.</p> <p>Electric power can be stored more cheaply, more safely, and with greater density than gas power. Also, the control possibilities made possible by electronic circuits have given electrical systems an advantage. Unfortunately, the actuators (electric motors and gear mechanisms) tend to be heavy and may result in prostheses that are noisy and naturally non-compliant. They also have zero efficiency when activated in the stalled condition. Some of the negative aspects of electrical actuators have been overcome electronically in today's powered prostheses.</p> <p>Electro-Hydraulic systems may be used in the future because they have the potential advantage of developing high torque in small actuators. However, cost factors for the special hydraulic mechanisms needed, along with technical problems, have restricted development work in this area thus far. Early work was conducted in Canada.<a></a> The Edinburgh arm has been converted to hydraulic power at a couple of centers in the U.K.</p> <p>Research work on multifunctional limb prostheses flourished in the United Kingdom during the 1960's and early 1970's. Most notable among the developments were the Hendon Arm<a></a> and the Edinburgh Arm.<a></a> Both were pneumatic, multi-functional limbs. Simpson used a position servomechanism control principle that he called extended physiological proprioception (EPP), a principle which enables control of multiple functions without excessive mental load on the user. This control technique has been shown to be a better information link between the body and prosthesis than "velocity" controllers.<a></a></p> <p>The Edinburgh Arm, which was pneumatic, worked in spherical coordinates from the shoulder and was controlled by protraction-retraction and elevation-depression of the two shoulders. If the arm was fitted on the right side, then elevation of the right shoulder elevated the hand about the shoulder joint. Protraction of the right shoulder moved the hand more distant from the shoulder (in a radial direction). Protraction of the left shoulder moved the hand medially, and elevation of the left shoulder supinated the hand. The wrist was linked to the shoulder and elbow so as to maintain attitude of the hand during shoulder or elbow motion. This made it possible to hold a glass of water without worrying too much about spilling the contents during arm movements. Carlson<a></a> has called this kind of joint coupling, "kinematic coupling." Opening and closing the hand or terminal device of the arm was controlled by a switch through some other motion of the body. The arm was complex and difficult to keep functional on active children but the control was remarkable. Children operated its multiple functions naturally, without much training, and seemingly without too much mental load. <a href="/files/original/ca2b3ffb8c94001e703bdd917b139e04.jpg"><b>Fig. 10</b></a> shows the mechanism. Less complex (and less functional) all-electric EPP-type controllers are now under study in the U.S. and Scotland.</p> <strong><a href="/files/original/ca2b3ffb8c94001e703bdd917b139e04.jpg">Figure 10.</a> Photograph of the mechanism of the Edinburgh Arm, developed by D.C. Simpson. This CO₂-powered limb had four degrees of freedom (five if the terminal device was included) and kinematic coupling of the wrist to the elbow and the shoulder. It used spherical coordinates and was controlled by position servos that mechanically linked shoulder girdle position with prosthesis position. It is one of the most complete powered arms ever developed.</strong><br /> <p>Proceedings of meetings form an excellent historical record of powered prostheses. The first meeting of consequence in the U.S. concerning powered prostheses was held at Lake Arrowhead, California in 1960,<a></a> and was sponsored by the National Research Council. The second major meeting of this kind in the U.S. was held in Warrenton, Virginia in 1965<a></a> with considerable international input. Subsequently, the Committee on Prosthetics Research &amp; Development (CPRD) held regular meetings related to applications of external power in limb prosthetics, and the reports of these meetings form a good record of U.S. activity in this field.</p> <p>Myoelectric control received a major boost in America through a 1966 symposium in Cleveland, Ohio (Case Western Reserve University) entitled "Myoelectric Control Systems and Electromyographic Kinesiology." Bottomley demonstrated his elegant myoelectric system at that meeting. The meeting was also attended by Professor Robert N. Scott of the University of New Brunswick. Scott headed a group that developed the first myoelectric control mechanism in North America.<a></a></p> <p>A Yugoslavia-based conference, around 1963, called "External Control of Human Extremities" was followed by a similar conference in Dubrovnik, Yugoslavia and this international conference has been held there every third year since 1966. The Proceedings of the "Dubrovnik Conference," as it is often called, are a singular record of international developments in powered limb research and development since the early sixties.</p> <p>Three other symposia produced significant early publications. The symposium on "Basic Problems of Prehension, Movement and Control of Artificial Limbs"<a></a> organized in London in 1968 by the Institution of Mechanical Engineers contains a wealth of information on powered limbs. The "Dundee Conference" held in Dundee, Scotland in 1969 resulted in the book <em>Prosthetic and Orthotic Practic</em>e.<a></a> It covers prosthetics generally but has a fair amount of material on powered prostheses. Finally, the Swedish conference of 1974<a></a> produced a book that concerned early research and development work on powered prostheses and orthoses.</p> <h3>Growing Up (1967-1977)</h3> <p>I have selected the decade of 1967-1977 as one of "growing up" because 1967 is about the time it became possible to purchase a powered prosthesis commercially in the United States, and it was approximately 1977 before powered upper-limb prostheses began to take on some real clinical significance (i.e. larger numbers of clients fitted).</p> <p>The Viennatone Hand was the first commercial system available in the U.S. This hand came about as a result of Otto Bock Orthopedic Industries, a German prosthetics company, and Viennatone, an Austrian hearing aid company with expertise in electronics. Shortly thereafter, Otto Bock developed their own myoelectric system and a new hand mechanism. The Viennatone and Otto Bock Hand mechanisms (both designed by Otto Bock) have been altered somewhat through the years, but their basic appearance and design principles remain essentially unchanged.</p> <p>In the early days of myoelectric control (e.g. 1968), the battery or battery and electronics had to be worn outside the prosthesis, usually in a chest pouch, on a clip at the waist, or on a band around the humeral section of the arm. The wires and connections required by this kind of configuration led to failures due to wire breakage. There was also electrical interference on occasion. In addition, the components outside the prosthesis were a nuisance to fit and to wear.</p> <p>In 1968, I was involved in fitting a college student with one of the first self-contained and self-suspended below-elbow prostheses.<a></a> The Viennatone Hand mechanism was used in conjunction with a myoelectric controller developed at Northwestern University. Self-containment and self-suspension are standard procedures for below-elbow prostheses today.</p> <p>The Veterans Administration Prosthetics Center (VAPC) modified the Viennatone Hand mechanism and packaged it with a modified version of the electronic system developed at Northwestern. The VAPC contracted for this system to be manufactured by Fidelity Electronics, Ltd. and this system was marketed for a period of time.</p> <p>An interesting electric powered hand of this period was the hand developed at the Army Medical and Biomechanical Research Laboratory.<a></a> This hand contained a "slip detector" in the thumb. The hand would grip to about 2 Lff at the finger tips. If the object to be held started to slip, the hand would automatically increase gripping force until slippage stopped.</p> <p>Schmidl<a></a> was actively fitting many upper-limb amputees with myoelectrically controlled, powered limbs during this period and he achieved clinical significance with powered limbs well before this happened in the U.S. His center in Italy was also involved early in fittings of multifunctional limbs. Three-state controllers are used to control electric elbow, electric wrist rotator and electric hand from three muscle electrode sites. The Italian group has been at the forefront of progress in the fitting of powered limbs.</p> <p>Engineers at Temple University-Moss Rehabilitation Hospital<a></a> were probably first to attempt multi-functional control of elbow, humeral rotation, and wrist using pattern recognition techniques on myoelectric signals from multiple muscle sites of the upper arm and shoulder. They had some laboratory success. Swedish scientists<a></a> did similar work to control multiple functions of the hand (rotation, flexion-extension, and prehension).</p> <p>The New Brunswick laboratory has played an active role in developing control methods for powered limbs in North America and is well known for three-state control design and development. They have also been active in research on sensory feedback<a></a> and the University of New Brunswick sensory feedback system is the only one available today, of which I am aware. Sensory feedback was examined by many research groups during the 1970's. I reviewed some of this work in an article appearing in the <i>Annals of Biomedical Engineering</i>.<a></a></p> <p>In the late 1960's and 1970's much experimentation and development were engendered in the field of external electric power. The Japanese developed a myoelectric powered hand.<a></a> MIT scientists designed the Boston Arm,<a></a> the first myoelectrically controlled elbow. The Ontario Crippled Children's Centre (OCCC) Elbow, a switch-controlled electric elbow was also developed in the late sixties, and is still in use. A number of electric elbows, the Rancho Electric Elbow (from Rancho Los Amigos Hospital) the AMBRL Elbow (from the Army Medical and Biomechanical Research Laboratory), and the VAPC Elbow (from the VA Prosthetics Center) also made their appearance in this time period. The Boston Elbow, AMBRL Elbow, and Rancho Elbow were evaluated by the Committee on Prosthetics Research and Development (CPRD).<a></a> Subsequently, the Applied Physics Laboratory in association with Johns Hopkins University developed a powered unit<a></a> capable of pulling the cable of conventional cable-operated, body-powered prostheses. It could be controlled by other inputs, such as from skin motion sensors, which were used with several fittings for high-level arm amputees.</p> <p>The Boston Elbow was redesigned extensively to become the Liberty Mutual Powered Elbow,<a></a> available through Liberty Mutual Insurance Company. The Boston Elbow was also undoubtedly a stimulus to Jacobsen who did his graduate studies at MIT and who later developed the finely-crafted Utah Arm,<a></a> available through Motion Control, Inc. in Salt Lake City. Likewise this research at MIT influenced Hogan,<a></a> who today is developing an elbow in which elbow compliance is controlled by myoelectric signals.</p> <p>The VAPC elbow was manufactured by Fidelity Electronics and used to some extent by VA clients. It was controlled by the VAPC pull switch.</p> <p>The OCCC elbow (available through Electro-Limb in Toronto) has been a workhorse for many years. It, along with other elbows of its period, influenced Lembeck<a></a> in development of the NYU Elbow at New York University. This elbow is presently manufactured by the Hosmer Dorrance Corporation.</p> <p>The OCCC has been a leader in the fitting and development of powered limbs. It is interesting how influential children's prosthetics programs in Germany, Sweden, Britain, and Canada have been on the field of powered prostheses. This is partially the result of government sponsored research programs directed toward amputations caused by the drug Thalidomide. Besides the electric elbow, the Ontario group have made small electric hands available through Electro-Limb for many years and their new electric hand is the latest evolutionary result of their continuing development work in this area.</p> <p>Sorbye<a></a> in Sweden, pioneered the fitting of child amputees with myoelectric hands during the early 70's. His work stimulated the development of the Systemteknik Hand. His work also stimulated interest in the U.K. and an evaluation program there found myoelectric hand systems valuable for child amputees. This undoubtedly had an influence on the development of the Steeper child-sized hand.</p> <p>When Colin McLaurin was at Northwestern University in the early 1960's he developed a "feeder arm" for the Michigan Area Amputee Center (MAAC) in Grand Rapids, Michigan. It was a kinematically coupled limb, designed to enable children with bilateral amelia to eat. A single electric drive mechanism at the elbow moved the terminal device from plate to mouth in a mechanically predetermined fashion. Subsequently, McLaurin moved to OCCC and was responsible for many developments there. Later, Dr. Aitken of MAAC requested the Prosthetics Research Laboratory at Northwestern to re-design the "feeder arm." The Michigan Arm resulted, which was a simple arm with electric hook and electric elbow similar in shape and function to one of Simpson's early CO₂ powered limbs. The electric terminal device for the Michigan Arm became commercially available through Hosmer Dorrance as the Michigan Hook. This was one of the first electric hooks to become commercially available. Of course CO₂ powered hooks had been used for many years. Also, it should be noted that Bottomley<a></a> designed a unique CO₂ powered hook in the 1960's that had many merits which were never exploited.</p> <p>The Michigan Hook was a stimulus for Lembeck at New York University to develop the Prosthesis Assist Device. Like the Michigan Hook and the earlier systems at Johns Hopkins, it pulls on a cable to open a voluntary-opening hook or hand against a resisting spring (e.g. rubber band). This form of electric power utilization in prostheses lacks control sophistication but has simplicity of design and operation.</p> <p>Electric-powered prosthetic hooks have generally been thought to be desirable, particularly by Americans in the prosthetics field. During the mid-seventies, the VAPC developed an electric hook.<a></a> A few years earlier, Northwestern had introduced the synergetic prehension concept and the Synergetic Hook.<a></a> The VA purchased 12 synergetic hooks and evaluated them on VA clients. However, only recently has there been interest in commercial development of this prehension device for interchangeable use with electric hands.</p> <p>Otto Bock developed the Greifer during the late 1970's. It is a novel prehension device that is interchangeable with the Otto Bock Hand. This device is valuable for persons engaged in heavy-duty activities.</p> <p>The commitment of Otto Bock Orthopaedic Industries, Inc. to the powered limb field cannot be overlooked in any historical review. Without availability of Otto Bock hands, wrist rotators, and electronic control systems, much research work in this field would have been stymied for lack of components. Of course, without available commercial components that were backed strongly by educational programs and literature, and by repair and maintenance, it would have been impossible for practicing prosthetists to serve their clients well. Needless to say, Otto Bock, through research, production, education, and product support has made an unparalleled contribution to development for almost a quarter century.</p> <h3>The Present (1977-1984)</h3> <p>The last seven years has been a period marked not by experimental powered fittings in a small number of research centers or elite institutions, but rather by the clinical use of powered limbs by prosthetists practicing all over the country. This "coming of age" was vividly evident at the education seminar entitled, "Current Clinical Concepts of Electrically Powered Upper-Limb Prostheses" in Chicago in September, 1984 and sponsored by the American Academy of Orthotists and Prosthetists. This seminar, convened within a few hundred yards of where prosthetics research was born in the U.S., was not a seminar of researchers or a seminar directed toward particular products or particular methods; it was a seminar of clinicians involved with powered-limb fittings. Undoubtedly, this meeting was a milestone in the history of powered prostheses in this country.</p> <p>An interesting aspect about this period has been the upsurge of clinical fittings of powered prostheses and the increase of commercially available powered components. At the same time, there seems to have been some reduction of research efforts in this area. It is an area that has received considerable attention over the last twenty-five years, and perhaps research is just gathering its breath for the next important push. Whatever the situation, the clinical results show that progress has been made. That this progress has been difficult and hard won with many setbacks, is an indication of the difficulty of the problem being addressed. Indeed, adequate replacement of the human hand and arm is one of the most difficult problems facing medical technology.</p> <h3>Future Trends</h3> <p>From a technical viewpoint there will probably be movement to smaller electronic systems that have extremely low quiescent power. This will enable small power sources to be used when they are coupled with highly efficient prehension devices. Consequently, it may be possible to fit myoelectrically controlled, electrically driven prehension devices to partial hand amputees. Availability of wrist function should make this kind of fitting very effective. This new possibility with technology, coupled with the new surgical reconstruction techniques for the hand, should open up many new possibilities for rehabilitation of partial hand amputees.</p> <p>There should be an increase in reliability and serviceability of powered limb systems. They will become more modular, as well as smaller and lighter.</p> <p>Electro-mechanical components will become more efficient and will have improved dynamic performance. That is, they will be faster and more responsive to the desires of the amputee. New prehension devices, interchangeable with hands and hooks, will be developed.</p> <p>Computer-based controllers will be used in artificial arms, particularly those for multifunctional control. The Utah Arm will probably be the first commercially available arm to contain a computer-based controller.</p> <p>Prosthetists will develop better suspension techniques that minimize or eliminate harnessing in powered limb fittings. They will also, through case studies, develop fitting principles that will enable the various components to be fitted components to be fitted effectively, used appropriately in combinations, and used creatively with body-power.</p> <p>I hope that new control strategies will become available which will enable arm amputees to use multifunctional prostheses without excessive mental load. When this may happen is difficult to predict.</p> <h3>Summary</h3> <p>I have attempted to put powered limb components available today into perspective from an historical viewpoint. None of the devices used today appeared "de novo." All have been influenced by historical events and concepts, the state of technology, and prosthetics practice.</p> <p><b>References:</b></p> <ol> <li>Alderson, S.W., "The Electric Arm," <i>Human Limbs and Their Substitutes</i>, Eds. Klopsteg, P. and William, P., McGraw-Hill, 1954 (Reprinted by Hafner Press, 1969), Chapter 13.</li> <li>Almström, C, Herberts, P., and Caine, K., "Clinical Application Study of Multifunctional Prosthetic Hands," Report 2:77, Research Laboratory of Medical Electronics, Chalmers University of Technology, Göteborg, Sweden.</li> <li>Battye, C.K., Nightingale, A., and Whillis, J., "The Use of Myo-Electric Currents in the Operation of Prostheses," <i>J. Bone &amp; Joint Surg.</i>, 37B, pp. 506-510, 1955.</li> <li>Berger, N. and Huppert, C.V., "The Use of Electrical and Mechanical Muscular Forces for the Control of an Electrical Prosthesis," <i>Amer. J. Occup. Ther.</i>, 6:110-14, 1952.</li> <li>Bottomley, A., "Myo-Electric Control of Powered Prostheses," <i>J. Bone &amp; Joint Surg.</i>, 47-B(3):411, 1965.</li> <li>Bottomley, A., "Design Considerations for a Prosthetic Prehension Device," <i>Proc. of Intl. Symp. on External Control of Human Extremities</i>, Dubrovnik 1966 (Published 1967), pp. 82-84.</li> <li>Bottomley, A., Kinnier Wilson, A.B., and Nightingale, A., "Muscle Substitutes and Myo-Electric Control," <i>J. Brit. I.R.E.</i>, 26, pp. 439-448, 1963.</li> <li>Carlson, L.E., and Radcliffe, C.W., "A Multi-Mode Approach to Coordinated Prosthesis Control," <i>Proc. of 4th Intl. Symp. on External Control of Human Extremities</i>, pp. 185-186, Dubrovnik, 1972, (published 1973).</li> <li>Childress, D.S., "Closed-Loop Control in Prosthetic Systems: Historical Perspective," <i>Annals of Biomed. Engr.</i>, Vol. 9, pp. 293-303, 1980.</li> <li>Childress, D.S., "Powered Limb Prostheses: Their Clinical Significance," <i>IEEE Trans. Biomed. Engr.</i>, BME-20, No. 3, pp. 200-207, 1973.</li> <li>Childress, D.S., "An Approach to Powered Grasp," Proc. <i>4th Intl. Symp. on External Control of Human Extremities</i>," pp. 159-167, Dubrovnik, 1972 (published 1973).</li> <li>Childress, D.S., and Billock, J.N., "Self-Containment and Self-Suspension of Externally Powered Prosthesis for the Forearm," <i>Bull. Prosthetics Research</i>, BPR 10-14, pp. 4-21, 1970.</li> <li>Dahlheim, W., Pressluft hand fur kreigsbeschädigte Industriearbeiter Z. komprimierte und flüssige Gase, German Patent (1915).</li> <li>Dorcas, D.S., and Scott, R.N., "A Three-State Myoelectric Control System," <i>Med. Biol. Engr.</i>, Vol. 4, pp. 367-370, 1966.</li> <li>Doubler, J.A., and Childress, D.S., "Design and Evaluation of a Prosthesis Control System Based on the Concept of Extended Physiological Proprioception," <i>J. of Rehab. Research and Development</i>, 21:1, BPR 10-39, pp. 19-31, 1984.</li> <li>"Externally Powered Prosthetic Elbows-A Clinical Evaluation," Comm. on Prosthetics Research and Development (CPRD), Report E-4, National Academy of Sciences-National Research Council, 1970.</li> <li>Geddes, L.A., Moore, A.C., Spencer, W.A., and Hoff, H.E., "Electropneumatic Control of the McKibben Synthetic Muscle," <i>Orthopaedic &amp; Prosthetic Appliance J.</i>, 13, pp. 33-36, 1959.</li> <li>Herberts, P., Almström, C, Kadefors, R., and Lawrence, P., "Hand Prosthesis Control Via Myoelectric Patterns," <i>Acta Orthopaedica Scandinavica</i>, Vol. 44, pp. 389-409, 1973.</li> <li>Herberts, P., and Petersen, I., "Possibilities for Control of Powered Devices by Myoelectric Signals," <i>Scand. J. Rehab. Med.</i>, 2:164-170, 1970.</li> <li>Hogan, N., Mechanical Impedance Control in Assistive Devices and Manipulators," <i>Proc. of the Joint Automatic Controls Conf.</i>, San Francisco, Vol. 1, August, 1980.</li> <li>Jacobsen, S.C., Knutti, D.F., Johnson, R.T., and Sears, H.H., "Development of the Utah Arm," <i>IEEE Trans. Biomed. Engr.</i>, BME-29, No. 4, pp. 249-269, 1982.</li> <li>Kato, I., et al., "Multifunctional Myoelectric Hand Prosthesis with Pressure Sensory Feedback System-WASEDA Hand-4P," Proc. <i>3rd Intl. Symp. on External Control of Human Extremities</i>, pp. 155-170, Dubrovnik, 1969 (published 1970).</li> <li>Kessler, H.H., and Kiessling, E.A., "Pneumatic Arm Prosthesis," <i>Am. J. Nursing</i>, 65:6, 1965.</li> <li>Kobrinskii, A.E., Bolkhoivin, S.V., Voskoboini-kova, L.M., Joffe, D.M., Polyan, E.P., Slavictskü, Ya. L., Sysin, A. Ya., and Yakobsen, Ya, S., "Problems of Bioelectric Control," <i>Proc. Intl. Fed. on Automatic Control Conf.</i>, pp. 1119-22, Moscow, 1960, (Butterworth, London, 1961).</li> <li>Lembeck, W., Personal Communication, 1984.</li> <li>Lucaccini, L.F., Kaiser, P.K., and Lyman, J., "The French Electric Hand: Some Observations and Conclusions," <i>Bull. of Prosth. Research</i>, BPR 10-6, pp. 30-51, 1966.</li> <li>Mann, R.W., "Cybernetic Limb Prosthesis," A<i>nnals of Biomed. Engr.</i>, Vol. 9, pp. 1-43, 1981.</li> <li>Marguardt, E., "The Heidelberg Pneumatic Arm Prosthesis," <i>J. Bone &amp; Joint Surg.</i>, 47-B:3, pp. 425-434, 1965.</li> <li>McWilliam, R., "Design of an Experimental Arm Prosthesis: Biological Aspects," <i>The Basic Problems of Prehension, Movement and Control of Artificial Limbs</i>, The Institution of Mechanical Engineers, Proc. 1968-69, Vol. 183, Part 3J, pp. 74-81, 1969.</li> <li>Montgomery, S.R., "Design of an Experimental Arm Prosthesis: Engineering Aspects," in <i>The Basic Problems of Prehension, Movement and Control of Artificial Limbs</i>, The Institution of Mechanical Engineer, Proc. 1968-69, Vol. 183, Part 3J, pp. 68-73, 1969.</li> <li><i>Prosthetic and Orthotic Practice</i>, based on Dundee Conference of 1969, Ed. G. Murdoch, Edward Arnold Ltd., London, 1970.</li> <li>Rakic, M., "The Belgrade Hand Prosthesis," in <i>The Basic Problems of Prehension, Movement and Control Artificial Limbs</i>, The Institution of Mechanical Engineers, Proc. 1968-69, Vol. 183, Part 3J, pp. 60-67, 1969.</li> <li>Reiter, R., "Eine neue Electrokunsthand," <i>Grenzgebiete der Medizin</i>, 4:133, 1948.</li> <li>Salisbury, L.L., and Colman, A.B., "A Mechanical Hand with Automatic Proportional Control of Prehension," <i>Med. Biol. Eng.</i>, Vol. 5, pp. 505-511, 1967.</li> <li>Schlesinger, G., "Der Mechanische aufbau der kunstlichen glieder," in <i>Ersatzglieder und Arbeitshilfen</i>, Borchardt, M., et al., Eds., J. Springer, Berlin, 1919.</li> <li>Schmidl, H., "The I.N.A.I.L. Experience Fitting Upper-Limb Dysmelia Patients with Myoelectric Control," <i>Bull. of Prosthetics Research</i>, BPR 10-27, pp. 17-42, 1977.</li> <li>Scott, R.N., Brittain, R.H., Caldwell, R.R., Cameron, A.B., and Dunfield, V.A., "Sensory Feedback System Compatible with Myoelectric Control," <i>Med. &amp; Biol. Eng. &amp; Comp.</i>, Vol. 18, No. 1, pp. 65-69, 1980.</li> <li>Seamone, W., "Development and Evaluation of Externally Powered Upper-Limb Prosthesis," <i>Bull. of Prosthetics Research</i>, BPR 10-13, pp. 57-63, 1970.</li> <li>Simpson, D.C., "An Externally Powered Prosthesis for the Complete Arm," in <i>The Basic Problems of Prehension, Movement and Control of Artificial Limbs</i>, The Institution of Mechanical Engineers, Proc. 1968-69, Vol. 183, Part 3J, pp. 11-17, 1969.</li> <li>Sorbye, R., "Myoelectric Controlled Hand Prostheses in Children," Int. J. of Rehab. Research, Vol. 1, pp. 15-25, 1977.</li> <li>Spaeth, J. P., <i>Handbook of Externally Powered Prostheses for the Upper Extremity Amputation</i>, Charles C. Thomas, Springfield, 111., 1981.</li> <li>Stevenson, D.A., and Lippay, A.L., "Hydraulic Powered Arm Systems," in <i>The Basic Problems of Prehension, Movement and Control of Artificial Limbs</i>, The Institution of Mechanical Engineers, Proc. 1968-69, Vol. 183, Part 3J, pp. 37-44, 1969.</li> <li>"The Application of External Power in Prosthetics and Orthotics," Report of Conference at Lake Arrowhead, California, Publication 874, National Academy of Sciences, National Research Council, September, 1960.</li> <li>"<i>The Basic Problems of Prehension, Movement and Control of Artificial Limbs</i>," The Institution of Mechanical Engineers, Proc. 1968-69, Vol. 183, Part 3J, 1969.</li> <li>"The Control of External Power in Upper-Extremity Rehabilitation," Report of Conference held at Warrenton, Virginia, April, 1965, Publication 1352, National Academy of Sciences-National Research Council, 1966.</li> <li>"<i>The Control of Upper-Extremity Prostheses and Orthoses</i>," based on a conference held in Göteborg, Sweden, 1971, Charles C. Thomas, Springfield, Illinois, 1974.</li> <li>VAPC Research Report, Development (Components), Powered Hook developed by C. Mason, <i>Bull. of Prosthetics Research</i>, BPR 10-16, pp. 217-219, 1971.</li> <li>Williams, T.W., "Clinical Applications of the improved Boston Arm," <i>Proc. Conf. on Energy Devices in Rehab.</i>, Boston (Tufts), 1976.</li> <li>Wilms, E., "Die Technik der Vaduzer Hand," <i>Orthopädie Technik</i>, 3, 7, 1951.</li> <li>Wilson, A.B., Jr., "Externally Powered Upper Prostheses," <i>Newsletter . . . Prosthetics and Orthotics Clinic</i>, Vol. 2, No. 1, pp. -4, 1978.</li> <li>Wirta, R.W., Taylor, D.R., and Finley, F.R., "Pattern-Recognition Arm Prosthesis: A Historical Perspective-A Final Report," <i>Bull, of Prosthetics Research</i>, BPR 10-31, pp. 8-35, 1978.</li> </ol> <div style="width: 400px;"><em><b>*Dudley S. Childress, Ph.D. </b> Dudley S. Childress, Ph.D. is Director of the Prosthetics Research Laboratory and Director of the Rehabilitation Engineering Program at Northwestern University, Room 1441, 345 East Superior Street, Chicago, Illinois 60611.<br /><br /><br /></em></div> Page Number(s) 2 - 13 Year 1985 Volume 9 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 8 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Historical Aspects of Powered Limb Prostheses Creator An entity primarily responsible for making the resource Dudley S. Childress, Ph.D. * 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. URL https://hope.org.pk/ Address HOPE Rehabilitation Center 866-B, Faisal Town. City Lahore Countries Served Pakistan Phone +92 42 35177791-2, +92 304 5177790 Email info@hope.org.pk Services Provided Consultancy clinic, braces and support, artificial limb solutions, physiotherapy, compression garments, foot bare Need I Financial Assistance - donate, sponsor an artificial limb, sponsor a special person Need II Volunteers Mission Hope Rehabilitation Society is welfare (Not for Profit Organization) body established to transfer the latest artificial limbs (orthotics and prosthetics) technology in Pakistan so that the quality of rehabilitation services be improved. The services are at ‘no profit no loss’ basis. However, the poor and very deserving disabled enjoy the services free of charge out of the donation funds maintained, for this purpose, by the Hope Rehabilitation Society. State/Province Pakistan Volunteer Contact https://hope.org.pk/support/become-volunteer/ Patient Contact https://hope.org.pk/new-patients/book-an-appointment-online/ Facebook Page https://www.facebook.com/hopesocietylahore 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 HOPE Rehabilitation Center Description An account of the resource Hope Rehabilitation Society is a welfare (Not for Profit Organization) body established to transfer the latest artificial limbs (orthotics and prosthetics) technology in Pakistan so that the quality of rehabilitation services be improved. https://staging.drfop.org/files/original/d1fa99c68ccb7ad17715ef0dc1dd6825.pdf 2673ebe4132713a88e1fc6bbbefeea96 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_04_007.pdf Text Any textual data included in the document <h2>Hydraulic/Pneumatic Knee Control Units A Prosthetist's Point of View</h2> <h5>Charles H. Pritham, CPO&nbsp;<a style="text-decoration: none;">*</a></h5> <p>As Mr. Wilson has demonstrated, the use of hydraulic and pneumatic control units had its genesis in the post World War II R &amp; D effort. The objective, of course, was to fit the returning veteran AK amputee with the best prosthesis technology could provide. Such amputees were young and physically fit, prime candidates to benefit from the advantages of advanced control units. The prime advantage, usually cited, is cadence responsiveness. As the patient walks at different rates, the control unit automatically adjusts to control heelrise and terminal swing impact. Constant friction knees can not duplicate this feature. All hydraulic and pneumatic units provide this feature and one, the Mauch S-N-S, provides stance phase control as well. This means that the unit provides enhanced knee stability in the early portion of stance phase to increase the patient's safety.</p> <p>In this mode, the S-N-S unit can be said to function in a fashion analogous to that of a conventional safety knee. In another mode, the function of the S-N-S can be likened to that of a simple manually locking knee. Two other knee control units, variants of Kingsley's Hydranumatic and USMC's Dynaflex, function in a similar fashion.</p> <p>The Hydracadence, in addition to swing phase control, also provides heel height adjustability and toe pick-up. Otto Bock has recently introduced a modular knee that includes a hydraulic swing phase control.</p> <p>As can be seen then, these are just a few of the variations available to the prosthetist and his patient. The principal advantages claimed for such control units are enhanced cosmesis and performance, and lower energy expenditure. Against these advantages, the disadvantages must be weighed. Bulk, size, and weight of some of the units preclude their use by many patients. The considerable expense of most, if not all, hydraulic and pneumatic control units rules out others. Moreover, the control units have been shown to be unreliable. Some patients derive satisfactory service from their units while other patients using the same brand unit are constantly having them replaced and repaired. As most of the units need to be factory serviced, the delay and expense of maintaining a unit under such circumstances can engender considerable frustration.</p> <p>Given these circumstances, the pool of available amputees for whom such advanced control units are suitable is a small proportion of the total AK population, and most closely resembles the patients for whom they were originally developed: young traumatic males; i.e. veterans. It must be borne in mind that this pool today represents a less important proportion of the amputee population than it did some 25 years ago. Statistics demonstrate that the majority of civilian amputees in the Western World are geriatrics who lose a leg due to arteriosclerosis and are as often as not female. Indeed, the very amputees who were originally provided hydraulic units by the VA are not getting any younger. The day will come for each of them when they, and the clinic teams who attempt to address their needs, must make a reappraisal of their prescription. So, the use of hydraulic/ pneumatic control units for a considerable portion of the amputee population can be ruled out. Not only that, but it is possible to be very skeptical in considering the suitability of such units for patients for whom it is theoretically ideally suited.</p> <p>Young, active traumatic amputees are probably, children aside, the hardest on their prostheses. Given the expense of purchasing and maintaining such a unit, does it make sense to fit an amputee with one if he is going to have more than average maintenance problems? Can he afford the time lost from work, interruptions in his daily life, and expense of repairs? Given the disproportionately rising cost of health care today, can society? Gait studies demonstrate that AK amputees walk slower than normal subjects and BK amputees because of increased energy expenditure. If this is so, is the prime advantage cited for hydraulic/pneumatic units, cadence response, relevant and worth the additional expense and problems? In another vein, given the aging nature of the population should further effort and money be devoted to developing newer and more sophisticated knee control units?</p> <p>In any event, it can be said that a prosthetist in attempting to formulate a solution to his patient's problems is confronted with a number of questions and a wide variety of devices all intended to perform the same function. It is also true that the prosthetist has little more than personal experience, hearsay, and the competing claims of the manufacturers to aid him in making his decision. The natural tendency on the prosthetist's part is to provide his patient with the most sophisticated unit possible, for all of us gain considerable satisfaction from doing so and from working with such units. The patient also wants the best prosthesis possible. The fact remains, however, that such tendencies must be resisted and both prosthetists and patient must make a realistic appraisal of the situation and logically weigh the pros and cons.</p> <b>*Charles H. Pritham, CPO </b> Technical Coordinator Durr-Fillauer Medical, Inc. Chattanooga, Tennessee Editor, C.P.O.<br /><br /> <div style="width: 400px;"></div> Page Number(s) 7 - 8 Year 1983 Volume 7 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Hydraulic/Pneumatic Knee Control Units A Prosthetists Point of View Creator An entity primarily responsible for making the resource Charles H. Pritham, CPO *