7 20 371 https://staging.drfop.org/files/original/c1b212e5569be3980845775e2e5a8a20.pdf b5411e7663896df2ca89672710d0c1cb Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1980_03_001.pdf Text Any textual data included in the document <h2>Irreversible Contractures: An Impediment to Prosthetic Rehabilitation</h2> <h5>Justin Alexander, Ph.D. </h5> Prosthetic rehabilitation of patients with severe contractures of the remaining joints of the affected lower extremity has been generally viewed as being difficult due to biomechanical problems in fitting, increased energy costs of ambulation and poor cosmesis of the prosthesis. As a result, attempts are often made to "stretch out the contracture" with minimal success, or suggestions are made to the patient to remain in the wheelchair. Our experiences with a number of patients who presented with "irreversible" contractures, indicate that another choice may be available. In 1965(1) we reported our experience in the management of a 59 year old man who had undergone bilateral amputations (BK and AK). Following a herniorrhaphy, he developed occlusions of both iliac arteries and despite attempts to reconstruct the vascular supply, he developed gangrene necessitating the amputations. When he was examined by us, he presented with bilateral hip flexion contractures of about 60° and a knee flexion contracture on the BK side of 90°. In addition, there was limited mobility of the lumbar spine. Primarily because the patient refused our recommendation for wheelchair independence, pylons were constructed. For the left, a bent knee pylon was fabricated and for the right the device was built to hold the stump in about 50° hip flexion with weight bearing on the posterior thigh. Since the patient demonstrated that this solution was a realistic one, prosthetic devices incorporating the features of the pylons were made. When the patient was discharged, he was able to ambulate with the aid of Lofstrand crutches. The patient was re-examined periodically, and after about 2 years it was noted that the contractures had decreased to a point where he was able to wear a PTB prosthesis on the left and a conventionally aligned AK quadrilateral socket prosthesis on the right. Lippman(2) described his observations of a 72 year old man who lost his right leg as a result of trauma, complicated by a long history of arteriosclerosis obliterans. Because of a 40° hip flexion contracture, his prosthetic treatment followed the course outlined above. In our prosthetics clinic (Bronx Municipal Hospital Center), we have seen a number of patients who had undergone below knee amputations and presented with severe knee flexion-hip flexion contractures to a degree which precluded fitting with a standard PTB or condylar bearing prosthesis. We have frequently fitted them with bent knee pylons followed by a similar prosthetic device after they had demonstrated their ability to function with the temporary device. On follow-up we again noted reduction of the "irreversible" contractures to the point where a more conventionally aligned prosthesis could be prescribed. <h3>Discussion</h3> Delagi and co-workers(3) (1955) as well as Blau, et. al(4) (1951) reported their impressions of the benefits of ambulation with a temporary device. Both emphasized the stretching effect of early ambulation. In the devices described in this article, however, stretching has been purposely minimized because the contractures were believed to be "irreversible." Despite the lack of active stretching, the contractures were relieved to a considerable degree. Partridge and Duthie (1963) (5) reviewed the literature describing the effect of immobilization on acutely inflamed rheumatoid joints and cite Hunter (1835) "nothing can promote contraction(s) of a joint so much as motion before the disease is removed." Hunter's observations were confirmed by Thomas (1878), Duthie (1951, 1952) and Partridge and Duthie. Harris and Copp(6) (1962) immobilized acutely inflamed knee joints, keeping one completely immobilized and the other being exercised intermittently. They noted that when the fixed knee lost more than 15° of motion, the mobile knee also lost range, thereby suggesting that some factors other than immobility might be a contributing factor. In their opinion immobilization produced a decrease in muscle spasm, thus permitting restoration of motion. Fried (1969) (7) concurs "complete immobilization is not only not harmful but frequently beneficial, provided that splinting is done judiciously, especially when a joint is inflamed and painful." Under those conditions when patients are likely to dread motion, immobilization leads to decreased pain and inflammation and "it is not unusual for immobilization to result in increase in motion." It seems that those amputees who experience considerable pain pre-operatively or in the immediate post-operative period, might react with a response similar to that described above and when pain is relieved, inhibition, spasm or another mechanism is decreased and motion can be restored. In addition, it appears that the judgment of "irreversible contractures" may be applied too quickly. Patients are treated for a finite period of time and if during that period no appreciable change is observed, a decision must be made based on demonstrable facts. It can, therefore, be concluded that for some patients interim solutions as outlined may be appropriate and that the clinic staff must accept the responsibility for regular, periodic and long term follow-up of patients in order to facilitate accommodation to changes in the patient's condition. References: <ol> <li>Alexander, Justin and Herbison, Gerald, "Prosthetic Rehabilitation of a Patient With Bilateral Hip-Flexion Contractures: Report of a Case." Archives of Physical Medicine and Rehabilitation, Vol. 46, 708-711, October, 1965.</li> <li>Lippmann, Heinz I., "Rehabilitation of the Lower Extremity Amputee with Marked Flexion Contractures: Report of Two Cases." Archives of Physical Medicine and Rehabilitation, Vol. 48:3, 147-149, March, 1967.</li> <li>Delagi, Edward F., Abramson, Arthur S. and Tauber, Arthur N., "Use of Temporary Plaster Pylon in the Management of the Lower Extremity Amputee." Archives of Physical Medicine and Rehabilitation, Vol. 36: 784-786, December, 1955.</li> <li>Blau, Leslie, Phillips, Joseph J. and Rose, Donald M., "Value of the Pylon in Pre-prosthetic Management of the Lower Extremity Amputee." Archives of Physical Medicine and Rehabilitation, Vol. 32: 585-589, 1951.</li> <li>Partridge, R. E. H. and Duthie, J. J. R., "Controlled Trial of the Effect of Complete Immobilization of the Joints in Rheumatoid Arthritis." Ann. Rheum. Dis., 22: 91, 1963.</li> <li>Harris, R. and Copp, E. P., "Immobilization of the Knee Joint in Rheumatoid Arthritis." Ann. Rheum. Dis., 21: 353, 1962.</li> <li>Fried, David M., "Splints for Arthritis." Arthritis and Physical Medicine, S. Licht (edit.), 1969, pp 285-314.</li> </ol> Page Number(s) 1 - 2 Year 1980 Volume 4 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Irreversible Contractures: An Impediment to Prosthetic Rehabilitation Creator An entity primarily responsible for making the resource Justin Alexander, Ph.D. https://staging.drfop.org/files/original/fa104bc2df9d1eb8a2e3fcfe1be372dc.pdf 3cac7ed2272aa4b36cb461ab73d777af https://staging.drfop.org/files/original/03c6dab500bcc8abcf2064a69651e3fb.jpg 78f6ebbe4d49f0e3d87c4a2431800fec https://staging.drfop.org/files/original/ef57e986fd642949abac655e0ddfbb48.jpg f228ca3d4b1bb1b07a591f5647f82f55 https://staging.drfop.org/files/original/6f3713a26a2d78a1af84b3371b05ee26.jpg 4cbdb84cf8ff35a7778b82dbb1364778 https://staging.drfop.org/files/original/984d8d4e3f3b4d44a11796f074d966bc.jpg fd661aac55fb812af0850e8319a6494b https://staging.drfop.org/files/original/a0e1497de95803eedb7c9bae27189933.jpg 86578a267fce21bebb761d96df09ad56 https://staging.drfop.org/files/original/ac40bae7d01bf2c9df78320ef938a453.jpeg 121965bd03be3afd015cb87750d6b2f5 https://staging.drfop.org/files/original/6ac0309f920adb45f06a6d73b90dbb23.jpeg 822b8149c492fcc9a1b2e8791f80a98d https://staging.drfop.org/files/original/ad272a01fb6edf60c48e85a6111e0d64.jpeg 28953020850578f0557a831f57db00da Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1980_03_003.pdf Text Any textual data included in the document <h2>An Ankle-Foot Orthosis Providing Mediolateral Stabilization While Allowing Free Plantar and Dorsiflexion of the Foot</h2> <h5>Lucia Klemmt, CO  Fritz Klemmt </h5> The development of an ankle-foot orthosis (AFO) providing mediolateral stabilization while allowing free plantar and dorsiflexion of the foot was prompted by a patient (W. F.) seen some months ago, who was wearing a posterior solid ankle-foot orthosis (PSAFO). However, rather than providing ankle stability, it was ineffective and an irritant during stance. W. F. was unhappy with it, and discouraged. In evaluating his condition, he was found to have good plantar and dorsiflexion, but suffered from mediolateral ankle instability. He was shown a conventional AFO with a metal stirrup and metal uprights, demonstrating the mediolateral protection the orthosis provides, while allowing free motion at the ankle. The fact that it was less cosmetic than a plastic orthosis did not concern the patient, if it allowed him to walk normally again and not with a stiff ankle. But considering his physician's preference for plastic over a metal orthosis, with its advantages, e.g., free choice of shoes, better appearance, etc., it occurred to us to combine mediolateral protection of the ankle with free ankle plantarflexion and dorsiflexion in a plastic orthosis. This idea was realized by incorporating an ankle joint similar to that used in fracture bracing in a PSAFO (<a href="/files/original/03c6dab500bcc8abcf2064a69651e3fb.jpg">Fig. 1</a>). From a plaster mold of the patient's limb, a PSAFO was fabricated with an anterior section for added tibial support. The distal aspect of the calf section was trimmed to clear the Achilles tendon. The proximal edge of the footplate was trimmed so as to include the malleoli (<a href="/files/original/ef57e986fd642949abac655e0ddfbb48.jpg">Fig. 2</a>). A contoured bar was riveted to the lateral aspect of the posterior calf portion and joined with the footplate over the malleoli, creating a pivot point allowing, rotation necessary for flexion or extension (<a href="/files/original/6f3713a26a2d78a1af84b3371b05ee26.jpg">Fig. 3</a>). Two velcro straps provided an intimate fit around the limb. The patient was pleased with the function and support provided by this orthosis. The second patient fitted with this type of orthosis (R. R.) had a similar ankle problem. A slight change in the design was made. A separate ankle joint as with W. F.'s orthosis was not used. Rather, the proximal edges of the footplate were extended to the proximal aspect of the malleoli. The distal edges of the posterior calf section were then made to overlap the malleoli portions of the foot plate (<a href="/files/original/984d8d4e3f3b4d44a11796f074d966bc.jpg">Fig. 4a</a> and <a href="/files/original/a0e1497de95803eedb7c9bae27189933.jpg">Fig. 4b</a>). This joint system works smoothly and is more cosmetic, although it requires a little more work. R. R. was delighted with the orthosis since he can wear it with regular Oxfords or boots (<a href="/files/original/ac40bae7d01bf2c9df78320ef938a453.jpeg">Fig. 5</a> and <a href="/files/original/6ac0309f920adb45f06a6d73b90dbb23.jpeg">Fig. 6</a>). A third patient (P. B.) with a similar problem of ankle instability was fitted with the same type of orthosis made for R. R., but eliminating the anterior portion. This patient, too, was happy with the freedom of motion it allowed (<a href="/files/original/ad272a01fb6edf60c48e85a6111e0d64.jpeg">Fig. 7</a>). In these three cases, free plantar and dorsiflexion were allowed while mediolateral ankle stability was achieved. Though it involves extra work and time during fabrication of this type of ankle joint on a posterior solid ankle foot orthosis, the security of the ankle on weight bearing, the freedom of movement while walking, and the satisfaction of the patients wearing the orthosis are achievements justifying the extra effort and expense. Page Number(s) 3 - 5 Year 1980 Volume 4 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1980_03_003/1980_03_003-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1980_03_003/1980_03_003-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1980_03_003/1980_03_003-3.jpg Figure 4 FIGURE 4A http://www.oandplibrary.org/cpo/images/1980_03_003/1980_03_003-4.jpg FIGURE 4B http://www.oandplibrary.org/cpo/images/1980_03_003/1980_03_003-5.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1980_03_003/1980_03_003-6.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/1980_03_003/1980_03_003-7.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1980_03_003/1980_03_003-8.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource An Ankle-Foot Orthosis Providing Mediolateral Stabilization While Allowing Free Plantar and Dorsiflexion of the Foot Creator An entity primarily responsible for making the resource Lucia Klemmt, CO Fritz Klemmt https://staging.drfop.org/files/original/78bf6788488bdf97bc8b5683d42a6f70.pdf 28499b5aee932356ff3db57649d54f41 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1980_03_005.pdf Text Any textual data included in the document <h2>Editorial: The Driving Force in Rehabilitation</h2> <h5>William M. Susman, M.A., R.P.T. <a style="text-decoration: none;">*</a></h5> By design, and in daily clinical practice, rehabilitation is a multi-disciplinary effort. The patient is best served by professionals addressing the psychosocial and vocational aspects of disability as well as the various aspects of physical impairment in a specialized manner. The driving force behind the effective functioning of this approach is communication among the professionals comprising the rehabilitation team. This communication may occur within the structured format of professional publications, the formal yet often spontaneous settings of team clinics and rounds, or the many informal daily contacts between colleagues involved in the treatment of any one patient. Such communication enhances patient management in numerous ways. Consistent definitions and coordination of treatment approaches and goals can be achieved. Different perspectives regarding the same clinical situation can be shared, perspectives tempered by the different relationship each team member has with the patient, the expertise each member brings to the clinical problem, and the priority of concerns each establishes according to his or her functional role. Perhaps most importantly, the team is able to bring its collective clinical experience to bear upon the problem at hand. No one clinician, regardless of depth or breadth of experience, should fail to search out and use this collective experience for it can only serve to broaden the range of possible solutions. An excellent example of such an opportunity is provided in the lead article by Dr. Alexander in this issue of the Newsletter. This is not to say that executive decisions should not be made in the rehabilitation setting, but that if they are based upon the communicated experience and viewpoints of all team members, such decisions will not be autocratic. It should not be forgotten that the clinician also benefits from such communication. The most stimulating workplace is one in which a free exchange of ideas can take place without the fear that image or role is being threatened. In an imperfect world with personality differences and professional pressures, this can be hard to achieve, but must be actively sought. The stimulation of thought through this collective process also leads to clinical innovation and new research ideas and, ultimately, improvement in the professional's level of expertise and advancement of the state of the art of rehabilitation as a whole. Clinical professions involved in rehabilitation are currently undergoing rapid growth in knowledge base, upgrading of standards for entry into practice, and increasing professional responsibility. The fields of orthotics and prosthetics and physical therapy may be the best examples of these trends. It is imperative that no one clinical field, regardless of increased training, authority, or specialization becomes more isolated in clinical practice. Obviously, a given level of clinical skill cannot be replaced by input from another discipline, but the effective use of that skill can be channeled by communication within the clinic team towards better patient treatment, our foremost concern. *William M. Susman, M.A., R.P.T. Assistant Professor, Ithaca College, Division of Physical Therapy, Albert Einstein College of Medicine, Jacobi Hospital, Bronx, New York. <div style="width: 400px;"></div> Page Number(s) 5 - 6 Year 1980 Volume 4 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Editorial: The Driving Force in Rehabilitation Creator An entity primarily responsible for making the resource William M. Susman, M.A., R.P.T. * https://staging.drfop.org/files/original/51f5adc7b73ba20f64f5b1072208d97e.pdf 22b566ecc169422c3f86252d9a20be5e https://staging.drfop.org/files/original/3af9a5ff106766a98f790a31724a2a1f.jpg f6e27c5ae43c78cb08a394d78fa3b275 https://staging.drfop.org/files/original/2aff81bed2e3b007be1b8792137c5788.jpg 28e771b1094c0b1209ef81372fd82ce6 https://staging.drfop.org/files/original/41beee5399a82e0e40acfda675701aad.jpg f1003cc7f042f683207455f6a189e513 https://staging.drfop.org/files/original/90ef2a1233e04d701819d9715038383f.jpg 4d02c130bcdd0706cf18f7b6fc0dd0be https://staging.drfop.org/files/original/634d5ee7cc369045d31e39da291ee0d3.jpg d7e48a87b19caa8b90142027b54ae166 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1978_01_001.pdf Text Any textual data included in the document <h2>Externally Powered Upper-Limb Prostheses</h2> <h5>A. Bennett Wilson, Jr. </h5> The earliest reference to externally powered upper-limb prostheses seems to be in connection with experiments that took place in Germany about 1918 in which electromagnets were used to close the fingers of an artificial hand <a></a>. The next reported effort apparently is the research and development program proposed and carried out by Alderson <a></a> on electrically powered arm systems during 1946-1952 with support from International Business Machines, Inc. and the Veterans Administration. Initial results of the Alderson-IBM project (Fig. 1) were quite impressive with respect to operation, but an extensive evaluation at UCLA in 1951 revealed that a disproportionate amount of mental effort by the wearer was required for use of the various systems<a></a>. As a result of the findings of the UCLA study, and because only a limited amount of money was available for work in artificial limbs, the Advisory Committee on Artificial Limbs (later the Committee on Prosthetics Research and Development) of the National Academy of Sciences recommended that development of actuators be delayed until sufficient research could be carried out concerning the control problem so as to provide means for control of the prosthesis without conscious thought by the wearer. <a href="/files/original/3af9a5ff106766a98f790a31724a2a1f.jpg">Fig. 1</a>. An early model of the Alderson-IBM Electric Arm. A project was initiated at UCLA about 1953 to explore various control methods. Among the various studies conducted at UCLA was an evaluation of the so-called Vaduz hand (Fig. 2)<a></a>, a design that originated in Lichtenstein which used bulging of the residual muscles in a forearm stump to provide control of an electrically actuated artificial hand. Some rather positive findings were overshadowed by the poor quality of the one unit that was available at the time, and perhaps by the introduction by Russia in 1958 of a "thought control" electric arm<a></a>. The Russian device actually consisted of an electric hand controlled by myoelectric signals from the residual forearm agonists and antagonists of a below-elbow amputee. <a href="/files/original/2aff81bed2e3b007be1b8792137c5788.jpg">Fig. 2</a>. The "Valduz" hand and control system. The "Thalidomide tragedy"<a></a> in 1958-1962 prompted England and Canada to secure manufacturing rights to the Russian design, but fabrication and distribution was not successful in either country. The "Thalidomide tragedy" also encouraged work at the University of Heidelberg in the development of pneumatically powered artificial arm systems<a></a>, and an agreement was obtained by Kessler and Kiessling<a></a> for continuation of this work in the U.S. (Fig. 3). This project was carried out between 1960 and 1969. Again the problem of control was the primary reason for discontinuing the work. <a href="/files/original/41beee5399a82e0e40acfda675701aad.jpg">Fig. 3</a>. On the pneumatic above-elbow systems developed by Kiessting at the American Institute for Prosthetic Research. Because of the Thalidomide tragedy, Sweden<a></a> also launched a modest program in development of externally powered upper-limb prostheses about 1960. Work in this area has been carried out continuously since, but with no commercially available devices resulting, as far as is known at this time. The Russian design caused an Austrian group, Viennatone, and the Otto Bock Company in Germany to develop and market about 1962 similar devices. A few years later Hannes Schmidl began fitting externally powered artificial arms on a relatively large scale at the INAIL Center, Budrio, Italy and continues to do so to the present time<a></a>. Pneumatic models were used initially, but all designs used now are electric. Simpson<a></a>, at the Princess Margaret Rose Hospital, Edinburgh, Scotland uses routinely pneumatic prostheses for a group of "Thalidomide" children, but his design is not widely available elsewhere. In 1960 while on Sabbatical study at the University of Southern California Tomovic from the Institute Pupin, Belgrade, suggested the use of electromechanical pressure sensitive systems to aid in solution to the control problem by introducing closed-loop feedback systems<a></a>. A number of prototypes (Fig. 4) were designed and fabricated upon the return of Tomovic to Yugoslavia. Results of evaluation were also overshadowed by poor workmanship and engineering, and work on this was abandoned about 1968. <a href="/files/original/90ef2a1233e04d701819d9715038383f.jpg">Fig. 4.</a> The "Belgrade" hand and control system. McLaurin, while at Northwestern University, designed the so-called Michigan feeding arm about 1960 which used a linkage to coordinate motions about the elbow and the wrist to make it possible for young bilateral children amputees to feed themselves<a></a>. This device met with considerable success in the clinical setting, but never became a commercial success. McLaurin continued work in electrical arms for children at the Ontario Crippled Childrens Centre, Toronto, between 1963 and 1975. Although he was able to persuade the Variety Club to develop a facility for manufacturing, at cost, some of the products of research as a philanthropic endeavor, to date only an electric elbow has been made available, but because of the low volume the cost is extremely high in spite of subsidization. In the late sixties a number of efforts in the U.S. were directed toward the development of electric elbows. By 1969 three designs were considered ready for clinical evaluation, the "Boston" elbow developed by M.I.T. and Liberty Mutual Insurance Co., the AMBRL elbow, developed by the Army Medical Biomedical Research Laboratory, and a design by Rancho Los Amigos Hospital. The clinical evaluation program was organized and coordinated by CPRD in 1969-70<a></a>. Of 20 subjects in the study only 3 elected to retain the electric device. Two of these subjects had physical problems that made operation of the body powered prosthesis more difficult than would have been the case otherwise. Out of this experience came a revised set of design criteria and objectives. In addition to all of these efforts, research and development programs in externally powered artificial arms have been carried out in the U.S. at Temple University - Moss Rehabilitation Hospital <a></a>, Northwestern University (Fig. 5)<a></a>, Veterans Administration Prosthetic Center, Duke University, Rancho Los Amigos Hospital, University of California at Los Angeles, the University of Colorado, and Johns Hopkins University<a></a>. <a href="/files/original/634d5ee7cc369045d31e39da291ee0d3.jpg">Fig. 5</a>. The self-contained and self-suspended below-elbow system using myoelectric controls developed at Northwestern University. Sweden, Great Britain, Italy, Germany, Russia, and others have continued to support research and development in this field. Yet today it is very difficult to obtain an electric or pneumatic arm in the United States, other than the electrically operated hands that are suitable for below-elbow patients. We will be pleased to hear the opinions of readers of the NEWSLETTER concerning the reasons for this. A. Bennett Wilson, Jr. March 16, 1978 References: <ol> <li>Alderson, Samuel W., The electric arm, (Chapter 13 in Klop-steg and Wilson's "Human Limbs and Their Substitutes," McGraw-Hill, 1954, reprinted by Hafner Press, 1969).</li> <li>Battye, C.K., A. Nightingale, and J. Whillis, "The use of myoelectric currents in the operation of prostheses," J. Bone Joint Surg., 37-B, 506, Aug. 1955.</li> <li>Berger, N., and CR. Huppert, The use of electrical and mechanical muscular forces for the control of an electrical prosthesis, Amer. J. Occup. Ther., 6:110-14, 1952.</li> <li>Childress, D.S., et al., Myoelectric immediate postsurgical procedure: A concept for fitting the upper-extremity amputee, Artif. Limbs, Vol. 13, No. 2, Autumn, 1969.</li> <li>Committee on Prosthetics Research and Development, Externally powered prosthetic elbows - a clinical evaluation, Report E-4 National Academy of Sciences, 1970.</li> <li>Committee on Prosthetics Research and Development, The application of external power in prosthetics and orthotics, National Academy of Sciences, Publication 874, 1961.</li> <li>Committee on Prosthetics Research and Development, The control of external power in upper-extremity rehabilitation, National Academy of Sciences, Publication 1352, 1966.</li> <li>Dankmeyer, Charles H., Sr., Charles H. Dankmeyer, Jr., and Martin P. Massey, An externally powered modular system for upper-limb prosthesis, Orth, and Pros., 26:3, Sept. 1972.</li> <li>Frantz, CH., An evolution in the care of the child amputee, Artif. Limbs, Vol. 10, No. 1, Spring 1966.</li> <li>Kadefors, R., et al., Stryning av armprotes med myosignaler, Electronic 3:42-49, 1967.</li> <li>Kessler, H.H., and Kiessling, E.A., Pneumatic arm prosthesis, Am J. Nursing, 65:6: June 1965</li> <li>Kobrinski, A.E., Bolkhovit-in, S.V., Voskoboinikova, L.M., Ioffe, D.M., Polyan, E.P., Popov, B.P., Slavutski, Y.L., Sysin, A.Y., and Yakobson, Y.S.: Problems of bioelectric control in automatic and remote control. Proceedings of the First International Congress of the International Federation of Automatic Control, Moscow, 1960, London, Butterworth & Co. (Publishers) Ltd., 1961, Vol. 2, p. 619.</li> <li>Marquardt, E., Heidelberg pneumatic arm prosthesis, J. Bone and Joint Surgery, 47-B:3:425-434, August 1965.</li> <li>Rakic, M., Practical design of a hand prosthesis with sensory elements, Proceedings of the Interna-, tional Symposium of the Application of Automatic Control in Prosthetics Design, 103-119, August 27-31, 1962, Belgrade, Yugoslavia.</li> <li>Reiter, R., Eine neue electro-kuntshand, Grenzgeb. Med., 4, 133, 1948.</li> <li>Schlesinger, G., Der Mechanische aufbau der kunst-chanische aufbau der kunstlichen glieder, in Ersatzglieder und Arbeitshilfen, Borchartd, M., et al., Eds., J. Springer, Berlin, 1919.</li> <li>Schmeisser, Gerhard, Wood-row Seamone, and C. Howard Hoshall, Early clinical experience with the Johns Hopkins externally powered modular system for upper-limb prostheses, Orth, and Pros. 26:3, Sept. 1972.</li> <li>Schmidl, Hannes, The I.N.A.I.L. experience fitting upper-limb dysmelia patients with myoelectric control, Bull Pros. Res. 10-27, Spring 1977.</li> <li>Scott, R.N., Myo-electric control, Science J., 2-7, March 1966.</li> <li>Simpson, D.C., An experimental design for a powered prosthesis for children, Health, Scottish Home and Health Department Bulletin, 22:4:75-78, October 1964.</li> <li>Tomovic, R., and G. Boni, An adaptive artificial hand, IRE Transactions on Automatic Control, 3-10, April 1962.</li> <li>Wirta, R.W., Taylor, D.R., and Finley, F.R., Engineering principles in the control of external power by myoelectric signals. Archives of Physical Medicine, 49:294-296, 1968.</li> </ol> Page Number(s) 1 - 4 Year 1978 Volume 2 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1978_01_001/1978_01_001-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1978_01_001/1978_01_001-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1978_01_001/1978_01_001-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1978_01_001/1978_01_001-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1978_01_001/1978_01_001-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Externally Powered Upper-Limb Prostheses Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr. https://staging.drfop.org/files/original/9df687fab2e971e5bdb448b8747dc9eb.pdf 78bf41dbabb6870890e75cc378aa3af1 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1978_01_004.pdf Text Any textual data included in the document <h2>"Should Functional Ambulation Be a Goal for Paraplegic Persons." - Readers' Comments</h2> The <a href="cpo/1977_04_004.asp">above article</a>, which appeared in the last issue of the Newsletter elicited a great number of responses from physicians, orthotists-prosthetists, therapists, and counselors. More than 90 percent of our respondents agreed with Michael Quigley's position that the majority of paraplegic patients should be fitted with lower-limb orthoses despite the fact that use of such orthoses is extremely inefficient. The major reason for providing these orthoses to patients is to either have the patient prove to himself that he will not be able to walk in a normal manner again, or to make sure that every patient has a chance to walk, inasmuch as few patients are able to use orthoses even for transfer purposes or upright mobility. The following comments represent a consensus from our respondents: <h3>Indications For Fitting Paraplegics With Orthoses:</h3> Most respondents agreed that the T10 lesion level seemed to be on the border between a functional ambulator and a non-ambulator. One or-thotist-prosthetist responded that in his area the L1 level is used, as this is the most proximal innervation of the major hip flexors and hip hikers. Margaret Henry, R.P.T., of the Mt. Wilson Center in Maryland stated that the patient must first have abdominal muscles present and have a desire to walk. He is then fitted with trial braces and must be able to complete 200 lattisimus dorsi push-ups before he is fitted with his own braces. This exercise is used to determine if the patient would have the strength and endurance to ambulate functionally. Another therapist stated, "I enjoyed the article and comply with author. However the reasoning behind Cerney's conclusions or Hus-sey's conclusions are faulty. Their conclusions are valid only on the type of braces their patients had and type of training. Study should be qualified!" A rather interesting letter was sent in by Howard V. Mooney, CP. of Burlington, Massachusetts. Mr. Mooney stated that he had no experience with paraplegics but mentioned similar experiences with bilateral, above knee amputations. Mr. Mooney stated "I learned early in the profession that to some there is no such word as 'fail.' " He states that it is his policy to describe the facts and the pitfalls of walking on two above-knee prostheses but if the patient still wants to continue he gives them all the help and encouragement possible. <h3>What Orthotic Designs Do You Recommend For Paraplegic Patients?</h3> The most commonly mentioned design of orthosis is the Scott-Craig KAFO. The respondents preferred this because of the simplicity of design, the lack of a pelvic band, ease of donning, and control of ankle motion. Those readers that did not use the Scott-Craig system preferred plastic molded knee-ankle-foot orthoses or light-weight designs. No one recommended the use of a pelvic band. All respondents were quick to point out the indications for orthoses for children and polio patients differed from that for adult traumatic paraplegic patients. John Glancy, C.O., University of Indiana, Indianapolis feels that rehabilitation practitioners are making a mistake when they assume that present designs of orthoses begin to provide the mechanical aid paraplegics require. Mr. Glancy feels that patient's motivation towards walking is generally poor because they have to work with such inadequate orthotic systems. Mr. Glancy is presently working on a system that uses elastic material as a source of external power and sees this as a possible solution to the problem. <h3>Is It Practical To Expect Ambulation With LSHKAFO's (Bilateral Long Leg Braces With Night Spinal Attachments)?</h3> A resounding "no!" was given by all to this question. One respondent stated that this type of orthosis is too cumbersome and hard to don and that if the patient is so severely involved that he needs this measure of stabilization he undoubtedly lacks adequate muscular and respiratory reserve to ambulate any distance and is better off with a wheelchair. Mr. Robert Penny, C.O. of the Shelby State Community College and Leo Betzelberger, R.P.T. of the VA Spinal Cord Injury Center, Memphis, Tennessee stated that we have had 3000 (conservative) spinal-cord-injury patients as of 1948 and gradually abandoned LASKAFO's as they were just thrown in the closet. We found patients could ambulate up to T10 with KAFO's in parallel bars. Daily living at home negates KAFO's too. We do try to keep them in metal KAFO's for dorsiflexion and ankle protection. Probably the most interesting response on this question came from Frank W. Clippinger, M.D., Duke University Medical Center, Durham, North Carolina. Dr. Clippinger stated "from a purely practical standpoint anyone in their right mind won't bother with this. By locking the trunk to the thighs and the legs to the feet is not standing in the true sense. It is lying down vertically. I think this treats the therapist, orthotist and the doctor but not the patient. The same function can be accomplished using a coffin instead of braces as is perfectly evident in the Egyptian section of any museum." In summary, the vast majority of all respondents felt it was important to give paraplegic persons the chance to stand and ambulate for the many reasons stated above. The term "motivation" ranked very high on everyone's list as one of the major indications for providing orthoses to paraplegic persons. For this reason I think it is proper to finish this synopsis of our readers comments with another quote from Howard Mooney, CP., "Never underestimate the potential of anyone with unlimited motivation." Page Number(s) 4 - 5 Year 1978 Volume 2 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Text Copy Edit 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 "Should Functional Ambulation Be a Goal for Paraplegic Persons." - Readers' Comments https://staging.drfop.org/files/original/809ea89a32d4d8e36fa8e6385772fa3a.pdf 3ee99a2bf09bacedf1558f9b28f4ed07 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1978_02_001.pdf Text Any textual data included in the document <h2>A Proposal for Delivery of Externally Powered Upper-Limb Prostheses</h2> <h5>Michael J. Quigley, C.P.O. </h5> Prepared by the American Academy of Othotists and Prothetists, 1444 N St., N.W., Washington, D.C. 20005. Editor: A. Bennett Wilson, Jr., B.S. M.E.; Managing Editor: Brian A. Mastro, B.A.; Editorial Board: Joseph M. Cestaro, C.P.O., Charles H. Epps, Jr., M.D., Robert B. Peterson, R.P.T. There are about 322,000 amputees in the United States today. Of this number, approximately 9,000 people have upper-arm amputations and 16,000 have forearm amputations. Many arm amputees choose not to wear a prosthesis for three major reasons; 1) lack of sensory feedback, 2) poor function and 3) poor cosmesis. Unfortunately, the vast majority of physicians, therapists, and prosthetists seem to believe that new amputees should always be provided a hook first, and a hand later, if the hook is accepted. Nearly all patients, however, want a hand first and dread the thought of using a hook for obvious cosmetic and psychological reasons. In a great number of cases, the hook and prosthesis are rejected due to the undue amount of attention attracted to the wearer. Body powered mechanical hands are heavy, cumbersome, and far less functional than hooks. The same amount of harnessing and body power is required to control these hands as with the hooks. The cosmetic gloves that cover these hands are easily stained, torn, and discolored. The major indication for prosthetic hands has been for unilateral amputees who are engaged in light-duty work and are very conscious of cosmesis. The introduction of the VA- Northwestern University, Otto Bock, Variety Village, and other powered hands and elbows for prostheses should change the dismal attitude concerning prosthetic hands. These prostheses are extremely cosmetic, and require very little body motion and little or no harnessing to control the hand. The hand can be controlled easily whether the wearer is reaching for something over his head or behind him, which was previously very difficult. Powered prostheses are of greatest value for patients with high amputations, whether they are unilateral or bilateral. These patients are normally present complicated problems because they lack the muscle power and leverage to control mechanical prostheses, but they can easily control powered prostheses by myoelectric or switch controls. Powered prostheses have received a very cool reception in the United States due to a number of factors; the cost of the prostheses is high- four to five times that of conventional prostheses-and therefore many third-party payers refuse to pay for them. The prosthetist fitting an externally powered prosthesis must be well trained in order to evaluate myoelectric potentials and to properly fit and maintain the prosthesis. As most prosthetists have no background in electronics, more than a short orientation course is required. Even after thorough training is obtained, the prosthetist may only see two or three patients per year requiring these types of prostheses, and therefore much of the information will be forgotten. In many cases, components that were intended to be modular in concept and simply plugged in need to be reworked or redistribued around on the socket in order to accommodate a long or non-standard type of amputation. In a study conducted by the Veterans Administration 18 prosthetists were involved in an evaluation of powered prostheses. All prosthetists were given a one-to-two-week course by the VA on myoelectric prostheses and patients were referred to them through VA clinics for fittings. Despite all this education, prosthetist errors were responsible for more malfunctions than any other cause. Faced with all of the above facts plus the fact that the cosmetic glove is still a problem, most prosthetists chose not to handle externally powered prostheses. Further, since such a small percentage of the amputee population can be fitted with this type of prosthesis, most prosthetists find it impractical to invest the great amount of time and money for education and equipment before they can provide satisfactory service. It has been shown that in areas where prosthetists learned enough about powered prostheses to be able to properly fit and maintain them, the prostheses received wide acceptance. John Billock, C.P.O., in Warren, Ohio uses a number of different powered prosthesis systems, including hybrid models using components of different systems on severely disabled upper-limb amputees that are referred from all over the Midwest. William Sauter at Ontario Crippled Childrens Center has also proven the practicality of powered systems on adults and children. In each area, however, institutional support has been the determining factor. Mr. Billock's success was achieved after years of participation in the research program at Northwestern University and Mr. Sauter's work is done in a large Rehabilitation Center. Similarly, the Bock system is used in Minneapolis due to a great amount of support from the Germany-based Otto Bock Company to its United States headquarters in Minneapolis. The Otto Bock Company is presently offering a free one-week course on the basic below-elbow system, and plans future courses on advanced powered components. We are faced with the situation that powered upper-limb prostheses are presently available but are not used for the many reasons stated previously. How do we solve the service delivery problem, particularly for the more severely disabled upper-limb amputee? I suggest that specialized fitting centers are the best solution to the problem. Such centers can be privately owned or located in an institution. The advantage of this system is that the prosthetist would see enough patients to become truly expert in the area of powered prostheses, and could well afford the expense of taking all relevent courses or preceptorships and obtaining the necessary staff and equipment. I have visited one such center in Warren, Ohio, which is owned by John Billock, C.P.O. Mr. Billock and his staff at Warren Orthotics and Prosthetics Restoration Laboratory fit three to four powered upper-limb prostheses per month, including all levels of amputation. His staff includes a full time electrical engineer and an electronics technician. There are enough equipment and spare parts available so that essentially all maintenance is carried out on the scene, which avoids long delays when repairs are done elsewhere. Patient referrals are mostly from the Midwest and East Coast, although patients from the West Coast are not uncommon. One patient being seen during my visit had a right shoulder disarticulation and a left above-elbow amputation and was being fitted with powered hands, elbows and wrist rotators controlled by switches. Components from at least three manufacturers had to be made compatible in the ten-month long project. I feel that a total of four centers in the United States could adequately handle the patient load. The average prosthetist with a good understanding of powered prostheses will be able to treat most unilateral below-elbow patients, so referrals to a powered prosthesis center will usually be for more difficult cases. It will be important for private centers to be closely allied with a rehabilitation center, as these patients will require therapy, counseling, and other services while the prosthetic services are being performed. It seems obvious to me that powered prostheses will be more common than body powered designs within the next twenty years, and it is time now to establish an efficient service delivery system. Page Number(s) 1 - 2 Year 1978 Volume 2 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Proposal for Delivery of Externally Powered Upper-Limb Prostheses Creator An entity primarily responsible for making the resource Michael J. Quigley, C.P.O. https://staging.drfop.org/files/original/0eb0155fd4a6657c71f5a235373aa4bf.pdf a9eff5f0c0999d72953d88dc04f93154 https://staging.drfop.org/files/original/f158ce59a35747a9d9020e944269da53.jpg 757f7d66742eb5392ce4c317b6cb55db https://staging.drfop.org/files/original/67ca44d880b4aca5258caa2712db2aab.jpg 802b68c5445dacd6da77b74473d6a6c8 https://staging.drfop.org/files/original/4536555d7f66980c8ddffa5cb6fb6905.jpg 6662f3e43b363f5633707abfd523a5f6 https://staging.drfop.org/files/original/0c036efb96682517789da461a8caa5b1.jpg bd4bc6c6da7b8254b78d3a008146646b https://staging.drfop.org/files/original/4d1d11c52e9a10c1859a7c1aacce2376.jpg 0126ae23c2d2a6c7aa2f5ca6c0971c37 https://staging.drfop.org/files/original/55483c1f96ae1c766e8d18f2843826cc.jpeg 9355ee3a449698ab5e54d338aa49cdf3 https://staging.drfop.org/files/original/2c9444bd9873add9855c30b383b9b0ec.jpeg 7e7c6d801120cf56fba8c150439ee460 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1978_02_002.pdf Text Any textual data included in the document <h2>Concerning Suspension Alignment, and Control</h2> <h5>Charles H. Pritham, C.P.O. </h5> In the prescription of any prostheses consideration is naturally given to the proper means of suspending the prosthesis and maintaining it in place. In contrast, not as much concern seems to be given to this crucial matter in the prescription of an orthosis. Paradoxically, this relative state of neglect is undoubtedly due to the very success with which suspension has been incorporated in most conventional orthosos. To cite but one example, the shoe that inevitably must be used with any ambulatory AFO, KAFO, or HKAFO provides for suspension of the device as well as providing support to the ground. In recent years with the expansion of new technology in the area of prosthetics and orthotics there has developed a corresponding interest in new techniques to overcome shortcomings in conventional devices. In the process, however, new problems can arise as a result of the intertwining roles played by various components of the device under consideration, and it would therefore appear worthwhile to attempt to sort out these various roles with special emphasis on suspension in order to clarify the picture, and possibly, as a result, to suggest new and unique applications for the various suspension systems available. For clarity a brief glossary has been prepared, and is included at the conclusion of this article. <h3>Maintenance of Alignment</h3> For any prosthesis or orthosis to provide the maximum benefit possible, it must be held in proper position relative to the body segments concerned. The prevention of inappropriate motion can be classified broadly as maintenance of alignment by either suspension or stabilization depending upon the direction of the motion. As it is defined, suspension is concerned with the prevention of linear displacement along the longitudinal axis, and it will be seen that no discrimination is made as to whether the direction is distal or proximal. Thus, the perineal straps that may be attached to a spinal orthosis to prevent proximal displacement ("riding-up") are just as much a suspension aid as is a suprapatellar cuff suspension strap on a below-knee prosthesis. Considered in this light, the weightbearing component of any given device naturally prevents proximal displacement, and, thus, may be confused as a suspensory component. The distinction must be made on the basis of intended function. Weightbearing is a primary characteristic of a lower-limb prosthesis or a weightbearing orthosis without which it cannot function. Suspension is a secondary characteristic inasmuch as it is but one of a number of different components intended to ensure proper weight bearing and thus function of the device. It can be seen, therefore, that the intended role of a weightbearing component is quite a bit different than suspension. However, the use of this same component as a non-weightbearing device for purposes other than weightbearing is not inconceivable. It is possible, if not practical, to use PTB brims about the knees of a patient to prevent proximal displacement of a corset, and the use of quadrilateral sockets as anchor points <a></a> for the powering of upper-limb prostheses comes to mind. Stabilization, as it is defined, is concerned with the prevention of displacement about the various rotatory axes of the body rather than along the linear axes. Motion does take place undoubtedly includes some linear motion, either laterally or anterioposteriorly, but in the author's opinion the rotary displacement is inevitably the predominant component. How then is stabilization to be differentiated from control which, as it is defined, is also involved, in part, with the prevention of motion? Two separate but interrelated definitions of the word control are given. In both instances control is to be considered as a primary characteristic. In the first definition control refers to the regulation of motion in one portion of the body segment relative to another portion, while stabilization (a secondary characteristic) refers to the regulation of the device relative to the body segment. In the second definition control refers to volitional regulation of motion in the device by the patient; while stabilization holds the device in firm contact with the body segment in order to maximize the efficiency of this volitional regulation. In any event, it can be appreciated that any given component of a prosthetic or orthotic device may play multiple roles in the function of that device. A hip joint and pelvic band fitted to an above-knee prosthesis while providing suspension also provides stabilization against lateral and rotary motion. The same component is likely to be fitted to an HKAFO to control motion about the patient's hip, and is unlikely to be used for suspension or rotary stabilization of the HKAFO since both of these functions are provided effectively by the fit of the foot in the shoe. Supracondylar wedge suspension in a below-knee prosthesis also provides effective stabilization against lateral thrust, while a cuff suspension strap fitted to a below-knee prosthesis does not. A figure-8 harness (Fig. 1) fitted to an above-elbow prosthesis not only provides suspension, but also stabilization against lateral or rotary motion of the socket and control of the elbow and terminal device, while a butterfly harness and Bowden cable (Fig. 2) fitted to a shoulder-driven WHO provides only control of motion in the metacarpal-phalangeal joints of the index and ring finger and neither suspension nor stabilization. <a href="/files/original/f158ce59a35747a9d9020e944269da53.jpg" target="_blank" rel="noopener">Fig. 1.</a> One Version of the Figure-8 Harness for Above-Elbow Amputees <a href="https://staging.drfop.org/files/original/67ca44d880b4aca5258caa2712db2aab.jpg">Fig. 2.</a> The "Butterfly" Harness These are but a few of the many examples that could be cited in designing or prescribing a device for a given situation. Consideration must be given to the many intertwining roles played by the many available design elements and selection be made of those elements that perform the intended function with maximum benefits and a minimum of adverse side effects. A particularly troublesome example of this dilemma is to be found in the design of an orthosis to control knee motion without involving the ankle-foot complex, the traditional source of suspension and rotary stabilization of devices to regulate the knee. If supracondylar suspension is used as with the IRM supracondylar knee orthosis (<a href="https://staging.drfop.org/files/original/4536555d7f66980c8ddffa5cb6fb6905.jpg">Fig. 3</a>) or Iowa knee orthosis (to name but two examples of this class of orthosis) adequate suspension and stabilization may be gained initially from the critical fit about the knee, but the patient may not be able to tolerate it, and with compression of the soft tissues fit and, thus, suspension may be lost. The CARS-UBC knee orthosis (<a href="https://staging.drfop.org/files/original/0c036efb96682517789da461a8caa5b1.jpg">Fig. 4</a>) avoids these problems by using a waist belt and suspension strap. Waist belts, however, are not well tolerated by many patients, and considerable effort must be taken in fitting the device to achieve adequate rotary stabilization. <a href="https://staging.drfop.org/files/original/4536555d7f66980c8ddffa5cb6fb6905.jpg">Fig. 3</a>. IRM Supracondylar Knee Orthosis <a href="https://staging.drfop.org/files/original/0c036efb96682517789da461a8caa5b1.jpg">Fig. 4.</a> CARS-UBC Knee Orthosis In any given instance it is necessary to weigh the pros and cons of the applicable suspension components available, and select the one that best fits the needs of the patient. <h3>Classification of Suspension Types</h3> In most instances, suspension is secured by obtaining a purchase above a flaring bony prominence (epicondyle, adductor tubercle) or other body segment (buttocks, shoulder). This general principle is the same regardless of type of suspension. Suspension may be classified into two major groups and a third miscellaneous one (<a href="https://staging.drfop.org/files/original/4d1d11c52e9a10c1859a7c1aacce2376.jpg">Fig. 5</a>). <a href="https://staging.drfop.org/files/original/4d1d11c52e9a10c1859a7c1aacce2376.jpg">Fig 5.</a> A. Extrinsic Suspension: The means of suspension are not contained within the proper borders of a device, and must be gained by the addition of extraneous elements that pass beyond the borders of the device and may not be otherwise absolutely necessary for the function of the device. However, the extrinsic elements may also serve as means of stabilization or control. <ol> <li> Examples of extrinsic suspension are: <ol> <li> PTB cuff suspension strap </li> <li> Knee joints and thigh corset </li> <li> Waist belt </li> <li> Rubber suspension sleeve </li> <li> Hip joint and pelvic band </li> <li> Silesian belt f. Suspenders </li> <li> Perineal straps on a spinal orthosis </li> <li> Various harnesses used in upper-limb orthotics and prosthetics </li> </ol> </li> </ol> B. Intrinsic Suspension: Suspension is gained by means of some elements) contained within the proper borders of the device. The elements) may also serve as a means of stabilization. <ol> <li> Examples of intrinsic suspension are: <ol> <li> All self-suspending prostheses </li> <li> All orthoses with few exceptions A shoe is necessary for the proper function of lower-limb orthoses while a waist belt used on a KO is not absolutely necessary for the function of the KO as suspension can be accomplished by other means. Therefore, an AFO is a case of intrinsic suspension while a KO is not necessarily an example. </li> </ol> </li> <li> Types of intrinsic suspension can be broken down as follows: <ol> <li> Supracondylar: purchase is obtained above any of the various condyles or epicondyles of the body. </li> <li> Flaring body segments other than bony prominences: purchase is obtained above any of the flaring body segments not covered in Item 1, such as the buttocks or shoulders. </li> <li> Suction, or negative atmospheric pressure: In general, suction suspension is used with amputation stumps that exhibit a high soft-tissue-to-bone ratio with few prominent subcutaneous bony prominences such as above-knee or above-elbow stumps; however, suction suspension has been used with below-knee prostheses in Europe and there is a current resurgence of interest in it in America. </li> <li> Muscular grasp: This is the often greatly overlooked ancillary of suction suspension and other suspension types. Rudolf Poets <a></a> has described briefly the principle of an "undercut socket" he attributes to Dr. Oskar Hepp, and every clinician is familiar with the admonition to the patient that he should use his stump muscles to hold the above-knee prosthesis on. Many below-knee amputees have reported being able to hold their prosthesis on with muscular contractions, and Dr. Ernest Burgess is currently studying how to capitalize on this phenomenon. </li> <li> Compression of soft tissue and friction: This means of suspension serves for such lightweight, elastic, and readily conformable devices as a spinal corset or knee support and may be used in conjunction with other means of suspension. </li> </ol> </li> </ol> C. Other Miscellaneous: This serves as a catch-all division to contain those means that do not readily fit in the other divisions and are rarely used in prosthetics and orthotics. <ol> <li> Examples of the miscellaneous category are: <ol> <li> Medical grade adhesive used with rigid dressings, some cosmetic finger prostheses, facial restoration, and stoma appliances. </li> <li> Skeletal attachment. While under active consideration by some, this means of suspension is not currently in use. </li> </ol> </li> </ol> <h3>Selection Criteria</h3> As can be seen in Fig. 6 and Fig. 7, selection of an appropriate means of suspension for a specific device can often pose problems. A variety of factors must be considered, a few of which are listed here. <a href="https://staging.drfop.org/files/original/55483c1f96ae1c766e8d18f2843826cc.jpeg">Table I.</a> Suspension Methods versus Orthosis Level <img src="/files/original/55483c1f96ae1c766e8d18f2843826cc.jpeg" alt="Italian Trulli" /> <a href="https://staging.drfop.org/files/original/2c9444bd9873add9855c30b383b9b0ec.jpeg">Table II.</a> Suspension Techniques and Additional Auxiliary Function Possible. <img src="/files/original/2c9444bd9873add9855c30b383b9b0ec.jpeg" ul="" /> <ul> <li> Medical contraindications </li> <li> Donning difficulties </li> <li> Clinic team preferences </li> <li> Patient preferences </li> <li> Maintenance </li> <li> Fitting difficulties and problems maintaining proper fit. </li> <li> Necessary related functions (stabilization or control) provided by a specific suspension system. </li> <li> Aesthetics </li> </ul> In any event the essential matter is to balance the pros and cons of the various suspension systems available and select the one that offers the most advantages with the fewest disadvantages. The matter becomes even more important when the emphasis is shifted from routine clinical prescription to the design of one-of-a-kind applications for a specific patient's unique problems or in research and development of a new style device. <h3>Conclusion and Summary</h3> Suspension is inevitably related closely to a wide variety of interrelated factors, all of which are involved in the determination of proper fit. An attempt has been made to logically sort out the various factors and concentrate on suspension. Further, suspension has been broken down into various categories and some of the inherent difficulties in selecting between a number of suspension techniques relevant to a specific patient or prosthetic or orthotic device have been suggested. <h3>Glossary</h3> Orthosis: An externally applied device for the control of motion about the joints of a body segment. Prosthesis: (Artificial Limb)-an externally applied device to substitute for a missing body segment. Suspension: The method of maintaining a prosthesis or orthosis in proper place relative to the affected body segment and resisting linear displacement along the longitudinal axis. <ol> <li> Not weight-bearing </li> <li> Displacement due to: <ol> <li> gravity </li> <li> momentum </li> <li> "oozing" "creeping" (movement due to compression of a conical section) </li> </ol> </li> </ol> Weight-Bearing: The transmission of a person's mass (or weight) to the ground from a relatively distant body segment by means of a prosthesis or orthosis. Stabilization: The method of maintaining a prosthesis or orthosis in proper placement relative to the affected body segment and resisting angular or rotary displacement about one of the three axes. <ol> <li> Due to: <ol> <li> Moments created by the eccentric application of forces about the various axes or centers of rotation. </li> </ol> </li> </ol> Control: <ol> <li> Orthotic: The maintenance of a body segment in a desired position or positions by an orthosis (also called correction or corrective control). </li> <li> Orthotic or Prosthetic: The voluntary activation of a prosthesis or orthosis (or of an artificial articulation thereof) by means of the body segment enclosed in the device or by a signal generated by a remote body segment and transmitted to the device or articulation by means of a mechanical, hydraulic, pneumatic, or electric linkage (also called volitional control). </li> </ol> Alignment: The relationships that exist or are to be created between the components of a device or between the device as a whole and the affected body segment. Pistoning: The cyclical linear displacement that takes place along a body segment with the cyclic application and removal of a load and due to inadequate suspension. "Bell-Clappering" : Cyclical angular displacement in the A-P or M-L planes due to inadequate angular stabilization. Whipping: A specific form of rotary instability that occurs in AK Prostheses. Primary Characteristic: An absolutely essential property of a device if it is to carry out its intended function. Secondary Characteristic: A property of a device necessary to facilitate one of its primary characteristics but not itself absolutely necessary to achieve the intended function of the device. References: <ol> <li>Blakeslee, Burton (ed.), The limb-deficient child, University of California Press, 1963.</li> <li>Poets, Rudolfe, The fitting of the above-knee stump, Orth. and Pros., 28:1, March 1974.</li> </ol> Page Number(s) 2 - 6 Year 1978 Volume 2 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1978_02_002/1978_02_002-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1978_02_002/1978_02_002-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1978_02_002/1978_02_002-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1978_02_002/1978_02_002-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1978_02_002/1978_02_002-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 TABLE I http://www.oandplibrary.org/cpo/images/1978_02_002/1978_02_002-6.jpg Figure 7 TABLE II http://www.oandplibrary.org/cpo/images/1978_02_002/1978_02_002-7.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Concerning Suspension Alignment, and Control Creator An entity primarily responsible for making the resource Charles H. Pritham, C.P.O. https://staging.drfop.org/files/original/6f7e3f82472638ae5c7d6a8fe6502b0c.pdf aafc0735d891c3ca5b70c59e5b9e4dca https://staging.drfop.org/files/original/c8b4856c8000a6349f542a3fc1d9792b.jpg 155701ed19ed5a4cc064357783299d6f https://staging.drfop.org/files/original/f42bc1634981d3ce3923261609c448f0.jpg 86bbb24b5c5ea6d276b246de92acb3e4 https://staging.drfop.org/files/original/9e3ce64e754060714e02f7e869bb56c1.jpg bcc33ceb1a17e7d1665e8600710bf8c7 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1978_03_001.pdf Text Any textual data included in the document <h2>Externally-Powered Upper-Limb Prostheses: An American Dilemma</h2> <h5>Charles H. Epps, Jr., M.D. <a style="text-decoration: none;">*</a></h5> The discussion by A. Bennett Wilson, Jr., in Vol, 2, of the Prosthetic and Orthotic Clinic Newsletter is an excellent historical summary of the saga of externally powered upper-limb prostheses. Ben Wilson has brought to this forum an abundance of personal knowledge about the development of these devices that can only be known by one who has been intimately involved with the problem. I think it also raises the question, when one considers the present state of the art and the availability of American made components why more could not have been done and is not being done. As one who has been intimately involved in the treatment of patients with upper-limb deficiency for the past 17 years, I have experienced the frustrations that are unique to this area of medical delivery. In the Juvenile Amputee Clinic at the D,C. General Hospital, in Washington, D.C., we have cared for almost 300 children with one or more limb deficiencies, I remember, vividly, when I first began this work in 1961, telling parents that in five years we should have available for the child (bilateral upper amelia), a good set of externally powered arms. Much to my chagrin, five years later we were unable to deliver this needed service to a degree that satisfied the patient or the Clinic Team. After 17 years, there are still unfulfilled expectations. <a href="/files/original/c8b4856c8000a6349f542a3fc1d9792b.jpg">Fig. 1.</a> This male was born with bilateral upper amelia and lower complete phocomelia. After acquisition of sitting balance, he was fitted with a shoulder disarticulation type prosthesis with nudge control for elbow lock and unlock and with terminal device and forearm lift control by chest expansion. At age five, a Michigan Feeder Arm was applied, and his feeding time and ease of eating were enhanced. One then has to ask the question, why has there not been greater progress in the United States? Research money has been available, to a limited extent and powered arms have been developed. These events have been developed historically by Ben and will not be reported in any depth here. I would mention the Michigan Feeder Arm, which was a very useful arm for the purpose of eating, in the young age group. Once the child became older, there was no model available. The Michigan Electric Hook was developed out of a similar need and can be purchased commercially today. We are using, at the present time, a number of these in our clinic. The Coordinated Arm, developed at the Ontario Crippled Children's Center, and which succeeded the feeding arm, can be purchased from a Variety Village in Toronto, Canada, but the problem is that this unit is suitable only for the younger child. There is literally nothing as good as the Coordinated Arm available for the older child or adult. <a href="/files/original/f42bc1634981d3ce3923261609c448f0.jpg">Fig. 2.</a> A fourteen-year-old with partial transverse hemimelia fitted with a Otto Bock Myoelectric hand that is available in a kit as shown. The battery pack can be attached to the belt. The shirt covers the wire and the socket resulting in excellent cosmesis. Another approach we have utilized is the combination of the OCCC electric elbow with the Michigan electric hook, in what we have termed a "Hybrid" prosthesis. Today, our experience has been satisfactory, as we are able to combine both units to operate with a single electrical system, supplied by one battery. Even under these circumstances, it is very difficult to import the electric elbows from Canada. The cost is not inconsequential, when one considers that the purchase of both items will be close to $1,000 and then one has to consider the cost of fabrication. The net result is that unless one is extremely zealous, it is not possible to supply children with severe limb deficiencies with externally powered devices. When they are supplied, there are mechanical problems, electrical problems, and frequent repairs are necessary. The "down time" is considerable. For this reason, many clinicians and patients have been discouraged and have abandoned use of these devices. <a href="/files/original/9e3ce64e754060714e02f7e869bb56c1.jpg">Fig. 3</a>. This youngster with right upper phocomelia and left amelia was given an opposition post early. A standard left shoulder-disarticulation prosthesis provided little function. A hybrid system utilizing an OCCC electric elbow and a Michigan Electric Hook, provides greater function. Both units are powered by one battery pack. It is ironic that the greatest development has been made for the patient with the below elbow deficiency. The Otto Bock System is available in a number of sizes and provides excellent cosmesis and function. Our experience has been satisfactory with this device. The cost, however, is considerable and this may be one reason that this prosthesis has not been applied extensively in this Country, in spite of the fact that there are large numbers of children with below-elbow level deficiencies. It is also a fact that below-elbow patients function quite well with body powered equipment. In either case, American industry has not been at the forefront. The majority of commercially available devices today have been developed in Europe or Canada. I recently had the opportunity to visit Doctor Rolf Sorbye, in Orebro Sweden, who in collaboration with Systemteknik has developed an excellent below-elbow self-contained self-suspended prosthesis, using myeoelectric control. This device has been fitted to a number of children as young as 18 months and the results are extremely promising. Two prostheses are fabricated for each patient so that there is no "down time" when one prosthesis becomes inoperative and needs bench repairs. The cost per patient therefore, is approximately $6,000 for the pair of arms. There is under development, at the present time, in Sweden, another multi-functional hand (also for the below-elbow level), which will provide powered function for grasp, release, dorsi- and palmar flexion of the wrist, and supination and pronation of the forearm. The project is funded by a joint effort on the part of the Swedish Government and private industry. It is unfortunate that we have not been able to have a similar effort in this Country. Dr. Dudley Childress, at Northwestern University has developed an excellent self-contained, self-suspended below-elbow system, using myeoelectric control. The fact of the matter is that this and similar devices, developed in this Country, have not found a manufacturing outlet for disbursement. It is, therefore, a financial matter that in the face of limited demand the manufacturers cannot produce these items at a cost that will make it profitable. It seems to me, therefore, that this is an area, where the Government should intervene and subsidize this effort. There are numerous precedents throughout industry in this regard. The railroads, the airlines, and the shipbuilders have been subsidized. The renal dialysis program is one health area where Government is presently providing a subsidy. The precedent is there. There also needs to be an effective lobbying effort mounted, not only by the profession, but by the affected individuals, that is, patients and their parents. I believe that this is the essence of the problem. The technical "know how" is available but what is lacking is sufficient funding to make these devices in sufficient numbers so that they can become available to patients. It is fortunate that there are not a large number of patients. Ironically, were there large numbers of patients and a large demand, then the cost, of course, would be reduced. In the absence of this unfavorable manufacturing circumstance, subsidies must be given to industry so that the necessary devices can be produced and made available at reasonable cost. Another aspect of the problem, which is paradoxical, is that there has been so much effort put into the below-elbow level, where the need, as I see it, is not nearly as great as it is in the above-elbow and the shoulder-disarticulation levels. The patients with more proximal limb deficiencies are greatly in need of externally powered devices. Yet the powered devices that are available for the proximal cases, are not the most efficient. The available commercial items, even at great cost, are not representative of the best technology available in this country, today. This can be partially explained by the fact that the numbers of patients affected at the higher level are substantially less than those at the below-elbow level. It is also natural to work on problems where success is more readily obtained. The challenge is there at the shoulder-disarticulation level and the above-elbow level, where these patients desperately need more function. There is need in this country for a concerted effort to develop and provide powered arms for patients with the more proximal limb deficiencies. It is a blight on our record as a nation, with such sophisticated technology and industrial and productive capacity, that this area of human need has been so long unfulfilled. <h5>Charles H. Epps, Jr., M.D. Professor and Chief, Division of Orthopaedic Surgery, Howard University, Washington, D.C.</h5> Page Number(s) 1 - 3 Year 1978 Volume 2 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1978_03_001/1978_03_001-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1978_03_001/1978_03_001-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1978_03_001/1978_03_001-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Externally-Powered Upper-Limb Prostheses: An American Dilemma Creator An entity primarily responsible for making the resource Charles H. Epps, Jr., M.D. * https://staging.drfop.org/files/original/a16c64d7ccf859685483448cdaa30655.pdf 030e2ddd7f33ca508ab0109a9cb77990 https://staging.drfop.org/files/original/20971c1df6a94f651c41c24f4b2fa35b.jpg 2531dc6b54ab731bd857b99ad1648727 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1978_04_001.pdf Text Any textual data included in the document <h2>Up-Date on Immediate Post Surgical Fittings</h2> <h5>Robert F. Hayes, CP. </h5> I would like to express some thoughts regarding the use of the technique of immediate post-surgical fittings of prostheses for below-knee amputees. Nearly all of us certainly agree that there are definite advantages to the patient in the use of prosthesis immediately after amputation, especially in the case of the BK amputee. However, the I.P.S.F. technique is not being used as standard practice in many areas. Perhaps one of the reasons is the lack of continuing education courses dealing with immediate postsurgical procedures. When the concept of immediate postsurgical fitting was first introduced approximately fifteen years ago there was a heavy concentration to the point of saturation on the application of prostheses in the operating room. This was good, because it gave us all an opportunity to be educated in such a revolutionary technique of treatment. However, today, there are many people entering the field involving amputation and amputee care every year, surgeons and prosthetists and in most cases they have only a limited knowledge of the I.P.S.F. techniques. Obviously, and for good reason, most surgeons are reluctant to use a technique with which they themselves are not familiar. It then becomes the role of the prosthetist to educate and encourage the use of I.P.S.F. and, ideally, apply the concept himself. Another reason for lack of use of I.P.S.F. is the inconvenience created by scheduling between doctor, prosthetist, and operating room. Often hours of valuable time are wasted when things are not proceeding on schedule, which is the norm rather than the exception. Another reason why I.P.S.F. techniques are abandoned is that when a surgeon and prosthetist first attempt this technique, they sometimes use a patient whose probability of healing is marginal under the best of circumstances. And sometimes ambulation is attempted too early, causing stump breakdown. The result is a surgeon convinced that this technique is not for his patients. Still another factor that discourages use of the I.P.S.F. concept is the application of a poorly fitting weight-bearing cast by individuals not fully trained. There have been individuals who, after reading an article or hearing a thirty-minute lecture on I.P.S.F., attempted to apply a weightbearing cast. Some of the more skilled are able to do this, but most have problems. If a cast is intended to bear weight, it must fit well, have proper relief areas and distal padding to provide relief if the patient should atrophy and settle in the socket. It is my opinion that no weight-bearing cast at all is better than a poor application of one that is supposed to bear weight. Please note, I said "weightbearing cast" and not a rigid dressing, which is and should be more readily applied immediately after the operation and does not require the same precision as does the weight-bearing cast. This will be taken up later. Now that we have discussed some of the problems that may have discouraged the utilization of I.P.S.F.- and I'm sure there are many more- let's constructively consider a couple of approaches that seem to work well. Since the inception of I.P.S.F., most of us have changed our thinking for some very solid reasons. One of the primary problems arose in the attempt to have the patient weightbearing and often ambulating within forty-eight hours postoperatively. We have learned that, in most cases, this concept is a disadvantage rather than an advantage and can be the cause of stump breakdown. If we agree that early ambulation is not intended, we may apply an immediate rigid dressing with the appropriate snugfitting sterile stump sock. <a href="/files/original/20971c1df6a94f651c41c24f4b2fa35b.jpg">Fig 1:</a> Schematic lateral view of method first recommended in the U.S. for immediate past surgical fitting of below-knee prostheses. From "Immediate Postsurgical Prosthetics in the Management of Lower Extremity Amputees, Ernest M. Burgess, Joseph E. Traub, and A. Bennett Wilson, Jr., Veterans Administration, TR 10-5, April 1967. When the rigid dressing is not intended for weightbearing, most surgeons will make the application since they need not be concerned about felt pads for relief over pressure areas. The initial rigid dressing can be left on for approximately two weeks. During this time we have: <ol> <li> Protected the wound by <ol> <li> Keeping external contaminates out </li> <li> Preventing injury to the stump </li> <li> Protecting the posterior flap from undue pressure </li> </ol> </li> <li> Maintained the size of the stump, preventing edema, which alleviates pain </li> <li> Made the patient more comfortable and able to move about without fear of injury to the stump </li> <li> Prevented knee flextion contracture </li> <li> Greatly reduced complaints of phantom limb </li> </ol> After two weeks the initial rigid dressing is removed; or, in some cases, the surgeon will remove the sutures and wait for an additional week or two. At the end of the two-week postoperative period, the prosthetist is called in to apply an early post-surgical prosthesis usually with a plaster socket and a pylon with a SACH foot. In the fabrication of our plaster sockets, we strive to keep the plaster high up over the condyles to the mid thigh area. We find this is beneficial in eliminating knee flexion contractures and, most importantly, eliminating piston action within the socket, a very hazardous condition, especially in the early stages of fitting. I know attempts are made to trim plaster to a P.T.B, level for increased knee motion. The advantages of enclosing the knee offset the short time needed for patients to regain knee motion. I also use a waist belt and fork strap for added suspension. This temporary prosthesis is worn for approximately six weeks. The very thin patient may not need a cast change before the end of six weeks, but more muscular and fatty tissue will require cast changes according to the amount of atrophy. After the patient has been ambulating for approximately six weeks, the plaster socket is bi-valved and a negative mold is taken for the definitive prosthesis. The plaster socket is then put back on the patient and closed with plaster or tape. The plaster socket and pylon stay on the patient until delivery of the definitive prosthesis and removed as needed for fittings. When minor changes in stump size occur, stump socks may be added while using the plaster pylon prosthesis. To reduce some expense to the patient, the hospital can inventory several pylon assemblies suitable for temporary use. We also supply various sizes of used SACH feet that can be used temporarily. The patient is then charged only for the professional services of the prosthetist, thus saving the considerable expense of components. I hope that some of my comments may be of assistance to others who would like to employ more immediate postsurgical prosthetic care for patients, and hopefully stimulate others to respond with other approaches so that we may all benefit. I would like to acknowledge Dr. Elmer Franseen, from whom I have used references many times in this paper. Dr. Franseen is an Orthopedic Surgeon at Baystate Medical Center, Springfield, Mass. I am sad to say that Dr. Franseen is retiring this month, and I will miss working with this truly professional man. In the past fifteen years of working with Dr. Franseen, I have witnessed him employing I.P.S.F. on all of his B.K. amputees and only on rare occasions was a revision necessary. Page Number(s) 1 - 3 Year 1978 Volume 2 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1978_04_001/1978_04_001-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Up-Date on Immediate Post Surgical Fittings Creator An entity primarily responsible for making the resource Robert F. Hayes, CP. https://staging.drfop.org/files/original/b6eb0984e5194084f16aa1bb9f96f8cf.pdf 9ceae6af2557c11b5e7c66bcaacd9215 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1978_04_003.pdf Text Any textual data included in the document <h2>Prostheses, Pain and Sequelae of Amputation, As Seen By the Amputee</h2> <h5>H. C. Chadderton </h5> <blockquote> Reprinted from Prosthetics and Orthotics International, Vol. 2, No. 1, 1978, by permission </blockquote> The War Amputations of Canada, Ottowa, Ontario <h3>Abstract</h3> Results of a survey of 19 organizations belonging to World Veterans Federation indicate that major complaints of amputees include; poor fitting, poor dissemination of knowledge to doctors and amputees regarding new prostheses, lack of opportunity for "input" from amputees at research level and inadequate measures to deal with phantom and stump pain. Suggested improvements by amputees; decrease in weight of prostheses, reduction in maintenance for swing and stance-phase control units, development of recreational prostheses, more frequent checks through use of X-ray and film techniques, particularly during the "break-in" of a new appliance. Older veterans showed increasing concern in regard to development of consequential disabilities arising from amputation; premature arthritic changes in spine and remaining limb, circulatory problems and gastro-intestinal problems due to ingestion of drugs to control pain. <h3>Introduction</h3> With the co-operation of the World Veterans Federation, information was requested from 19 veteran organizations in 14 countries. Replies were received of varying significance from all. The enquiries were based on a questionnaire, the basic elements of which were: Legs Weight of the prosthesis. SACH feet versus articulated feet. Wearing of rubber-soled shoes. Cosmetic appearance. Soft socket versus hard socket, below-knee. Plug socket versus quadrilateral socket, above-knee. Swing phase control units, above-knee. Modular versus standard limb. Arms Munster fitting versus harness. Myo-electric hands. Cosmesis—hands. Wearing of prosthesis, above-elbow. Adjustment Do you see yourself in your dreams as an amputee? Psychological effect of dismemberment. Sequelae (medical) of amputations. Recreational limbs. The replies to the questionnaire were, in the initial stages of review, sent to a computer firm for analysis. It was evident, however, that the response could not be measured in terms of "yes" or "no" and it was recommended that an attempt be made to obtain a "feeling" from the replies which might be useful. Therefore, this survey should not be considered as a fully accurate statement of response and the views herein must be seen in this light. Fitting It seems possible to draw a startling conclusion from the replies concerning comfort. It appears that many amputees were prepared to accept an uncomfortable fit as "part of the game". A significant number of amputees suggested that use should be made of X-ray and film techniques and of bio-mechanical devices in measuring the accuracy of a prosthetic fit. Information on new prostheses The amputees seemed to be overwhelmingly of the opinion that there was a lack of information on the part of medical doctors in this area. It was evident also that, with certain exceptions the amputees themselves were poorly informed on new prostheses. Understandably, a number of amputees commented that they knew far more about the new models of automobiles than about the new models of limbs. Input at the research level The respondees stated they were unaware of any concerted effort to obtain opinions from amputees concerning the types of research which should be done to improve prostheses. To be fair, some replies indicated that "amputee input" may be going on but they did not know about it. Significantly, however, they felt that there should be more liaison at the "user" level with the researchers. Pain Universally, phantom limb pain appeared to be a significant problem and the amputees felt that very little was being done to develop remedial measures. A review of the replies indicated that the usual advice was to take aspirin and a hot drink. Obviously this has not been effective and the amputee is looking for something more concrete. Many amputees complained also of stump pain, as separate from phantom limb pain, stating that massage, heat treatments and sometimes surgery had been successful in its elimination. Weight of prostheses There were two distinct "camps" in the replies, some 62 per cent wanted lighter prostheses but 12 percent stated some weight was essential and felt that good hardware should be used, despite additional weight. Feet No trend was evident on the question concerning SACH versus articulated feet. There was, however, a small but dedicated group of amputees who sincerely believed that an articulated foot was much superior. This group described the SACH foot as "too springy" or "unstable". Rubber-soled shoes By far the majority of leg amputees preferred rubber-soled shoes for stability and heel strike. Cosmetic appearance This did not appear to be a factor. However, the respondees were all war amputees whose average age would be 60 which is perhaps significant. Sockets By far the majority of below-knee amputees preferred a soft socket for reasons of comfort. The question on the plug versus quadrilateral socket for the above-knee amputee elicited the information that, for the most part, the quadrilateral socket users were well aware of the advantages, stating them as being "better circulation ", " more comfort", "easier standing", "taking the weight on the ischium", etc. Tragically, perhaps, many plug socket users were unaware of the difference between the two types. Controls The question concerning swing phase controls elicited a very high response, indicating that a large proportion of the amputees were not familiar with these devices. (We had not dared ask for information on stance phase controls as we were reasonably certain that the concept is not known to the majority of amputees.) It would seem, from the replies, that many more amputees would be prepared to try these devices if they knew of their existence! Modular versus exo-skeletal Here again the majority of the amputees replying (approximately 60 per cent) did not know the difference. There were, however, a dedicated group of modular users who recognized the advantages of alignment, light weight and cosmesis who were "sold" on modulars. Here again, a conclusion can perhaps be drawn regarding the necessity for the dissemination of more information. Munster versus harness fitting The answer was predictable. The below-elbow amputee is very partial to a light fitting for a passive hand. Alternatively, he seems to have a passionate love affair with his hooks and harness when he wants to do heavy work or engage in recreation. This was an area in which the amputee seemed to be fairly well satisfied, except as brought out below. Myo-electric hands There was a distinct feeling among World War II veterans that they had been passed over by the myo-electric stage. Many had apparently been told that they were too old to adjust to myo-electric fittings. The majority of the replies stated "yes" to the question of whether they would like an opportunity to be fitted with a myoelectric hand. Cosmesis The replies on cosmesis (or lack of it) for hands contained comments such as "disgusting" and "lack of sensitivity". Surprisingly, many hand amputees appeared to have no knowledge of the cosmetic skins and stated they were wearing either brown or black leather gloves over their passive hands. Wearing of prosthesis, above-elbow amputees The rejection rate was predictably high. Some farsighted individuals (amputated one side only) suggested that they should get used to wearing a prosthesis in the event that they developed medical difficulties in their other arm, arising from strokes, arthritis, etc. The second part of this question indicated there was little knowledge of lighter prostheses now available through the use of modular designs. Dreams The question on dreams was thrown in only for general interest. The respondees seem to divide 50-50 as to whether they visualize themselves as amputees in their dreams or not. Psychological effect Perhaps surprisingly, a large number of war amputees describe their feelings about the loss of their limb in terms of being "grief stricken", "lost my best friend", "embarrassed", etc. It should be remembered that this survey asked for truthful answers. Psychological effect is perhaps an area which we tend to ignore as it could be interpreted as indicating a lack of machismo, etc. The Adolph Meyer school of psychiatric thought may be of interest on this subject should any one wish to develop it further, that is, depression can follow from a physical disorder such as amputation. Sequelae Most of the replies indicated consequential disabilities. Leg amputees; bad backs, arthritis in the remaining leg and foot. Arm amputees; cervical pain, headaches. Both; gastro-intestinal problems which were believed due to ingestion of drugs as well as "inner tension" associated with the continuing discomfort of amputation. The respondees were careful to suggest they were not trying to prove their case, but felt that more study should be done upon the medical after effects and side effects of amputation. Recreational limbs This question resulted in possibly the most significant response. There were requests for special legs for swimming, golfing, skiing, tennis, rowing and motor sports. The arm amputees were almost frightening in their requests for the development of special prostheses for fishing, playing baseball, cricket (for holding bats), golf, tennis and rowing. <h3>Conclusion</h3> It must be said that the information presented in this paper was not the subject of any strict statistical treatment. In this sense this is not a "scientific paper". This highlights the problem of communication in this field between the consumer on the one hand and the professionals involved on the other. However, it is essential that such communication be fostered if energies and resources are to be channelled in the most fruitful direction. It is hoped that against this background the views contained herein will prove useful, highlighting as they do the opinions of a substantial number of patients. Page Number(s) 3 - 5 Year 1978 Volume 2 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 Prostheses, Pain and Sequelae of Amputation, As Seen By the Amputee Creator An entity primarily responsible for making the resource H. C. Chadderton https://staging.drfop.org/files/original/4c1c2659ace14b6587c3c801d470aa96.pdf dbc48fb2203d6c75e5adce812a9b03de https://staging.drfop.org/files/original/97b98628d90aad9bfbaac84c646fe3fe.jpg 4c4de5849811d644713ec7230d7d0f02 https://staging.drfop.org/files/original/9bf2b7836dee688f0bca62bfc38c7209.jpg 131fef1ae751f64e310d683f6e52c098 https://staging.drfop.org/files/original/27a2d16cac19d4fe68e3aead92053f88.jpg 0ceb64af346708b11b688bc9aec46035 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1978_04_005.pdf Text Any textual data included in the document <h2>Vacuum Forming</h2> <h5>Ben Wilson </h5> In an article I wrote in 1974 on vacuum forming of sheet plastics<a></a> I erred in stating that the first reference to vacuum forming of sheet plastics in orthotics and prosthetics was a paper by Gordon Yates in 1968<a></a>. I should have remembered that Dana Street presented this concept in Volume 1 of the Orthopedic Appliances Atlas<a></a> for the fabrication of cervical orthoses. This is certainly an excellent example of how long it takes to get a technological development from the idea stage to fairly widespread application. <a href="/files/original/97b98628d90aad9bfbaac84c646fe3fe.jpg">Fig. 1</a> Vacuum-forming a shank for a below-knee prosthesis using the hand-drape. In the time since my article was published in "Orthotics and Prosthetics" vacuum forming of sheet plastics has been used more and more by private practitioners in both orthotics and prosthetics. Although the educational programs, with a few exceptions, seem to have been very slow in teaching vacuum forming techniques, use of the technique seems to be expanding, owing in part to the several workshops sponsored by the American Academy of Orthotists and Prosthetists. Every process and system has its limitations, and we all recognize that each design in orthotics and prosthetics represents a compromise, but as time goes on the gaps that engender compromise are narrowed as experience is gained. Although the "Orthotics and Prosthetics Clinic Newsletter" has discussed several aspects of vacuum forming in the relatively recent past, in view of what seems to be a rapidly expanding program it seems appropriate that another survey be made concerning the uses of and problems encountered by the private practitioners. A questionnaire on this subject is included in this issue. It will be appreciated greatly if each recipient will complete the enclosed form and add any comments he or she feels that will be helpful in improving service to patients. <a href="/files/original/9bf2b7836dee688f0bca62bfc38c7209.jpg">Fig. 2</a>. Vacuum-forming thigh section of knee-ankle-foot prosthesis using automatic machinery. <a href="/files/original/27a2d16cac19d4fe68e3aead92053f88.jpg">Fig. 3.</a> Vacuum-forming a below-knee socket with use of a platen and form for holding plastic sheet. <h3>References:</h3> <ol> <li>"Vacuum-Forming of Plastics in Prosthetics and Orthotics," A. Bennett Wilson, Jr., Orthotics and Prosthetics, Vol. 28, No. 1, March 1974.</li> <li>"A Method for the Provision of Lighweight Aesthetic Orthopedic Appliances," Gordon Yates, Orthopaedics, 1:2:153-162, 1968.</li> <li>"Plastic Braces," Dana M. Street; pp. 90-95 in Orthopaedic Appliances Atlas, Edwards Brothers, Ann Arbor, Michigan, 195.</li> </ol> <h3>Additional Bibliography:</h3> <ol> <li> "Fabrication and Application of Transparent Polycarbonate Sockets," Vert Mooney, M.D., Roy Snelson, Orthotics and Prosthetics, Vol. 26, No. 1, March 1972. </li> <li> "Fabrication of Vacuum-Formed Sockets for Limb Prostheses," Roy Snelson, Orthotics and Prosthetics, Vol. 27, No. 3, September 1973. </li> <li> "Report of Workshop on Below-Knee and Above-Knee Prostheses," Hector Kay, June D. Newman, Orthotics and Prosthetics, Vol. 27, No. 4, December 1973. </li> <li> "The Use of Check Sockets in Lower-Limb Prosthetics," Samuel Hammontree, Roy Snelson, Orthotics and Prosthetics, Vol. 27, No. 4, December 1973. </li> <li> "A Thermoplastic Structural and Alignment System for Below-Knee Prostheses," Hans Richard Lehneis, Orthotics and Prosthetics, Vol. 28, No. 4, December 1974. </li> <li> "Development of a Thermoplastic Below-Knee Prosthesis With Quick Disconnect Feature," Charles H. Pritham, Orthotics and Prosthetics, Vol. 28, No. 4, December 1974. </li> <li> "Vacuum-Formed Sockets in Prosthetics Education," Bernard C. Simons, Alan V. Dralle, Orthotics and Prosthetics, Vol. 29, No. 2, June 1975. </li> <li> "Ultralight Prostheses for Below-Knee Amputees," A. Bennett Wilson Jr., Melvin L. Stills, Orthotics and Prosthetics, Vol. 30, No. 1, March 1976. </li> <li> "Use of Thermoplastic Components in Temporary Prostheses," Charles H. Pritham, Ivan E. Letner, David Knighton, Orthotics and Prosthetics, Vol. 30, No. 4, December 1976. </li> <li> "Applications of Transparent Sockets," S.I. Reger, I.E. Letner, CH. H. Pritham, M.D. Schell, and W.G. Stamp, Orthotics and Prosthetics, Vol. 30, No. 4, December 1976. </li> <li> "Above-Knee Polypropylene Pelvic Joint and Band," Erich Fischer, Orthotics and Prosthetics, Vol. 30, No. 4, December 1976. </li> <li> "A Lightweight Above-Knee Prosthesis with an Adjustable Socket," George Irons, Vert Mooney, Sandra Putnam, Michael Quigley, Orthotics and Prosthetics, Vol. 31, No. 1, March 1977. </li> <li> "Welding Plastics," Neil R. Donaldson, Michael J. Quigley, Orthotics and Prosthetics, Vol. 31, No. 1, March 1977. </li> <li> "Functional Partial-Foot Prosthesis," Gustav Rubin, Michael Danisi, Bulletin of Prosthetics Research, BPR 10-16, Fall 1977. </li> <li><a href="http://www.acpoc.org/library/1972_06_003.asp"></a> <a href="http://www.acpoc.org/library/1972_06_003.asp">"A Functional Chopart Prosthesis," Gustav Rubin, Michael Danisi, Inter-Clinic Information Bulletin, Vol. 11, No. 6, March 1972.</a> <a href="http://www.acpoc.org/library/1972_06_003.asp"></a></li> <li><a href="http://www.acpoc.org/library/1972_10_009.asp"></a> <a href="http://www.acpoc.org/library/1972_10_009.asp">"Vacuum-Forming Techniques & Materials in Prosthetics & Orthotics," Alex Artamonov, Inter-Clinic Information Bulletin, Vol. 11, No. 10, July 1972.</a> <a href="http://www.acpoc.org/library/1972_10_009.asp"></a></li> <li><a href="http://www.acpoc.org/library/1975_04_011.asp"></a> <a href="http://www.acpoc.org/library/1975_04_011.asp">"A Foot Amputation Orthosis-Prosthesis," H.J. Ruben-stein, G.J. Sweeney, P. Strong, G. Durrett, Inter-Clinic Information Bulletin, Vol. 14, No. 4, April 1975.</a> <a href="http://www.acpoc.org/library/1975_04_011.asp"></a></li> <li><a href="http://www.acpoc.org/library/1975_04_011.asp"></a> <a href="http://www.acpoc.org/library/1975_04_011.asp">"Partial Foot Amputation-A Case Study," Charles H. Pritham, Newsletter. . . Prosthetics and Orthotics Clinics, Vol. 1, No. 3, Summer 1977.</a> <a href="http://www.acpoc.org/library/1975_04_011.asp"></a></li> <li> Manual for an Ultralight Below-Knee Prosthesis, A. Bennett Wilson, Jr., Charles H. Pritham, Melvin L. Stills, Rehabilitation Engineering Center, Moss Rehabilitation Hospital-Temple University-Drexel University (1977). </li> <li> The Rancho Ultralight Below-Knee Prosthesis, Michael Quigley, George Irons, Neal Donaldson, Rehabilitation Engineering Center, Rancho Los Amigos Hospital County of Los Angeles, University of Southern California (1977). </li> </ol> Page Number(s) 5 - 6 Year 1978 Volume 2 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1978_04_005/1978_04_005-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1978_04_005/1978_04_005-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1978_04_005/1978_04_005-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Vacuum Forming Creator An entity primarily responsible for making the resource Ben Wilson https://staging.drfop.org/files/original/39661617c0a9eba6b610fe42b024ce94.pdf 80938ab1a7c2213a21e860229c9f5c1c https://staging.drfop.org/files/original/d2190975fcf22aaf4d36cd1f1486eadc.jpg 52102233724241493879e8180f7fe559 https://staging.drfop.org/files/original/c229382fb9182331c340914d8f7e4521.jpg 9c97aed7e57f467d273fe1b5df97c576 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_01_001.pdf Text Any textual data included in the document <h2>Preparatory Prosthetics</h2> <h5>Bruce P. McClellan, C.P.O. <a style="text-decoration: none;">*</a> Donald R. Cummings, CP. <a style="text-decoration: none;">*</a></h5> The use of preparatory prostheses has for some time been a widely accepted methodology for the immediate or early management of the amputated limb. Burgess, et al., first introduced and popularized the immediate postoperative fitting procedure back in the late 60's.<a></a> Since that time, the use of early weight bearing prostheses has become the norm in fitting centers around the country and indeed in other parts of the world. This paper will deal primarily with preparatory prostheses as they relate to the below-knee amputee. The rationale for such devices will be emphasized in a generalized fashion, as opposed to presenting a different array of commercially available systems or components. The word "preparatory" denotes that these prostheses are used to prepare the amputated limb for definitive fitting with a prosthesis. Within this context, the scope of prostheses which may be considered preparatory in nature ranges from immediate postoperative fitting to the laminated socket with pylon and S ACH foot. In between these two ends of the spectrum are such devices as the pneumatic air cast and Wu early fitting prosthesis. All of these devices have the major purpose of either controlling postoperative swelling or promoting the inevitable atrophy of muscles which were transected during surgery. <h3>Short Term Versus Long Term Devices</h3> The differences between prostheses used for immediate or very early fitting and those used for long term are worth noting. We will clarify the terms "temporary" and "intermediate" to distinguish between the two types of devices. The term "temporary" will be used to describe those prostheses which are intended for relatively short usage; they are applied soon after amputation, and usually are applied directly to the patient using plaster or a plaster substitute. "Intermediate" describes those prostheses which are intended for relatively long-term use; they are generally applied following the use of a temporary prosthesis and are fabricated from plastic over a positive model instead of being formed directly over the patient. <h3>Temporary Prostheses</h3> A temporary prosthesis is primarily used to control postoperative edema and is often the initial step in the residual limb maturation process. But the temporary prosthesis has many additional functions, one of which is early mobilization of the patient. This is especially critical to the physiological well-being of elderly patients. The less time the generally debilitated patient is confined to a bed or a wheelchair, the better the chances for overall recovery and successful long-term prosthetic use.<a></a> Indeed, the early mobilization of any patient can shorten the hospital stay and, therefore, save the patient and the insurance company the costs of increased hospitalization. Another benefit of the temporary prosthesis is the psychological lift it can give the new amputee by reducing phantom pain and permitting early ambulation. Temporary fitting may also help offset some of the anxiety the patient experiences after an amputation. <h3>Temporary Design Concepts</h3> A temporary prosthesis is essentially a rigid dressing with a foot and pylon attached (<a href="http://www.oandplibrary.org/cpo/images/1987_01_001/1987_01_001-1.jpg">Fig. 1</a>). It is a total contact system, encapsulating the amputated limb, including the patella, and extending to the mid-thigh. The knee is maintained in five to ten degrees of flexion. Suspension is by total contact, with some purchase over the adductor tubercle of the femur, and by a waist belt incorporated into the cast. Padding is provided for the distal end and bony prominences. <a href="http://www.oandplibrary.org/cpo/images/1987_01_001/1987_01_001-1.jpg">Figure 1. Temporary below-knee prosthesis.</a> The standard mid-thigh height of the temporary prosthesis serves some definite purposes. This design assists in sharing weight bearing over a larger surface area, which reduces the load on the amputation site itself. The amputee can also ambulate with less risk of traumatizing the residual limb. Encapsulating the knee also helps prevent knee flexion contractures, which are a very real threat to successful rehabilitation. In spite of the well-documented benefits of early fitting, all too often patients are sent home in an Ace® wrap to languish in a wheelchair for a period of weeks until their "stump toughens up enough" to be fitted with a prosthesis. This is the scenario that results in the elderly patient appearing for prosthetic fitting with hip and knee flexion contractures and an edematous residual limb. Although the knee is fully encapsulated in the traditional temporary prosthesis, knee contractures are rare; partially because the cast is usually changed at weekly or biweekly intervals over the period of use. To enhance knee motion, the patient should be encouraged to flex and extend the knee through its range of motion at the time of each cast change. Intermittent weight bearing in the prosthesis also prevents a knee contracture, much as it does in the case of a long leg weight bearing case used in fracture management. The non-removable nature of the temporary prosthesis has the advantage of continuous control of the tissues. When left to the patient to control via an Ace® wrap or shrinker, the limb is often wrapped intermittently or not at all. Rigid dressings have proven in most cases to be far superior to elastic wrappings in reducing the limb's soft tissue volume, especially in conjunction with controlled weight bearing.<a></a> The inclusion of a waist belt, or billet, is essential in maintaining suspension in this type of system. As the residual limb shrinks, the prosthesis will piston on the limb if not supported by this auxiliary suspension. The pylon system is equally important with respect to the success of the temporary prosthesis. Although the patient walks with a stiff knee, appropriate alignment is essential for single limb stance stability. <h3>Intermediate Prostheses</h3> The primary role of the intermediate prosthesis is to act as a preparatory device to reduce the limb to a definitive fitting status. It is generally fit when the postoperative swelling and distal edema have been reduced to a point where the bulbous end can be introduced into a socket. This prosthesis acts as the interim step between the temporary and definitive, thus the term "intermediate." The intermediate differs significantly from a temporary in that it is removable and allows free flexion of the knee. Residual limb shrinkage is accommodated by prosthetic socks as opposed to cast changes. Aside from the obvious advantages of full range of motion and free access to the residual limb, the intermediate prosthesis allows the patient to learn appropriate sock ply management prior to being fitted with a permanent prosthesis. The length of time a patient wears his intermediate prosthesis varies from person to person. Body type, cause of amputation, level of activity, and other considerations all play a part in how rapidly a residual limb will mature to a definitive fitting status. The duration of use can be anywhere from two months to six months, or longer. A general guideline which may be used to determine whether a limb has "plateaued" with regard to shrinkage is when weight bearing and wearing time have stabilized, and the patient has gone approximately three weeks without adding any additional plys of socks. <h3>Intermediate Design Concepts</h3> The design of the intermediate socket is generally consistent with the standard PTB or TSB configuration (<a href="http://www.oandplibrary.org/cpo/images/1987_01_001/1987_01_001-2.jpg">Fig. 2</a>). A soft liner may or may not be incorporated in the system. In either case, it is appropriate to fit the socket to the patient with as few ply of socks as possible. A one ply or even a nylon sheath fit is preferable in light of the fact that shrinkage, and thus the need for additional plys, is inevitable. As with the temporary, dynamic alignment plays an important role. This importance is now magnified by the fact that the patient is ambulating in essentially the same manner as he will in his definitive prosthesis. Again, it is recommended that the patient be fit with some sort of waist belt suspension to minimize relative motion between the socket and limb as shrinkage continues. <a href="http://www.oandplibrary.org/cpo/images/1987_01_001/1987_01_001-2.jpg">Figure 2. Intermediate below-knee prosthesis.</a> <h3>Gait Training</h3> At the time of fitting of the intermediate prosthesis, gait training becomes most significant. This is one of the great advantages of preparatory prostheses: the patient can be monitored and guided by a physical therapist in regard to an appropriate gait pattern while a prosthetist can periodically make alignment modifications as the patient becomes a more proficient ambulator. This advantage is lost, of course, in some of the commercially available systems, which do not allow for fairly precise alignment adjustability. <h3>The Forgotten Limb</h3> One of the least considered aspects of the benefits of preparatory fitting is the contralateral leg. Not only does the preparatory device make it easier for the amputee to maintain his balance, it also allows him to share his weight partially on the prosthesis instead of totally on his remaining limb. In the case of the diabetic or peripheral vascular disease patient, this can be critical, as the remaining leg is usually at risk as well. Any additional trauma, such as prolonged single limb body support or hopping, should be avoided. Preparatory prostheses make this weight sharing possible, and thus prevents overuse or trauma to the remaining leg and foot. It is clear that the role of preparatory prostheses and the management of the new amputee is a necessary and essential component in reaching the fullest rehabilitation potential of the patient.<a></a> The encroachment of non-traditional providers into the prosthetic arena, especially with regard to early fittings, poses a real threat to the realization of these patients' full potentials. It is critical that the prosthetist understand and appreciate the important role of preparatory prostheses in the total regimen of medical and prosthetic care. Success with preparatory fittings depends upon competent management by all members of the rehabilitation team. Temporary and intermediate systems must be applied and managed competently by the prosthetist. Weight bearing, gait training, and residual limb atrophy must be monitored carefully. The term "preparatory" implies that such systems are designed to achieve specific desirable objectives. In this case, the objectives are the maturation of the residual limb and optimum patient readiness for definitive fitting. Comprehensive patient management with preparatory systems produces many advantages, including the provision of maximum early function, improved evaluation of the patient's long-term needs, and reduction of rehabilitation time and expense.<a></a> References: <ol> <li>Burgess, E.M., M.D., "Amputation Surgery and Post-Operative Care," In Bonjeree, Sikhar Nath (ed)., Rehabilitation Management of Amputees, Baltimore/London; Williams & Wilkins, 1982.</li> <li>Burgess, E.M., "Post-Operative Management," Atlas of Limb Prosthetics, St. Louis, The C.V. Mosby Company, 1981.</li> <li>Burgess, E.M. and Zettl, J.H., The Management of Lower Extremity Amputations, Washington, D.C., U.S. Government Printing Office, 1969.</li> <li>Friedmann, Lawrence W., The Surgical Rehabilitation of the Amputee, Springfield, Charles C. Thomas, 1978.</li> <li>Mooney, Vert, M.D., McClellan, Bruce, C.P.O., Cummings, Donald, B.S., and Smith, Patty, R.P.T., "Early Fitting of the Below Knee Amputee," Orthopedics, 8:2, February, 1985, pp. 199-202.</li> </ol> *Donald R. Cummings, CP. Donald R. Cummings, CP., is Chief Prosthetist at Prosthetic-Orthotic Associates of North Texas, Inc. in Lewisville, Texas. *Bruce P. McClellan, C.P.O. Bruce P. McClellan, C.P.O., is Director of Orthotics and Prosthetics at the Dallas Rehabilitation Institute in Dallas, Texas. Page Number(s) 1 - 4 Year 1987 Volume 11 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1987_01_001/1987_01_001-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 2 http://www.oandplibrary.org/cpo/images/1987_01_001/1987_01_001-2.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 Preparatory Prosthetics Creator An entity primarily responsible for making the resource Bruce P. McClellan, C.P.O. * Donald R. Cummings, CP. * https://staging.drfop.org/files/original/134d9851f6fd34f10b98fac119946d9b.pdf c9a03496075767605fc06bd5d6ac4780 https://staging.drfop.org/files/original/fea6766a6495664f5260b51cbff436da.jpg 2e5dfdcbd0b96f663f5470b95ebe80a0 https://staging.drfop.org/files/original/b0db79c79f26f20be00e643367cdaa15.jpg 33873f40f357926954a3ccc9907a4e72 https://staging.drfop.org/files/original/3a7f8361eb473cf4b078c9f8d8c050a5.jpg 0ce7d7a42e382acb91b859f476cc606c https://staging.drfop.org/files/original/ca3ca8e14a2047103f815a282222d402.jpg 0606d742b82c86d87ae8e3750f3f4ce5 https://staging.drfop.org/files/original/ba4b3555b1b4d3697712c9583451c279.jpg 4dd8248ec379a7a364390de2dd9e4097 https://staging.drfop.org/files/original/0a4be97418198a9f496239b0614dbc9f.jpg 0ece3b4b41b32030ebfd864956ad1720 https://staging.drfop.org/files/original/b5afeb1c4d62e046282c3d489417b9be.jpg c67123038b2fd3fd5c451d5fa83d1552 https://staging.drfop.org/files/original/819880245c9711ba14636f81f2b4dfbb.jpg 32a971bc21c5714eaf7d010fd9ebf314 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_01_005.pdf Text Any textual data included in the document <h2>The Stat Limb: A Prosthesis for Immediate Postoperative Fitting of AK and BK Amputations</h2> <h5>Joseph CM. Sheehan, M.D. <a style="text-decoration: none;">*</a> Michael J. Quigley, C.P.O. <a style="text-decoration: none;">*</a></h5> <h3>Introduction</h3> Postoperative care of amputation wounds varies significantly ranging from simple daily dressings to rigid immobilization. These variations make it difficult for the occasional surgeon to judge the virtues of each method from available literature. A basic prefabricated plastic supportive structure is described here to simplify the use of an immediate postoperative prosthesis (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-1.jpg">Fig. 1)</a>. <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-1.jpg">Figure 1. The Stat Limb is a prefabricated high density polyethylene shell that can be applied in less than ten minutes in the operating room.</a> Although immediate post surgical fittings (IPSF) were in common use 20 years ago, they are used only in isolated areas today. The reasons for the decline of IPSF were both educational and logistical. Most amputations today are done by general and vascular surgeons who are not trained in IPSF principles or rehabilitation, and who do not have a working relationship with a prosthetist. Secondly, to use the conventional IPSF technique as taught by Weiss and Burgess, a prosthetist needs to be available at surgery with a number of special socks, attachment plates, tubes, padding materials and the associated tools needed to apply the prosthesis. Scheduling the prosthetist caused logistical problems, so physicians began to simply apply a rigid dressing in surgery and call the prosthetist in a week or so later to apply a shrinker. A preparatory prosthesis is not usually prescribed until three to four weeks post-surgery. <h3>Advantages Of Early Mobilization</h3> The postoperative disease problems of the amputee are typical of any long term illness encountered in medical practice. Thinking solely of the amputated limb is a grave mistake, not only for the mental health of the patient, but also for the surgical wound itself. Early mobilization after surgery is a necessity in preventing bowel, bladder and cardiopulmonary complications. The post-amputated patient is usually a high risk patient. Often, severe diabetes with restricted cardiopulmonary reserve is a common associated medical problem. Small pulmonary emboli cause major cardiac changes, and bladder/bowel stasis of recumbency may lead to recurrent septicemias. Each day of postoperative immobilization adds a significant risk to ultimate survival. First or second day mobilization into the standing position is a necessity to reduce basilar atelectasis, reduce the residual urine volume in the bladder, and allow feces to move into the rectum for evacuation. Even without the psychological and balance effect of a second limb, the process of getting a weak postoperative patient to stand on the unaffected leg alone is next to impossible. However, a rigid locked knee above a "weightless" prosthesis gives the patient more stability than when they had a painful necrotic leg before surgery. It is possible to mobilize a patient within 24 hours post-surgically or to at least have the patient stand and transfer to a commode or wheelchair using a limb, even though they have been bedridden entirely for many weeks preoperatively. Minimal ambulation in therapy from the second day onwards is important. The wound risk involved with minimal weight bearing and the brief stance phase on the amputated leg is outweighed by all the general advantages to the patient for ultimate survival. The Stat Limb was designed to allow even the surgeon doing an occasional amputation to apply an immediate postoperative prosthesis himself following surgery. The Stat Limb comes in one size that fits both right and left legs, eliminating the requirement for inventory. The patient receives all the advantages of a rigid dressing, with the added advantages of early weight bearing. The psychological boost given to a patient who wakes up following surgery with two feet under the covers cannot be easily measured, but is definitely a positive factor. In addition, the medical team working with the patient (physician, nurse, therapist, etc.) automatically become rehabilitation oriented. The patient is no longer laying in bed week after week waiting for his new leg. Early ambulation is safe and is encouraged as early as one day postoperatively. The lack of knee flexion in the prosthesis poses no particular problem to the patient during walking, and the extremely light prosthesis allows the patient to move the leg around easily in the sitting and supine positions. Patients who have worn the Stat Limb make the transfer to a preparatory prosthesis very easily; they already know how to walk and are not afraid to place weight on the residual limb. <h3>Application Procedure</h3> The major advantages of the Stat Limb immediate postoperative fitting are as follows: <ol> <li> a rigid dressing, </li> <li> the knee fixed in hyperextension, </li> <li> rapid application of the prosthesis while the patient is under anesthesia, </li> <li> light weight due to the structural strength at the periphery of the prosthesis, and </li> <li> modification of the limb as rehabilitation continues. </li> </ol> Rigid Dressing The application of a rigid protective dressing is important to the survival of a poorly perfused limb. By surrounding the limb in a soft, heat-insulated environment, free of shearing forces, the limb is maintained at near 37 degrees centigrade, which is optimal for almost all physiological functions of wound healing, tissue resistance, and arteriolar dilation, and gives the surgery its best chance of success. Daily opening of the wound by tearing off adherent, coagulated dressings is not only painful, but rarely indicated unless for observation of unexplained pyrexias or blood loss. The dressing is nothing other than a gauze dressing over the wound site, to allow for any drainage which might occur, followed by multiple layers of cotton, giving a total of about two centimeters of thickness of cotton from groin to the distal end. A thin layer of fiberglass casting material is then applied to provide a rigid outer layer, preventing knee flexion and maintaining the residual limb shape, and protecting the wound (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-2.jpg">Fig. 2</a> and <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-3jpg">Fig. 3</a>). If plaster is used for the rigid dressing, it must be allowed to dry 24 hours before the Stat Limb is applied. At no stage is compression ever applied in the application of the rigid dressing. The speed of limb application is important in the critically ill, and with prior experience of one or two applications, it should be successfully applied in less than eight minutes (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-4.jpg">Fig. 4</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-2.jpg">Figure 2. A simple dressing creates pressure between the skin and bone and forces the weight of the gastrosolei flap to pull on the wound against the amputated distal tibia.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-3.jpg">Figure 3. The rigid dressing maintains the knee in extension.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-4.jpg">Figure 4. Left, a bulbous residual limb after compression wrap. Right, a cylindrical residual limb after rigid dressing.</a> Stat Limb Application Following the application of the rigid dressing, the Stat Limb is applied. The Stat Limb is designed to fit both left and right legs and can be cut to fit around the rigid dressing in nearly all cases. The desired length of the Stat Limb is approximated by either measuring the sound side, or by laying the Stat Limb next to the patient and marking the section to be cut off. The top edge of the Stat Limb should be trimmed a few inches short of the top of the rigid dressing (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-5.jpg">Fig. 5</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-5.jpg">Figure 5. The rigid dressing consists of a gauze bandage over the wound, about two centimeters thickness of cast padding, and two layers of fiberglass casting tape to mid-thigh. The Stat Limb should be one centimeter shorter than the sound side, and the knee cast in extension.</a> Six vertical cuts are then made in the Stat Limb to allow it to form around the rigid dressing (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-6.jpg">Fig. 6</a>). Alignment is approximated while wrapping the Stat Limb onto the rigid dressing. The Stat Limb should be about a half inch shorter than the sound limb to allow toe clearance with an extended knee (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-7.jpg">Fig. 7</a>). Toe out, foot in-set and out-set, and the anterior-posterior positioning of the foot should be held in a normal position as the casting material sets (<a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-8.jpg">Fig. 8</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-6.jpg">Figure 6. A scissors or cast saw is used to cut off excess length and multivalve the Stat Limb. Six longitudinal cuts are recommended. The cuts may have to extend past the end of the rigid dressing if a bulbous end is present.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-7.jpg">Figure 7. For most applications, the vertical cuts can stop two centimeters from the distal end of the rigid dressing, and the proximal edge of the Stat Limb should be a few centimeters distal to the rigid dressings upper edge. A drain hole can be punctured through the Stat Limb, allowing removal in 24-48 hours.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-8.jpg">Figure 8. A double layer of fiberglass material is used to fasten the Stat Limb to the rigid dressing. All of the vertical slits should be covered. For heavy duty users, reinforce the ankle area with casting material as well. Normal toe-out and foot positioning should be maintained while the casting material sets.</a> Knee in Extension Keeping the knee in extension, or locking it in about two degrees of hyperextension, makes the knee stable at the tibiofemoral joint. Subsequently, the quadriceps, hamstrings, and gastrocnemius are reflexly relaxed. Pain and associated spasms are reduced. The reduction of spasm of the gastrocnemius reduces the stress placed upon the distal myodesis and, indirectly, on the wound itself. With the knee in extension, the distal residual limb can be molded to prevent posterior migration of the long posterior flap. In extension, limb application is easier and it is easier to judge valgus, varus, rotation, and length of the limb. Application under anesthesia is justifiable because the patient is relaxed and this avoids fighting with a flexed knee joint four days later. Lightweight Due to Exoskeletal Construction Using the mechanical principles of the square area of inertia, the prosthetic material and the intended forces acting through the prosthesis are distributed to the periphery. This allows the use of a minimum amount of material while gaining the maximum strength to the prosthesis. A semi-pliable thermoplastic of high density polyethylene is used to give toughness to the prosthesis, to reduce the chance of any brittle failures, and to allow for cold forming of the prosthesis around the rigid dressing. <h3>Modification As Rehabilitation Continues</h3> As the patient's healing improves and rehabilitation continues, the thigh length rigid dressing is changed for a padded P.T.B, socket, also made of fiberglass cast material and attached to the limb. Depending on the strength of the quadriceps and hamstrings, the suspension is either a supracondylar strap or a simple single axis hinge from a knee orthosis; this usually occurs at the end of the second week. At the end of the seventh week, the residual limb is usually mature enough for a standard P.T.B, prosthesis. In a similar manner, the prefabricated limb can be used with less complexity for an above-knee prosthesis. A non slip sole material should always be worn when a patient is using the Stat Limb, as the plastic foot section is very slippery. A hospital slipper can be used as can elastoplast adhesive tape. On some occasions, buckling of the plastic at the ankle has occurred. This is usually a sign that the patient has become either very active or is wearing the prosthesis for a longer time than for which it was designed. Reinforce the ankle and foot with fiberglass tape during the original application process if it is felt that the patient will be a heavy user. The same Stat Limb module can be used for cast changes. However, it is important to cut off the cast carefully to prevent damage to the Stat Limb. It is not recommended to reuse the Stat Limb on other patients since it is designed for limited use. The earlier a prosthesis is applied, the more successful and pain free is the final fitting. The problems encountered in the use of any system have to be recognized, but it is difficult to scientifically explain why a minimally weighted limb can impede wound healing. If the prosthesis is not applied to the patient for a few days, we note the rate of progress is retarded. This is detrimental to the functional recovery of wound healing and the entire patient. <h3>Case History</h3> Although over 1,000 Stat Limbs have been used to date, one case history will be presented to illustrate the benefits of the Stat Limb in a community hospital setting. Patient A.B. is an 80 year old woman who had a right below-knee amputation, secondary to diabetic gangrene, two years ago. She was fit with a Stat Limb immediately and began weight bearing in physical therapy two days later. A cast change was made 12 days postoperatively when the stitches were removed. The Stat Limb was reapplied and the patient was discharged home with a walker and wheelchair. Two weeks later, a second cast change was made and measurements were also taken for a preparatory prosthesis. The following week, the Stat Limb was removed and the patient was fitted with her prosthesis. She walked six full lengths of the parallel bars without hesitation. One year later, the same patient lost her left leg below the knee and was immediately fit with a Stat Limb. Within two weeks she was home with a walker using a definitive right below-knee prosthesis and her Stat Limb. Without the availability of the Stat Limb in this case, this patient would have been wheelchair bound for weeks, the time needed for physical therapy would be lengthened, and many activities of daily living would have required assistance. <h3>Summary</h3> With the decline in use of immediate postsurgical fitting of prostheses, most amputees do not walk for several weeks post-surgically. The Stat Limb is designed for easy application by even the occasional surgeon and allows weight bearing within days following surgery. The Stat Limb does not provide the answer to every amputation. Each patient is entirely different from another in any series, and many other factors must be taken into account, including the initial pathology, age, cooperation of the patient, availability of nursing and physical therapy care, and other associated problems. The Stat Limb does remove most of the logistical and educational problems that are associated with IPSF, and should allow many new amputees to benefit from early weight bearing and walking. *Michael J. Quigley, C.P.O. Michael J. Quigley, CPO is President of Oakbrook Orthopedic Services, Ltd., 1 South 132 Summit Avenue, Oakbrook Terrace, Illinois 60181. *Joseph CM. Sheehan, M.D. Dr. Joseph CM. Sheehan is Associate Clinical Professor for Orthopedic Surgery and Rehabilitation at Loyola University in Chicago, Illinois. He is also Attending Surgeon at Marianjoy Rehabilitation Center in Wheaton, Illinois. Page Number(s) 5 - 10 Year 1987 Volume 11 Issue 1 Figure 2 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-7.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-8.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1987_01_005/1987_01_005-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Stat Limb: A Prosthesis for Immediate Postoperative Fitting of AK and BK Amputations Creator An entity primarily responsible for making the resource Joseph CM. Sheehan, M.D. * Michael J. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_01_011.pdf Text Any textual data included in the document <h2>A Variable Volume Socket for Below-knee Prostheses</h2> <h5>A. Bennett Wilson, Jr. <a style="text-decoration: none;">*</a> C. Michael Schuch, C.P.O. <a style="text-decoration: none;">*</a> Robert O. Nitschke, C.P.O. <a style="text-decoration: none;">*</a></h5> The benefits concerning control of edema by fitting the lower limb amputee as soon as the stitches are removed are well documented,<a></a> yet for a number of reasons, mostly economic, the majority of new amputees are not treated in this manner. As a result, most patients present for their first prosthesis with an edematous residual limb that can be expected to shrink even when it has been wrapped properly with an elastic bandage or with a shrinker sock. Proper management of these patients has usually required the fabrication of several provisional sockets in successively smaller sizes until the soft tissues have reached a point where no further reduction is to be expected. Besides the expense involved in this procedure, a truly proper fit occurs only for a very short period after each new provisional socket is provided, a condition which is bound to have an effect on the activity of the newly fitted patient. Thus, a socket that can be adjusted to accommodate the gradual change in residual limb volume is desirable. <h3>History</h3> Attempts to provide adjustable socket volume are found more commonly at the above-knee level.<a></a> The Irons, et al.<a></a> socket design has evolved to become available as a non-custom fitted, prefabricated socket system, manufactured and distributed by Orthomedics<a></a> and United States Manufacturing Company.<a></a> To quote Mooney,<a></a> a co-author of the paper by Irons, et al.,<a></a> "For the above-knee stump, the design constraints are simpler in that the residual limb usually presents no significant bony contours and adequate soft tissue covers all bony elements. On this basis, the fabrication of a lightweight above knee prosthesis with an adjustable socket is a relatively simple problem." Referring again to the Irons, et al.<a></a> study, Dr. Mooney7 states that, "a significantly higher percentage of amputees became functional users due to the availability of the adjustable above-knee prosthesis than would have been expected by previous experience if they had waited for the maturation time to be considered for a conventional socket. The average time to fitting with a conventional socket in the past was about six months. In this group, using earlier fit of adjustable sockets, which were also lightweight, a higher percentage of patients became functional users." The only volume adjustable below-knee socket system reported on to date is by Mooney, et al.<a></a> from the University of Texas at Dallas, who report early gratifying results with use of this system. However, it is an off-the-shelf item, which inherently presents fitting problems. As opposed to the above-knee limb, the below-knee limb requires more exacting contours of fit due to prominent bony contours, and relatively less soft tissue. In addition, the below-knee amputee often presents with adherent scar tissue in the suture areas. For these reasons, most will agree that a custom fit is mandatory at the below-knee level. An interesting fact can be noted in all of the designs cited: ease of volume adjustments were concentrated in the proximal aspect of the socket as opposed to the distal aspect, where the greatest reduction in volume occurs. <h3>Goals And Design Criteria</h3> After reviewing existing designs in which the volume of the socket can be adjusted, and considering the use of materials and techniques now available, a set of criteria was established for a custom fitted variable volume below-knee socket as follows: 1) the socket would be custom fitted to the individual patient; 2) existing prosthetic molding, modification, and fabrication techniques would be used as appropriate; 3) the volume would be controlled equally or selectively between proximal and distal parts of the residual limb; 4) normal prosthetic cosmesis would be possible and practical; and 5) the finished prosthesis would be light, but durable. The original, primary purpose of the project was to design a socket for use as a preparatory prosthesis, and thus avoid the need for several socket changes before stabilization occurs. However, it appears that the design that has resulted may also be very appropriate for use over extended periods where fluctuation in limb volume is difficult to control, or where the shear stresses normally encountered with present day socket designs present a problem. Because of the two-piece design (<a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-01.jpg">Fig. 1</a> and <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-02.jpg">Fig. 2</a>), it is possible to don and doff the prosthesis without subjecting the skin of the residual limb to shearing forces, and thus should be considered when it is desirable to avoid shear on the limb. Additionally, the two-piece construction should add a measure of suspension if this element is considered in the individual design. <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-01.jpg">Figure 1. Exploded schematic view of the variable volume socket showing major components.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-02.jpg">Figure 2. Schematic showing relationship of the major components of the variable volume socket.</a> We are confident that the concept is valid and useful. What follows here is, we hope, sufficient information for an experienced prosthetist to try the concept. The materials and dimensions given are those that have been found to work in our still limited experience, but are by no means considered to be the best. Our original method for controlling volume, by use of two conventional hose clamps, is described here, because we have yet to locate a commercially available adjustment buckle that is suitable. We made some progress in designing a buckle especially for this purpose, but have not pursued the idea since the hose clamps can be made to work satisfactorily. However, there is probably a place for a more convenient method of controlling the circumferential dimensions. <h3>Casting And Modifying The Positive Model</h3> As stated in the design criteria, this socket system is intended to make use of existing prosthetic molding, modification, and fabrication techniques. We recommend use of the casting procedure described by Fillauer<a></a> in which an impression of the anterior portion of the limb is made first, using plaster splints to capture the bony definition before enclosing the remainder of the residual limb with plaster. Model modification should be carried out in normal function. We also recommend the use of a transparent diagnostic socket and algination procedure as described by Schuch and Lucy,<a></a> before proceeding with pouring the final positive model and fabrication of the socket. Fabrication of the Socket <ol> <li> <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-03.jpg">Step 1 </a> Place the positive model in a vise horizontally with the anterior section facing up. </li> <li> <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-04.jpg">Step 2 & 3</a> Over the positive model, form a Pelite™ liner for the anterior half of the socket. After heating a proper size sheet of Pelite™, a piece of latex rubber can be used to form the Pelite™ around the cast model. </li> <li> Trim the Pelite™ liner so that it extends posteriorly slightly past the midline, dividing the anterior-posterior halves of the model. Skive all edges that will be inside the socket. Remove the Pelite™ liner from the cast in preparation for the next step. </li> <li> <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-05.jpg">Steps 4 and 5</a> Rotate the model in the vise 180° so that the posterior surface is up. </li> <li> Using conventional drape molding techniques, vacuum form a piece of 1/8 inch polyethylene (or Surlyn®) around the model, posterior side up so the seam is on the anterior side. </li> <li> <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-06.jpg">Step 6</a> Trim the polyethylene to form a posterior socket shell that extends anteriorly just past the midline and "underlaps" the Pelite™ anterior liner by about 3/8-1/2 inch. Again, skive all edges that will be inside the socket. </li> <li> <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-07.jpg">Step 7</a> With the Pelite™ anterior liner and the polyethylene posterior shell in place on the model, pull a thin sheath of nylon over both to hold them in place. </li> <li> <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-08.jpg">Step 8</a> On the posterior aspect of the model, glue a 1/4 inch diameter rope to form the cutout for the posterior volume control panel. Prepare for lamination in the usual manner. For use as a temporary design prosthesis, we use Otto Bock<a></a> modular endoskeletal components and laminate the 4R42 component (socket adaptor with pyramid and lamination anchor) directly into the socket. </li> <li> <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-09.jpg">Step 9</a> Before beginning the lamination procedure, cut two polyethylene strips 1/16 inch thick by 9/16 inch wide by the circumference, plus 1/2 inch of the cast model at the levels shown. The strips are placed in the lamination layup and are removed after the lamination sets up to form channels for the volume control straps. Layup for the lamination is as follows: <blockquote> 1 layer of 1/2 oz. dacron felt 1 nylon stockinette the 4R42 component (if used) I.P.O.S.<a></a> glass matting over the lamination anchors of the 4R42 component and over the medial, lateral, and posterior aspects of the layup 1 nylon stockinette; the two polyethylene strips cut earlier are placed at the appropriate levels; 1 nylon stockinette 2 nyglass stockinettes; laminate with 80:20 mixtures of acrylic resin </blockquote> </li> <li> <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-10.jpg">Steps 10, 11, and 12</a> When the laminate has set and cured, cut out the window over the rope and trim as shown. </li> <li> Using a pair of needle nose pliers, pull out the two polyethylene strips imbedded in the lamination. This leaves a clean, hidden track for guiding the pull of the control straps. </li> <li> Cut out an area about 1 1/2 inches along each control strap track in the anterior-lateral area of the socket, to allow for exposure of the adjustable part of the control strap. </li> <li> Make up control straps of 1/2 inch da-cron tape and two to three inches of the hose clamps. </li> <li> Put the socket system back on the cast model for determination of the initial volume setting. Insert the dacron straps through the tracks and speedy rivet the hose clamp section so that the hex head of the clamp is exposed in the slots cut in step 12 above (<a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-11.jpg">Fig. 3</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-11.jpg">Figure 3. Photograph of laminated outer socket prior to mounting on adjustable leg. A foam block is shown here but this practice has been superceded by use of the Otto Bock 4R42 component which is laminated into the distal end of the outer socket.</a></li> <li> Attach the pylon and foot and align in the conventional way (<a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-12.jpg">Fig. 4</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-12.jpg">Figure 4. Variable volume socket mounted on an adjustable leg.</a></li> </ol> <h3>Clinical Experience</h3> To date, seven variable volume below-knee sockets have been fitted on six carefully chosen amputees. Five of these patients were new amputees and the variable volume socket prosthesis was their first prosthesis. One of these five had an extremely edematous limb due to a recent infection, and required two successive variable volume sockets before being fitted with a definitive conventional P.T.B, prosthesis. The remaining patient was a young amputee, three years post-amputation, who was having difficulty maintaining consistency in limb volume. The variable volume socket proved to be very useful in managing this patient. Evaluation was basically simple and subjective. The clinic team discussed and recorded any problems that arose with the socket design and documented that atrophy was accommodated by the variable volume socket. In all cases, maintenance of socket fit was made possible by decreasing socket volume as atrophy of the residue limb took place. At no point was comfort compromised by a reduction of socket volume. In addition to the patients fitted at the University of Virginia; trial fittings were made by Mr. Nitschke in the courses of development at Leimkuehler, Inc. in Cleveland, Ohio, American Orthotic and Prosthetic Laboratory, Inc. of Columbus, Ohio, and Rochester Orthopedic Laboratories, Inc. in Rochester, NY where we were given much help and encouragement. In addition, Karl Fillauer, CPO of Fillauer Orthopedic, Inc. in Knoxville, Tennessee has fit two patients and Robert Gooch, CP and John Michael, CPO of Duke University have fit one patient, all of whom are currently being followed. <h3>Summary And Conclusion</h3> Rationale, design criteria, and fabrication techniques for an adjustable volume below-knee socket have been discussed and described. Successful fittings with the system have been noted. It is felt that this system can meet a need by providing new amputees with a durable, cosmetic, and reasonably long lasting preparatory prosthesis that accommodates the familiar problem of residual limb volume shrinkage. <h3>Acknowledgments</h3> This work was made possible by support from the Veterans Administration Rehabilitation Research and Development Service. We are also grateful for the help and encouragement provided by Messrs. Jon Leimkuehler, CPO, Peter Ockenfels, CPO, Karl Fillauer, CPO, Carlton Fillauer, CPO, Robert Klebba, Robert Gooch, CP, John Michael, CPO, and Dr. Frank Clippinger. References: <ol> <li>Brownsey, ZZ; Fillauer, ZZ: "Temporary Prosthesis with Adjustable Socket," Physical Therapy, 47:12:December, 1967, pp. 1129-1131</li> <li>Fernie, Geoff, R. and Pamela J. Holiday, "Volume Fluctuations in the Residual Limbs of Lower Limb Amputees," Archives of Physical Medicine and Rehabilitation, 63:4:April, 1982, pp. 162-165.</li> <li>Fillauer, Carlton, "A Patella-Tendon-Bearing Socket with a Detachable Media Brim," Orthotics and Prosthetics, 25:4:December 1971, pp. 25</li> <li>Irons, G., V. Mooney, S. Putnam, M. Quigley, "A Lightweight Above Knee Prosthesis With an Adjustable Socket, Orthotics and Prosthetics, 31:1:March 1977, pp. 3-15.</li> <li>Malone, J. et al, "Rehabilitation for Lower Extremity Amputation," Archives of Surgery, 116:1:January 1981, pp. 93-98.</li> <li>Malone, J. et al., "Therapeutic and Economic Impact of a Moderate Amputation Program," Annals of Surgery, 189:6:June 1979, pp. 798-802.</li> <li>Mooney, V., B. McClellan, D. Cummings, P. Smith, "Early Fitting of the Below Knee Amputee," Orthopedics, 8:2:February 1985, pp. 199-202.</li> <li><a href="cpo/1986_03_101.asp">Schuch, C. Michael, and Tony Lucy, "Experience with the Use of Alginate in Transparent Diagnostic Below-Knee Sockets," Clinical Prosthetics and Orthotics, 10:3:Summer 1986, pp. 101-104.</a></li> <li>Orthomedics, Inc., 2950 East Imperial Highway, Brea, California 92621.</li> <li>Otto Bock Orthopedic Industry, Inc., 4130 Highway 55, Minneapolis, Minnesota 55422.</li> <li>United States Manufacturing Company, 180 North San Gabriel Blvd., Pasadena, California 91107.</li> <li>I.P.O.S., U.S.A., 155 Portage Road, Lewiston, New York 14092.</li> </ol> *Robert O. Nitschke, C.P.O. Robert Nitschke is a consultant and lives in Rochester, NY. *C. Michael Schuch, C.P.O. Department of Orthopedics and Rehabilitation at the University of Virginia. *A. Bennett Wilson, Jr. Department of Orthopedics and Rehabilitation at the University of Virginia. <div style="width: 400px;"> </div> Page Number(s) 11 - 19 Year 1987 Volume 11 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-01.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 2 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-02.jpg Figure 3 STEP 1 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-03.jpg Figure 4 STEP 2 &3 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-04.jpg Figure 5 STEP 4&5 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-05.jpg Figure 6 STEP 6 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-06.jpg Figure 7 STEP 7 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-07.jpg Figure 8 STEP 8 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-08.jpg Figure 9 STEP 9 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-09.jpg Figure 10 STEP 10,11&12 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-10.jpg Figure 11 FIGURE 3 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-11.jpg Figure 12 FIGURE 4 http://www.oandplibrary.org/cpo/images/1987_01_011/1987_01_011-12.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Variable Volume Socket for Below-knee Prostheses Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr. * C. Michael Schuch, C.P.O. * Robert O. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_01_020.pdf Text Any textual data included in the document <h2>The Design a<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-09.jpg"></a>nd Testing of a Gradient Pressure Sock for Control of Edema</h2> <h5>Martha Field, M.S. <a style="text-decoration: none;">*</a> Joseph Zettl, CP. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> Since the fit of a prosthesis on a residual limb influences skin condition, gait, comfort, and even whether or not the prosthesis will be worn, the stability of the limb size is critical. Even in a whole leg, prolonged standing without the 'pumping' action of the leg muscles leaves a poorly supported column of blood within the veins. "The amputated limb has virtually no muscle contraction to aid venous return."<a></a> External pressure, when well applied, does facilitate venous return, reduces hemo-stasis, and provides comfort. Pressure must be sufficient to offset the increased hydrostatic pressure of trauma, standing, or straining and yet not interfere with arterial flow.<a></a> Poorly applied pressure may be injurious. Various investigators have charted the wide range of pressures obtained by elastic wrap and have cautioned against the harmful effects that could result from this edema control method.<a></a> Isherwood states that "elastic wrap bandaging is unreliable and dangerous in terms of pressure and pressure distribution,"<a></a> because pressure can become so great from too tight a wrap that a tourniquet effect results. The use of tubular elastic bandaging results in more predictable and less pressure fluctuation, and requires considerably less skill in application. Especially for below-knee edema problems, Compressogrip<a style="text-decoration: none;">*</a> and similar products, including the Puddifoot method,<a></a> have proven to be effective, inexpensive, easy to apply, and well liked. However, as early as 1961, Beninson recognized that, "Pressure gradient dressings can, in some instances, be used following surgery to hasten healing prior to application of the supports."<a></a> In 1971, Mooney, et al., stated that their study revealed postoperative residual limb care using plaster shell or plaster with pylon resulted in more successful prosthetic fittings than those using soft dressings.<a></a> In 1975, Isherwood defined the requirements of a good dressing by stating that "as intracapillary pressure varies with dependency, the ideal bandage should provide a graded pressure which is maximum at the most dependent distal point, decreasing proximally."<a></a> Shaping the residual limb is also recognized as a function of a shrinker sock. Available shrinker socks generally lack the shaping capacity, particularly at the distal end. Our objective, therefore, was to make a shrinker sock which would shape the distal end, have gradient pressure, and be accepted by wearers. This sock would not only accomplish the task of reducing post-amputation edema, but would also control fluids which might recur as the result of illness, injury, or any number of conditions. When any edema is uncontrolled, the tendency is not to wear the prosthesis. In defining the size and shape of the residual limb, two studies were helpful. In the July, 1983 Journal of the American Geriatrics Society, Dr. Clark, et al., described ideal limb characteristics including length below knee (6-8 inches) and above knee (8-10 inches) and shape (cylindrical).<a></a> A Swedish study actually measured 58 below-knee amputations. They found that 66 percent of the residual limbs were conical, 28 percent cylindrical, one percent bulbous, and five percent were other. The length in the supine position from the knee joint, i.e. the anterior rim of the medial condyle to the most distal part of the soft tissues at the end of the residual limb, was six inches (8 to 20 cm.).<a></a> No average measurement has been found in the literature for above-knee residual limbs. This lack of information about residual limb measurements may result from the fact that, in spite of what researchers have said, wrapping has been the most universal method of residual limb reduction. It may be that prosthetists feel no two limbs are identical and each needs to be treated individually. Nevertheless, with cooperation and knowledge, general parameters can be established for socks which will exert the desired graded pressure over a limited measurement range so that standard sizes of socks can be readily available. Although the benefits of using pressure as a prophylactic aid to reduce edema after amputation, or whenever edema develops in a mature stump, have been recognized for centuries, no precise definition of the amount of pressure to be used has been created. Part of the reason is that each researcher has used a different instrument for measurement, and although each instrument can be calibrated to a manometer, certain features of each instrument result in un-comparable readings.<a></a> Much of the research on using pressure to alleviate pain and ulcers in cases of deep venous insufficiency supports much higher mmHg readings than those indicated by the fairly limited research on wrapping and tubular elastic bandaging pressures. Our request for information on instruments being used to obtain the pressures printed on packaging of various companies making pressure garments only revealed the use of the Kompritest II (<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-01.jpg">Fig. 1</a>). We secured that instrument and found it gave readings 15-20 mmHg higher than the CTC 250 we had been using (<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-02.jpg">Fig. 2</a>). We pursued this with Midwest Research Institute<a style="text-decoration: none;">*</a> and received the following explanation: <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-01.jpg">Figure 1. Kompritest II for measurement of pressure values of elastic stockings.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-02.jpg">Figure 2. CTC 250 Digital Pressure Gauge.</a> <blockquote> Both devices accurately measure pressure imposed upon their respecting sensing elements. When placed under an elastic fabric, the devices produce different readings because the Kompritest II (K-II) device distends the elastic fibers surrounding the bulge of its inflated bladder and thus produces a local increase in pressure over the measurement site. This local pressure increase observed using the K-II accounts for the difference between values produced by the two devices, and suggests that the CTC device is the more accurate of the two for measuring the pressures exerted by elastic fabric.<a></a> </blockquote> Although some instruments have misrepresented pressures on the high side and some researchers have advocated unusually low pressures,<a></a> a 1985 study by Hendricks and Swallow used stockings "designed to exert graded compression from 24 mmHg pressure at the ankle to 16 mmHg pressure at the calf." They admit that "the optimal amount of compression at the ankle and calf necessary to heal and prevent statis leg ulcers is not known at this time." Their explanation of the value of external compression therapy is that "it compresses the superficial veins and prevents extravasation of fluid into the subcutaneous tissues . . .," thus reducing "swelling of the leg as measured by total leg volume and by lower extremity circumference measurements."<a></a> The study by Varghese, et al., obtained similar results with similar pressure readings using the CTC instrument. To date, capillary and anteriolar blood pressure have not been related for the purpose of establishing pressure values that would reduce edema; nor has the difference between new or mature residual limbs been studied. Different pressure readings have been observed over bony areas versus fleshy areas.22 <h3>Procedures</h3> Since our aim was to develop a sock which would be fashioned to give greater pressure distally, less pressure proximally, and have a rounded toe to shape the distal end, the flat, V-bed type machine was employed. <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-03.jpg">Fig. 3</a> is a close up of the carriage and the needle bed where needles are picked up or dropped according to machine programming so that wid-enings or narrowings (fashionings) can be made. All standard prosthetic socks are full-fashion knit in this way, with gradual wid-enings up both sides of the sock. To give even greater rounding, a new widening for the toe was programmed. On circular machines, as used for most currently available shrinkers, widening can only be achieved by loosening the knitting tension. Knitting a rounded toe on a circular machine is not possible. <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-03.jpg">Figure 3. Needle bed of knitting machine where widenings and narrowings can be made.</a> The yarn to be used for this sock needed firmness in its stretch so that the desired pressures could be obtained. Softness, strength, and washability were also considered important. A corespun yarn was selected, with Lycra spandex being the core and Avril rayon being the covering. Attempts were made to obtain postoperative edemic residual limb measurements from various facilities. Not enough measurements were obtained to make any generalizations. Therefore, our knowledge was combined with that of the Knit-Rite production manager to formulate an experimental size range (<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-04.jpg">Table 1</a>). Specifications were made for the knitting machines so that the desired pressures would be obtained when tested over a steel cylinder (<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-05.jpg">Fig. 4</a>) at the Fits Circumference measurements. Heavy pressure was defined at the top of the effective range, i.e. 25-30 mmHg for the distal pressure and 15-20 mmHg for the proximal pressure. The recognition that some patients could not tolerate heavy pressure, and that some researchers suggested less pressure for nighttime wear, led to the development of a sock having distal pressure in the 15-20 mmHg range and proximal pressure in the 10-15 mmHg range. Socks were identified with color stitching at the top: green for heavy pressure and gray for medium pressure. The increase in pressure caused by the increased stretch over the range was measured to be no greater than the allowed variance. Shrinker socks were sent to many prosthetists who indicated that they would use them and return evaluation forms. <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-05.jpg">Figure 4. Testing cylinder with pressure sensing device in position.</a> <h3>Results</h3> Forty-five evaluations were returned representing 43 patients. All but three of these evaluations were for below-knee amputees (<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-06.jpg">Table 2</a>). Of the 42 below-knee evaluations, 17 had toe measurements ranging in circumference from eight inches to 11 inches; 18 had toe measurements ranging from 11 1/8 inches to 13 5/8 inches; four had toe measurements ranging from l4 1/2 inches to 16 inches; and three did not give measurements (<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-07.jpg">Table 3</a>). The significance of grouping the measurements in this way was so they would correspond with the size range we had developed for testing purposes. A smaller toe circumference measurement was encountered than had been anticipated, but the actual toe sizing ranges could be compared with the experimental toe sizing ranges in the narrow, medium, and wide. Top measurements were ranged as they corresponded with toe measurements in each size (<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-07.jpg">Table 3</a>). Note, the actual tester range of top circumference measurements was both larger and smaller than the experimental sizing range for the narrow and the regular, but was only smaller for the wide (<a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-05.jpg">Table 1 </a>and <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-07.jpg">Table 3</a>). Pressure measurements were again taken which defined ranges of each size as reported for the wearers. <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-08.jpg">Fig. 5</a> shows pressure measurements of heavy shrinker socks at circumferences one inch from the distal end. These pressures should relate to pressures exerted on those fitted with the narrow, the medium, and the wide as indicated by the rectangles. Our KU study indicated laboratory pressure measurements over steel cylinders are approximately ten percent higher than pressure measured on patients, or control volunteers making these pressures in agreement with our criteria, if the larger circumference in each specified Fits Circumference range is the cut off point; therefore, if 11 inches is the larger suggested circumference, 11 1/8 circumference inches would be fit with the next size unless greater pressure is desired. <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-08.jpg">Figure 5. MmHg of pressure exerted by heavy shrinker sock on inch from distal end.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-09.jpg">Fig. 6</a> shows pressure measurements of heavy shrinker socks at circumferences six to eight inches from the distal end. These pressures should relate to pressures exerted on those fitted with the narrow, the medium, and the wide as defined by the rectangles. These pressures are less than the distal end pressures. However, particularly in the narrow size, some readings were at the 20 to 25 mmHg level. Since some wearers' residual limbs were exceeding the suggested range in top circumference measurement and were obtaining greater proximal pressure than might be desired, patterns were made using the measurements given for each limb. These were grouped by shape. As a result of comparing these shapes and listening to comments from several facilities, a double tapered shrinker was developed. Comparison to the regular taper is shown in <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-10.jpg">Fig. 7</a> where the dotted lines represent the regular tapered sock and the three toe lengths represent the 10, 12, and 14 inch sock lengths. <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-09.jpg">Figure 6. MmHg of pressure exerted by heavy shrinker sock six to eight inches from distal end.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-10.jpg">Figure 7. Scale of regular and double taper.</a> When knitted, the regular taper and double taper can be compared as in <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-11.jpg">Fig. 8</a>. The toe is the first consideration for fit using the Fits Circumference range as the guide. Then, if the top circumference exceeds the recommended limit of the regular range, a double taper should be ordered or at least considered. <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-11.jpg">Figure 8. Comparison of regular and double taper shrinker sock (14 inch length).</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-12.jpg">Fig. 9</a> shows pressure measurements of medium pressure shrinker socks at circumferences one inch from the distal end. These pressures should relate to pressures exerted on those fitted with the narow, the medium, and the wide as indicated by the rectangles. These pressures met our criteria for a sock with medium pressure of 15 to 20 mmHg. <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-13.jpg">Fig. 10</a> shows pressure measurements of medium pressure shrinker socks at circumferences six inches to eight inches from the distal end. These pressures should relate to pressures exerted on those fitted with the narrow, the medium, and the wide as defined by the rectangles. These pressures were lower than our criteria when circumferences were less than our sizing guide. This was not considered to be a problem unless a lack of pressure caused slippage. Where circumferences were more than our sizing guide, the pressures of the narrow exceeded our criteria as did those of the heavy shrinker sock. As for the heavy shrinker sock, when the top circumference exceeds the Fits Circumference recommendation, the double taper is recommended to get the advantages of gradient pressure. <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-12.jpg">Figure 9. MmHg of pressure exerted by medium pressure shrinker sock one inch from distal end.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-13.jpg">Figure 10. MmHg of pressure exerted by medium pressure shrinker sock six to eight inches from distal end.</a> Evaluation forms revealed that both green top, heavy compression socks, and gray top, medium compression socks, were used for day and night wear. Four testers used two socks: heavy compression for daytime wear and medium compression for nighttime wear. Seventy percent of the testers wearing the heavy compression felt the tops stayed up adequately; 65 percent of the testers wearing the medium compression socks felt the tops stayed up adequately. Night-time was the most difficult time. To one tester who complained in detail about the roll down, we sent him a shrinker with a turned down zigzagged stitched top. He liked this top, but it was not pursued for fear the doubled top would cause greater pressure prox-imally. Some trials indicated the shrinker should come up proximally past the patella and that if it comes a little higher, it is less likely to roll. All but one of the testers using the heavy compression felt that the shrinker was improving the shape, decreasing the edema, and/or maintaining the limb. One tester, who felt the heavy pressure was not adequate, used both heavy and medium socks at the same time and still felt the need for greater pressure. The prosthetist noted this was a young man with a high pain level and a drive to get back on his legs. Sixty-four percent of the testers using the medium compression felt the shrinker was maintaining the limb's size and shape. Thirty-five percent of the respondents felt the pressure of the medium compression sock was not sufficient. Most of the amputees using the experimental shrinker socks were new patients who lost a leg because of vascular disease, usually diabetes. Any undue pressure over the residual limb serves as an excuse to take the shrinker off; therefore, medium pressure may help to start the process of controlling edema so that heavy pressure will eventually be tolerated as needed. Some of the shrinkers were worn over Ace® bandaging and some comments were made about using Ace® bandaging some of the time. Prosthetists' comments revealed that the experimental shrinkers were effective in shaping the distal end, hugging the anatomy, and giving good overall suspension. The distal end support was positive as long as the patients applied the shrinker firmly. Some residual limbs are very bulbous initially following surgery. This depends on the patient's physique, the surgical technique use, and the amount of edema. Previous experience indicates a bulbous residual limb will, in time (six to 12 weeks post-surgery), become slowly cylindrical, and a cylindrical amputation will become cone-shaped. Thirty percent of the wearers said they had not washed their shrinker sock which may have meant that they were wearing it continuously. Five percent did not answer the question. Of the 65 percent who did wash their shrinker, none mentioned any washing problems. In answer to the question, "Is the sock easy to apply", 100 percent of the testers said, "Yes." One said, "Very." In answer to the question, "Is the sock comfortable?," all but one tester replied positively. This one tester was having some orientation problems. Other comments were "Feels good," "Feels great, except at first when a little tender." <h3>Conclusions</h3> Evaluation forms for a new below-knee shrinker sock revealed it was comfortable, easy to put on, stayed up on most but not all wearers, gave desired shrinking and shaping in the heavy compression, and some shaping and residual limb maintenance for 65 percent of the medium compression wearers. When pressure was greater and the sock was fitted longer, proximally past the patella, roll down was less of a concern. Analysis of residual limb measurements and pressure measurements determined that both the heavy and the medium compression shrinker socks did exert greater pressure distally than proximally, and that wider circumferences than those recommended at six or more inches from the distal end could be accommodated by the double tapered sock. This study did not offer the opportunity to study above-knee shrinkers, but they are being custom made in order to gain knowledge of fit and support. The same fabric used in the below-knee shrinkers can be cut and sewn to make above-knee socks. To meet the needs of shrinking stumps, below-knee shrinkers can be altered with a sewing machine stitch if the sock is not to be used for walking. If the sock is to be used for weight bearing, it can be returned to be altered with a flat seam according to specified markings, or a smaller size can be fitted. <h3>Acknowledgments</h3> We are especially indebted to the prosthetists from the various facilities who did most of the reporting for the testers. Without their help, this report would not have been possible. We also wish to thank William B. Smith, CO, President, and Larry Pierce, Production Manager, of Knit-Rite, Inc.. Without their product, knitting knowledge, and encouragement, no sock would ever have been made. References: <ol> <li>Beninson, Joseph, M.D., "Six Years of Pressure Gradient Therapy," Angiology, Volume 12, No. 1, January, 1961, pp. 38-45.</li> <li>Bauer & Black, Elastic Stocking Compression in the Therapy of Varicose Veins, Chicago, Il., 1956, pp. 4-14.</li> <li>Chavatzas, Dimetrios, and Jamieson Crawford, "A Simple Method for Approximate Measurement of Skin Blood-Pressure," The Lancet, April 20, 1974, pp. 711-712.</li> <li>Clark, Gary S., M.D.; Barbara Blue, R.N.; and John B. Bearer, RPT, "Rehabilitation of the Elderly Amputee," Journal of the American Geriatrics Society, Volume 31, No. 7, July, 1983, pp. 439-447.</li> <li>Cohen, Havey D., Ph.D., Letter to Knit-Rite, Inc. on "Equipment Evaluation Service," November 14, 1984, p. 1.</li> <li>Hendricks, William M,, M.D. and Roger T. Swallow, B.A., "Management of Statis Leg Ulcers with Unna's Boots Versus Elastic Support Stockings," Journal of the American Academy of Dermatology, Volume 12, No. 1, January, 1985, pp. 90-98.</li> <li>Hera, J. Alan, M.D.; Antonio M. Sotlo, M.D.; Peter S. Kaufman, Ph.D.; and Stephen M. Weiss, Ph.D., "Cardiovascular Instrumentation," Proceedings of the Working Conference on Applicability of New Technology to Biobehavioral Research, March 16-19, 1982, pp. 207-217.</li> <li>Horner, J., R.N.; L.C. Loruth; and A.N. Nicolaides; "A Pressure Profile for Elastic Stockings," British Medical Journal, March 22, 1980, pp. 818-821.</li> <li>Husni, Elias A., M.D.; Jose O.C. Xemenes, M.D.; and Frederick G. Hamilton, M.D., "Pressure Bandaging of the Lower Extremity," Journal of the American Medical Association, Volume 206, No. 12, December 16, 1986, pp. 2715-2718.</li> <li>Isherwood, P.A.; J.C. Robertson; and A. Rossi, "Pressure Measurements Beneath Below-Knee Amputation Stump Bandages: Elastic Bandaging, the Puddifoot Dressing and a Pneumatic Bandaging Technique Compared," British Journal of Surgery, Volume 62, 1975, pp. 982-986.</li> <li>Johnson, George, Jr., M.D.; Cynthia Kupper, R.N.; David J. Farrar, Ph.D.; and Roger Swallow, "Graded Compression Stockings," Archives of Surgery, Volume 117, January, 1982, pp. 69-72.</li> <li>Makin, G.S.; F.B. Mayes; and A.M. Holroyd, "Studies on the Effect of 'Tubigrip' on Flow in the Deep Veins of the Calf," British Journal of Surgery, Volume 56, No. 5, May, 1969, pp. 369-372.</li> <li>Manella, K.J., "Comparing the Effectiveness of Elastic Bandages and Shrinker Socks for Lower Extremity Amputees," Physical Therapy, Volume 61, No. 3, pp. 334-337.</li> <li>Mooney, Vert, M.D.; J. Paul Harvey, M.D.; Elizabeth McBride, M.D.; and Roy Snelson, C.P.O., "Comparison of Post Operative Stump Management: Plaster Vs. Soft Dressings," The Journal of Bone and Joint Surgery, Volume 53-A, No. 2, March, 1971, pp. 241-248.</li> <li>Puddifoot, P.C.; P.C. Weaver; and Sheila A. Marshall, "A Method of Supportive Bandaging for Amputation Stumps," British Journal of Surgery, Volume 60, No. 9, September, 1973, pp. 729-731.</li> <li>Renstrom, Per, The Below-Knee Amputee, University of Goteborg, Sweden, 1981, p. 18.</li> <li>Sigg, K., M.D., "Compression with Pressure Bandages and Elastic Stockings for Prophylaxis and Therapy of Venous Disorders of the Leg," Fortschritte Der Medizin, No. 15, August 15, 1963, pp. 601-606.</li> <li>Spiro, M.; V.C. Roberts; and J.B. Richards, "Effect of Externally Applied Pressure on Femoral Vein Blood Flow," British Medical Journal, Volume 1, March, 1970, pp. 719-723.</li> <li>Swallow, Ramsey; and Roger Swallow, "How to Use Tester to Measure Compression Force of Support Hosiery," Knitting Times, November 22, 1976, p. 55.</li> <li>Van Pijkeren, Teun; Marinus Naeff, M.D.; and Him Hok Kwee, Ph.D., "A New Method for the Measurement of Normal Pressure Between Amputation Residual Limb and Socket," Bulletin of Prosthetic Research, Volume 17, No 1, Spring, 1980, pp. 31-34.</li> <li>Varghese, George, M.D.; Peter Hindle, M.D.; Serge Zilber, Ph.D.; Judith Perry, RPT; and John B. Redford, M.D., "Pressure Applied by Elastic Prosthetic Bandages: A Comparative Study," Orthotics and Prosthetics, Volume 35, No. 4, December, 1981, p. 34.</li> </ol> Footnote Midwest Research Institute is a professional not-for-profit corporation doing contract research for business, industry, government, individuals and groups. Footnote Available from Knit-Rite, Inc. Joseph Zettl, CP. Joseph Zettl, CP., is President of the American Artificial Limb Co., Inc., 1400 East Pike Street, Seattle, WA 98122. Martha Field, M.S. Martha Field, M.S., is Manager of Research and Development for Knit-Rite, Inc., 2020 Grand Avenue, Kansas City, MO 64141. Page Number(s) 20 - 32 Year 1987 Volume 11 Issue 1 Figure 2 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-03.jpg Figure 4 TABLE I http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-04.jpg Figure 5 FIGURE 4 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-05.jpg Figure 6 TABLE II http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-06.jpg Figure 7 TABLE III http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 FIGURE 5 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-08.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-01.jpg Figure 9 FIGURE 6 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-09.jpg Figure 10 FIGURE 7 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-10.jpg Figure 11 FIGURE 8 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-11.jpg Figure 12 FIGURE 9 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-12.jpg Figure 13 FIGURE 10 http://www.oandplibrary.org/cpo/images/1987_01_020/1987_01_020-13.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Design and Testing of a Gradient Pressure Sock for Control of Edema Creator An entity primarily responsible for making the resource Martha Field, M.S. * Joseph Zettl, CP. * https://staging.drfop.org/files/original/d49da90fa9f0c0ee8147b96e291908d3.pdf 7f08e42eea8bbbd23d3d4d6b91d0a0d2 https://staging.drfop.org/files/original/943afc173437b395a3f94b4ff2659a5e.jpg aa7edcef18db620b1fa2f490e5abf250 https://staging.drfop.org/files/original/e5efcf538172dab88f36c526b06a5f91.jpg aba531f72f2e4837c3a0a0b0996a73b8 https://staging.drfop.org/files/original/4ccde9a701dd6d5771ce107d46ac1bc2.jpg 5982b814b207265768b8e8750f90685f https://staging.drfop.org/files/original/aa05931a1d684780719bffdfc3498e7a.jpg b880cef406760c7ee2e1a038abc28149 https://staging.drfop.org/files/original/421de63be1138b2062533ad526050cd9.jpg 88152a35fb9192cc5d5b0a5e982bf642 https://staging.drfop.org/files/original/f4ec3d7373a8b0783fac25fe09b090b3.jpg 3f7eebb64f66e1965cf88142303178ed https://staging.drfop.org/files/original/f65c0df2d21adfa0a03a47a88fbf4c89.jpg d1a7c7c76a17d4b01701aa2a3b301a19 https://staging.drfop.org/files/original/4d3edf70ddb64346ebd926f557b44423.jpg df371f26240fe9a9af112a646a920e90 https://staging.drfop.org/files/original/130be2ed482165f3c83e4db139d76775.jpg 1e67cc03d90ff9c36c754e076e4cf71d https://staging.drfop.org/files/original/7559e1b4fd16d73a7c5698a4499dd5a7.jpg 225d1d21859fd91c9ebad5bc7191a4ed https://staging.drfop.org/files/original/08cd8d811779f982414986d31a527e19.jpg d3771dbd56799b33182af35d1c92d2ae https://staging.drfop.org/files/original/0939223082872fe05d76f44303b19cca.jpg 93a3a96df839aeb10aef4f65b4baf868 https://staging.drfop.org/files/original/df210d8c1bc8a0526c3cc9c380a65f3b.jpg ab58e114ecbeb9a449d2ccc395937275 https://staging.drfop.org/files/original/95e5e807e78ed5211798f516f1166caa.jpg 788a7ede4aa0a25137bd4a58b820245d https://staging.drfop.org/files/original/a0b47ea6e200a0bd2d2c28ae25937015.jpg 866795b24cb4c9e1f5970dc549e5e4dc Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_01_033.pdf Text Any textual data included in the document <h2>Removable Rigid Dressing for Below-knee Amputees</h2> <h5>Yeongchi Wu, M.D. <a style="text-decoration: none;">*</a> Harold Krick, CP. <a style="text-decoration: none;">* </a></h5> <h3>Background</h3> According to the National Center For Health Statistics, there were 274,000 patients with amputations of major limbs in 1971 in the United States. This number rose to 358,000 in 1977. Kay in 1975 reported 53.8 percent of the 6,000 reviewed new patients had had amputations at the below-knee level.<a></a> If the percentage and the number of amputees remained unchanged, there would be at least 200,000 below-knee amputees in this country at any given time. It is possible that this number could have been doubled in the past ten years. The most recent information regarding amputation available to the authors was the Vital and Health Statistics published by the U.S. Department of Health and Human Services in April, 1986. A review of 192,000 medical records from the 407 hospitals that participated in the 1984 National Hospital Discharge Survey showed an estimated 32,000 below-knee amputations alone. Therefore, improvement in the management of below-knee amputees will certainly benefit a significant number of patients. At the V.A. Lakeside Medical Center (VALMC) and Rehabilitation Institute of Chicago (R.I.C.), members of Northwestern University-McGraw Medical Center, Chicago, three techniques have been developed for treatment of below-knee amputees. These include the Removal Rigid Dressing (R.R.D.), Scotch-cast™ preparatory prosthesis, and the "one-step socket lamination definitive prosthesis." These approaches have been invaluable in the management of below-knee amputees. This paper describes the Removal Rigid Dressing for postoperative management of the below-knee amputee. Clinical experiences since 1977 have shown the benefits of the R.R.D. to be the following: <ol> <li> Rapid residual limb shrinkage </li> <li> Prevention of edema </li> <li> Possibility of frequent residual limb observations </li> <li> Soft tissue immobilization to facilitate wound healing </li> <li> Elimination of skin breakdown commonly seen in elastic bandaging </li> <li> Simplicity of donning and doffing </li> <li> Development of tolerance to weight bearing </li> <li> Prevention of residual limb trauma </li> <li> Reduction of wound pain </li> </ol> With nine years clinical experience at this university medical center and dissemination through the Northwestern University Prosthetic School, it appears to us that this technique has its merits in the postoperative and pre-pros-thetic management of the below-knee amputee. In a study done in 1977, the average hospital stay for amputees at VALMC was reduced by 90 days after the development of the R.R.D.<a></a> This was achieved primarily by complete elimination of skin breakdown seen previously from elastic bandaging and by speeding stump shrinkage with the R.R.D.<a></a> In the 1970s, at the VALMC in Chicago, there were many problems in postoperative below-knee residual limb care. For many years, the below-knee amputees were managed with a soft dressing or thigh high cast, i.e. Immediate Post-Surgical Fitting (IPSF) without pylon, followed by elastic bandaging, as many hospitals did at that time. The technique was done by the therapists, nurses, and patients, following the procedure learned directly or indirectly from the Northwestern University Prosthetic/Orthotic School. There was no special team or particular therapists assigned to amputee care. Inevitably, many techniques differing from the original were used by different individuals. For a long time, the staff was puzzled by the very high frequency of skin breakdown and distal edema (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-01.jpg">Fig. 1</a>). At times, it was a surprise at the V.A. Prosthetic Clinic when a patient presented who was free of any residual limb complications. <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-01.jpg">Figure 1. A typical pressure sore over the tibial tubercle and distal edema from conventional elastic bandaging.</a> It was apparent that inconsistent limb care techniques by the staff and the patient himself was a contributing factor (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-02.jpg">Fig. 2</a>). Many thoughts came to mind and many attempts were made to remedy this problem, such as using a protective covering made of thermoplastic or a donut shaped sponge over the tibial tubercle to prevent skin breakdown. Nothing was promising until one afternoon in early 1977 when the idea of the R.R.D. came to light. <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-02.jpg">Figure 2. A conventional elastic bandage is an unreliable technique in a patient's hand.</a> This happened after seeing a 90 year old man develop a tibial pressure sore on his well healed limb only three hours following the change from a thigh high plaster cast to an elastic bandage. We decided that the elastic bandage was guilty and should never be used for below-knee amputees again, and the thigh high cast could be modified to continue the excellent results. We analyzed the principles behind the thigh high plaster cast and incorporated them into the R.R.D. system. The design was completed on the same day and the same principles have been kept until this date without any further modifications. This system is a below-knee plaster cast suspended by a stockinette to a supracondylar suspension cuff (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-07.jpg">Fig. 7</a> (a, b, c) and <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-08.jpg">Fig. 7</a> (d, e, f)). Underneath the below-knee plaster cast, sport tube socks are added to provide-continuous controlled compression. <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-08.jpg">Figure 7 d, e, and f. Application of the Removable Rigid Dressing: d) the supracondylar cuff, e) pull the stockinette, and f) fold the suspension stockinette to make sure the cast is secured over the supracondylar cuff.</a> <h3>Why Does R.R.D. Work?</h3> No matter how successful this method has been, we certainly were inspired by the important pioneer work by Dr. Weiss in Poland, and later by Dr. Burgess<a></a> in this country. A few of the principles that made the R.R.D. an effective procedure were originally utilized in the IPSF system: <ol> <li> Use of a non-expandable dressing prevents the development of edema following amputation. </li> <li> Use of supracondylar suspension keeps the cast in place. </li> <li> Rigid dressing is effective in immobilization of soft tissue, which is essential for wound healing and pain control as well as trauma prevention. </li> <li> Controlled compression of the residual limb avoids skin breakdown and facilitates shrinkage. </li> </ol> <h3>Fabricating The R.R.D.</h3> The R.R.D. consists of four components: a) tube socks, b) below knee plaster cast, c) suspension stockinette, and d) supracondylar cuff (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg">Fig. 3</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg">Figure 3. Components of the Removable Rigid Dressing: a) athletic tube socks with the elastic band removed, b) below-the-knee cast, c) suspension stockinette, and d) thermoplastic supracondylar suspension cuff.</a> Tube Socks The idea of using tube socks arose because of the difficulty in obtaining wool socks from the V.A. supply center in early 1977 and the necessity of hand care of wool socks. By replacing the elastic bandaging with R.R.D., we noted that below-knee residual limbs changed from their previous conical shapes to cylindrical contours. The measurements of properly fitted wool socks for our patients differed from those supplied by the V.A. supply center. For a while there was a shortage of socks for our patients. This led to the need for alternatives. One day, we tried a large size tube sock on sale at the V.A. canteen store. To this date, we still use tube socks routinely at the V.A. hospital and R.I.C. They can be changed daily by the patient and are machine washable. They also provide excellent sock marks on the skin for determining the degree of pressure over the residual limb. They are cheaper and available at most department stores (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg">Fig. 3A</a>). We simply cut off the elastic tops and use them as nice fitting #2 size, 2 ply socks. Tube socks are cut in long and short lengths. Short tube socks are effective for localized compression with a bulbous limb so that progressively diminishing shrinkage can be achieved from the distal to proximal area. For the large residual limb, when the tube socks may not be long or wide enough, Soft-socks (Knit-Rite, Inc.) can be used. Plaster Cast The cast for a R.R.D. (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg">Fig. 3B</a>) is shorter than that of the IPSF. It extends only up to the knee level for easy removal. The casting procedure also differs slightly for pressure relief. In the IPSF, felt paddings are used to bridge the bony areas. In the R.R.D., cotton paddings, six layers at the center and tapered to the margins, are used as "spacers" over the bony prominences of the tibial tubercle, tibial crest, fibular head and any pressure sensitive areas. Once the cast is made, the spacers are discarded. An empty space between the cast and the skin is formed to provide a controlled pressure relief (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-04.jpg">Fig. 4</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-04.jpg">Figure 4. Cotton paddings are used as spacer for pressure relief.</a> The trim line of the plaster cast is up to mid-patellar level anteriorly and lower posteriorly to allow knee flexion. It is wider proximally in order to ensure easy removal and reapplication of the cast. This is especially true with a bulbous limb where the concave side needs additional padding to avoid a cast that is too tight at the top (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-05.jpg">Fig. 5</a>). In case of a narrow proximal opening, a longitudinal cut on the back of the cast can be used to widen the proximal part and allow reapplication (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-06.jpg">Fig. 6</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-05.jpg">Figure 5. Adequate medial padding is needed to assure a wider proximal opening for easier cast re-application (a). A narrow opening makes cast reapplication impossible (b).</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-06.jpg">Figure 6. If cast opening is too narrow, a longitudinal cut on the back of cast allows widening of the cast proximally while still maintaining distal compression.</a> Suspension Stockinette The suspension stockinette, made of 4-inch casting stockinette with one end tied, secures the cast to the suspension cuff (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg">Fig. 3C</a>). Supracondylar Suspension Cuff The suspension cuff is made of thermoplastic material. It has a Velcro® closure to keep the cuff in place and a strip of Velcro® hook along the upper edge to secure the suspension stockinette (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg">Fig. 3D</a>). For the obese patient who has very limited purchase over the femoral condyles because of tissue bulk, a fork strap with a waist belt can be used. <h3>Application Of The Removable Rigid Dressing</h3> After the surgical wound is properly dressed, the proper number of tube socks are applied layer by layer to avoid possible wrinkles. Then the plaster cast is applied and followed by the suspension stockinette and the supracondylar cuff (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-07.jpg">Fig. 7 (a, b, c)</a> and <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-08.jpg">Fig. 7 (d, e, f)</a>). To make the application easier, a semi-circular mark is made on the cast and another on the supracondylar cuff so that the patient can match both marks to form a circle over the patella. <h3>When To Apply The R.R.D.</h3> The R.R.D. can be applied at the completion of surgery or when the first thigh-high rigid dressing is removed for wound inspection. It can be used whenever there is a need for limb shrinkage in any new or old amputee. <h3>Adding Socks</h3> When possible, additional socks are applied to maintain a comfortable snug fit and to facilitate progressive shrinkage. Sometimes short socks distally are preferred to provide localized distal compression without building up the thickness proximally (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-10.jpg">Fig. 9</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-10.jpg">Figure 9. Short tube socks provide localized compression in bulbous stump.</a> <h3>Weight Bearing Exercise</h3> It is not possible to say how many days after amputation one can start weight bearing. In general, initiation of weight bearing exercise is determined by the state of wound healing, usually seven to 14 days after surgery. Immediate postoperative weight bearing is likely to cause mechanical shearing from movement and delay wound healing during the first two weeks after amputation, as reported by Mooney.4 However, steady pressure without mechanical shearing on the residual limb using a wheelchair strap can be very beneficial (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-09.jpg">Fig. 8</a>). We have found this can be used even within the first week after surgery. While in the wheelchair, the patient is encouraged to push frequently with the R.R.D. against resistance of the strap. <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-09.jpg">Figure 8. A strap is attached to the arm rests for the patient to exert partial weight bearing exercise while in the wheelchair (left). A car jack mounted onto plywood becomes an inexpensive adjustable stool for weight bearing and balance exercise (right).</a> Because it is removable, one can decide the time to start body weight bearing exercise based on the wound condition. The R.R.D. allows observation of the limb after each graded weight bearing exercise. By doing so, one can plan both the amount and duration of the next weight exercise. For unilateral amputees, the weight bearing exercise can be done by standing on a padded car jack (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-09.jpg">Fig. 8</a>). For bilateral amputees, the tilt-table is used for weight bearing. The degree of weight stress is controlled by the inclination of the tilt table and the duration of standing. This proceeds progressively to the upright position and is followed by ambulation with walking heels attached to the casts (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-11.jpg">Fig. 10</a>). Walking with Rigid Dressings helps bilateral amputees develop balance and sometimes is preferred by the obese and cardiac patients at home (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-11.jpg">Fig. 10</a>). Walking with the R.R.D. also assists the evaluation of questionable candidates for prosthetic fitting. Ambulatory use of the R.R.D. produces simulation of prosthetic stress, allowing the amputee to quickly adapt to the actual prosthesis, an impossible step when using the conventional elastic bandaging method. <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-11.jpg">Figure 10. A) For bilateral amputees, weight bearing exercise is done on the tilt table. B) The stump is examined to modify the amount of weight bearing, i.e. the degree of inclination and duration of weight bearing. C) Weight bearing continues to the upright position in the parallel bars, and D) eventually to ambulation with walking heels attached to the casts or with a preparatory prosthetic fitting.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-12.jpg">Fig. 11</a>, <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-13.jpg">Fig. 12</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-12.jpg">Figure 11. A stump with bony prominence and scars cannot tolerate the elastic bandage, but has no difficulty with Removable Rigid Dressing.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-13.jpg">Figure 12. A one handed patient, either due to hemiplegia or upper limb amputation, can use the system easily.</a> <h3>Making A New Cast</h3> The below-knee cast is changed whenever the residual limb has shrunk to the point at which too many tube socks are being used, usually about 10-14 ply of socks. The total number of casts needed depends on the speed of progressive shrinkage. Frequently three or four casts are required before the patient is ready to be fitted for a preparatory prosthesis. <h3>R.R.D. Compared To IPSF</h3> Both the R.R.D. and the thigh high rigid dressing provide immobilization of soft tissue, prevention of trauma, and prevention of edema. However, being removable, the R.R.D. allows frequent limb observation without a need for cast-cutting and cast-reapplication as needed in a thigh high rigid dressing. More importantly, it permits frequent addition of tube socks for fast shrinkage. Because space is provided between bony prominences and the plaster, adding tube socks will produce compression force to soft tissues, but will not cause pressure sores (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-04.jpg">Fig. 4</a>). If there is excessive pressure over an area, the cast can be softened from outside with a hammer, then pushed from inside for relief. Being removable, the R.R.D. has been very useful in monitoring the limb's response to weight bearing exercise. This facilitates progressive weight bearing within the safe tolerance range. Both undesirable skin breakdown from excessive weight bearing activity and hesitation in application of early graded weight bearing stress are minimized. <h3>R.R.D. Compared To The Shrinker</h3> The residual limb shrinker is an effective method for shrinkage, except for the danger of excessive pressure over bony areas or thin grafted skin. It does not protect the limb from unexpected falling, nor does it allow weight bearing exercise. The compression force can be adjusted by sewing the shrinker periodically rather than by adding socks as with the R.R.D. <h3>R.R.D. Compared To The Elastic Bandage</h3> The elastic bandage is not only difficult to apply for the staff and the elderly below-knee amputees,<a></a> but also is so unreliable that it frequently causes skin breakdown and distal edema (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-02.jpg">Fig. 2 </a>and <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg">Fig. 3</a>). It cannot protect the limb from trauma due to accidental falling. With the R.R.D., it is much easier for the patient to don and doff as well as adjust the compression, accommodate progressive shrinkage,<a></a> and perform weight bearing exercise. Since the adoption of the R.R.D. at this medical center, the problems of skin breakdown and distal edema, commonly seen in the past from elastic bandaging, have been completely eliminated (Fig. 13). <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-14.jpg">Figure 13. One of the first patients achieved 15-ply shrinkage in 7 days and spontaneous healing of the right pretibial sore caused by an elastic bandage.</a> <h3>R.R.D. For Delayed Wound Healing</h3> Delayed wound healing is not a contraindication for using the R.R.D. or a preparatory prosthesis. The R.R.D. is a useful means to facilitate wound healing, because the system reduces edema and tissue tension. The size of the open wound can be reduced and the edges of the wound can be brought closer together. With frequent debridement of the necrotic tissue and adding socks for shrinkage, often a big open wound can be healed without surgery (<a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-15.jpg">Fig. 14</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-15.jpg">Figure 14. Removable Rigid Dressing facilitated shrinkage of the limb (upper left) and the open wound. By frequent debridement and prosthetic fitting (upper right), the wound completely healed without skin graft (lower left).</a> <h3>Scotchcast™ Preparatory Prosthesis</h3> When the patient is able to tolerate full weight bearing in the R.R.D. and the residual limb is no longer bulbous, a Scotchcast™ preparatory prosthesis can be fit for early gait training and further shrinkage.<a></a> The advantages of the Scotchcast™ preparatory prosthesis are its moderately light weight, comfortable fitting, rare need for realignment, and reduction of fabricating time. This is achieved by, 1) direct formation of the socket on the residual limb with special pressure relief techniques, 2) use of a wool sock lining as the soft interface, and 3) precise semi-dynamic alignment of the prosthesis. Since the Scotchcast™ prosthesis can be fabricated within 1 1/2 hours during the patient's initial visit, the delivery of this prosthetic service is very efficient and cost effective. <h3>Conclusion</h3> The Removable Rigid Dressing has proved to be a very reliable means of preprosthetic management of the below knee amputee at this institution and others for the past nine years. It has proven to shorten the time from amputation to the initial preparatory prosthesis; is shown to be equal to or superior to all other means of preprosthetic stump management; features easy application; simple donning and doffing by the patient; progressive stump shrinkage by adding socks under the cast; gives protection through its rigidity for the not yet healed stump; ease in wound inspection; and allows early weight or pressure bearing to be started, thus conditioning the soft tissues for the first prosthesis. The R.R.D. has no contraindications other than application to a residual limb with a deep wound infection that requires surgical intervention. <h3>Acknowledgments</h3> The authors wish to express their appreciation to Henry B. Betts, M.D., Robert Keagy, M.D., Nasim Rana, M.D. and Dudley Childress, Ph.D., for their support in the development and demonstration of this technique. References: <ol> <li>Burgess, E.M. and Romano, R.L., "The Management of Lower Extremity Amputees Using Immediate Postsurgical Prostheses," Clin. Orthop., 57, 1968, pp. 137-146.</li> <li>Burgess, E.M., Romano, R.L., and Zettl, J.H., "The Management of Lower Extremity Amputations," Technical Report TR10-6, Prosthetic and Sensory Aids Service, Departments of Medicine and Surgery, Veterans Administration, Washington, D.C., 1969.</li> <li>Kay, H.W. and Newman, J.D., "Relative Incidence of New Amputations: Statistical Comparisons of 6,000 New Amputations," Orthotics and Prosthetics, Vol. 29, No. 3, 1975.</li> <li>Mooney, V., Harvey, J.P., Jr., Mcbride, E., and Snelson, R., "Comparison of Postoperative Stump Management: Plaster vs. Soft Dressings," Journal of Bone and Joint Surgery, 53-A, March, 1971, pp. 241-249.</li> <li>Mueller, M.J., "Comparison of Removable Rigid Dressing and Elastic Bandages in Preprosthetic Management of Patients with Below-knee Amputations," Physical Therapy, 62, 1982, pp. 1438-1441.</li> <li>Wu, Y. and Flanigan, D.P., "Rehabilitation of the Lower-Extremity Amputee with Emphasis on a Removable Below-Knee Rigid Dressing," pp. 435-453, and "Gangrene and Severe Ischemia of the Lower Extremities," edited by John J. Bergan, M.D. and S.T. James Yao, M.D., Grune and Stratton, New York, 1978.</li> <li>Wu, Y., Keagy, R.D., Krick, H.J., Stratigos, J.S., and Betts, H.B., "An Innovative Removable Rigid Dressing Technique for Below-the knee Amputation," Journal of Bone Joint Surgery, 61A, 1979, pp. 724-729.</li> <li>Wu, Y., Brncick, M.D., Krick, H.J., Putnam, T.D., and Stratigos, J.S., "Scotchcast™ P.V.C. Interim Prosthesis for Below-knee Amputees," Bulletin of Prosthetics Research, BPR 10-36, Fall, 1981.</li> <li>Parhad, A., Gervis, B., and Wu, Y., "From The Clinic: The Rigid Dressing; Pre-prosthetic Ambulation for the Below-knee Amputee, Amer. Corr. Ther. J., 37, 1983, pp. 66-89.</li> <li>Gervis, B., Parhad, A., and Wu, Y., "From The Clinic: Fabrication of the Removable Rigid Dressing and Supracondylar Cuff for the Below-knee Amputee," Amer. Corr. Ther. J., 35, 1982, pp. 126-133.</li> <li>Wu, Y., Krick, H.J., and Sankey, J.A., "Postoperative and Prosthetic Management of Below-knee Amputee with Removable Rigid Dressing and Scotchcast™ Preparatory Prosthesis." Proceedings of 8th annual Conference of Rehabilitation Engineering Society of North America, 1985, pp. 370-372.</li> </ol> Harold Krick, CP. Rehabilitation Institute of Chicago, 345 E. Superior Avenue, Chicago, Illinois 60611. Yeongchi Wu, M.D. Rehabilitation Institute of Chicago, 345 E. Superior Avenue, Chicago, Illinois 60611. <div style="width: 400px;"></div> Page Number(s) 33 - 44 Year 1987 Volume 11 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-02.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-06.jpg Figure 7 FIGURE 7 (a,b,c) http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-07.jpg FIGURE 7 (d,e,f) http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-08.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 3 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-03.jpg Figure 8 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-09.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-10.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-11.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-12.jpg Figure 12 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-13.jpg Figure 13 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-14.jpg Figure 14 http://www.oandplibrary.org/cpo/images/1987_01_033/1987_01_033-15.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Removable Rigid Dressing for Below-knee Amputees Creator An entity primarily responsible for making the resource Yeongchi Wu, M.D. * Harold Krick, CP. * https://staging.drfop.org/files/original/c4b9c484b01dbcb349e2f7553d8c16d3.pdf a0e06974f43dc39c32206828207898bb https://staging.drfop.org/files/original/6b9aa45d405b3eb6edf60ed6f2583718.jpg ec3cec476e908cf5388f484ed47c4021 https://staging.drfop.org/files/original/ad87bb362ff24b53b0bd4c87f0bc9055.jpg e2e1755f9d34505fd352ad608b70b1b4 https://staging.drfop.org/files/original/e4ef8c646c8299dea2dcaf82690c7033.jpg 6f834bb52cdba95d3228c37cdfe360fe https://staging.drfop.org/files/original/0495aa63dee60d41844c8045ccfe9f17.jpg 8ed64542446ac701a3e0cb8696d61f00 https://staging.drfop.org/files/original/2b9b8acc8d0d10ae27922541c7846cf9.jpg b1aeeea2be400bc3155d32ec17438c86 https://staging.drfop.org/files/original/838448779f3df30146197fb16d701a12.jpg 67e983e840d84f6fd7d70e0ac5bdc721 https://staging.drfop.org/files/original/2c2e777bb3d61d2e18a76c9eb109d2fc.jpg 3d695f19795573f5c956f14eba7bf3d5 https://staging.drfop.org/files/original/905f9f7a7990bdd2e91147c76b480421.jpg 8097f171d6eaefdbbdd1b0648a85ccbb https://staging.drfop.org/files/original/d365de13e8ef358378928b8d72c355f6.jpg a155984092d328cef91c3a43e36ed846 https://staging.drfop.org/files/original/c00d56cd7eb635ebe196a82082567556.jpg 728482c9abdc3071fab1d4d5a219c141 https://staging.drfop.org/files/original/bc6d72ff9c92b0b0b491c095cb2c1e9a.jpg 3e9426381c4011ee132611a0e63a8988 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_01_045.pdf Text Any textual data included in the document <h2>Transparent Preparatory Prostheses for Upper Limb Amputations</h2> <h5>Terry J. Supan, C.P.O. <a style="text-decoration: none;">*</a></h5> The use of preparatory prostheses for lower extremity amputations has been widely published and publicized throughout the United States. Although techniques may differ from thermoplastic, laminated, or synthetic casting material for the socket, the concept of early fitting with a prosthesis to reduce the volume of the residual limb are fairly well adhered to. However, little has been publicized about preparatory fitting for arm amputations. Since 1982, the Southern Illinois University School of Medicine has extensively used preparatory prostheses within the 30 day post-amputation time period. Techniques have changed gradually over the last four years, but a fairly constant, successful technique has evolved at the present time. Although myoelectric prostheses with their ease of therapy training have been the componentry of choice, the prosthesis design can also use conventional componentry. The technique has also allowed us to utilize different componentry on an experimental basis to best determine the optimum componentry for the individual amputee. Prostheses have been used on all levels of amputation from wrist disarticulation through forequarter amputation (<a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-01.jpg">Fig. 1</a>, <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-02.jpg">Fig. 2</a>, <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-03.jpg">Fig. 3</a>, <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-04.jpg">Fig. 4</a>, <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-05.jpg">Fig. 5</a>, and <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-06.jpg">Fig. 6</a>). Since 1984, all prosthetic interfaces have been fabricated out of transparent material. Materials have either been Surlyn® or Durr-Plex. The transparent materials were chosen to improve monitoring of the residual limb during volume change. Surlyn™ is used for below and above fitting sockets, while Durr-Plex is used for shoulder disarticulation and forequarter frames. With each of these systems, the prosthesis can be altered through heat forming as the patient's volume changes. <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-01.jpg">Figure 1. Left wrist disarticulation amputation secondary to trauma.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-02.jpg">Figure 2. Left wrist disarticulation myoelectric prosthesis with supracondylar cuff to maximize supination and pronation.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-03.jpg">Figure 3. Right mid-shaft below-elbow amputation, secondary to trauma and reattachment failure.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-04.jpg">Figure 4. Right below-elbow prosthesis with supracondylar suspension and electric wrist rotator. Note that electronic controls, Otto Bock #, are mounted parallel to the electric rotator.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-05.jpg">Figure 5. Right humeral neck above-elbow amputation secondary to trauma.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-06.jpg">Figure 6. Shoulder disarticulation frame type prosthesis fitted to short above-elbow amputation.</a> Standard electric prosthetic componentry has been used in all cases. However, minor modifications to the prosthesis/componentry interface have been necessary. Componentry which utilizes separate stainless steel electrodes from the amplifiers (Motion Control, VANU, and UNB) have been modified to use the stainless steel electrode developed for the Motion Control systems. Prostheses which utilize one piece electrode amplifiers (Otto Bock, Liberty Mutual) are primarily held in place utilizing Velcro® compression straps (<a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-07.jpg">Fig. 7</a> and <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-08.jpg">Fig. 8</a>). All loose wires are held in place with either strapping tape or duct tape. Manufacturers' recommendations concerning shielding of wires and electrodes are also followed. <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-07.jpg">Figure 7. Close-up view of electrode site in Surlyn® wrist disarticulation prosthesis. The area of the Otto Bock electrode extension tabs have been modified in the socket with a Dremmel tool to prevent rotation of electrode on skin.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-08.jpg">Figure 8. Otto Bock electrode mounted into preparatory prosthesis. Velcro® maintains the electrode from passing completely through the socket.</a> An amputee's decrease in limb volume is monitored monthly until the volume has stabilized. If revisions of scar tissue, skin grafts, etc., are necessary, it is recommended that they be done during this time period as well. Modifications to the prosthesis must be made to maintain good electrode contact as well as suspension. Sockets may be split and Velcro® compression straps added if necessary. Electrodes may be replaced or locations adjusted if necessary (<a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-09.jpg">Fig. 9</a>). Although this is easily done with the Motion Control stainless steel electrodes by simply drilling another hole, it also can be accomplished with the Otto Bock or Liberty Mutual electrodes. If a hole saw is used to drill out the new location for the electrode, the cut-out material can be utilized to repair the previous location in the preparatory prosthesis. <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-09.jpg">Figure 9. Close up view of preparatory below-elbow prosthesis. Hook Velcro® adhesive backing is used to suspend the electrode in the prosthesis. Previous incorrect electrode site is repaired with cut-out from new electrode site. Battery pack is held in place with adhesive backed Velcro® as well.</a> Since 1982, 25 upper extremity amputees have been fit with this system. It has allowed us to closely monitor the development of the maturation process of the residual limb. Adjustments to the prosthesis have been made with minimal fabrication time. Total replacement of the preparatory prosthesis was only necessary in two cases. All other cases could be accommodated by modifying existing prostheses. All but one patient (forequarter amputation) went on to fitting and delivery of their permanent prosthesis. The results of these patients' permanent prostheses are consistent with the findings of Malone, et al.<a></a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-10.jpg">Fig. 10</a>, <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-11.jpg">Fig. 11</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-10.jpg">Figure 10. Posterior view of preparatory shoulder disarticulation prosthesis. Elastic strap superior to the shoulder improves comfort. Split of posterior frame into sections allows sitting comfort without electrode displacement.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-11.jpg">Figure 11. Lateral view of shoulder disarticulation prosthesis. Auxiliary switch is used to alternate EMG control between electric wrist rotation, hand opening, and closing.</a> References: <ol> <li>Malone, J.M., M.D., et al., "Immediate, Early, and Late Postsurgical Management of Upper-Limb Amputation," Veterans Administration Journal of Rehabilitation, Volume 21, No. 1, May, 1984, pp. 33-42.</li> </ol> *Terry J. Supan, C.P.O. member of the clinical faculty at Southern Illinois University School of Medicine. Correspondence should be addressed to Southern Illinois University, Orthotic and Prosthetic Services, Room 102. 707 North Rutledge Street, Springfield, IL 62702. <div style="width: 400px;"></div> Page Number(s) 45 - 48 Year 1987 Volume 11 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1987_01_045/1987_01-045-11.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 Transparent Preparatory Prostheses for Upper Limb Amputations Creator An entity primarily responsible for making the resource Terry J. Supan, C.P.O. * https://staging.drfop.org/files/original/3ffbae347395bd6358c27cde8e640cb0.pdf 3c1e43504bc5fe368e6d0b52b9ee3f23 https://staging.drfop.org/files/original/9ac99d90904964fbf707150717e8a50d.jpg e8ed5e738c54bbb55d742a611ae695ee https://staging.drfop.org/files/original/ae0d69cc03a931e61faf1371e769a573.jpg d2fbffa8ce932cf04e3bbdd2c30ac089 https://staging.drfop.org/files/original/d14a435b32caa77db0a8b81558fc2602.jpg 7ce6b179856dd2279ee95f246865d131 https://staging.drfop.org/files/original/ae0b927d201ab181204f175621d042cd.jpg 83325cd779700fe7327eb2b2a9fe16c2 https://staging.drfop.org/files/original/579595b2c3c9b825d4166f0f46b2ddcb.jpg b4f9c82d3f4974e187d4f4d785cde9cb https://staging.drfop.org/files/original/5ec23f79cd46fa212e8306f193030545.jpg e405e2a5b3e94e3baf1ae65b44e6f8c6 https://staging.drfop.org/files/original/b0762e6b36e5df9b2a7e8c7426c8d107.jpg 2c44ad68219084068c067bd70e3bf532 https://staging.drfop.org/files/original/9cfc6bce48e4a77f4899bd6853abaaca.jpg 7559251e1534b6a37a9dafafac9208f5 https://staging.drfop.org/files/original/f0f4b6501a67d0595fce6cd598f39cdb.jpg b7c470836998260c1b30dccb65f3d5e6 https://staging.drfop.org/files/original/b5efb724727d5b4455261299add09b51.jpg 7cbd41bff0429cfb9b1ca402ec264ca7 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_01_049.pdf Text Any textual data included in the document <h2>Modular Seat-Shells and Standardized Manufacture of Individually Shaped Seats for the Severely Disabled: The Tubingen Experience</h2> <h5>George Neff <a style="text-decoration: none;">*</a> Klaus Fischer <a style="text-decoration: none;">*</a></h5> From the Editor: This article was received too late for inclusion in the Fall, 1986 issue devoted to seating and thus is presented in this issue. The authors' effort in submitting it is greatly appreciated. Over the years, proper seating for the severely disabled has been neglected. Often, an approximate position of the patient in commercially available "grandfather-chair" seats, upholstered with cushions, seemed to be sufficient for the needs of these individuals. Custom shaped seats manufactured in the usual manner to taking a plaster cast, and molding the seat-shell of plastic material on this plaster model, after rectification, have proven to be helpful at least for limited periods, especially for growing children. However, often, during the time of plaster taking, an unfavorable position of a child, especially in cerebral palsy children, could be achieved, causing a permanently defective position for the child in such a seat. Moreover the entire process was time consuming, requiring the presence and active participation of an experienced and, therefore, expensive orthotic specialist. Also, the presence of the patient for a long period was necessary in comparison to our present procedure. In 1978, we started a program for the improved manufacture of seats, using prefabricated seat shells and standardized patterns for the manufacture of individually shaped and adjusted seats for patients with seating problems, due mainly to neuromuscular diseases like cerebral palsy, muscle dystrophy, multiple sclerosis, and so on. The idea was to improve the seating comfort of our patients and to increase the adjustability for growth and clothing. At the same time we wanted to reduce the amount of work necessary, especially for the orthotist. Presently, there are six different sizes of prefabricated seat shells made from glassfiber-reinforced polyester resin. These are divided in the seat and the back section and are connected with strong hinges integrated into the laminated resin (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-01.jpg">Fig. 1</a>). For each size of these seat shells, standardized inserts of polyethylene are necessary to form a second, innershell. The inner shells consist of one seat, one back, two upper and lower lateral parts (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-02.jpg">Fig. 2</a>). The parts of the innershell are fixed to the outer seat-shell with screws. The holes are drilled with the use of a permanent pattern or die (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-03.jpg">Fig. 3</a>). This allows for the quick exchange of one or the other part of the seat. They can also be removed for easy cleaning, reshaping, or for the addition of spacers between the inner and outer wall for proper fit with respect to clothing and climate (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-04.jpg">Fig. 4</a>). Foot-rests, headsupports, handles, quick-exchange boards are also prefabricated in standardized sizes and on stock in the workshop. By this means, the orthotist gains more time to devote attention to the needs of the patient and to optimize his position, because he does not need to devote time to the production of these items. <a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-01.jpg">Figure 1. Four of six sizes of the modular seatshell. Two hinges connect the back and seat sections.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-02.jpg">Figure 2. Seat, back, two upper side, and two lower side inner sections to be mounted in the seatshell.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-03.jpg">Figure 3. Use of the permanent pattern, or die, for drilling of screw holes, in a standardized array, in the seatshell for mounting of the inner sections.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-04.jpg">Figure 4. In the foreground, spacers for insertion between seatshell and inner shell to allow for seasonal variation in clothing. In the background can be seen foam rubber pieces to be glued to the inner shell.</a> Prior to the initiation of this fitting procedure, the responsible physician, physiotherapist, occupational therapist, and the orthotist have to decide what they want and how the patient is to be best positioned with respect to his daily living and physical abilities. The individual fitting of the module is achieved by optimal positioning of the patient in a seat shell of appropriate size and by positioning roughly cut foam rubber pieces between the patient's body and the sidewalls, seat, and back of the seat shell. After having made a rough alignment of the foam rubber pieces, they are glued to the inner parts of the seat. Then they are removed entirely and ground down to the proper shape until each of the six pieces fit properly (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-05.jpg">Fig. 5</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-05.jpg">Figure 5. Foam rubber pieces have been glued in place and ground to proper contour and fit.</a> Another solution is used for children with extensive spasticity. After selection of the proper size seat shell and inner-liner, the child is covered completely, including legs, arms and head, with layer of foam rubber and isolated by a piece of plastic foil or film. This is to prevent polyurethane foam from coming into direct contact with the patient's clothing or skin and to prevent burns. The patient is then positioned as well as possible in the modular seat shell. This is preferably done by the therapist or the mother of the child so as to prevent spasticity as much as possible and to optimize the posture of the child. If necessary, a foam rubber wedge is placed between the knees to create slight abduction of the legs. Then, the free space between the body and the seatshell module is filled with polyurethane foam (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-06.jpg">Fig. 6</a>). After the foam hardens, the child is removed from the seat and the foam is cut along the borderlines of the six parts of the insert, including the lengthened backpart for a headsupport if its use is necessary (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-07.jpg">Fig. 7</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-06.jpg">Figure 6. The child is held in place while the void between him and the seat is filled with polyurethane foam. Child is protected against exposure to foam with a layer of plastic film and against thermal burns with a layer of foam rubber. This also allows for the layer of foam rubber to be subsequently added for comfort.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-07.jpg">Figure 7. Seat following completion of the foaming procedure.</a> Each piece of foam is then ground to the proper fit and covered with a layer of foam rubber to prevent pressure sores and for sitting comfort. The same procedure is carried out for those seats for which polyurethane foam was not used. By adding more foam rubber and grinding the six different parts to proper fit, an individually optimized shape of the interior of the modular seat shell is achieved. A headrest may be made from a separate piece of polyethylene padded with foam rubber and shaped to properly fit the individual patient. It is fixed with adjustable metal bars on the backside of the seatshell. Another solution is the so-called integrated headsupport which is not removable, in contrast to the above-mentioned type. It is made from a sheet of polyethylene as an elongation of the polyester inner-layer of the back (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-08.jpg">Fig. 8</a>) on which foam rubber is glued and shaped to size. An additional pillow for the neck and head is easily removed and attached to the headrest by means of Velcro® fasteners. <a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-08.jpg">Figure 8. Section of polyethylene added to the top of the innershell to serve as the foundation upon which an integrated headrest will be built.</a> In most cases, additional fixation of the patient is necessary to prevent him from falling out of the seat, e.g. during a sudden spastic convulsion. In moderate cases, safety belts adapted to the seat may be sufficient. If a more secure purchase is necessary, the lateral parts of the backrest are elongated at the level of the sternum and closed in around the front of the chest by an additional belt (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-09.jpg">Fig. 9</a>); or, an entire thoracic pad, made of a sheet of polyethylene, covered with foam rubber and ground to a snug fit, is fixed firmly to the seat by a hinge on one side and a clasp on the other to provide proper hold of the body. In severe cases, for example in athetoid spasticity, we use a kind of apron with a belt-system (<a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-10.jpg">Fig. 10</a>) to keep the pelvis and the trunk in proper position within the seat. <a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-09.jpg">Figure 9. Completed seat showing restraint system and anterior thoracic extension.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-10.jpg">Figure 10. Completed seat showing apron and belt arrangement for restraint.</a> It is essential to provide enough free space for the bent knee joints. If necessary, the module and the seat part have to be cut out to allow for comfortable sitting. The abduction wedge must fit correctly too; otherwise it may increase spastic adduction patterns. Due to the hinges between the seat and the backpart, and a stop on either side of the seat module, the patient can be leaned back in his seat, if desired. In patients with limited movement in the hip joints, the seat part may be divided longitudinally. Then, each half can be adjusted independently to the individual position of either leg. Additional armrests are used to prevent injuries to hands and arms if they are uncontrollable. For children and wheel-chair-bound adults a removable table may be added to the seat within the range of motion of both arms and the body, providing enough space for playing with toys, eating, paper work, and so on. Finally, prefabricated footrests make sure that the entire body is in a proper and comfortable position. Our footrest is adjustable to height and inclination as dictated by the patients' needs. The quick-exchange board system allows for easy removal of the entire seat from the wheel chair, normal chair, or the regular seat of a car. The wooden board of the seat is fixed with one or two special clasps and a "U" shaped metal stop to a second board which is screwed to the wheel chair or another chassis. This disconnecting device provides stable and safe fixation of the seat and the patient to the respective underlying surface. If it seems preferable to first try the unfinished seat before finishing, the patient uses the seat at home for one or two weeks. After a final check and correction, the different parts of the insert are removed once more and covered with a strong and long lasting colored nylon-velour. This gives the entire assembly a lively appearance, quite different from the ordinary "medical" wheelchair design. Since we started this seating program, approximately 500 patients have been fit with this device. Each was provided with an individually shaped seat by using modular seat shells and pre-fabricated componentry to the largest extent possible. Only a few severely handicapped individuals had to be fit in the conventional manner by taking an individual plaster of Paris cast to create a mold for a seat. Thus, we recommend the use of prefabricated modular seat shells and componentry for satisfying the seating needs of the physically disabled. *Klaus Fischer Klaus Fischer, Orthopadie-Mechanikermeister, can be contacted c/o Fa. Brillinger at Orthopadie-Technik, Rhein-landstraBe 18, D-7400 Tubingen, Federal Republic of Germany. *George Neff Priv. Doz. Dr. Med. Georg Neff is with the Department Technical Orthopaedics at the Orthopaedic University Hospital, Calwer Straße 7, D-7400 Tubingen, Federal Republic of Germany. Page Number(s) 49 - 54 Year 1987 Volume 11 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1987_01_049/1987_01_049-10.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 Modular Seat-Shells and Standardized Manufacture of Individually Shaped Seats for the Severely Disabled: The Tubingen Experience Creator An entity primarily responsible for making the resource George Neff * Klaus Fischer * https://staging.drfop.org/files/original/57984a195780837231c3d47547393acc.pdf 11789779a85e2b709280689bf0e71309 https://staging.drfop.org/files/original/229e5d0143847fe4a628fb14ddec46e4.jpg be7e746d002f06941f613b3ffcdfe220 https://staging.drfop.org/files/original/c42e1a9caf2711b34235fffd340b847a.jpg b9f313905f981a7b1b591b553ac76025 https://staging.drfop.org/files/original/65483353f040cfd3076c229f9103ba79.jpg f7f25aeeda8fcb9417fcb2a3f14480d5 https://staging.drfop.org/files/original/48332643526aa1b923893a54d16f1d14.jpg 6fdbc24c287659b506d32920ab794a07 https://staging.drfop.org/files/original/2bfcb2f521edd120186e036fda6d7d8f.jpg 6ecc7fab73b16908b5797aa5757d6bfd Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_02_066.pdf Text Any textual data included in the document <h2>A Physiologic Rationale for Orthotic Prescription in Paraplegia</h2> <h5>Robert L. Waters, M.D. <a style="text-decoration: none;">*</a> Leslie Miller, R.P.T. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> A difficult clinical decision to be made when treating a paraplegic patient is deciding if walking is a realistic goal, if orthoses should be prescribed, and what the functional outcome will be. It has been demonstrated that the energy expenditure for paraplegics, utilizing a crutch assisted swing-through gait pattern, is markedly elevated. Many patients have learned to walk with crutches and orthoses, but discontinued their use after discharge from a rehabilitation center.<a></a> Studies of other forms of bracing also reveal elevated energy expenditure.<a></a> In this review, we will describe the indications for prescribing ankle-foot orthoses and knee-ankle-foot orthoses. We will then outline the criteria used at Rancho Los Amigos Medical Center to determine whether or not a paraplegic is a candidate for ambulation. These criteria are based on the results of energy expenditure measurements of 150 patients with traumatic paraplegia.<a></a> Further investigation of the data collected revealed that the proprioception level or pattern seemed a reliable indicator of which patients would achieve ambulation, while muscle function seemed to determine the quality of their ambulation. These results have helped us to develop guidelines for projecting the functional outcome of ambulation of paraplegics. <h3>Orthotic Prescription</h3> The goal of orthotic management in paraplegia is to provide the external support necessary to compensate for the motor and sensory deficits. Joint range of motion, muscle strength, proprioception, sensation, and spasticity are evaluated when determining the orthotic prescription. Knee-Ankle-Foot Orthosis (KAFO) Quadriceps strength less than "Fair+" on manual muscle testing is the most common indication for a KAFO. The KAFO is locked at the knee while walking. Although some patients with less than "Fair+ " strength are able to ambulate a short distance without a locked knee (knee stabilization), knee instability usually occurs after a few steps. The exception is the patient with severe quadriceps spasticity which maintains the knee in extension, eliminating the need for external support. Another indication for a KAFO is impaired or absent knee proprioception. The lack of proprioception can result in knee instability even when the quadriceps strength is "Fair+" or greater, as the patient is unable to monitor joint position. If light touch sensation is present on the front of the thigh, a KAFO which allows knee flexion is usually sufficient to control the knee. The anterior stop of the knee mechanism limits extension at 180 degrees and the patient feels pressure from the anterior thigh cuff. In this regard, the brace serves as a transducer that converts proprioception (which is not perceived) into pressure (which is perceived). The final indication for extending bracing above the knee is a severe hyperextension thrust during stance. Paraplegics whose gait is characterized by a hyperextension thrust may develop ligamentous instability, due to attenuation of the posterior cruciate ligament and posterior knee capsule resulting in hyperextension deformity. Range of motion at the hip from 0 degrees of extension to 110 degrees of flexion should be present. In the absence of hip extensor muscles, full hip extension range is necessary to allow the patient to lean backwards and move the center of gravity of the trunk posterior to the hip joint (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-1.jpg">Fig. 1</a>). Hip flexion to 110 degrees, with the knee extended, enables the patient to come to standing with locked KAFO's and rise from the ground after a fall. Full knee extension is required for optimal fit. <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-1.jpg">Figure 1. Standing posture.</a> Ten degrees of dorsiflexion at the ankle is the minimum necessary for unassisted upright balance (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-1.jpg">Fig. 1</a>). Normal proprioception in at least one hip also facilitates unassisted standing. Inability to meet the joint range requirements described above commonly occurs and is most often due to spasticity or contracture. If satisfactory orthotic fit and posture cannot be achieved, a physical therapy regime that includes stretching exercises or serial casting is often successful when spasticity is mild and the deformity is not longstanding. When severe spasticity or deformity is present, or the deformity has been present for an extended time, the patient should be referred to an orthopedic surgeon. Good trunk strength is necessary to maintain an erect posture in the standing position without excessive weight bearing in the arms. High level paraplegics without adequate trunk strength must exert a strong upwards force by the arms throughout the entire gait cycle to prevent forward collapse and accomplish forward progression. This contributes to the high energy demand. (All swing-through gait candidates are required to perform 50 consecutive dips on parallel bars to insure they have sufficient upper extremity strength and endurance.) Ankle-Foot Orthosis (AFO) Quadriceps strength greater than "Fair" should be present to stabilize the knee if an AFO is prescribed. The patient must also have adequate hip flexion strength to swing the leg forward to achieve a reciprocal gait pattern. The indications for AFO are numerous and include any or all of the following: plantarflexion strength less than "Good," dorsiflexion strength less than "Fair," impaired ankle proprioception, and moderate to severe plantar-flexion spasticity. During normal walking, the plantarflexors are active during the stance phase of gait to prevent excessive forward advancement of the tibia. As a result of forward momentum, the knee passively extends as the body advances forward over the stabilized tibia, and the demand placed on the quadriceps is minimal. Customary manual muscle testing methods fail to place a sufficient load on the plantarflexors to evaluate the force required during gait. The strength required to provide ankle and knee stability is present in patients who can perform 15 to 20 toe raises on one leg. Failure to provide adequate orthotic stabilization of the ankle in patients with inadequate plantarflexion strength may result in ankle instability and knee instability, if the quadriceps and/or hip extension strength is also inadequate. Knee wobble can be a sign of impaired ankle proprioception and/or weakness. This can be eliminated by an AFO with a rigid ankle or anterior ankle stop, which provides distal stability and kinesthetic information via the calf cuff. An AFO may be utilized to hold the ankle in the neutral position when dorsiflexion strength is impaired or there is excessive plantarflexion spasticity. When spasticity is severe, it may not be possible to maintain the foot in neutral, and the patient should be referred to an orthopedic surgeon if non-operative measures prove inadequate. When the ankle is held in a rigid orthosis, ankle stability is gained during midstance. However, a forward thrust is imposed, forcing the knee into flexion at the moment of heel contact. (This knee flexion torque is generated because the rigidly immobilized ankle rotates forward about the point of heel contact.) During normal gait, this torque is avoided by ankle plantarflexion, minimizing the effect of the heel lever. There are two courses of action available to provide ankle stability during stance, while still maintaining knee stability at heel strike. If the patient has "Fair+ " or better ankle dorsiflexion strength and intact proprioception, we fit a metal AFO with a double adjustable ankle joint. A set screw in the anterior channel provides an adjustable stop that prevents excessive dorsiflexion. The posterior stop is left open to allow free ankle plantarflexion. Springs can be added posteriorly if dorsiflexion strength is less than "Fair+." The advantage gained is that restriction of motion during terminal stance is maintained while the normal plantarflexion motion during heel contact is preserved, avoiding the undesired knee flexion torque. If the patient has less than "Fair" dorsiflexors or absent proprioception at the ankle, then the ankle is locked and either metal or plastic is used. To avoid the excessive knee flexion torque when the AFO is locked, the heel of the shoe is undercut. This decreases the heel lever and, thus, the knee flexion torque. <h3>Orthosis Weight</h3> Weight is an important factor to some patients, as is the availability of joint motion of the orthotic system. Plastic, because of its potential to be lighter than metal, is sometimes preferable. For the patient with weak hip flexors, efforts to minimize weight are warranted since any extra weight at the end of the limb will make it more difficult to lift the foot and advance the leg. Lehneis, et al.<a></a> found that improving orthotic stability at the ankle reduces energy costs. It follows, then, that in any orthotic design, stability (control about a joint) should not be sacrificed merely to achieve lighter weight. <h3>Exercise Physiology</h3> It is necessary to understand several fundamental principles of exercise physiology to interpret the results of energy expenditure measurements in paraplegic patients.<a></a> The use of oxygen consumption is based on the fact that during sustained exercise, most of the ATP for muscle contraction is generated by aerobic metabolic pathways. After several minutes of exercising at a constant submaximal workload, the rate of oxygen consumption rises until it reaches a level sufficient to meet the metabolic demands of the exercising muscle. Measurement of the rate of oxygen consumption at this time reflects the energy cost of the activity and indicates the exercise intensity. The oxygen cost per meter walked determines the efficiency of ambulation. The principle fuels for aerobic metabolism are carbohydrates and fats. The oxidation of glucose can be summarized by the following equation: GLUCOSE + 36 ADP + 6 O2 --> 6 CO2 + 44 H2O + 36 ATP During exercise, the extent to which anaerobic pathways contribute to the production of energy depends upon the intensity of the effort. In mild to moderate exercise (approximately 50 percent of the maximal aerobic capacity for untrained individuals), the oxygen supplied to the tissue for the aerobic energy producing reactions is usually sufficient to meet energy requirements. During more strenuous exercise, anaerobic oxidation processes also occurs. The amount of energy that can be produced by anaerobic means is limited. Nineteen times more energy is produced by the aerobic oxidation than by anaerobic oxidation. Also, accumulation of lactate in muscle and blood leads to acidosis, limiting the extent to which intense exercise can be performed. From a practical standpoint, anaerobic oxidation provides an extra supply of energy for sudden bursts of strenuous effort, but these pathways cannot be routinely utilized for a prolonged time. In contrast, when exercise is performed below anaerobic threshold, an individual can sustain exercise for many hours without exhaustion. <h3>Maximal Aerobic Capacity</h3> The maximal aerobic capacity (VO2 max) is the single best indicator of physical work capacity and fitness. It measures the individual's maximum energy production capability. Generally, an individual is able to reach the VO2 maximum within two to three minutes of instituting strenuous exercise. Any disorder of the respiratory-cardiovascular muscle or metabolic systems that restricts the supply of oxygen to the muscle decreases the VO2 max. A physical conditioning program can increase aerobic capacity by several processes which include improving cardiac output, increasing the capacity of the muscle to extract oxygen from the blood, increasing the level of hemoglobin, and increasing the muscle mass. On the other hand, the maximal aerobic capacity can be reduced due to blood loss, paralysis, surgery, negative nitrogen balance, or bed rest.<a></a> The important clinical implication is that the paraplegic patient is usually severely deconditioned as a consequence of the injury. The prescription of orthoses and a walking program should not be initiated until the patient has sufficient strength and maximal aerobic capacity to meet the required energy demand. The deconditioned paraplegic patient will respond to a physical conditioning program just as an able bodied subject with respect to increased strength, endurance, and maximal aerobic capacity.<a></a> In able bodied subjects, the VO2 max also depends on the type of exercise. During lower limb exercise, the VO2 max is greater than the VO2 max for the upper limbs. Since paraplegic patients rely on the upper extremities to walk with the aid of crutches, their energy production capability is inherently limited. The problem in paraplegics is further compounded by the effects of the spinal injury. The upper extremity VO2 max for paraplegics is lower than for able bodied subjects, presumably due to the effects of paralysis and interruption of the autonomic neurological pathways which regulate blood flow and cause venous pooling in the lower extremities.<a></a> For the typical adult male paraplegic, we establish a VO2 max of 20 ml/kg-min during upper arm cranking as the minimal criteria acceptable for entering gait training if a swing-through crutch assisted gait pattern will be required. <h3>Energy Expenditure</h3> Wheeling Versus Normal Walking On a hard, level surface paraplegic wheelchair use is as efficient as normal walking. A comparison of the data in <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg">Fig. 2</a> indicates that when propelling a chair around a 60.5 meter circular track, the speed was almost as fast as normal walking (72 versus 80 m/min).<a></a> The oxygen rate was approximately the same (11.5 versus 11.9 ml/kg/min) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg">Fig. 3</a>), as was the oxygen cost (.16 versus .15 ml/kg/ min). The heart rate was higher in paraplegics using the wheelchair than in normal walking (123 versus 100 BPM) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg">Fig. 4</a>). As previously mentioned, this relates to the lower upper maximal aerobic capacity in paraplegics during arm exercise. From a clinical standpoint, it may be concluded that the wheelchair is a highly efficient means of transportation whose speed and energy requirements are comparable to that of normal walking. <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg">Figure 2. Average velocity in normal subjects and in patients using wheelchairs or orthoses.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg">Figure 3. Rate of oxygen consumption in normal subjects and in patients using wheelchairs or orthoses.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg">Figure 4. Heart rate in normal subjects and in patients using wheelchairs or orthoses.</a> Swing Through Gait Crutch walking with a swing-through gait requires the arms and shoulder girdle to lift the entire weight of the body and swing it forward with each step. The average speed in paraplegics trained to use a swing-through crutch assisted gait was 64 percent lower than normal walking (20 versus 80 m/min) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg">Fig. 2</a>); the rate of oxygen consumption was 38 percent greater (16.5 versus 11.9 ml/kg/min) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg">Fig. 3</a>); the oxygen cost was 560 percent greater (.84 versus .15 ml/kg/min); and the heart rate was increased 46 percent (145 versus 99 BPM) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg">Fig. 4</a>).<a></a> This rate of energy expenditure requires most of the aerobic capacity of the typical adult male paraplegic with a complete T12 lesion and is well above the anaerobic threshold. The extreme exertion required for a swing-through gait demands a greater intensity of physical effort than a normal individual customarily expends on sports activity such as recreational jogging. Consequently, it is not surprising that while the athletic paraplegic may be willing to expend this level of exertion for recreational purposes, he is unwilling to sustain these efforts for normal activities of daily living. Even those patients, who are physiologically capable of sustaining the intense physical effort of a swing-through gait for a sustained time period to travel longer distances, find tachypnea (rapid breathing), tachycardia (rapid heart rate), and hidrosis (sweating), unacceptable for routine activities of daily living. We believe that the highly motivated paraplegic who is willing to exercise strenuously should not be discouraged from walking, but a more realistic approach should be taken for the average patient. The average patient should be given walking training and bilateral knee-ankle-foot orthoses only if walking is necessary for psychological reasons, for purposes of exercise, or because of architectural barriers in the living environment. It should be clearly explained that the wheelchair should be considered as the primary means of mobility. We have tested three patients with "Fair+" hip flexors who used bilateral KAFO's and preferred a reciprocal gait pattern.<a></a> Interestingly, the effort expended by these patients was just as great as in swing-through gait (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg">Fig. 2</a>, <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg">Fig. 3</a>, and <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg">Fig. 4</a>). Energy Expenditure: Reciprocal Gait In a review of spinal cord injured patients, Hussey and Stauffer found that those patients who were able to walk in the community had pelvic control with at least "Fair" hip flexor strength and at least "Fair" extensor strength in one knee so that a maximum of one KAFO was required, enabling the patient to achieve a reciprocal gait pattern.<a></a> Having "Fair+" or greater quadriceps strength sufficient to stabilize one knee eliminates the need for one KAFO and enables the patient to walk with a crutch assisted reciprocal gait pattern at a rate of energy expenditure and heart rate that are significantly below that required for a swing-through gait pattern (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg">Fig. 3</a> and <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg">Fig. 4</a>). Surprisingly, we found no difference in the speed and rate of energy expenditure in patients with one free knee or two free knees and requiring bracing only below the knee (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg">Fig. 2</a> and <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg">Fig. 3</a>). Nevertheless, paraplegics who have intact hip flexion and knee extension bilaterally require orthoses only below the knees, and those who use a reciprocal crutch assisted gait pattern are still severely impaired (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg">Fig. 2,</a> <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg">Fig. 3,</a> and <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg">Fig. 4</a>). Compared to normal walking, the rate of oxygen expenditure is 20 percent greater (16.3 versus 11.9 ml/kg/min) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg">Fig. 3</a>), the heart rate 31 percent greater (131 versus 100 BPM) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg">Fig. 4</a>), and the speed 67 percent slower (80 versus 20 m/min) (<a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg">Fig. 2</a>).<a></a> The typical paraplegic who uses crutches and a reciprocal gait still exerts a force of 25 to 50 percent of total body weight on the crutches with each step, accounting for the increased rate of energy expenditure. The only spinal cord injured patients we have tested whose energy expenditure during walking does not exceed normal values are those patients with minimal involvement who have intact sacral function (in addition to lumbar function) and a sufficient hip abductor and extensor strength to maintain an erect posture without crutches. The average distances necessary to perform different daily living activities are listed in <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-5.jpg">Fig. 5</a> and were obtained from numerous measurements made in different types of urban areas in Los Angeles.<a></a> Since the average speed of walking in low lumbar paraplegics who used bilateral ankle-foot orthoses and a reciprocal crutch assisted gait pattern was only 26 m/min, it would take more than five minutes to travel 150 meters. Because five minutes of walking will require a strenuous effort, it is apparent why even the typical low lumbar paraplegic is a limited walker outside the home and is not able to routinely ambulate comfortably for activities which require walking a longer distance. In this regard, clinicians are justified in prescribing a wheelchair to any spinal injury patient who requires crutch assistance. The patients should be encouraged to use the wheelchair as necessary and be reassured that reliance on the wheelchair, when necessary, should not be considered a failure. <a href="http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-5.jpg">Figure 5. Average distances necessary to perform customary activities of daily living.</a> References: <ol> <li>Aastrand, P.O. and K. Rodahl, Textbook Work Physiology, Ed. 2, McGraw-Hill, Inc., New York, 1977.</li> <li>Cerny, K., R. Waters, H. Hislop and J. Perry, "Walking and Wheelchair Energetics in Persons with Paraplegia," Physical Therapy, 60:1133-1139, 1980.</li> <li>Clinkingbeard, J.R., J.W. Gersten, and D. Hoehn, "Energy Cost of Ambulation in the Traumatic Paraplegic," American Journal of Physical Medicine, 43:157-165, 1964.</li> <li>Gordon, E.E., "Physiological Approach to Ambulation in Paraplegia," JAMA, 161:686-688, 1956.</li> <li>Huang, C.T., A.B. McEachran, K.V. Kuhlemeier, M.J. DeVivo, and P.R. Fine, "Prescriptive Arm Ergometry to Optimize Muscular Endurance in Acutely Injured Paraplegic Patients," Arch. Phys. Med. Rehab., 64:578-582, 1983.</li> <li>Hussey, R.W. and E.S. Stauffer, "Spinal Cord Injury: Requirements for Ambulation," Arch. Phys. Med. Rehab., 54:544-547, 1973.</li> <li>Lehneis, H.R., E. Bergofsky, and W. Fresina, "Energy Expenditure with Advanced Lower Limb Orthoses and with Conventional Braces," Arch. Phys. Med. Rehab., 57:20, 1976.</li> <li>Lerner-Frankiel, M.B., S. Vargas, M. Brown, L. Krusell, and W. Schoneberger, "Functional Community Ambulation: What Are Your Criteria?" Clin. Man. in Phys. Ther., 6:12-15, 1986.</li> <li>Waters, R.L., H.J. Hislop, J. Perry, and D. Antonelli, "Energetics: Application to the Study and Management of Locomotor Disabilities," Orthop. Clin. North America, 9:351-377, 1978.</li> <li>Waters, R.L. and B.R. Lunsford, "The Energy Cost of Paraplegic Locomotion," Journal of Bone Joint Surgery, 67A: 1245-1250, 1985.</li> <li>Wolf, E. and A. Magora, "Orthostatic and Ergomet-ric Evaluation of Cord-injured Patients," Scandinavian Journal of Rehabilitation Medicine, 8:93-96, 1976.</li> </ol> *Leslie Miller, R.P.T. Leslie Miller, R.P.T. is a spinal cord injury clinical specialist at Rancho Los Amigos Medical Center. *Robert L. Waters, M.D. Robert L. Waters, M.D. is Chairman of the Department of Surgery at Rancho Los Amigos Medical Center, HB-121, 7601 E. Imperial Highway, Downey, California 90242. Page Number(s) 66 - 73 Year 1987 Volume 11 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-4.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 5 http://www.oandplibrary.org/cpo/images/1987_02_066/1987_02_066-5.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource A Physiologic Rationale for Orthotic Prescription in Paraplegia Creator An entity primarily responsible for making the resource Robert L. Waters, M.D. * Leslie Miller, R.P.T. * https://staging.drfop.org/files/original/9dbe52f7fdd35578cf5246376f655c2a.pdf a3efeb93b0ab8f0a71f9da3dd1aae1cc https://staging.drfop.org/files/original/49c519d9cfc114bc2adb3d22a688c55c.jpg 019d282606c1c336d88f88bb227ae5f9 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_02_074.pdf Text Any textual data included in the document <h2>Post-polio Syndrome: An Overview</h2> <h5>Neil R. Cashman, M.D. <a style="text-decoration: none;">*</a> Irwin M. Siegel, M.D. <a style="text-decoration: none;">*</a> Jack P. Antel, M.D. <a style="text-decoration: none;">*</a></h5> Poliomyelitis was a dreaded disease in developed countries, affecting tens of thousands of children and adults during each of the epidemic years up to the mid-1950s. The polio virus is a small RNA virus whose only natural host appears to be man. The vast majority of exposed persons develop either an inapparent infection or a non-specific flu-like illness (non-paralytic poliomyelitis). Secondary invasion of the brain and spinal cord is associated with infection and death of motor neurons, with loss of innervation to muscle fibers, and consequent muscle weakness and atrophy. Postmortem studies show that muscle weakness in poliomyelitis is clinically apparent only when more than half of the corresponding motor neurons are destroyed.<a></a> Frequently, muscles can be reinnervated by healthy neighboring motor neurons by a process of axonal sprouting. Thus, partial or complete recovery of muscle bulk and strength can occur, in which subnormal numbers of motor neurons support increased (up to 8-fold) numbers of muscle fibers.<a></a> It is estimated that about 250,000 people in the United States have survived paralytic poliomyelitis and are alive today.<a></a> Recently, it has become clear that some patients who had paralytic poliomyelitis may develop new complaints after decades of stable function.<a></a> These new symptoms have been designated the "post-polio syndrome" (PPS) or "late sequella of poliomyelitis." Although some reports of new weakness following polio can be found in the medical literature since 1875,<a></a> recent epidemiologic studies indicate that new symptoms are common, occurring in approximately 25 percent of patients with antecedent paralytic poliomyelitis.<a></a> If this estimate is correct, over 50,000 persons in the U.S. are at risk of developing PPS. From published reports, the mean latency of onset has been calculated to be 36 years.<a></a> Thus, an increasing incidence of new cases will probably continue into the early 1990s, reflecting the last epidemics of the mid-1950s. The risk of developing PPS appears to correlate with severity of the original poliomyelitis. Thus, a patient with four-limb involvement and a history of respiratory dependence during his polio is more likely to develop new symptoms than a patient with one-limb involvement.<a></a> The severity of the original onset of polio also seems to predict the latency of developing the syndrome; severely affected patients may develop new symptoms after only 10-20 years, whereas mildly affected patients are more likely to exhibit extended delays in time of onset of PPS.<a></a> What causes PPS? Why should a patient who has had stable function for decades develop new symptoms? At the present time, there is little definitive data on this subject. Early conjecture focused on a possible reactivation of the polio virus which had remained latent in the nervous system since the original infection. However, there appears to be little or no evidence for inflammation in post-polio patients; spinal fluid is without the cells, protein, and immunoglobulin which characterize other nervous system viral infections. Some investigators have suggested that the normal attrition of neurons with aging may trigger the post-polio syndrome when superimposed on previous static damage of polio.<a></a> However, aging-related loss of neurons in the spinal cord normally begins at about age 60<a></a>; the onset of PPS most commonly occurs 30 years after polio and does not correlate with chronological age of the patient.<a></a> Weichers and Hubbel<a></a> and Dalakis, et al.<a></a> have suggested that motor units grossly enlarged by reinnervation in recovery from poliomyelitis may begin to experience peripheral disintegration with the passage of time. Our own data support this hypothesis in part; late denervation is most common in muscles with the greatest degree of reinnervation. However, we find that group atrophy, a putative indicator of motor neuronal disease (and not terminal axonal degeneration), is also common in patients with prior poliomyelitis.<a></a> Although a bewildering variety of new symptoms are recognized as occurring in PPS,<a></a> most new complaints appear to be subsumed under the three major problems of new pain, new weakness, and fatigue (Table 1). Some investigators have theorized that new muscle atrophy and weakness constitutes a separate syndrome, "postpoliomyelitis progressive muscular atrophy" or PPMA.<a></a> In this scheme, other symptoms of PPS, such as pain and fatigue, are thought to be manifestations of a separate "musculoskeletal" syndrome due to chronic strain of muscles and joints that have been forced to bear weight in an unnatural fashion.<a></a> Common orthopedic deformities in patients with poliomyelitis include knee valgus, varus, and recurvatum, as well as ankle equinus.<a></a> However, new weakness can result in new joint instability, and new joint problems may interfere with efficiency of movement. Although a symptomatic approach to separate complaints of PPS patients is warranted, there is little scientific data that supports a division of sub-syndromes of PPS at present. We have found that even patients without new symptoms have evidence of an ongoing neuromuscular disorder. Table 1 <img src="/files/original/49c519d9cfc114bc2adb3d22a688c55c.jpg" /> New pain is the most common symptom in PPS based on our experience (Table 1) and is a frequent complaint in other series as well.<a></a> We have evaluated patients experiencing pain in conjunction with an orthopod experienced in neuromuscular disease. Several causes of pain are commonly identified in PPS patients. Perhaps the most common cause is insertional tendonitis and/or bursitis from chronic overuse and strain of muscle groups with subnormal strength. Palpation of tendons and bursae at common sites of involvement, such as the pes tendon at the medial knee and the trochanteric bursa, will often reveal profound point tenderness consistent with this syndrome. A trial of rest and non-steroidal anti-inflammatory agents may induce remission in this remitting/relapsing syndrome. For certain local sites, a steroid injection may be useful; weight reduction and readjustment of weight-bearing (through retraining and/or orthotic devices) may also produce long-range benefits. Degenerative arthritis, found most often in weight-bearing joints (where walking aids are used, the joints of the upper extremities may indeed become weight-bearing), may also respond to the same regimen. Nerve compression syndromes characterized by pain and paraesthesias, secondary to positional or repetitive stress, should also be considered in the differential diagnosis of pain in PPS patients. Another type of pain, unrelated to joint "wear and tear" is muscle pain. This occurs frequently during or after exercise and may be associated with cramps, fasciculations, or intense local fatigability. This may be related to muscle substitution and/or overwork in denervated muscle, and may ultimately be associated with permanently increased weakness.<a></a> Treatment of this muscle pain includes avoiding the circumstances which induce it. Rest, orthoses, or even intermittent wheelchair use should also be considered to reduce the load on overworked muscle. Medications which reduce muscle cramps (quinine, diphenylhydantoin) may increase weakness and should be avoided. Fatigue is also a common complaint in PPS patients, occurring in over 60 percent of our series (Table 1). Two types of fatigue are reported by patients: generalized fatigue requiring rest or sleep, and local muscle fatigue. Local muscle fatigue is most common in muscles previously severely affected by polio and is often associated with cramps and fasciculations. Local fatigue may be a manifestation of ongoing muscle denervation and is also reported by patients with classic denervating diseases such as amyotrophic lateral sclerosis.<a></a> Generalized (systemic) fatigue is common in PPS, but may also be a symptom of a variety of other states, including medical conditions such as diabetes mellitus, cardiopulmonary dysfunction, and thyroid disease. Depression ("low energy") may also lead to systemic fatigue. Once medical and psychiatric diseases have been ruled out, systemic fatigue in PPS may be a symptom of widespread neuromuscular junction transmission defects. We have found that patients with fatigue and marked increased jitter in single-fiber electromyography (an indicator of defective neuromuscular transmission) respond to agents which enhance neuromuscular transmission, such as the anticholinesterase pyridostigmine (Mestinon). Rest, ambulatory aids, and activity planning may also alleviate generalized fatigue. New weakness is the third major component of the "post-polio triad" (Table 1). When new weakness occurs with new muscle atrophy, PPS patients are thought by some investigators to suffer from a specific syndrome of post-poliomyelitis progressive muscular atrophy (PPMA).<a></a> It has been suggested that evidence of ongoing denervation (fibrillations and positive waves on EMG, increased jitter on single-fiber EMG, and atrophic muscle fibers on muscle biopsy) are diagnostic for this syndrome.<a></a> However, we have found that electrophysiologic and muscle biopsy evidence of denervation is as common in polio patients who are not having new symptoms, as in patients who have clinically defined PPMA.<a></a> Moreover, evidence of denervation is most severe in muscles which show the most signs of old polio.<a></a> Thus, late denervation appears to be a concomitant of massive monophasic antecedent denervation and not a sign of new disease. In addition, we found that although 14 out of 15 patients who complained of new atrophy also reported new weakness, only about one-half of patients who reported new weakness noted new atrophy.<a></a> Thus, the relationship of atrophy to weakness is not clear. New muscle weakness may put extra stress on a previously borderline compensated muscle, producing pain, cramping, and an "overwork myopathy," with accelerated weakness as an end result.<a></a> It has been estimated that a partially denervated muscle graded "good" must work two and a half times as hard as a normal muscle to accomplish the same task.<a></a> We caution patients with new weakness to reduce activity. Exercise programs must be undertaken with extreme caution, and exercise should never be performed to the point of pain or muscle cramps. We advise patients to exercise limbs not previously affected by polio or, if this is impossible, participate in a carefully graded program in a therapeutically heated pool. One should exercise enough to prevent atrophy of disuse, but not enough to cause damage from overuse. High repetition, low resistance exercises are favored, as well as stretching and isometric drills. Orthotic devices, including the ankle-foot orthosis and knee-ankle-foot orthosis, may provide support for certain critically weakened muscle groups, although adequate function of other muscle groups (e.g., knee and hip extensor function for an ankle-foot orthosis) is a prerequisite for effective use. Wheelchair use should also be considered, sometimes only intermittently, as prolonged activity may predispose the patient to osteoporosis or venous thrombosis. Training in effective transfers, efficient movements, etc. by the physical and occupational therapist may also be useful, as can home help aids such as a shower chair and raised toilet seat. Limb weakness may result in new joint instability, which in turn may be associated with new pain and increasing deformity. It has been noted, for example, that floor reaction with knee hyperextension serves a knee-locking function when the quadriceps is weak.<a></a> However, profound degrees of weakness can provide a "positive feedback" situation where posterior knee ligaments are subjected to more torque stress, leading to further stretching.<a></a> A knee-ankle-foot orthosis (fit with a posterior offset knee hinge) may prevent progressive joint damage in this situation. Pulmonary complaints may occur in patients with previously weakened diaphragm, intercostals, abdominal, or accessory muscles. Frequently, a patient with previous paralytic poliomyelitis, involving muscles of respiration, will have borderline respiratory compensation for decades and will undergo precipitous respiratory failure later in life.<a></a> Increasing scoliosis, aspiration pneumonia, gradual loss of motor units with aging, and other factors may contribute to respiratory insufficiency. Respiratory symptoms (daytime somnolence, snoring, dyspnea, etc.) must be sought in all patients, particularly those with a history of respiratory involvement with polio. Baseline spirometry is also obtained in patients attending clinics. Muscle relaxants and medications which suppress respiratory drive should be avoided. Vaccines (pneumonia and flu vaccines) and cessation of smoking are also important in patient management. New respiratory muscle weakness may also present as sleep apnea, which may respond to medication (e.g., protripty-line), or may require night time oxygen or mechanical ventilation. Pulmonary complaints should always be evaluated and treated in conjunction with a pulmonary physician versed in neuromuscular diseases. The prognosis of the post-polio syndrome depends upon the symptoms experienced by the patient and upon individual (as yet uncharacterized) differences in disease progression. General health care measures (proper rest, nutrition, weight management, etc.) as well as psychosocial support are important. Inflammation in joints and muscles may be managed well with the treatments cited above. At least some patients with PPS fatigue respond to anticholinesterase medications. Progressive weakness, with or without atrophy, is the least responsive symptom of PPS. Respiratory complaints, particularly, should be considered seriously. Fortunately, weakness progresses slowly (about one percent per year according to a recent study),<a></a> and plateaus in function are observed. Although rapid progression of weakness does occur in some PPS patients, other diagnoses such as medical illnesses or superimposed neurologic and orthopedic problems must be considered. A common complaint of post-polio patients is that health professionals do not understand or even believe their new symptoms. Although a breakthrough of understanding on PPS may not occur in the immediate future, it is the responsibility of all health personnel to listen carefully to patients with new problems and provide the best care possible. Specific symptomatic treatment should be made available where appropriate. The patient who has been rehabilitated from the effects of acute polio must now be helped to accept the activity aids and lifestyle modifications necessary to ameliorate his "second disability." <h3>Acknowledgments</h3> This paper was based on our experience at the University of Chicago Post-Polio Clinic, which was made possible by the fruitful collaboration of R. Maselli, R. Wollmann, R. Roos, E. Salazar, F. Brown, E. Nichols, R. Simon, P. Heidkamp, and R. Martia. We thank C. René de Cotret for preparing the manuscript. References: <ol> <li>Sharrad, W.J.M., "Correlation Between Changes in the Spinal Cord and Muscle Paralysis in Poliomyelitis", Proceedings of the Royal Society of Medicine, 40, 1953, p. 346.</li> <li>Cöers, C, and Woolf, A.L. The Innervation of Muscle: A Biopsy Study, Blackwell Scientific Publications (Oxford), 1959.</li> <li>Halstead, L.S., and D.O. Weichers, "Introduction," Late Effects of Poliomyelitis, L.S. Halstead and D.O. Weichers, Symposia Foundation (Miami, FL), 1985, pp. xv-xx.</li> <li>Codd, M.B., D.W. Mulder, L.T. Kurland, CM. Beard, and W.M. O'Fallon, "Poliomyelitis in Rochester, Minnesota, 1935-1955: Epidemiology and Long-term Sequelae: A Preliminary Report," Late Effects of Poliomyelitis, L.S. Halstead and D.O. Weichers, Symposia Foundation (Miami, FL), 1985, pp. 121-134.</li> <li>Jubelt, B. and N.R. Cashman, "Neurologic Manifestations of the Post-Polio Syndrome," Critical Reviews in Clinical Neurobiology, in press.</li> <li>Halstead, L.S., D.O. Weichers, and CD. 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Antel, "Postpoliomyelitis Syndrome: Evidence of Ongoing Denervation in Symptomatic and Asymptomatic Patients," Proceedings of the Second Annual Symposium on the Late Effects of Poliomyelitis, Symposia Foundation (Miami, FL), in press.</li> <li>Maynard, F.M., "Differential Diagnosis of Pain and Weakness in Post-polio Patients," Late Effects of Poliomyelitis, L.S. Halstead and D.O. Weichers, Symposia Foundation (Miami, FL), 1985, pp. 33-41.</li> <li>Tomlinson, B.E. and D. Irving, "The Number of Limb Motor Neurons in the Human Lumbosacral Cord Throughout Life," Journal of Neurological Sciences, 34, 1977, pp. 213-219.</li> <li>Clark, D.R., J. Perry, and T.R. Lunsford, "Case Studies-Orthotic Management of the Adult Post Polio Patient," Orthotics and Prosthetics, Vol. 40, No. 1, 1986, pp. 43-50.</li> <li>Bennett, R.L. and G.C. Knowlton, "Overwork Weakness in Partially Denervated Skeletal Muscle," Clinical Orthopedaedics, 12, 1968, pp. 22-29.</li> <li>Mulder, P.W., E.H. Lambert, and L.M. Eaton, "Myasthenic Syndrome in Patients with Amyotrophic Lateral Sclerosis", Neurology, 9, 1959, p. 627.</li> <li>Perry, J., "Orthopedic Management of Post-polio Sequellae," Late Effects of Poliomyelitis, L.S. Halstead and D.O. Weichers, Symposia Foundation (Miami, FL), 1985, pp. 193-206.</li> <li>Ringel, S.P. and R.J. Martin, "Respiratory Complications and Their Management in Neuromuscular Disorders," Interdisciplinary Rehabilitation of Multiple Sclerosis and Neuromuscular Disorders, F.P. Malone, J.S. Burks, and S.P. Ringel, J.B. Lippincott Co. (Philadelphia), 1985, pp. 211-227.</li> </ol> *Jack P. Antel, M.D. Jack P. Antel, M.D. is Professor of Neurology and Neu-rologist-in-Chief at the Montreal Neurological Institute. *Irwin M. Siegel, M.D. Irwin Siegel, M.D. is an Associate Professor in the departments of Orthopaedic Surgery and Neurological Services, Rush-Presbyterian-St. Luke's Medical Centre, Chicago, IL; Chairman of the Department of Orthopaedic Surgery at Louis A. Weiss Memorial Hospital in Chicago, Illinois; and Director of Muscular Dystrophy Clinics of the above facilities. *Neil R. Cashman, M.D. Neil R. Cashman, M.D. is an Assistant Professor of Neurology at the Montreal Neurological Institute, 3801 University Street, Montreal, Quebec H3A 2B4, CANADA. He developed and directed the University of Chicago Post-Polio Clinic 1985-86. Page Number(s) 74 - 78 Year 1987 Volume 11 Issue 2 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 1 TABLE 1 http://www.oandplibrary.org/cpo/images/1987_02_074/1987_02_074-1.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 Post-polio Syndrome: An Overview Creator An entity primarily responsible for making the resource Neil R. Cashman, M.D. * Irwin M. Siegel, M.D. * Jack P. Antel, M.D. *