8 20 371 https://staging.drfop.org/files/original/934d9d58cdc431c9e0221d32ee8fe951.pdf 9ab98303a3e42383d5edd757b0da7d06 https://staging.drfop.org/files/original/9a0943f435a6d9fe4ed610d2caba0b86.jpg b20aa7224fab12563b41462c3dd6fe20 https://staging.drfop.org/files/original/ac1c440073b39ee145136d5d5c0f8990.jpg caadd7555cef407c05e9e41c66a61ecb 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_079.pdf Text Any textual data included in the document <h2>A New Look at the RGO Protocol</h2> <h5>Lou Ekus, C.P.O. <a style="text-decoration: none;">*</a> Linda McHugh, R.P.T. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> The L.S.U. Reciprocal Gait Orthosis (RGO) is an orthotic device that gives structural stability to the patient with lower trunk and lower limb paralysis while allowing, through a cable coupling system, reciprocal hip joint motion for ambulation. The device has been used at the Shriners Hospital in Springfield, Massachusetts since December, 1980. Our experience with the Reciprocal Gait Orthosis has led us to a simplified approach in the selection, fitting, and training of patients suitable for fitting with this device. <h3>Patient Distribution</h3> Sixteen fittings with the Reciprocal Gait Orthosis have been reviewed for this article. Seven of these children were under the age of four years at the time of their first fitting, with a total of 12 children under the age of eight at the time of first fitting. All 12 children were discharged from the hospital using the orthosis effectively. One child in this group later rejected the orthosis because he was able to ambulate with bilateral knee-ankle-foot orthoses and felt the Reciprocal Gait Orthosis was too much bracing. Out of this group, the remaining 11 children are currently community ambulators and wear the orthosis for most of the day. In addition to these 12 children, we have four young adults who are fit with the Reciprocal Gait Orthosis. Three of them were 13 years old at the initial fitting. Two of these children were discharged from the hospital using the orthosis effectively and are currently household ambulators. The last of the 13 year olds rejected the brace due to an extreme fear of the upright position. Our last fitting was done on a 21 year old male with severe hip and knee flexion contractures. This patient had a tremendous desire to ambulate and so the fitting was attempted. However, after numerous fittings and adjustments, the attempt was abandoned as a result of the severity of his contractures. <h3>Protocol</h3> Our first patient was fit with a reciprocator in December, 1980. Subsequently, 12 children were fit following the general guidelines established by Louisiana State University. In November, 1985, we developed our own written protocol. The protocol was extremely specific, outlining prerequisites before fitting with the Reciprocal Gait Orthosis. The protocol included such criteria as, 1) hip and knees free of flexion contractures greater than 20 degrees, 2) patient required to demonstrate independent mobility in a parapodium, and 3) parents required to admit children for training. After a review of our series up to that point, we realized that few of the patients actually met 100 percent of the criteria in our existing protocol, and yet our success rate was quite high. After a further review of the fittings was done, a revised protocol was written and instituted in June, 1986. Our new protocol for fitting with the Reciprocal Gait Orthosis is outlined below: <ol> <li> Parents and child will watch a video prepared by the hospital showing the fitting and training process for the Reciprocal Gait Orthosis. </li> <li> A team meeting will be held prior to admission with parents and child, physical therapist, orthotist, nurse, social service representative, and physician. At this meeting, goals are set for admission and parents are given the opportunity to ask any member of the team questions that they might have. The child's abilities will be discussed, including a) ability to stand and move in the parapodium, b) emotional and cognitive ability to tolerate training, c) upper extremity strength, and d) any existing joint contractures and their influence on fitting and training. </li> <li> Goals will be set, regarding a) cooperation for training, b) balance and confidence with movement, c) quality of mobility, d) independency in transfers, and e) donning and doffing of the orthosis. </li> </ol> Following fitting and dynamic alignment of the Reciprocal Gait Orthosis, gait training begins. It includes 1) momentary standing balance, 2) training on the parallel bars (patient instructed to "shift weight" and "push back"), 3) progression to a rollator walker when consistent orthotic control, good balance, and even stride length are demonstrated in parallel bars, and 4) progression to Loftstrand crutches when improved independence in balance is achieved and the patient is cognitively able to use them. Three weeks into training, a second team meeting is held. Each goal is addressed and the team determines the best way to continue training based on the reassessed goals. At discharge, the patient will 1) ambulate with the walker, 2) exhibit consistent control in step length, balance and stability, 3) exhibit good standing balance, and 4) be able to negotiate a ramp. <h3>Fitting Problems</h3> Without a doubt, the most consistent problem we've seen in fitting the Reciprocal Gait Orthosis is existing hip, knee, and ankle contractures. We have fit patients with significant contractures of these joints and have accommodated for the contractures in alignment by wedging the shoes (<a href="http://www.oandplibrary.org/cpo/images/1987_02_079/1987_02_079-1.jpg">Fig. 1</a> and <a href="http://www.oandplibrary.org/cpo/images/1987_02_079/1987_02_079-2.jpg">Fig. 2</a>). Our intention is to enable the child to exhibit effective ambulation and then to consider joint releases when possible. <a href="http://www.oandplibrary.org/cpo/images/1987_02_079/1987_02_079-1.jpg">Figure 1. Front view of patient showing extensive pre-existing contractures and shoe wedging to accommodate the contractures.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_02_079/1987_02_079-2.jpg">Figure 2. Lateral view.</a> We have seen, in a few cases, where it is difficult for the patient to comprehend that pushing back will advance the leg. To make this concept more easily understood in the early stages of training, the hip joints are flexed slightly more than usual to allow the patient to grasp this concept easily. This usually makes standing balance impossible. However, after a day or two, the orthosis can be extended and standing balance can be addressed. We found this to be an extremely useful tool in expediting the initial stages of training. <h3>Early Intervention</h3> Taking into consideration the importance of upper limb strength, preservation of range of motion, and weight control before fitting a patient with the reciprocating orthosis, it is easy to see the importance of early intervention in cases of congenital deficiency. Through our myelodysplasia clinic, we are able to follow the patients on an ongoing basis from birth to insure continuing follow up in these areas. It is also possible to insure the delivery of an infant Stander at the appropriate time. The clinic also gives us the opportunity to observe the child in the Stander or parapodium. Mobility in these devices is a good indication of motivation, balance, and the child's awareness of his body moving through space. The myelodysplasia clinic gives us an invaluable opportunity to insure that all of the prerequisites are being nurtured and that we can initiate a fitting with the Reciprocating Gait Orthosis at the appropriate time. <h3>Results</h3> Included in our series of 16 patients are 12 children who are community ambulators. In addition, two children are ambulatory in their household or for short distances, and two rejected the Reciprocal Gait Orthosis as their means of mobility. The age of initial fitting for these children spanned two years to 21 years, with children under the age of eight all being community ambulators. <h3>Conclusion</h3> Clearly, the results demonstrate the importance of both early intervention and early fitting with the Reciprocal Gait Orthosis. We hope that children with congenital paraplegia who initiate ambulation with a Reciprocal Gait Orthosis at an early age will continue to be ambulatory further into adult life than those who have used knee-ankle-foot orthoses in the past. In conclusion, we would like to propose the idea that, based on experience with our protocol, the fitting and training of a child using the Reciprocal Gait Orthosis is no more difficult than other bracing modalities and can be approached with the same ease. References: <ol> <li>Douglas, R., P. Larson, R. Ambrosia, and R. McCall, "The LSU Reciprocation-Gait Orthosis," Orthopedics, Vol. 6, No. 7, July, 1983, pp. 834-838.</li> <li>McCall, R., R. Douglas, and N. Rightor, "Surgical Treatment in Patients with Myelodysplasia Before Using the LSU Reciprocation Gait System," Orthopedics, Vol. 6, No. 7, July, 1983, pp. 843-848.</li> <li>Shanks, K., "LSU Reciprocating Gait Orthosis," Durr-Fillauer Medical, Inc.</li> <li><a href="http://www.acpoc.org/library/1985_03_046a.asp">Ekus, L., "Reciprocator Orthosis: A Protocol," ACPOC, April, 1985.</a></li> </ol> *Linda McHugh, R.P.T. Linda McHugh, R.P.T. is also with Shriners Hospital for Crippled Children. *Lou Ekus, C.P.O. Lou Ekus, C.P.O. is Director of Orthotics and Prosthetics at Shriners Hospital for Crippled Children, 516 Carew Street, Springfield, Massachusetts 01104. <div style="width: 400px;"></div> Page Number(s) 79 - 81 Year 1987 Volume 11 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1987_02_079/1987_02_079-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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Title A name given to the resource A New Look at the RGO Protocol Creator An entity primarily responsible for making the resource Lou Ekus, C.P.O. * Linda McHugh, R.P.T. * https://staging.drfop.org/files/original/22f2bcc00fd13d3ee3dbba5a01cf9dfd.pdf f5dcb905e27a0297a27464a85893dcbb https://staging.drfop.org/files/original/739b1a9158b00278582d96d76ac19145.jpg 925b8b94e9c4b16ea14a5b8e612748f3 https://staging.drfop.org/files/original/c03ea9b706c703a0c23b955ca07c7da5.jpg 6114438d0c7b0f11b4f55fa8ed817d8b https://staging.drfop.org/files/original/13144e1ac56398758d04b22fc4b25fc5.jpg 464fa1a98a48cb3d50fe5a79ca02b7ba https://staging.drfop.org/files/original/d621137e255ef9d7c7e242e2122776f2.jpg 3a8ed62b5588399a696c3c1e1529768f https://staging.drfop.org/files/original/360efe6c756b05e84d50d65ed85add45.jpg cb981259d0b15353cd7336e14fd68c8c https://staging.drfop.org/files/original/8d2cd187f502495317c736775b95b3b1.jpg 7fe8a40aa682646a3bc9513370614734 https://staging.drfop.org/files/original/12aab77dddaf713fca6201a3a944eb99.jpg 89aa7327ec6c0d36aaacad28471c6ea0 https://staging.drfop.org/files/original/743a4583056a4ffceb44d54938b38c0f.jpg c26243f82589c6280ee0cb1f38b09bd7 https://staging.drfop.org/files/original/7bde68b6fc67e46a86f42233817d383a.jpg 8f117df5f4cf67539777c80e85427227 https://staging.drfop.org/files/original/2c4626ebe0deef97dca3a79434d65014.jpg 1774df62ca57088bb04d63e5bfb1501e 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_082.pdf Text Any textual data included in the document <h2>Wheelchairs for Paraplegic Patients</h2> <h5>A. Bennett Wilson, Jr. <a style="text-decoration: none;">*</a></h5> The best current estimates of the incidence and prevalence of spinal cord injury in the U.S. is 30-32 and 900 cases per million of population respectively.<a></a> About half of these cases are paraplegic. Added to this are paraplegics due to spina bifida, a few polio cases, etc. By definition, paraplegics have to rely on one or more assistive devices if mobility is to be achieved. Only a small segment of the paraplegic population make use of lower-limb orthoses, and even those who do have orthoses, and use them, need a wheelchair as well, in order to make the most of their available energy. For the very few who can "walk" enough not to feel the need for a wheelchair in work and activities of daily living, wheelchairs permit participation in athletic activities that would otherwise be impossible. Wheelchairs can be classified as either "manual" or "powered". The manual wheelchair is designed to be propelled by the occupant or by an attendant. Tests have shown that the energy cost of using a manual wheelchair for mobility on a smooth, level surface can be appreciably less than that of unimpaired persons walking on the same type of surface.<a></a> The conditions, of course, are reversed when uneven surfaces or ascending surfaces are encountered. The "powered" wheelchair is designed to be propelled by a battery-powered electric motor or motors. Originally conceived to be used by patients unable to propel themselves, powered chairs are sometimes indicated so that a paraplegic can make more effective use of his own energy. The basic manual wheelchair has two side-frames connected by a cross-bar that is pivoted about its intersection and a flexible seat and back to allow folding, two large driving wheels at the rear, and two caster wheels at the front (<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-01.jpg">Fig. 1</a>).<a></a> This is a configuration that has evolved over the years since the original patented design of Everest and Jennings<a></a> in 1936 for the folding mechanism, and represents a rather elegant compromise between maneuverability, stability, and portability. Many concerted attempts, especially in recent years, to develop better designs have not been very successful. The use of new materials has made it possible to produce significantly lighter wheelchairs, but the original configuration is basically the same. <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-01.jpg">Figure 1. The basic wheelchair-folding frame, 24-inch diameter wheels in the rear, 8-inch diameter casters in the front, flexible seat and back.</a> It must be remembered that a change in the design to emphasize one feature generally affects adversely one or more of the other features. An example is when the wheelbase of the basic chair is lengthened to provide more stability for the bilateral leg amputee; maneuverability is sacrificed. Designers of some of the "sports" chairs, in order to reduce weight, have eliminated the folding mechanism. Portability is achieved by connecting and disconnecting driving wheels for transport in an automobile. <h3>Prescription Considerations</h3> Variations of the basic chair are available for amputees, hemiplegics, and others, but the basic chair of proper dimensions is generally the most suitable for paraplegic patients. The range of dimensions of the basic wheelchairs available in the United States are shown in<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-02.jpg"> Fig. 2.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-02.jpg">Figure 2. Dimension ranges for the basic adult wheelchairs from major U.S. manufacturers.</a> Even when sensation is present, the hammock type seat is seldom used without cushions, which are needed to provide a better distribution of pressure over the thighs and buttocks for comfort, if for no other reason. Cushions and other seating systems affect the relationship between the user and the chair and, therefore, must be selected and taken into account before the final dimensions of the chair are determined. The importance of selecting the most appropriate chair and seat cushion cannot be over emphasized. The dimensions of the chair must distribute the forces of the body properly while also placing the user in a position, with respect to the driving wheels, to provide maximum efficiency during propulsion. <h3>Seat Width And Depth</h3> Selection of the proper seat width is important to comfort and stability. A seat that is too narrow is not only uncomfortable, but access to the chair is made difficult. Furthermore, the chances of pressure sores developing is increased. A seat that is too wide encourages the user to lean toward one side, thus promoting scoliosis and increased pressure over the buttocks on one side. In addition, a seat wider than is necessary makes propulsion more difficult. A seat that is too shallow reduces the area in contact with the buttocks and thighs and causes more pressure on the soft tissues in contact with the seat than is necessary or safe. Furthermore, the location of the footrests is changed so that the feet and legs are not supported properly, and the balance of the user can be affected. A seat that is too long can restrict circulation in the legs. <h3>Seat Height</h3> The height of the seat above the ground of the basic adult chair is 19 1/2 - 20 1/2 inches. Tall persons require a seat that is higher and deeper; short persons require a seat that is lower. Usually these requirements can be met by a stock chair; if not, properly dimensioned units can be had on special order. Obviously, the cushion or seating system to be used will affect the end result. <h3>Seat Type</h3> Seats available from wheelchair manufacturers are sling or hammock types, made of a flexible material, and solid seats which are generally removable (<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-03.jpg">Fig. 3</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-03.jpg">Figure 3. Seat types-a. hammock or sling; b. solid.</a> The sling seats are, by far, the type most used. A solid seat installed to permit folding is available, or a removable solid wooden seat may be purchased or made. <h3>Backrest</h3> The backrest of the basic chair is made of a flexible material stretched between the two side frames which are fixed with respect to the seat. The backrest should be high enough to provide support without inhibiting motion, yet not so low that the scapulae can hang over the back of the chair and cause discomfort. <h3>Arms</h3> <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-04.jpg">Fig. 4</a> <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-04.jpg">Figure 4. The basic wheelchair with the most popular types of arms-removable full-length, removable desk-type, and removable, adjustable desk-type.</a> The lightest chairs have fixed arms or none at all. But an overriding factor in wheelchair prescription is transfer into and from the wheelchair, especially when the patient is unable to stand for a brief period. For this reason, most patients require chairs with arms that can be removed easily. Chair arms not only provide support for the patient's arms in a resting attitude, but also provide lateral support and a reaction point for the hands when the asensitive patient elevates his body at regular intervals to prevent restriction of circulation and thus pressure sores. Both removable and fixed arms are available in full-length and desk models; both of these styles are available with the height fixed or adjustable. The desk models are foreshortened to permit the user to get closer to a desk or table top. The removable desk arm is by far the most popular type. The full length models are indicated when the forepart is needed to support the arms of the user in rising from the chair, or when lordosis, obesity, or some other physical factor makes it necessary to use the front part of the arm for support. The standard removable desk model can be reversed to provide this feature. <h3>Wheels And Tires</h3> The basic chair has two 24 inch diameter rear wheels and two eight inch caster wheels in the front (<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-05.jpg">Fig. 5</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-05.jpg">Figure 5. Basic wheelchair with standard 24-inch diameter wire-spoke wheel and two options: the cast magnesium wheel and a wheel with special built in hand rim.</a> The standard rear wheel for many years has been a wire spoke wheel, but wheels of cast metal alloy and wheels of cast plastic have been made available recently to overcome the maintenance problems inherent in the wire wheel design without adding more weight. Three types of tires are available in several widths and tread types. Pneumatic, semi-pneumatic, and solid tires are available (<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-06.jpg">Fig. 6</a>). The eight inch diameter wheel with solid rubber tires is standard on the basic chair, and is suitable for use on smooth surface and indoors. The semi-pneumatic and pneumatic tires provide shock absorption, and, thus, are more suitable for rough surfaces and outdoor use. <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-06.jpg">Figure 6. Basic wheelchair and optional casters available. Shown on the chair is the standard 8-inch diameter wheel with solid rubber tire. Next in order are: the 8-inch wheel with the semi-pneumatic tire; the 8-inch wheel with pneumatic tire; a 5-inch diameter wheel with solid rubber tire.</a> Pneumatic tires provide a more cushioned ride and their shock absorber action tends to prolong the life of a wheelchair when kept inflated properly. <h3>Handrims</h3> Handrims are attached to the driving wheels of wheelchairs to permit control without soiling the hands. The standard handrim is a circular steel tube. For users who have problems gripping the smooth surface of a metal ring, vinyl coated rings and a variety of knobs and projections can be added to the ring. <h3>Casters</h3> Casters make steering possible and are available in two diameters: eight inches and five inches. The five inch model is available only with solid tires, and is used on children's chairs and in special circumstances on adult chairs and basketball chairs, when more maneuverability is desired. <h3>Parking Locks</h3> Most users need some means of securing one or more wheels to keep the chair from rolling down inclines or to provide stability during transfer to and from the chair. Two types of parking locks are available from the large wheel (<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-07.jpg">Fig. 7</a>): toggle and lever. Selection depends upon user preference. <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-07.jpg">Figure 7. Two types of parking locks-left, toggle type; right, lever type. Variations of these two types of locks are available.</a> Pin type locks are also available. These retain a caster in the trail position and are used to prevent swiveling during lateral transfer. <h3>Cushions</h3> The vast majority of paraplegics require, and can use successfully, seat cushions that are mass produced and are widely available at reasonable prices. A great many designs of seat cushions are available. Some have been developed by trial and error, the designs being based on what has proven to be acceptable to the inventor or his customers; other designs have a more scientific basis, but because the exact cause of decubitus ulcers is not known, precise criteria for design of wheelchair seating have not been established.<a></a> Although each of the cushion designs available has advantages and disadvantages, most of which are not clearly defined, selection of seat cushions for individual cases is seldom simple or straightforward. Commercially available cushions may be divided roughly into five categories, including "miscellaneous" or "other", based on material and design (<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-08.jpg">Fig. 8</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-08.jpg">Figure 8. Various types of seat cushions that are available.</a> <ol> <li> Foam </li> <li> Viscoelastic foam </li> <li> Gel </li> <li> Fluid </li> <li> Other </li> </ol> Foam Cushions Foam cushions generally use polyurethane or polyether foam, and are available in various configurations. The simplest are homogeneous rectangular blocks 2-4 inches thick; some are contoured; and others are composed of two or more layers of material of different densities, some of which may contain hollow spaces or cores in an attempt to distribute the load to specific areas. Viscoelastic Foam Cushions Viscoelastic foam is less resilient than ordinary foam. Gel Cushions Gel cushions consist of rather firm emulsion enclosed in a "non breathing" plastic casing. Fluid Flotation Cushions Water, air, or water-and-foam particles are used in a flexible, tailored plastic bag to provide distribution of forces. The overall effect varies with the amount of fluid introduced. Other Types Many other designs that combine several elements are available. Prominent among these are the ROHO, which uses a collection of air-filled tufts to distribute the loads and the VASIO (Veterans Administration Spinal Injury Orthosis), in which foams of two different densities are combined and contoured to meet the special needs of paraplegic patients. Each type and design has advantages and disadvantages, and, therefore, selection of the type most appropriate for individual patients is not easy. Until more is known, selection has to be made on a trial basis. <h3>Sports Chairs</h3> Since the introduction of wheelchair basketball shortly after World War II, a constant stream of modifications and refinements has been made to the basic wheelchair to meet the needs of wheelchair athletes. Development of the lightweight, high-performance, sports chair has led to racing among wheelchair users and has made playing tennis from wheelchairs practical and enjoyable. These chairs have also been found useful in non-competitive recreation, such as camping and mountain climbing. Much that has been learned in developing and using sports chairs has resulted in improved performance and quality of prescription wheelchairs, just as automobile racing has led to improvements in the family car. At the same time, many of the people who have been using conventional wheelchairs are now using sports chairs full-time. Like the basic prescription wheelchair, the sports chair (<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-09.jpg">Fig. 9</a>) has evolved through a series of refinements to where the general configurations of most chairs are strikingly similar. At least 20 manufacturers at this time offer one or more models. Most use 24 inch diameter wheels; some use 27 inch wheels. Weight varies from 16 to 38 pounds, due mainly to material selection and whether or not the chair can be folded. A number of designs incorporate provisions for folding; Others use wheels that can be disconnected (and connected) quickly without tools to make transportation easier. <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-09.jpg">Figure 9. Three types of sports chairs. The one shown at the top is limited primarily for use in racing. The other two are more versatile.</a> Nearly all use five inch diameter front castors, except one manufacturer that uses four inch wheels. Two make eight inch castors available as an option. Nearly all, if not all, have a feature that permits a choice of rear wheel axle position with respect to the frame (<a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-10.jpg">Fig. 10</a>). Only a very few offer arm rests. <a href="http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-10.jpg">Figure 10. Schematic showing adjustability often found in sports chairs that permit an optimum relationship between position of the user and the wheels.</a> Many active wheelchair users prefer to use a sports type chair all the time, and in many instances options are offered that make regular use practical. Many models have adjustable features, and most manufacturers will provide a chair with dimensions to suit a given individual. A feature found on most sports chair, but not on other types, is the easy adjustability of wheelbase and seat height afforded by the positioning plate for the rear wheels. In many models, the position of the castor wheels can also be adjusted. Such adjustability, of course, permits the user to be seated in a position which puts the muscles in the upper limbs and shoulders in the optimum arrangements for maximum biomechanical efficiency. Because refinements and advances are being introduced so frequently, the periodical SPORTS 'N' SPOKES, published by the Paralyzed Veterans of America, has been devoting one issue each year to sports chairs and their specifications.<a></a> <h3>Summary</h3> Because of increased competition and refinements brought about by the sports chair movement, paraplegics now have available high quality wheelchairs. No single chair design is apt to meet all the needs of each individual, but careful thought and attention to detail in prescription preparation can result in a chair that meets most of the needs of the paraplegic. References: <ol> <li>Cochran, George Van B. and Vincent Palmieri, "Development of Test Methods for Evaluation of Wheelchair Cushions," Bulletin of Prosthetics Research, 10-22, 17:1:9-30, Spring 1980.</li> <li>Everest, H.A., et al., U.S. Patent No. 2,095.411, October 12, 1937.</li> <li>SPORTS 'N' SPOKES, 5201 N. 19th Avenue, Suite 111, Phoenix, Arizona 85015.</li> <li>Grimby, Gunnar, "On the Energy Cost of Achieving Mobility," Scand. J. Rehab. Med., Supplement 9, 1983, pp. 49-54.</li> <li>University of Alabama at Birmingham, Spinal Cord Injury Project, "Spinal Cord Injury - The Facts and Figures," 1986.</li> <li>Wilson, A. Bennett, Jr., Wheelchairs: A Prescription Aid, Rehabilitation Press, Charlottesville, VA, 1986.</li> </ol> *A. Bennett Wilson, Jr. A. Bennett Wilson, Jr. is an Associate Professor with the Department of Orthopedics and Rehabilitation at the University of Virginia, Charlotteville, Virginia 22908. Page Number(s) 82 - 90 Year 1987 Volume 11 Issue 2 Figure 2 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-07.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_02_082/1987_02_082-08.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-01.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1987_02_082/1987_02_082-10.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 Wheelchairs for Paraplegic Patients Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr. * https://staging.drfop.org/files/original/e596fe333824d5e3e2ff725137adec85.pdf 22d8a4a169b4a0521aefc4ea4c48e32d https://staging.drfop.org/files/original/7c8fef8ce5d7b9f45506e144497e38bd.jpg 4cc537e63119f220d2a5d43722b3f2c2 https://staging.drfop.org/files/original/1ada071125459a546f751d970b00a5c8.jpg f8a160cd40afca3e0239b722030d3ecf https://staging.drfop.org/files/original/42144af7cd4c081838ba0ccfce4d5357.jpg 637f5bc31f36cb709581380fd3907536 https://staging.drfop.org/files/original/7abe20d1503c047c2ec9ee334918231e.jpg 6323600ff95773536016f3121ee8684a 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_091.pdf Text Any textual data included in the document <h2>Knee Joint Materials and Components</h2> <h5>M.L. Stills, CO. <a style="text-decoration: none;">*</a></h5> The primary purpose of any orthotic knee joint, regardless of material or design, is to aid in providing stability to the patient's anatomical knee during loading of the extremity. In the paraplegic patient population, resistance to flexion of the knee is required during the periods of ground contact that occur during reciprocal gait. Orthotic knee joints can be used to provide medial-lateral control while permitting free flexion and extension, provide stance phase stability only during gait, or maintain locked knee extension during all phases of gait. Materials used in the fabrication of knee joints for management for people with paraplegia are generally a hybrid of various metals, or in some cases, high-strength, reinforced composite plastics. Aluminum, and/or stainless steel machined preformed components, are common and can be considered state-of-the-art. Mechanical knee joints are only a single component of a very complex system (<a href="/files/original/7c8fef8ce5d7b9f45506e144497e38bd.jpg">Fig. 1</a> and <a href="/files/original/1ada071125459a546f751d970b00a5c8.jpg">Fig. 2</a>). How that component is incorporated into the entire system has an effect on the outcome of successful orthotic management. The success or failure of the entire orthotic system is dependent on many variables, i.e., accuracy of the original prescription, fabrication procedures, placement and alignment of mechanical joints relative to anatomical joints, lever arms, overall fit, training in the use of the orthosis, and the motivation of the patient. <a href="/files/original/7c8fef8ce5d7b9f45506e144497e38bd.jpg">Figure 1.</a> Conventional metal and leather bilateral knee-ankle-foot orthosis with single axis drop lock knee and double adjustable ankle joint. <a href="/files/original/1ada071125459a546f751d970b00a5c8.jpg">Figure 2.</a> Bilateral polypropylene knee-ankle-foot orthosis with single axis drop lock knee and semi rigid ankle. FES was used with KAFO to facilitate swing through during gait. <h3>Free Knee Joints</h3> Free knee joints, having only hyperextension stops, are used to provide medial-lateral stability to the knee, or in situations when the patient has adequate extension power, but due to knee ligament laxity or muscle imbalance, is unable to control hyperextension. Care must be taken when using free knee joints to check hyperextension. The orthotist must be assured that the patient has adequate voluntary muscle control to maintain knee extension. The orthosis may be required to permit a limited amount of hyperextension in order to provide stability during stance. <h3>Offset Knee Joint</h3> The purpose of the offset knee joint is to provide stance phase stability of the knee while permitting free knee flexion during swing phase. This should provide a more anatomical reciprocal type of gait and should reduce energy consumption. The patient must have adequate voluntary muscle control to place the mechanical joint in a fully extended position and to move the ground reaction force anterior to the axis of rotation. The combination of ground reaction force, posteriorly offset orthotic knee joint, and a mechanical extension stop can provide stance phase stability for the paraplegic. Many of the same factors that influence stability of the bilateral above-knee amputee also can be applied to the paraplegic patient using bilateral offset knee joints. Voluntary hip extension power is required. The use of crutches or assistive devices are almost always mandatory. Consideration must be given to the problems of uneven walking surfaces, changes in heel heights, and patient endurance. Dynamic extension assists are often added to this type joint, or an extension lock may be added and dropped into place when additional security is required. <h3>Locked Knee Joints</h3> A locked knee joint (<a href="/files/original/7c8fef8ce5d7b9f45506e144497e38bd.jpg">Fig. 1</a> and <a href="/files/original/1ada071125459a546f751d970b00a5c8.jpg">Fig. 2</a>) provides stability during the stance phase of gait and remains locked even during phases of non-ground contact. A mechanism is generally provided to unlock the knee for cosmesis and comfort during sitting. Mechanisms for locking the knee joint in extension vary from simple gravity ring (drop) locks, spring-assisted drop locks, cams, pawls, and Swiss locks. Difficulty in unlocking the knee to permit sitting has led to the development of a variety of designs, again beginning with the simple ring lock, extensions added to drop locks, and bails (mechanical links between medial and lateral locks on a single extremity). To avoid accidentally unlocking a joint, designers have added ball retainers, springs, and elastic straps, all in an attempt to prevent accidental, unintentional flexion of the knee joint and subsequent falls and possible injury to the patient. There does not exist, however, a failsafe system that will completely eliminate the possibility of inadvertent knee flexion. Solid knee orthoses have been used with limited success because of functional difficulties. Granted, the knee is stable during gait, but the inability to flex the knee during sitting makes the use of public and private transportation difficult and many times impossible. Social and public functions are difficult to manage when the user of a solid knee type device tries to sit and avoid blocking aisles or passageways. Difficulties related to a stiff knee have greatly reduced the use of surgical knee arthrodesis. The use of medial and lateral components when fabricating knee-ankle-foot orthoses (KAFO) is commonplace. The use of such bilateral double upright construction certainly increases the weight of an orthosis and requires that the fabricator use techniques that ensure both medial and lateral joint surfaces are absolutely parallel and in alignment with each other. Nitschke in 1971 reported the results of using a single lateral upright in the fabrication of KAFOs. This technique reduced the weight of the KAFO and the problem of joint alignment. Incorporation of knee joints into a conventional metal and leather type KAFO provides the orthotist with the option of adjustability and limited skin contact (<a href="/files/original/7c8fef8ce5d7b9f45506e144497e38bd.jpg">Fig. 1</a>). Incorporation of knee joints into laminated and thermo-formed KAFOs (<a href="/files/original/1ada071125459a546f751d970b00a5c8.jpg">Fig. 2</a>) provides a means for more intimate fit, better control of the extremity, improved cosmesis, and lighter weight, but limited adjustability in alignment and fit of the orthosis. The Lower Extremity Telescoping Orthosis (LETOR) (<a href="/files/original/42144af7cd4c081838ba0ccfce4d5357.jpg">Fig. 3</a>) incorporates a new concept in knee joints. It really does not have a knee joint, but a telescoping posterior rod that, when in its extended position, bridges the anatomical knee joint and does not permit knee flexion. By lowering the telescoping rod, knee flexion is permitted during sitting. This simple telescoping bar attachment and a solid ankle system provides knee stability in ambulation and becomes a valuable training system and may be used as a definitive orthosis for the limited household ambulator. <a href="/files/original/42144af7cd4c081838ba0ccfce4d5357.jpg">Figure 3</a>. LETOR-Posterior telescoping rod bridges the knee and prevents knee flexion. Other methods of controlling the knee joint externally must include the use of Functional Electrical Stimulation. These externally applied electrodes provide a means of electrically stimulating the muscles controlling the knee. Work has been done using electrical stimulation with and without forms of external knee support with mixed results. This work is still considered experimental, but there is every indication that it may become a means of providing control of the knee in the paraplegic population. <h3>Conclusion</h3> A number of knee joint designs exist. Those developed from metal, i.e., stainless steel and/ or aluminum, are best used when orthotically managing the paraplegic patient. Thermoplastic knee joint designs can be used in the unilaterally involved patient or when the problem is related to structural instability and not voluntary muscle control. Knee joints are made stable by including mechanical locks or stops, by alignment techniques to ensure that the ground reaction force is anterior to the axis of rotation, or by the addition of springs, elastic straps, or cords that dynamically extend the knee. Ground reaction forces can be combined with the paraplegic's own intact anatomical knee joint to provide knee extension without orthotic extension above the knee joint (<a href="/files/original/7abe20d1503c047c2ec9ee334918231e.jpg">Fig. 4</a>). This has been used with limited success in selected pediatric paraplegic patients. <a href="/files/original/7abe20d1503c047c2ec9ee334918231e.jpg">Figure 4.</a> Floor reaction orthosis—posterior directed force on knee producing knee extension. Note hyperlordosis due to hip flexion contracture. Present and future research may drastically alter components and materials used in the future. At present, however, the combination of appropriate prescription, components, fabrication and fitting skills, along with skilled training in the use of an orthosis, will result in the potential for successful orthotic management of the paraplegic patient. References: <ol> <li>Anderson, E.G., and J.T. Henshaw, "The Design and Prescription of Above Knee Orthosis." Orthotics and Prosthetics, Vol. 31, No. 3. September, 1977, pp. 31-40.</li> <li><a href="cpo/1986_03_111.asp">Bajd, T., B.J. Andrews, A. Krulj, and J. Katakis, "Restoration of Walking in Patients with Incomplete Spinal Cord Injuries by Use of Surface Electrical Stimulation-Primary Results." Clinical Prosthetics and Orthotics, Vol. 10, No. 3, Summer, 1986, pp. 111-114.</a></li> <li>Clark, D.R., J. Perry, and T.R. Lunsford, "Case Studies-Orthotic Management of Adult Post Polio Patients." Orthotics and Prosthetics, Vol. 40, No. 1, Spring, 1986, pp. 43-50.</li> <li>Condie, D., C. Pritham, A.B. Wilson, III, and M. Stills, Lower-Limb Orthotics, A Manual, First Edition, Rehabilitation Engineering Center, Moss Rehabilitation Hospital, Philadelphia, PA.</li> <li>Foster, R., and J. Milani, "The Genucentric Knee Orthosis-A New Concept." Orthotics and Prosthetics, Vol. 33, No. 2, June, 1979, pp. 31-44.</li> <li>Glancy, J., and R.E. Lindseth, "The Polypropylene Solid Ankle Orthosis." Orthotics and Prosthetics, Vol. 26, No. 1, March, 1972, pp. 14-26.</li> <li>Pokora, M.B., J. Ober, and P.T. Milewski, "Lower Extremity Telescoping Orthosis LETOR." Prosthetics and Orthotics International, Vol. 8, No. 2, August, 1984, pp. 114-116.</li> <li>Pritham, C, and M. Stills, "Knee Cylinder," Orthotics and Prosthetics, Vol. 33, No. 4, December, 1979, pp. 11-18.</li> <li>Rubin, G., M. Dixon, and M. Danisi, "VAPC Prescription Procedures for Knee Orthosis and Knee Ankle Foot Orthoses," Orthotics and Prosthetics, Vol. 31, No. 3, September, 1977, pp. 9-25.</li> <li>Stills, M., "Lower Limb Orthotics." Report: The Current Status of Prosthetics and Orthotics and Trends for Future Research and Development, University of Miami, April 1-3, 1977.</li> </ol> *M.L. Stills, CO. M.L. Stills is an Instructor of Orthopedic Surgery in the Division of Orthopedics at the University of Texas Health Science Center in Dallas, Texas and Assistant Professor at the University of Texas School of Allied Health Sciences. Page Number(s) 91 - 94 Year 1987 Volume 11 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1987_02_091/1987_02_091-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_02_091/1987_02_091-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_02_091/1987_02_091-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 4 http://www.oandplibrary.org/cpo/images/1987_02_091/1987_02_091-4.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. 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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_02_095.pdf Text Any textual data included in the document <h2>The Anterior Shell Orthosis: An Alternative TLSO</h2> <h5>Carrie L. Beets, CO. <a style="text-decoration: none;">*</a> Tom Faisant, R.P.T. <a style="text-decoration: none;">*</a> Vernon Houghton, R.T.O. <a style="text-decoration: none;">*</a> C. Michael Schlich, C.P.O. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> Postoperative spinal management has undergone progressive changes in recent years. The merits of early mobilization following spinal surgery are well documented<a></a> and it is now generally agreed that earlier mobilization leads to quicker and more successful patient recovery. The recent advent of DRGs and predetermined payment to hospitals, regardless of length of hospitalization, adds even more incentive to the concept of earliest possible mobilization. Traditional approaches to postoperative spinal immobilization have been plaster body casts,<a></a> Jewett hyperextension orthoses,<a></a> and Knight-Taylor orthoses.<a></a> More recent approaches include the use of total contact TLSO's (body jackets), either with an anterior or posterior opening, or a bivalved, clamshell design.<a></a> Each of the above orthoses has inherent deficiencies with respect to very early patient mobilization attempts. Briefly, plaster casts lack total contact, lack volume adjustability, and do not promote or allow acceptable skin hygiene. Metal frame type orthoses such as a Jewett or Knight-Taylor do not control motion in all three planes, which is necessary for immediate postoperative mobilization. The ability of these orthoses to control lateral trunk flexion and/or rotary motion of the trunk is questionable. On the other hand, total contact TLSO's provide excellent control, but are very difficult to independently don and doff and, more important, they require rolling the patient into a prone position, or use of a Stryker frame, for molding. An additional deficiency of total contact TLSO's is they are too restrictive or confining, and actually slow the rehabilitation/recovery process by limiting range of motion necessary for independence. <h3>Development And Description</h3> In late 1977, Richard Rosenberger, CP. (deceased March, 1985) and physicians with the Department of Orthopaedics and Rehabilitation at the University of Virginia Medical Center developed the "anterior shell" orthosis as an alternative TLSO, designed to address all of the above mentioned deficiencies found in these other orthotic approaches. As its name implies, the anterior shell orthosis is a TLSO that provides total contact coverage to the anterior three quarters of the trunk, with the anterior trimlines the same as those of any standard body jacket type TLSO, and the lateral trim-lines just posterior to the lateral midline of the trunk (<a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-01.jpg">Fig. 1</a>). Suspension and immobilization are afforded by this total contact anterior section coupled with a Jewett type posterior pad with adjustable straps and a two inch wide Velcro® posterior strap across the sacral-coccygeal junction of the pelvis (<a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-02.jpg">Fig. 2</a>). Although quite flexible upon first impression, this TLSO becomes sufficiently rigid when properly tightened on a patient (<a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-03.jpg">Fig. 3</a> and <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-04.jpg">Fig. 4</a>), deriving its strength and rigidity from the tubular principle. This orthotic design provides a three point pressure system which is effective from T5 to L5; however, a cervical extension can be added to the orthosis to extend its support to the upper thoracic region. Originally designed for postoperative spinal management following Harrington rod instrumentation secondary to traumatic injury, the anterior shell orthosis permits the cast impression to be taken with the patient comfortably supine without the need for proning or other patient movement. <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-01.jpg">Figure 1. Anterior view of Orthoplast™ anterior shell orthosis.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-02.jpg">Figure 2. Posterior view of Orthoplast™ anterior shell orthosis.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-03.jpg">Figure 3. Anterior view of patient wearing orthosis.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-04.jpg">Figure 4. Lateral view of patient wearing orthosis. Note Jewett type posterior pad and strap arrangement.</a> <h3>Advantages</h3> In addition to the advantage of not having to move the patient while casting, the anterior shell orthosis is felt to be superior to the bi-valved and circumferential TLSO designs for postoperative management in other respects. Additional .advantages offered by the anterior shell orthosis include ease of donning and doffing the orthosis initially for the nursing staff and later, the ability to independently don and doff the orthosis by the patient while in the supine position (<a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-05.jpg">Fig. 5 </a>and <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-06.jpg">Fig. 6</a>), ease of inspection of the surgical wound site without having to doff the orthosis, increased air circulation to the surgical wound site, and more efficient cooling due to less body containment within the orthosis. The anterior shell orthosis provides anterior, posterior, lateral, and rotary control, however, because there is no posterior section, the lateral aspects are slightly more flexible than in a circumferential design. This quality of slight flexibility facilitates maneuverability during transfers and activities of daily living, yet the orthosis provides sufficient external stabilization to protect the Harrington rod instrumentation. <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-05.jpg">Figure 5. Patient in supine position donning orthosis.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-06.jpg">Figure 6. Patient, lying down, rolls to side and fastens the posterior pad and strap. Allowing for the posterior pad and strap to fasten on the same side facilitates donning and doffing in the lying position.</a> <h3>Indications</h3> As the advantages of the anterior shell design were proven with experience with postoperative patients, opportunities were sought for its use with other spinal diagnoses (<a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-07.jpg">Table 1</a>). Indications for use of the anterior shell orthosis now include various vertebral fractures, treated surgically or non-surgically; vertebral degeneration and pain due to diffused malignancy; progressive kyphosis due to osteoporosis, ankylosing spondylitis, and neurological conditions; degenerative joint disease; and postoperative management of spinal stenosis. <h3>Experience</h3> Over a period spanning 1979-1985, 232 patients were treated orthotically with the anterior shell; 137 of these patients were treated postoperatively (<a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-08.jpg">Table 2 </a>and <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-09.jpg">Table 3</a>). Over this seven year period, no postoperative patients experienced failure of surgical instrumentation while in the orthosis. During the initial development phase in 1978, only one postoperative patient experienced failure of his surgical instrumentation while in the orthosis. <h3>Treatment Regime</h3> Current treatment of thoracic and lumbar spinal cord injuries at the University of Virginia Medical Center includes molding and subsequent fit and delivery of an anterior shell orthosis within a few days post-surgery. Patients are usually maintained supine in bed until the orthosis is fit and delivered, with rehabilitation beginning immediately after fitting and delivery. At two weeks post-surgery, patients are allowed unlimited forward leaning in the orthosis for level and uneven surface transfers (wheelchair to bed, wheelchair to mat, etc.). Once the basic transfers are mastered, appropriately supervised advanced wheelchair transfers are permitted, including wheelchair to floor, floor to wheelchair, ascending and descending stairs in a sitting position, and in and out of a bathtub. At three to four weeks post-surgery, patients are taught independent donning and doffing of the orthosis in the supine position. <h3>Technical Information</h3> Material Selection At the University of Virginia Medical Center, the anterior shell orthosis is normally fabricated utilizing Orthoplast™. This thermoplastic material offers quick and easy fabrication that permits removal from the mold immediately after cooling without risk of shrinkage or other distortion. This allows for quick fabrication and delivery of the orthosis. Other noteworthy advantages of Orthoplast™ include pre-ventilation for air circulation, light weight, and due to its low temperature thermomolding properties, it is easily adjusted or modified in hospital and clinical settings. In cases where the orthosis is going to be used definitively, thermoplastics such as polyethylene or Vi-trathene are used in lieu of Orthoplast™. Patient Molding To cast a patient for an anterior shell orthosis, a piece of 12 inch wide stockinette is split lengthwise and placed over the patient with the edges of the stockinette tucked under the patient to prevent shifting during casting. A piece of narrow stockinette is passed carefully under the patient in the lumbosacral region of the back and through to the other side. The two ends are pulled tight over the iliac crests, tied off, and placed under tension as for pelvic traction (Fig. 7). Indelible anatomical markings are made and include the xiphoid process, sternal notch, costal margins, anterior superior iliac spines, and the superior border of the symphysis pubis. Plaster splints ase then applied making sure to cover from the symphysis pubis to the sternal notch anteriorally and down to the surface of the table on the sides, being sure to follow the patient's contours. When hardened, the plaster cast impression is removed and sealed and the positive model is poured. <a href="http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-10.jpg">Figure 7. Patient, in supine position, is ready to be casted. Patient does not have to be rolled or turned to complete casting.</a> Model Modification The positive model is modified in a normal TLSO modification fashion, including flattening the anterior lower thoracic and abdominal area for increased intraabdominal pressure and defining the area above the iliac crests for good suspension on the pelvis. Plaster buildups are added over the anterior superior iliac spines if the patient is thin. The lateral posterior border is extended two inches in the posterior direction from the iliac crests inferiorally, to cover the gluteals laterally and increase lateral stability. Because the anterior trimline of the orthosis extends to within an inch of the sternal notch, female patients require design variations in the model modification and the subsequent orthosis. For large busted female patients, an opening is frequently designed in the breast area to free the breasts. For smaller busted female patients, the breast area is built up on the plaster model to permit room for the breasts in the orthosis with the patient upright. In both situations, the area superior to the breast area is reduced on the plaster model to ensure good contact within the orthosis; also, the area superior to the breasts is reinforced in the fabrication process to ensure rigidity. When total contact for support and/or dispersement of pressure over a greater area is needed, as in cases of degenerative disease, such as osteoporosis, arthritis, and diffused cancer, the breast area is built up slightly on the plaster model and incorporated into a solid design in the orthosis. Fabrication Techniques When molded with Orthoplast™, reinforcement is provided by a double thickness of Orthoplast™ in appropriate areas: the anterior superior and the lateral posterior edges. The metal anchor plates for attachment of the posterior pad straps are sandwiched in between layers of Orthoplast™ and later drilled and tapped for 8-32 screws. If vacuum formed using a more durable thermoplastic, reinforcement can be provided with hybrid carbon composite inserts (available from Durr Fillauer). In this fabrication technique, the metal anchor plates for the posterior pad straps can be mounted on the plaster model for incorporation into the vacuum formed shell. In either case, the posterior pad is patterned after the Jewett orthosis posterior pad and has two sets of 1/2 inch dacron straps with 3/16 inch diameter holes, 1/2 inch apart in both ends for connection to the anterior shell. The posterior pad floats freely on the dacron straps, which are permanently attached to the metal anchor-plate on the left side of the orthosis with 8-32 screws and have roller buckles on the right hand ends of the straps. The right side straps, which are attached under 8-32 screw studs, pass through the roller buckles and double back on themselves for adjustable tension control and attachment to the stud-heads of the 8-32 screw studs. The roller buckle system acts as a pulley system, thereby reducing the mechanical force needed to properly tighten the posterior pad. The final component in the system is the two inch wide Velcro® sacral-coccygeal strap, which is permanently attached on the left side of the anterior shell, passes through a two inch stainless steel loop on the right, and doubles back on itself for a secure closure. This adjustable closure system is described as was originally designed by Rosenberger, et al. It is not necessarily deemed to be the simplest. Any of the adjustable closure systems utilized in the available prefabricated spinal extension orthoses should provide a suitable alternative to the above closure system. <h3>Summary</h3> The anterior shell orthosis provides quickly accessible orthotic support for early mobilization of patients with spinal cord injury and other diagnoses, allowing for independent donning and doffing with relative ease. Though sufficiently rigid to protect surgical instrumentation while boney fusion takes place, the anterior shell orthosis allows maximum maneuverability possible for a patient in a TLSO. <h3>Acknowledgments</h3> The authors would like to acknowledge Michael Smith for his efforts in the chart reviews. References: <ol> <li>Albee, F.H., E.J. Powers, and H.C. McDowell, Surgery of the Spinal Column, F.A. Davis Co., 1945, pp. 213-215.</li> <li>Bauer, R., "Preoperative Correction and Post-operative Fixation Using Harrington Instrumentation," Operative Treatment of Scoliosis, George Chapchal, editor, 1973, pp. 82-85.</li> <li>Bradford, D.S. and R.C. Thompson, "Fractures of the Spine," Minnesota Medicine, 59:1976, pp. 711-720.</li> <li>Dickson, J.H., P.R. Harrington and W.D. Erwin, "Results of Reduction and Stabilization of the Severely Fractured Thoracic and Lumbar Spine," Journal of Bone and Joint Surgery, 60A:1978, pp. 799-805.</li> <li>The Unstable Spine, edited by S.B. Dunsker, H.H. Schmidek, J. Frymoyer and A. Kaan, pp. 12-15.</li> <li>Edmonson, A.S. et al., "Report: Panel on Spinal Orthotics," Orthotics and Prosthetics, Vol. 31, No. 4, December, 1977, pp. 67-71.</li> <li>Edmonson, A.S., "Spinal Orthotics," Orthotics and Prosthetics, Vol. 31, No. 4, December, 1977, pp. 31-42.</li> <li>Flesch, J.R., et al., "Harrington Instrumentation and Spine Fusion for Unstable Fractures and Fracture-Dislocations of Thoracic and Lumbar Spine," Journal of Bone and Joint Surgery, 59A:1977, pp. 143-153.</li> <li><a href="http://www.acpoc.org/library/1976_01_007.asp">Friddle, W.D. and L.P. Brown, "Greenville Spinal Orthosis, Polypropylene," Inter-Clinic Information Bulletin, 15(9&10):Sept.-Oct. 1976, pp. 7-12.</a></li> <li>Norton, P.L. and T. Brown, "The Immobilization Efficiency of Back Braces," Journal of Bone and Joint Surgery, 39A:1957, pp. 111-139.</li> <li>Van Hanswyk, E.P., H.A. Yuan, and W.A. Eckhardt, "Orthotic Management of Thoraco-Lumbar Spine Fractures With A Total-Contact TLSO," Orthotics and Prosthetics, Vol. 33, No. 3, September, 1979, pp. 10-19.</li> <li>Wallace, S.L. and K. Fillauer, "Thermoplastic Body Jackets for Control of the Spine After Fusion in Patients With Scoliosis," Orthotics and Prosthetics, Vol. 33, No. 3, September, 1978, pp. 20-24.</li> <li>Wharton, G.W., "Stabilization of Spinal Injuries For Early Mobilization," Orthopedic Clinics of North America, 9(2): April, 1976, pp. 271-276.</li> </ol> *C. Michael Schlich, C.P.O. C. Michael Schuch, C.P.O. is Assistant Professor in the Department of Orthopaedics and Rehabilitation and Associate Director in the Division of Prosthetics, Orthotics, and Rehabilitation Engineering Services at the University of Virginia Medical Center in Charlottesville, Virginia. *Vernon Houghton, R.T.O. Vernon Houghton, R.T.O. is an Orthotic Assistant in the Division of Prosthetics and Orthotics at the University of Virginia Medical Center in Charlottesville, Virginia. *Tom Faisant, R.P.T. Tom Faisant, R.P.T. is a Supervisor of Physical Therapy in the Adult Rehabilitation Unit at the University of Virginia Medical Center in Charlottesville, Virginia. *Carrie L. Beets, CO. Carrie Beets, CO. was formerly with the Division of Prosthetics and Orthotics at the University of Virginia Medical Center in Charlottesville, Virginia. Page Number(s) 95 - 100 Year 1987 Volume 11 Issue 2 Figure 2 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-06.jpg Figure 7 Table 1 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 Table 2 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-08.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-01.jpg Figure 9 Table 3 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-09.jpg Figure 10 FIGURE 7 http://www.oandplibrary.org/cpo/images/1987_02_095/1987_02_095-10.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 The Anterior Shell Orthosis: An Alternative TLSO Creator An entity primarily responsible for making the resource Carrie L. Beets, CO. * Tom Faisant, R.P.T. * Vernon Houghton, R.T.O. * C. Michael Schlich, C.P.O. * https://staging.drfop.org/files/original/c4f7c87a6d3b45eaeeb780028322aac3.pdf 2f3019f3a58522e9c6c9ef279008e662 https://staging.drfop.org/files/original/e3fa45ed04f25031b0eae1b1ae3563f7.jpg 1d480fe476876e4ae28210d460878f00 https://staging.drfop.org/files/original/8d9753f4b6b5322d836534694564a736.jpg 18e2d169d78ebf6f59e41dce49306715 https://staging.drfop.org/files/original/ba2d5caaf2bb5a526891c65720e02f75.jpg 4c419b14d2f5c2e8b85e998eec950f1e https://staging.drfop.org/files/original/1bb426ed68464888794dcdf4a783cf53.jpg d1da7506184096c8d68116798a87facd https://staging.drfop.org/files/original/1c12f7dc0e21d73986874eddb77e705e.jpg 6f0727ef350636789bc9df62f3eccbf4 https://staging.drfop.org/files/original/00d157335a62ec44dbfdf98f9c624906.jpg f4e81019aca87bb8e609ca049e7db794 https://staging.drfop.org/files/original/5e53449d0db91f56ed12371c0939588b.jpg 38d62fb95c884d54aa066fc874713827 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_101.pdf Text Any textual data included in the document <h2>The Cast Off Valve: An Improved Method for Removing and Retaining Above Knee Casts and Prosthetic Sockets</h2> <h5>Albert F. Rappoport, M.A., CP. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> The fabrication of a prosthesis continues to be a labor intensive process. The advent of prefabricated components, together with the use of central fabrication, has allowed many prosthe-tists to utilize their time more effectively. Time saving devices have always been welcomed by the prosthetic practitioner, especially when the quality of work is not compromised. Removal of an above-knee socket from a plaster model is a common procedure in most prosthetic facilities. There are several methods for removing the socket from the cast. These methods will be addressed later in the text and the problems of each discussed. The most improved method is the Cast Off Valve (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-1.jpg">Fig. 1</a>). The Cast Off Valve uses compressed air, linking it directly to the above-knee socket (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-2.jpg">Fig. 2</a>). The female coupling of the air hose is attached to the male connector of the Cast Off Valve (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-3.jpg">Fig. 3</a>). The Cast Off Valve is then threaded into the suction valve housing of the above-knee socket. This method saves manpower, time, and energy by allowing removal of the socket from the cast in a matter of seconds. It is also effective in the duplication of any definitive above-knee suction socket. The concept is credited in its design to Judd Lundt, B.S.A.E., Assistant Director at UCLA's Prosthetic Education Program. <a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-1.jpg">Figure 1. The Cast Off Valve.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-2.jpg">Figure 2. Female couple of air hose to male connector on Cast Off Valve.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-3.jpg">Figure 3. Cast Off Valve attached to female air hose coupling.</a> <h3>Methods Of Removing Socket From Cast</h3> Several methods have been used, with varying degrees of success, in removing an above-knee socket from a plaster model. The oldest method involves breaking the plaster out of the socket with a cold chisel and hammer, or air chisel. This is a labor intensive process which is still practiced by many prosthetists (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-4.jpg">Fig. 4</a>). This process is not always necessary to facilitate the removal of a definitive socket. <a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-4.jpg">Figure 4. Age old method of removing socket by breaking out plaster by hand.</a> <h3>Bivalving</h3> Many times, the prosthetist would like to save the plaster model for further modification or reference. One approach to saving the model is to bivalve the socket with a cast saw (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-5.jpg">Fig. 5</a>). Once the socket has been bivalved, the cast can be touched up with minor plastic additions and used again. After the socket is bivalved, it cannot be reused. This process is not only time consuming, but can be eliminated in many circumstances. <a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-5.jpg">Figure 5. Bivalving socket to retain cast.</a> <h3>Compressed Air</h3> The use of compressed air is by far the most popular method. It saves labor, time, sockets, and casts. A newly formed check socket or laminated socket may be easily blown off using an air gun. The newly fabricated socket must be trimmed just proximal to the desired trim line. A hole must then be drilled at the distal end of the socket to correspond in size to the tip of the air gun (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-6.jpg">Fig. 6</a>). One person holds the air gun with compressed air in the hole at the distal end of the socket, while the other person gently taps, trying not to fracture the socket, at the proximal brim. This is continued until the air is forced through the socket and assists in forcing the socket off the cast. Some radical socket shapes may prevent the ease of this technique, in which case it may be helpful to attempt this procedure while the socket is still warm or to refer back to the previously mentioned methods. The compressed air technique is an effective way to remove the socket from the cast without damaging either one. Two drawbacks to this method are: 1) it requires two persons to remove the socket, and 2) it is possible for air to leak through the hole where the air gun is held at the socket's distal end. <a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-6.jpg">Figure 6. Removing socket from cast using compressed air. This two-person operation requires one person to use air gun to direct air through hole in bottom of socket and second person to tap proximal socket. </a> <h3>Cast Off Valve</h3> The use of the Cast Off Valve can improve the effectiveness of the compressed air method (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-7.jpg">Fig. 7</a>). This improved technique can be employed whenever a valve housing is used in either a laminated socket or clear check socket. The Cast Off Valve is designed to fit the valve housing and link the air hose coupling directly to the socket. This approach allows a stronger air pressure to be obtained and little chance for air leakage. The use of this method requires only one person, freeing the hands of a second person who holds the air gun in the hole (<a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-6.jpg">Fig. 6</a>). First, the proximal brim of the socket should be trimmed with a cast saw. Once the Cast Off Valve is installed, the air hose can then be connected and the socket will blow off without any further effort. One may need to gently tap the proximal brim with a piece of wood dowling and hammer to assist the removal. (Note: certain radical socket shapes may prevent the use of this method.) In summary, the Cast Off Valve requires only one person to remove a socket from the cast with a minimum amount of effort, reduction of time and improved results over methods previously discussed. <a href="http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-7.jpg">Figure 7. The Cast Off Valve is threaded into valve housing and air hose is connected to blow socket off with minimum effort and maximum results.</a> <h3>Socket Duplication</h3> The Cast Off Valve also is excellent when an above-knee suction socket is to be duplicated from a definitive limb. No longer is an alginate impression or use of duplicating foam necessary. The patient's socket should be filled with plaster and a holding pipe inserted once the plaster has set. The valve housing must be cleared of any material so the Cast Off Valve can be inserted. The air hose coupling can then be hooked up and the socket is blown off in a matter of seconds. The socket is duplicated exactly in plaster and ready for lamination or check socket fabrication. <h3>Summary</h3> The Cast Off Valve has been well accepted and tested clinically with great success for the past two years by the staff at UCLA's Prosthetic Education Program and Prosthetic-Or-thotic Laboratory. The UCLA prosthetic staff has found this device to be valuable, in many cases, in removing an above-knee socket in both quadrilateral and CAT-CAM designs. This method allows the cast to remain undamaged for further reference and can be useful when duplicating a definitive socket. When working with an appropriately shaped cast, the Cast Off Valve allows the removal of the socket from the cast with improved results from the previously aforementioned methods. <h3>Acknowledgments</h3> This work is supported by VA Contract #633P-1667 Rehabilitation Research & Developmental Funds. Special thanks to Shirley M. Forsgren for the photography on this article and to Diane I. Lyons for preparation of the manuscript. Special thanks also to Dr. Ernest M. Burgress for his continued support in the research and development of advancing prosthetics. Thanks to Christopher Hoyt, CP, David Litig, CP, Mark Yamaka, CP, Richard Boryk, CPO, and Kenneth Neal, O/P Technician for their clinical evaluation of the cast-off valve at UCLA's Prosthetic-Orthotic Laboratory. *Albert F. Rappoport, M.A., CP. Albert F. Rappoport, M.A., CP., is Chief of Research Prosthetics with the Prosthetics Research Study, 1102 Columbia Street, Room 409, Seattle, Washington 98104, (206) 622-7717. He is formerly Senior Prosthetist-Orthotist at UCLA's Prosthetic-Orthotic Laboratory in Los Angeles, California. <div style="width: 400px;"></div> Page Number(s) 101 - 105 Year 1987 Volume 11 Issue 2 Figure 1 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-6.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 7 http://www.oandplibrary.org/cpo/images/1987_02_101/1987_02_101-7.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 The Cast Off Valve: An Improved Method for Removing and Retaining Above Knee Casts and Prosthetic Sockets Creator An entity primarily responsible for making the resource Albert F. Rappoport, M.A., CP. * https://staging.drfop.org/files/original/6212151a4fd93fa9dfd236829b610b9d.pdf 189fa090d4acf3dfea37b1693a79a780 https://staging.drfop.org/files/original/74352196c91439b746c487380d4c7d77.jpg 05c134f6b80ae4f5c032ba27b11de016 https://staging.drfop.org/files/original/10e30ded97b085e2b2892d7eea9365a3.jpg 25847e110d18fb0e9863908ef7b26efb https://staging.drfop.org/files/original/c14ca2b677fa08c269cdf300b3ac8d05.jpg 6aa3d9f3fdbb8117d775aec6125b3749 https://staging.drfop.org/files/original/56605a5d73b41e6c48d52f069c0109e4.jpg 0d4dd9bf592027776b6b43c7fb8e2dfd https://staging.drfop.org/files/original/8b2233e0b1a3db5f4e26c29029c28d52.jpg c9c9ed230bf33f6d1f48fe13e3d4c838 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_03_109.pdf Text Any textual data included in the document <h2>The Amputee Athlete</h2> <h5>Richard Riley, CP. <a style="text-decoration: none;">*</a></h5> An increasing number of amputees in the United States are moving beyond mere ambulation into active sports and recreation activities. Estimates of the number of amputees actively involved range from 15,000 to 20,000, with over 5,000 participating in organized competitive sports. <a href="http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-1.jpg">Figure 1. Below-knee amputee, George Lombard, member of the Fisher-Saloman Marathon Team and the U.S. Disabled Ski Team.</a> Ten years ago, the athletic amputee was a unique phenomenon in our practice. Today few practitioners cannot count two or three among their clientele. These amputees are at the cutting edge of our field because they push us as professionals to expand our perceptions of what is possible. They also provide the positive role models that we hold out to the rest of our clients as an example of what can be done. The able-bodied sports world has taken some giant leaps of perception regarding the amputee athlete. No longer is it just "inspirational" to have a disabled person competing in sports. Today there are amputees that compete in world class events alongside the able-bodied. The skiing world has demonstrated this by naming below-knee amputee George Lombard to the Fischer-Saloman Marathon cross country ski team and awarding above-knee amputee Diana Golden with the U.S. Ski Writers Award for Outstanding Alpine Competitor. Not only are there more elite amputee athletes today, there is a much larger body of rec-reationally oriented amputees. The days are gone when the prosthetist and rehabilitation team could be satisfied with being able to get the amputee to just walk. Expectations of our clients have changed. Not only the younger amputee, but also the active geriatric expects to be able to ride a bicycle, play golf, tennis, or jog around the block.<a></a> Our challenge is to meet these expectations. <h3>Psychology of the Amputee Athlete</h3> What causes one amputee to become an elite cross country skier (one of the most demanding physical sports in the world) and another with the same level of disability to be unable to even return to gainful employment? Part of the answer lies in the individual's ability to handle the stress and trauma of amputation. These are factors that we have little control over. The other part of the answer lies with environmental issues and can be addressed. Most amputee athletes are highly motivated individuals with a strong desire to overcompen-sate for their disability. A percentage of these people will rehabilitate themselves with practically no help at all and go on to accomplish great things in their personal lives as well as in sports. Others need the influence of role models to show them that their limitations are what they place upon themselves. One of the most positive experiences for any new amputee is when they meet another amputee with a positive attitude.<a></a> This positive motivation is best facilitated by a support structure of family, friends, and the rehabilitation team. If any one of these aspects is continually placing limits on the amputee, eventually the amputee will accept these limitations. There are physical limitations for the amputee, but these should be discovered not imposed. There are ways around most physical limitations by keeping an open mind and being willing to innovate. Pain is an aspect of amputation that in many cases is initially the greatest barrier to overcome. All athletes know pain through training and the physical exertion of competition. People who are athletic prior to becoming an amputee will generally be able to deal with pain more easily due to their previous development of strategies to perform while enduring levels of pain. The successful amputee will develop ways of minimizing discomfort, either through increasing the conscious tolerance for pain or seeking a lifestyle that reduces trauma to the residual limb. The amputee athlete not only has the pain of general physical exertion to deal with, but also the added trauma of torques and stresses far beyond normal to the skin and bone structure of the residual limb. Most of these athletes have developed very high pain tolerances and their body readily reacts to pain stimuli by releasing endorphines<a></a> (the body's natural pain medication) into the body. These factors enable the amputee athlete to achieve great physical accomplishments. It also sets up potential for serious damage to the residual limb tissue because of overactivity. Pain is the body's message to the brain that something is wrong and many amputees have developed ways to short-circuit this signal. This is a fact we must all be aware of in caring for and guiding the amputee athlete. <h3>Prosthetic Care</h3> For the prosthetic professional, the active amputee can be either a great source of pride and stimulation or a perpetual problem fraught with frustration. Nevertheless, this group of our clientele will continue to occupy a greater share of our patient load and we must develop strategies to successfully accommodate their needs. As important to the success of the athletic amputee as the prosthesis is his knowledge of how it works. Of equal importance are the limitations of the prosthesis and problem solving strategies for residual limb breakdown. The time spent in educating the amputee about his prosthesis and ways to deal with skin problems is always well spent. Regardless of how well fitting a prostheses is, there is a potential for skin breakdown of the residual limb due to overactivity.<a></a> Athletes will continually push themselves to their limits and beyond. If they are armed with methods to deal with skin breakdown, they will benefit greatly. Advances in sports medicine for runners was bound to spill over into prosthetics. Of particular use is a skin protection material called "2nd Skin™" (Table 1). It is a 1/16" thick piece of gel that is applied directly onto the skin. It prevents friction between the skin and any moving surface. It does not stick to normal skin, yet because of its viscosity, will stay where it is placed. It is perforated so as to let the wound breathe as well as being sterile to prevent infection. 2nd Skin™ absorbs secretions, feels cool, alleviates itching, and can relieve pain. 2nd Skin™ comes with plastic on both sides of the gel material. Before the plastic is removed, cut a piece one third larger than the area to be covered. This allows coverage of the affected area despite migration. The directions recommend removing the plastic from one side or from both sides. Personal experience has shown that removing the plastic from both sides prevents most migration. Because 2nd Skin™ is so thin, it does not increase pressure on blisters or abrasions. It prevents most friction and can actually promote healing even during heavy usage. 2nd Skin™ comes in a variety of sheet sizes which can be cut to the size needed and has to be kept in the zip-lock container provided. Unfortunately, it can be used only once and has to be cleaned off the sock after use. It works very well on below-knee amputees, especially when used beneath a sheath. In above-knee amputees, only suction wearers will experience difficulty in usage due to excessive migration from pulling into the socket. Second Skin™ is an inert material made from 96 percent water and four percent polyethylene oxide. Another product which provides excellent friction reduction and is also reusable is "Spenco® Skin Care Pad" (<a href="http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-3.jpg">Table 1</a>). This product comes in three thicknesses, 1/2", 3/16", and 1/8". The 1/8" thickness produces the least amount of pressure inside the socket. Spenco® Skin Care Pad acts like a second layer of fat to protect the skin from friction or abrasion. It adheres to the skin without sticking due to its viscosity. Made from a reticulated closed cell elastomer, it can be gas sterilized or washed in soap and warm water. It should also be stored in the zip-lock bag and has a shelf life of two years. It is best used as a preventative measure in circumstances where skin breakdown is a danger.<a></a> <a href="http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-2.jpg">Figure 2. Applying 2nd Skin™ to a residual limb abrasion.</a> One of the problems with most skin protection materials is that suction socket wearers cannot utilize them. When the amputee pulls into the suction socket, "2nd Skin™" or "Spenco® Skin Care Pads" become displaced and usually do not cover the areas intended. A product that can be of use to suction socket wearers, or any amputee for that matter, comes with a variety of names. It is a transparent dressing with one adhesive side that is paper thin and porous both to air and water. The trade names are "Op-Site," "Bioclusive," "Tega-derm," and "Acuderm" (<a href="http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-3.jpg">Table 1</a>). This material can be applied directly to the skin and acts as another layer of protection, while still allowing normal dermal respiration and perspiration to occur. It can be left on the skin for four to five days before it needs to be removed. If left on much longer, the epidermis does not get an opportunity to slough off properly.<a></a> These products work well to prevent friction, but do not provide any relief for pressure problems. The transparency of these materials allow for continual evaluation of the healing process. There is a problem that the adhesive is quite strong and oftentimes pulls hairs out upon removal. Different brands utilize different ad-hesives, but in general it is recommended that some soaking of the covered area in warm water will help remove the covering with minimal discomfort. Careful attention should be paid to the application instructions so as to avoid getting it adhered to itself when applying it. Most brands come with a paper backing and application method that allows it to be cut to the desired size. Until the time when skin abrasions and adherent scars become a thing of the past, we will have the need for skin protection materials. These products can give relief to thousands of prosthetic wearers as well as prevent much discomfort for active amputees. They should become a standard part of the amputee's "survival kit." <h3>Sports Organizations for Amputees</h3> The perceptions that amputees have of their capabilities has risen dramatically in the last decade. Paralleling the growth of competitive sports for amputees has been the organizations that provide the forum for these activities (<a href="http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-4.jpg">Table 2</a>). Prior to these organizations bringing together amputees from around the nation and the world, there was little opportunity for exchange of ideas on the consumer level. <a href="http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-5.jpg">Figure 3. The United States Disabled Ski Team.</a> Organizations such as the "National Handicapped Sports and Recreation Association," sponsor and provide for competitive sports activities. Competition is based on ability and level of amputation with competitive levels ranging from local races to world class and a parallel Olympic structure. The impact of these organizations on the field of prosthetics has been enormous. All of us have fielded questions concerning amputee athletes and their various prostheses. This direction from the people whom we serve has been healthy for prosthetics for many reasons. First, we have had to expand our horizons and adapt technologies and techniques to accommodate these athletic amputees. Secondly, it has created a demand and thus a market for new components to accommodate extra-ambulatory activities. Third, there now exists a forum for amputees to exchange ideas, compare techniques, and services, as well as push each other to greater accomplishments. Another important contribution is the role model aspect of these athletic amputees. They provide inspiration to all of our clientele to continue to expand their perceptions of what is possible. All of these factors have changed prosthetics. Because of publicity surrounding some of the more astounding accomplishments, not only has the field gained more public recognition, but there is a growing acceptance of us as professionals. These organizations will continue to provide and promote sports and recreation as a normal part of the amputees lifestyle. Not only is it our responsibility and challenge to continue to adapt prosthetics to these activities, but it will play a major role in the future of our profession.<a></a> <h3>Conclusion</h3> As leisure time in our society increases, the need to accommodate sports and recreation in our society becomes essential. The perception of the amputee's lifestyle parallels this societal shift. Prosthetics must be able to accommodate this change in our patients' attitudes toward activity. This can best be accomplished through education and communication, as well as further development of componentry geared to the athletically inclined.<a></a> The amputee athlete has given rise to a new specialty in our field. The sports prosthetist is now a viable specialist that as professionals we should recognize and refer our patients to. We will continue to provide state-of-the-art prostheses for our active amputees, and armed with information about proper care, they will be among the best athletes in the world. References: <ol> <li>Riley, Richard, "The Amputee Athlete," Sports Medicine, Volume 4, October, 1984, pp. 31-32.</li> <li>Kegel, Bernice, "Recreational Activities of Lower Extremity Amputees: A Survey," Archives of Physical Medicine and Rehabilitation, Volume 61, June, 1980, pp. 258-264.</li> <li>Foort, James, "How Amputees Feel About Amputation," Orthotics and Prosthetics, Volume 28, March, 1974, pp. 21-27.</li> <li>Gaylor, Michael, M.D., personal communication, April, 1987. Presently Professor, Dartmouth College, Specialty in Sports Medicine.</li> <li><a href="poi/1980_01_037.asp">Levy, W. S., "Skin Problems of the Leg Amputee," Prosthetic and Orthotic International, Volume 4, 1980, pp. 37-44.</a></li> <li>Riley, Richard, "Skin Protection Materials," lecture given at American Academy of Orthotists and Prosthetics Annual Meeting, Tampa, Florida, February, 1987.</li> <li>Riley, Richard, "Sports Organizations for the Disabled and Their Impact on Prosthetics," lecture given at American Academy of Orthotists and Prosthetists Annual Meeting, Tampa, Florida, February, 1987.</li> <li>Riley, Richard, "A Survey of Active Below-Knee Amputees," study undertaken at Northwestern Orthotic and Prosthetic Research Center, Chicago, Illinois, December, 1980.</li> <li>Kegel, Bernice, Sports for the Leg Amputee, 1986.</li> </ol> *Richard Riley, CP. Richard Riley, CP., specializes in sports prosthetics and has a private practice with SportsMedicine Portsmouth, in Portsmouth, New Hampshire. Also a below-knee amputee, Riley is a member of the U.S. Disabled Nordic Ski Team and the Vice President of the National Handicapped Sports and Recreation Association. <div style="width: 400px;"></div> Page Number(s) 109 - 113 Year 1987 Volume 11 Issue 3 Figure 2 http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-2.jpg Figure 3 TABLE 1 http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-3.jpg Figure 4 FIGURE 3 http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 5 TABLE 2 http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-4.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1987_03_109/1987_03_109-1.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 Amputee Athlete Creator An entity primarily responsible for making the resource Richard Riley, CP. * https://staging.drfop.org/files/original/2758dcc8f04d4645d2251d024de4b117.pdf 47ba774f7aaadae410bf2c3710d4d082 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_03_114.pdf Text Any textual data included in the document <h2>Winter Sports for the Amputee Athlete</h2> <h5>Doug Pringle <a style="text-decoration: none;">*</a></h5> Organized participation in winter sports by people with disabilities has a relatively short history. It began in the early 1950s when amputee veterans of World War II began to experiment with skiing despite the loss of limbs. The West Germans are credited with the invention of the outrigger, a crutch with ski tips attached, which are used as balance assisters. This invention helped popularize the sport and several amputee ski clubs were formed in the United States. During the late 50s and early 60s, amputee skiing was the mainstay of the sport. It was during the late sixties and early seventies that others with one "bad" leg, such as polio victims, began to ski using the technique developed for amputees. It was also during this time that amputees began experimenting with skiing with a prosthesis. Simultaneously, visually impaired people began to participate and the sport began to include more than amputees. In the late 70s, the major innovation was development of the "Four-Track" technique, which allowed many types of severely disabled people to ski. The 1980s have contributed the technique known as 'sit skiing.' This technique allows people who are wheelchair bound to participate in the sport. The benefits of participation in skiing are numerous. Physically the participant develops stamina, strength, balance, and coordination. These are all valuable physical traits for a person trying to compensate for a physical problem. Psychologically, participants begin to develop a positive self-image and a "can do" attitude. This positive thought cycle carries over into other aspects of life such as education and employment. Skiing offers a unique opportunity as a sport that can be done with family and friends in a facility open to the public. In that sense it is a mainstreamed activity done with everyone else rather than in a special facility. Finally, there is something wonderful and invigorating about the freedom of movement, speed, risk, and the natural environment of skiing. All these add to the experience. Skiing is the only winter sport offered to people with disabilities through formal programs. These programs offer adaptive equipment, qualified instruction and a competition system. Participation in other winter sports is not extensive. <h3>Downhill Skiing</h3> Alpine Skiing Alpine (or downhill) skiing is the most popular winter sport of people with disabilities in the United States. There are approximately 10,000 disabled skiers. The sport offers unique benefits to participants who are mobility impaired, not the least of which is that gravity supplies the means for movement. The development of adaptive equipment and techniques has made it possible for even the severely disabled to participate. Adaptive skiing is divided into five major categories or techniques: <ol> <li> Three track skiing </li> <li> Four track skiing </li> <li> Blind skiing </li> <li> Sit skiing </li> <li> Other adaptive techniques </li> </ol> Three Track Skiing Above-knee and below-knee amputees, persons with polio or birth defects, and those with a variety of other problems, ski three track in which the common element is having one good leg and two good arms. Above-knee amputees ski without their prosthesis because it is difficult to control. Below-knee amputees can ski with their prosthesis. The advantage is that they can stand on it when stopped. The disadvantage is increased risk of injury. Adaptive equipment for three trackers are outriggers. Outriggers are forearm crutches with ski tips attached. They act as balance as-sistors and are used to "walk" on the flats. Three track skiing derives its name from the three tracks made in the snow by two outriggers and the single ski. Some three trackers, especially racers, learn to ski with ski poles instead of outriggers. In fact, that is how people with one leg skied before the invention of outriggers. While more difficult, "one tracking" is also a possibility for many and skiing with poles is an advanced instructional method. Four Track Skiing Four track skiing is used by people with a wide variety of disabilities including: double leg amputees, spina bifida, cerebral palsy, muscular dystrophy, multiple sclerosis, stroke, head trauma, paraplegia, and polio. An individual with two legs and arms, natural or prosthetic, who is capable of standing independently (static balance), or with the aid of outriggers, could use this method. Many severely disabled people ski using this technique. In addition to outriggers, a lateral stability device is often used. This device is commonly referred to as a "ski bra." It helps keep the skiis parallel and also allows the student's strong side to help control the weaker side. Blind Skiing Visually impaired students are taught the same as any other skier with the exception that the instructor must learn to communicate more clearly. A number of holds or assists have been developed as well. Once the student can ski, the task becomes one of guiding or talking them down the hill. No adaptive equipment is required for the visually impaired. Often the student and instructor (or guide) wear bright bibs which signal to other skiers to be alert. Sit Skiing Sit skiing is the technique used by anyone who cannot ski standing. Sit skiers include people with muscular dystrophy, multiple sclerosis, cerebral palsy, spina bifida, paraplegia, and quadriplegia. This technique has been used since 1980 and it has opened skiing to people who are wheelchair bound. The sit ski has a fiberglass shell and metal edges. It is steered by leaning the body and by dragging a "pole" on the side to which the skier wants to turn. An instructor skies behind the device holding a length of nylon mesh cord in order to stop the skier and to assist with turns when necessary. Sit skiers often become proficient enough to ski "untethered" or without the instructor and safety line. The most recent development in sit skiing is the mono-ski. Here the fiberglass shell is mounted on a single ski and the skier uses outriggers. Use of a mono-ski requires good upper body strength. Therefore, it is a technique that is not suitable to quadriplegics and high-level paraplegics. Other Adaptive Techniques This catch-all category is used for a variety of people with disabilities who don't fit into any of the other four. Among them are upper extremity impairment: people who have lost the use of one or both arms. Those with one good arm use one ski pole and a pole can also be used with an arm prosthesis. Below-knee amputees may choose to ski using their artificial leg or legs. A heel line is usually necesary to achieve a bent knee position. Waist straps and thigh lacers help provide lateral stability, a snug fit, and reduced pis-toning and rotation. A special ski leg can be made if the student decides to seriously pursue skiing. The combination of disabilities and adaptive equipment are numerous. In competitions, some 19 different classes are recognized. But, generally, most people ski using one of the four major techniques. Instruction There are a number of programs of ski instruction available. Most are voluntary, weekend programs. There are five full-time professional ski schools which specialize in adaptive skiing and about 25 voluntary ones. All but a few of these programs are chapters or affiliates of the National Handicapped Sports and Recreation Association (NHSRA). The NHSRA has also developed a clinic team which trains instructors in adaptive ski teaching. The team also advises on program delivery. There is an instructor testing and certification program conducted by NHSRA which is approved and recognized by the Professional Ski Instructors of America. Competition A natural outgrowth of participation in sports is the development of competition. A very well developed system is in place. Learn to Race clinics and training camps are conducted by a few of the instructional programs locally and by the NHSRA nationally. Those interested in competition can race in any number of programs open to the public such as NASTAR and United States Ski Association races. Further, there are ten sanctioned regional championships at which racers can qualify for the nationals. Both the NHSRA and U.S. Association of Blind Athletes conduct annual national championships. Both organizations also select athletes for the U.S. Disabled Ski Team which competes in the World Winter Games for the Disabled and the Winter Olympics for the Disabled. In 1986, the U.S. Disabled Ski Team was number one in the world at the games in Sweden. Resources National Handicapped Sports and Recreation Association 4405 East West Highway, Suite 603 Bethesda, MD 20814 U.S. Association of Blind Athletes Professional Ski Instructors of America 5541 Central Ave. Boulder, CO 80301 Alpine Skiing, contact: Vineland National Center P.O. Box 308 Loretto, MN 55357 <h3>Nordic Skiing</h3> Nordic (or cross country) skiing is also popular among people with disabilities. Since the sport does require more muscular effort for motion than Alpine skiing, it is not an option for some severely disabled individuals. Among the participants are amputees skiing with their prosthesis and some who ski on one leg. Those on one leg must rely upon upper body strength and use their poles to push themselves along. Nordic skiing is well suited for the visually impaired. They may ski with a guide or follow pre-set tracks in the snow. Some more severely disabled people who would be four-trackers in Alpine skiing, such as those with cerebral palsy, muscular dystrophy, multiple sclerosis, stroke, head injury, etc., can also participate in Nordic skiing if they are able to ambulate well. Some will require assistance, pushing or pulling with a rope, and frequent rest breaks are always a safe practice. There is a sit ski for Nordic skiing. The sit skier will need excellent upper body strength to push themselves over any appreciable distance. Again, assistance and rest stops will help. Instruction There are very few Nordic skiing instructional programs in the U.S. The sport is just beginning to develop. Those interested in learning the sport should check with a local cross country ski resort to see if they have an instructor willing and qualified. Most will have difficulty finding a program nearby. Competition The competition program described under Alpine skiing exists for Nordic skiing. Nordic events are held separately from Alpine events, but the U.S. Disabled Ski Team includes both Alpine and Nordic competitors. <h3>Other Winter Sports</h3> Snowmobiling has been a sport in which people with disabilities have participated for at least 15 years. It was one option open to more severely mobility impaired individuals before development of four track and sit skiing. Ice boating and bike sailing are adaptable to a wide variety of mobility impairments. Ice fishing can also be enjoyed by many people. *Doug Pringle Doug Pringle is the past president of the National Handicapped Sports and Recreation Association, 5946 Illinois Avenue, Organeville, California 95662. <div style="width: 400px;"> </div> Page Number(s) 114 - 117 Year 1987 Volume 11 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/. 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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_03_118.pdf Text Any textual data included in the document <h2>The UCLA Total Surface Bearing Suction Below-Knee Prosthesis</h2> <h5>Timothy B. Staats, M.A., CP. <a style="text-decoration: none;">*</a> Judd Lundt, B.S., A.E. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> While there was clear evidence to support examination of suction as a suspension technique for below-knee prostheses<a></a> in the early 1950s, overwhelming activity was in a direction that led ultimately to the development of the PTB design.<a></a> What is truly remarkable is the almost blind obedience that the practitioners and educators have given to PTB theories, a recognition that has rendered them all but untouchable gospel. Introduction and widespread use of transparent check sockets has probably done more to cause the prosthetist to question the accuracy of his PTB fitting methods than any other development in the last decade. Inaccuracy in socket fit that this powerful tool has revealed has led to the obvious conclusion: more precise casting and modification methods are required. This is the intent of the technique described here. This paper presents a departure from PTB philosophy and technique. The methods described freely borrow from and recognize individuals who have developed alternative ideas, many of which have been integrated into the UCLA Total Surface Bearing Suction Below-Knee Prosthesis. The substance of this paper includes suction as the obvious mode of suspension. However, the essence of suction suspension, and of this article as well, is the critical anatomical accuracy of the socket fit. We refer to it as the total surface bearing or TSB technique. Without TSB, successful long-term suction suspension cannot be achieved. With TSB, the prosthetist can achieve suction if desired or may choose to fit with a sock and without suction if so indicated. Whatever the case, the final result will be improved fit and better patient comfort. <h3>Suction Suspension</h3> Suction below-knee prostheses are unique in that they do not require auxiliary suspension systems such as straps, cuffs, thigh lacers, or sleeves to maintain the socket on the residual limb. This is not to suggest that auxiliary suspension need not be employed as an extra measure of protection, particularly with a very active patient. However, in principle no other suspension should be required (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-01.jpg">Fig. 1</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-01.jpg">Figure 1. UCLA Total Surface Bearing Suction Prostheses.</a> Three variations of suction socket are discussed in this article. The first is the "tension suction" variation.<a></a> This socket is made vol-umetrically smaller than the residual limb. Suction is maintained in the same manner as with the rigid above-knee suction prosthesis. This is probably through tension placed on the skin, thereby enhancing the friction between the tissue and the socket. Normally, a valve is placed at the distal end to release air while the socket is being applied. The second classification is "atmospheric suspension," mentioned by Murphy<a></a> in 1950 and later by others.<a></a> In atmospheric suspension, a non-elastic, but flexible interface is used, which virtually collapses around the residual limb when the prosthesis is unweighted. The third type of suction will be called "active compression suction." In this case, the socket interface is made of an elastic or elastomeric material which must be stretched or rolled over the residual limb, thereby gripping the skin through compression as well as through friction created between the skin and the socket.<a></a> <h3>Fitting Variables</h3> The primary concern of any prosthetist attempting to fit a suction below-knee prosthesis should be the general health of the residual limb tissues. The UCLA experience has been similar to studies by Holmgren<a></a> and Bedouin.<a></a> Types of Patients The suction below-knee prosthesis, properly fitted, appears to stimulate circulation and can be used on vascular amputees as well as amputations due to other causes. The suction below-knee may actually help to more quickly stabilize tissue fluid volume. Ages of patients have ranged from five to 88 years. Skin Problems A suction below-knee prosthesis virtually eliminates skin problems caused by movement and friction created between the residual limb and the socket interface. Problems of skin irritation related to hygiene and allergic reaction are covered in a later section. Bony Prominences Grevsten,<a></a> using x-ray evaluation of suction below-knee fittings, found that the movement of skeletal anatomy inside the socket is less than one-half that inside ordinary PTB sockets. The UCLA experience, which employs a more intimate casting and cast modification technique (TSB), suggests an even greater reduction in skeletal movement. More importantly, few problems with bony prominence pain or discomfort were reported by patients in the over 150 fittings conducted at UCLA and other locations during the teaching of this technique. Length We have found no correlation between residual limb length and the ability to wear a suction below-knee prosthesis. Fittings and suction suspension have been successfully achieved with residual limb lengths as short as 3 1/2". However, these are not all long-term results. Volume More important was the finding that many residual limbs initially fit with suction would lose this effect within one or two hours of wear. There is an immediate fluid volume adjustment. Patients fit with suction over longer periods of weeks and months will continue to experience residual limb volume changes until a point of volume stability is achieved. This normally will occur within six weeks. Any loss of body weight will certainly contribute to loss of suction as well. Shape Generally, with enough effort almost any shape residual limb can be fit with suction. However, to achieve suction with conical shape residual limbs, whether bony or fleshy, can be difficult. With such cases, it is often necessary to enlarge the gastrocnemius muscle bulge area of the socket while tightening slightly proximal to this to maintain suction. Many prosthetists might question the long-term effect of this technique on the health of the residual limb. Short term effects have not been adverse and results look encouraging. Patient Cooperation Patients who intend to wear suction below-knee prostheses must be intelligent, cooperative and aware of the critical nature and accuracy required in this type of fitting. Numerous adjustments may be required during the first several months to maintain the intimacy of the fit. The patient must fully understand the function of the valve and the socket liner. It is imperative that any patient wearing a suction below-knee prosthesis, no matter how effectively fit, wear an auxiliary suspension as a back-up in case loss of suction does inadvertently occur. <h3>Comparison of Theories</h3> In the below-knee prosthesis, suction is a mode of suspension that can only be maintained through a precisely fit socket. A major aim of this article is to present a technique whereby such a fit can be achieved. Development of the total surface bearing (TSB) below-knee socket combines a staged precision casting method with a significantly different model modification to yield this result. In order to understand these differences, it is necessary to contrast the TSB and the more traditional PTB sockets. The basic philosophy of the patellar tendon bearing below-knee prosthesis can be stated as follows: Increase weight bearing on areas of the residual limb over pressure tolerant areas and relieve pressure over those areas which are pressure sensitive. With the total surface bearing below-knee prosthesis weight is distributed over the entire surface of the residual limb, including areas which have in the past been considered pressure sensitive. In TSB, the accuracy of fit and careful use of measurements has eliminated the need for relief buildups over bony areas of the residual limb during the plaster casting and model modification procedures. The resulting corrected model for a TSB socket is thus distinctly different from that developed in accordance with PTB modification techniques. <h3>Evaluation and Measurement</h3> Measurements include all standard below-knee prosthetics parameters. The following additional considerations are necessary. Circumferences Carefully located circumferential measurements are taken at one inch intervals. The intervals are laid out from a bony landmark which can be defined accurately during the plaster casting procedure. Normally, the apex of the head of the fibula or the distal anterior tip of the tibia are chosen, depending on which is more prominent. The tibial tubercle may also be used. However, it is necessary to measure at least one interval more proximal when this location is chosen. In very fleshy or redundant residual limbs, it is wise to select the fibular head as some elongation may occur during casting which will obscure the distal end. Length The length measurement must be accurately gauged from the distal end of the residual limb to both the medial tibial plateau and to the inferior edge of the patella while under forceful upward loading. Evaluation Patients with chronic skin problems or burn scar tissue may not be suitably fit in sockets where the skin is directly in contact with the socket liner, unless the interface surface is impervious to body fluids. Perspiration can cause maceration even in healthy skin and an appropriate interface must be selected in such cases. <h3>Plaster Casting Technique</h3> An essential element of a successful TSB socket is a precisely cast residual limb. The diagonal four stage casting technique which draws from work adapted from Fillauer,<a></a> Gleaves,<a></a> Tranhardt,<a></a> Morris,<a></a> Hayes,<a></a> Stokosa,<a></a> and Vinnecour<a></a> was developed to best achieve that end. Unusual elements of the technique include: <ol> <li> Sheer nylon stockings for an ultra-thin barrier between skin and plaster, resulting in a more accurate cast. </li> <li> A beveled anterior first stage splint which is very accurately tailored to encompass the head of the fibula, the shaft of the tibia, and the entire medial flare. This first stage (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-02.jpg">Fig. 2</a>) is carefully molded to all bony anatomical structures. If properly applied, it will establish the medio-lateral dimension within 1/8" of patient measurement in most situations and require little or no model modification of the anterior aspect of the medial flare of the tibia. <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-02.jpg">Figure 2. The entire medial tibial flare and all bony prominences are carefully molded.</a></li> <li> A second stage of elastic plaster bandage which is wrapped with about half the available stretch applied. This stage must not extend more proximal than about 1" to 1 1/2" below the crease of the skin in the popliteal fold. The anterior stage is maintained in position during this second procedure with firm proximal compression. As the second stage sets, the proximal posterior aspect is lightly compressed to help define the antero-posterior dimension of the cast. The medial lateral dimension is never sacrificed in any attempt to decrease the antero-posterior dimension. </li> <li> A third stage splint, which creates the posterior brim shape and completes the basic cast used when a non-supracondylar trim line, is desired. The salient point of the third stage is the hand molding of the plaster bandage in the hamstring tendon region. When properly applied, the posterior brim will appear premodified with a diagonal trim which accommodates the lower anatomical insertion of the medial hamstring muscle group. It is necessary to do four things simultaneously to create an acceptable third stage, and generally will take considerable practice before re-peatable accuracy and skill is achieved. It is necessary first to locate and create the shape of the tendons; secondly, compress the antero-posterior dimension of the cast both proximally and compression-ally; third, mold the medial and lateral posterior areas of the third stage to prevent looseness in the hamstring areas proximal to the medial tibial plateau region; and fourth, spread the fingers of both left and right hands to stretch the plaster bandage to prevent a ridge from forming in the posterior aspect between the second and third stages (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-03.jpg">Fig. 3</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-03.jpg">Figure 3. The posterior trim and hamstring muscle reliefs are created during the wrap casting procedure.</a></li> <li> A fourth stage splint is used when supracondylar suspension is planned. It is applied in a manner similar to that used in Fillauer's three stage casting technique. </li> </ol> <h3>Alginate Pressure Fitting</h3> The first step in the fitting process occurs immediately after the hardened cast is removed. Through application of dental alginate to the inside of the wrap and a refitting on the patient, a more intimate contour is achieved. Though somewhat of a messy procedure, this will minimize the need to remove plaster from the model during modification. When casting very obese patients or those with excessive redundant tissue, this step may not be successful and may result in distortions in the final model. The nylon stockings are carefully removed from the cast and a hole is cut in each of the distal, lateral, medial, and posterior aspects to permit air to escape when the alginate is applied. The holes should be approximately 1/4" in diameter and should be cut using a knife. (A hand drill or drill press will likely grab the fabric in the wrap and destroy it.) About eight to ten ounces of dental alginate are mixed to a thick, but creamy consistency and quickly applied to the entire inner surface. The cast is replaced on the residual limb and forced proximal with moderate pressure. Alginate should exude from all cut holes (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-04.jpg">Fig. 4</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-04.jpg">Figure 4. The wrap cast is alginated and pressure fitted.</a> The instant the alginate stops flowing from the holes, they are covered with the hands or fingers to prevent further leakage. Any excess alginate can be smeared about the proximal brim to perfect the fit in this area (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-05.jpg">Fig. 5</a>). This procedure must be conducted quickly and precisely or air pockets will occur. If air pockets do occur, we have found that additional algination attempts have been unsuccessful. <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-05.jpg">Figure 5. The completed diagonal four stage wrap cast.</a> <h3>Total Surface Bearing Model Modification</h3> The antero-posterior and medial lateral are modified exactly to residual limb measurements. The anterior modification of the anteroposterior is markedly different from the PTB "Bar." The TSB modification follows the shape of the anatomy in this region as shown in the xeroradiograph of the below-knee amputation (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-06.jpg">Fig. 6</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-06.jpg">Figure 6. Xeroradiographs lateral view of below-knee amputation. Notice the shape proximal to tibial tubercle.</a> Notice that the shape of the tibia angles posteriorly immediately above the tibial tubercle. Plaster removal follows this shape. The inferior edge of the patellar area is modified as though the patella were being lifted proximally about 1/4". In other words, the true tibial plateau is below the inferior edge of the patella in most cases (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-07.jpg">Fig. 7</a>). The posterior aspect of the model normally requires only smoothing or only slight reduction to establish the correct AP. <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-07.jpg">Figure 7. Modification inferior to patella simulates shape of anatomy rather than "PTB" patellar bar.</a> Plaster is removed from the posterior aspect of the medial flare of the tibia. This half moon shape sweeps into the medial hamstring area. Up to 3/8" of plaster may be removed in a very redundant residual limb. It is not unusual to see a medial hamstring 1/2 to 3/4" lower than the lateral side. Generally, the lateral side hamstring can be kept almost at tibial plateau level and is maintained at this level across the popliteal fossa. Absolutely no buildups are applied to the crest of the tibia, the head of the fibula, the anterior distal aspect of the tibia, or any other bony prominences. Reliefs are created by removal of plaster from around these areas to accentuate their shapes and to compress the tissues. Usually no more than 1/8" of plaster is carved away using a curved blade flexible knife (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-08.jpg">Fig. 8</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-08.jpg">Figure 8. No plaster buildups are added to master model. Plaster is carefully removed around bony prominences and over bony prominences.</a> The model is next measured for circumferences using the previously established bony landmark as a guideline for accurately locating the measurement levels (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-09.jpg">Fig. 9</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-09.jpg">Figure 9. Circumference measurements of master model are reduced below patient measurements to achieve suction.</a> It is generally found that the model at this point will be approximately at the residual limb measurement or somewhat larger, even if fairly liberal modifications have been performed. If the model were to be smoothed and a socket fabricated at these measurements (0" to +1/8") it will result in about a two-ply heavy cast sock fit or about one "Socket Liner Stump Sock."<a></a> However, this may not in itself achieve suction. In order to create a suction fit, the model must be carefully reduced in its circumferential measurements starting from a point approximately one inch above the tibial plateau and proceeding distally the entire length of the cast. As a beginning, a minimum of 1/2" of tension reduction less than the patient's measurements is applied at each measured level. Ultimately, in a new patient (any patient who has never worn a suction socket) the tensions may well reach 3/4" to 1" less than the original anatomical measurements. However, it is not a simple matter of initially bringing the tensions on the model to these values. This is inadvisable and potentially harmful for the patient. A gradual reduction process over time must be followed in order to achieve the results just stated. In pilot studies and in pilot courses conducted at UCLA in 1984, an attempt to empirically arrive at appropriate TSB suction tension values was made. Each prosthetist was asked to carefully record how much reduction in residual limb measurements was required to finally achieve suction suspension. The compiled results of these efforts suggest an initial tension value of 3/4" is necessary at each level to achieve suction. This value may vary depending on residual limb musculature, length, and tissue type. <h3>Check Sockets</h3> It is advisable, if not imperative, to use transparent check socket fittings to confirm the accuracy and precision of the wrap cast and subsequent model modifications. The UCLA technique involves two types of check sockets: flexible check sockets and more conventional rigid check sockets. The Flexible Check Socket A check socket is vacuum formed using 1/8" Surlyn® plastic. On a five to seven inch residual limb this will result in a very thin socket probably no thicker than 1/32". A valve is located distally to release air from the socket as it is donned (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-10.jpg">Fig. 10</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-10.jpg">Figure 10. A flexible check socket is vacuum formed with small valve placed distally.</a> Lotion or Vaseline® is used to lubricate the surface of the residual limb to aid in donning<a></a> (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-11.jpg">Fig. 11</a>). Flexible socket fit can be confirmed by direct palpation of the anatomy from the outer surface. Any air spaces or otherwise loose areas are located and subsequently corrected on the model. It is not unusual for this flexible socket to hold suction even if inadequate tensions were applied to the model (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-12.jpg">Fig. 12</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-11.jpg">Figure 11. The flexible check socket is "wet" fit to the patient.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-12.jpg">Figure 12. Suction, total contact, volumetric and anatomic accuracy of check socket are determined in the flexible check socket.</a> Accordingly, if the socket is made rigid by an application of a roll of fiberglass casting tape to the outer surface, suction will invariably be lost almost immediately. This demonstrates one of the many problems facing anyone wishing to fit or wear a suction below-knee prosthesis. The flexible socket in this case is exhibiting atmospheric suction. The socket collapses around the residual limb as any attempt is made to remove it. Rendering the socket rigid transforms this flexible membrane into a rigid socket and as the socket wall cannot move, suspension is lost. The Rigid Check Socket A rigid check socket may be used after the model corrections, determined by the fit of the flexible check socket, have been performed. With the rigid fitting, it is common to find the need to increase tension values to an average of 5/8" to 3/4". It must be assumed that fluids rapidly leave the residual limb as a more rigid, accurate fitting socket is applied. It might also be speculated that the muscles flatten out somewhat as excess fluid leaves the residual limb. Examination of residual limbs in properly fit rigid transparent suction check sockets after several hours of wear reveal good color and lack of a distal discoloration which one might expect in a "tight" socket. <h3>Socket Materials</h3> A variety of materials and fabrication techniques have been examined for their application to the suction socket. Varying levels of success have been achieved; however, there are usually trade-offs involved. Suction may be achieved with a removable liner/insert alone that keys into the prosthesis much like a liner in a PTB socket. A prosthesis may also be constructed with a hard suction socket with no liner or with a soft liner that is permanently attached. In any case, some type of valve is usually necessary, installed either in the liner, in the socket, or at the end of a tube extending from the distal end of the socket to the outside finish lamination of the prosthesis. Valveless liners are also possible; they will be discussed later. In considering a method of constructing a suction socket, it is important to realize that there will be no sock to absorb moisture; the patient will likely require some type of powder, cream or lotion application to don the socket, and the skin will be in direct and intimate contact with the inner material. All of these factors dictate a non-porous, easily cleaned material that will minimize the growth of bacteria, yet provide the necessary cushioning and comfort for daily or specialized activities. Whichever approach is taken, the prospects of success are limited only to the ingenuity of the prosthetist and the materials employed. Hard Socket Variations This is perhaps the most difficult variation with which to achieve success since the demands of precision required for fit and comfort are the highest. Firm residual limbs of good muscle mass are the most likely candidates for this design. The hard socket is undoubtedly the easiest to fabricate, and for the patient is the easiest to keep clean. Even if accepted by the patient, these sockets will feel hard and, while suitable for walking, they are probably not appropriate for heavy activities such as running. However, hard sockets, with the addition of a single nylon sheath, have been very successful in the long-term with low activity level patients. Flexible acrylic and polyester laminates backed on the outer surface with soft foams such as PE-LITE™ or Aliplast™ have enjoyed about the same level of success as a hard socket. Patients report that these sockets feel hard despite the padding. Additionally, allergic skin reactions seem to be more common when flexible resins are used. Minute cracking in the interface may create a breeding ground for bacteria or lead to skin irritation through surface friction. A number of thermoplastic liners have been successfully fit (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-13.jpg">Fig. 13</a>). Some have been quite comfortable, notably the "total flexible brim" variation suggested by IPOS<a></a> and Sabolich.<a></a> Both are frame-supported polyethylene designs. Since thermoplastics may exhibit "cold flow" and may actually shrink, they are not ideal materials. An interesting characteristic of thin thermoplastic sockets is the enhanced capability of atmospheric suction. However, this advantage is basically negated by a lack of long-term durability. The suggested ease of refabrication and/or inexpensive nature of replacement does not hold up to criticism by patient used to no-nonsense prosthetic care. Another negative characteristic of thin thermoplastic liners such as Surlyn® and polyethylene is the inability to make adjustments after fabrication. <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-13.jpg">Figure 13. Surlyn® inner flexible socket with outer frame fitted in 1985 as a suction below-knee prosthesis.</a> A major point of consideration in fitting any socket material that directly contacts the skin is the coefficient of friction at the interface. There are definite differences which are recognized empirically and clinically, but not objectively related to prosthetic fit in the below-knee as well as in above-knee suction sockets. For example, Surlyn® and Durr-Plex both seem to have a surface which adheres very well to slightly damp skin. When these surfaces are lightly sanded, they lose some of this gripping capability. This can be both a positive and a negative factor, depending on the skin tolerance of the patient involved. Generally, hard socket variations of suction below-knee prostheses, while feasible, are not very practical for most patients. Moreover, the instance of inadvertent loss of socket suction must be expected. This is not really considered a problem since we recommend that auxiliary suspension be worn even on the best suction below-knee fitting. Soft Socket Variations Early suction liners were made of leather backed with Neoprene™. Even when given a sealant coating, the leather will begin to deteriorate and develop offensive odors in a fairly short period. However, good comfort has been achieved as has adjustability. Replaceability is not really possible in this variation. PE-LITE™ and Surlyn®-backed PE-LITE™ have both been successfully used for soft suction liners (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-14.jpg">Fig. 14 </a>and <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-15.jpg">Fig. 15</a>). It wears fairly well and can be cleaned with baking soda, vinegar, or rubbing alcohol to eliminate both odor and dirt. These liners will likely pack-out in time, and thus, normal prosthetic delivery should include a duplicate. Replacement duplication after wearout of thermoplastic foam liners is not really practical to the level of precision necessary to maintain suction. <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-14.jpg">Figure 14. Pelite™ liner with Plastozote distal end, distal valve and Surlyn® outer shell fitted as suction below-knee prosthesis in early suction below-knee courses at UCLA in 1985.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-15.jpg">Figure 15. The TSB Suction below-knee can be fitted on almost any length below-knee residual limb. Auxiliary suspension is not shown in this diagram but is recommended for all suction below-knee wearers.</a> Another major advantage of these materials is that they may be easily added to or otherwise adjusted. By use of selectively placed materials of varying durameters, comfort can be achieved in very bony patients and those with poor skin conditions. It is important to further note that some foams are not closed cell and will, therefore, permit moisture, dirt, and bacterial buildup which may not be easily removed. However, coatings have been developed which may solve the interface cleansing problem. Additional considerations in the use of a liner coating are potential allergic reactions, alteration of friction and shock absorption characteristics of the liner material, and adequacy of adherence. Foam liners, it must be remembered, provide comfort by absorbing load forces of axial, shear, and torque. The shock of impact is absorbed in the compression of the foam or in the compression of the gases within the individual cellular structure of the foam. Any buildup of heat within a liner could lead to problems for the patient in an intimate suction fit. In summary, soft foam liners are very practical from the point of view of comfort and the ability to adjust to maintain fit. Their major drawbacks are that they change shape with wear and they do get dirty and smell if not meticulously cleaned daily. Three known types of silicone liners are presently in use or in experimentation at this time. Koniuk<a></a> reported fabricating cast silicone liners (<a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-16.jpg">Fig. 16</a>) which can be later duplicated from the same mold. There have been some problems with tearing of these liners in early phases of development, but this is viewed as a materials problem only. Early liners were fairly thick and heavy which can be detrimental. Some problems of skin reaction to direct contact with silicone have been reported. Since silicones are relatively inert, skin irritation most likely may be attributed to friction between the skin and the liner. It may actually be holding the skin too well. Some patients may also be allergic to the catalysts used in the preparation of the silicone elastomer. <a href="http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-16.jpg">Figure 16. Silicone below-knee socket liner with expulsion valve installed.</a> Experiments with very thin laminated sheath-like silicone liners have been attempted with some positive initial results. However, adjustments are not possible because of the inability to cement to the material, a characteristic of the entire silicone group. Bedouin has reported using fills between the socket liner and the outer lamination as a means of reestablishing lost suction. Kristinsson<a></a> has demonstrated a preformed silicone liner which either rolls on or is pulled on the residual limb. The effect is to create distension of the distal tissues. Some problems have been seen in initial demonstrations, among which are tearing of the liners during application, some discomfort by patients with a hairy limb, and heat build-up. It may be too early in the development of these direct-contact silicone liners to determine with fairness their ultimate practicality. It is certainly true that lack of adjustability will likely continue as a source of considerable concern. A relatively new system, the PM Liner, developed by Peyton Massey<a></a> has been used as a suction below-knee liner. While proprietary in nature, it appears to be a vinyl-like foam which may be heated and formed with ease directly over the below-knee model. It has the comfort and padding of silicone but is much easier to work with and does not migrate as is the tendency with some silicone materials. Massey has been adapting this liner for use with adhe-sives so as to make it possible to glue patches of similar material to the PM Liner. A new concept in liners under development, called the Socket Liner Stump Sock,<a></a> offers an additional variation for potential use with a suction below-knee prostheses. It is a neoprene sock that is fabric-backed on both sides. When properly fitted, it maintains suspension by compression. The problem with this variation at present is that the smooth surface of the cloth outer face of the liner against the smooth inner socket surface does not provide sufficient friction to hold suspension. A coating is under development to resolve this problem. This liner offers an excellent compromise for the patient wishing to have an intimate TSB fit without complete suction. There is reportedly very little or no motion between the liner and the residual limb. Suction Below-Knee Valves Several specialized valves have been developed for the suction below-knee prosthesis although any valve can probably be used. An important feature in a valve for suction below-knee application is air expulsion capability. With such a valve, the patient simply forces his residual limb into the socket to expel the air through the distal end. Problems experienced with all valves have been accessibility and leakage brought on by inability to securely bond the valve seat to the liner. <h3>Auxiliary Suspension</h3> As has been previously emphasized, auxiliary suspension is mandatory on all suction below-knee prostheses. Sleeve type suspension offers the best compromise of comfort, security, and maintenance of suction. Cuff suspension in all forms has been tried, but cannot assist in sealing the socket to the residual limb. Three types of sleeves should be considered. The Latex Sleeve This provides the best seal and the most positive suspension, but has the problem of skin irritation, durability, odor, discoloration, and loss of shape. The Neoprene Sleeves These offer an acceptable seal that, while not as positive as the Latex, are acceptable so long as the sleeve has been properly manufactured. Neoprene sleeves are similar to Latex sleeves with respect to skin rashes and durability. Daily cleansing with alcohol can greatly reduce the incidence to skin problems. Providing the patient with multiple sleeves and proper hygienic education will reduce the incidence of skin rashes. Cloth Lined Neoprene Sleeves While these sleeves do not work well for total suspension, they can afford a margin of back-up for good suction wearers. <h3>Some Suggestions for Skin Problems</h3> For any serious rashes or other skin conditions, the patient should always be directed to his physician. A number of techniques have been tried by patients to clear up simple rashes. One technique is to wear a "Baggie®" or a thin polyethylene sheet directly against the skin of the residual limb until the rash clears. Some patients wear this inner protection at all times as a method of preventing rashes which might be caused by friction. When used with sock fittings, this will keep moisture out of the sock, thereby helping to prevent skin maceration. Some athletic patients apply transparent surgical tape over areas that are known to be prone to skin breakdown during heavy sports activities. Some brands that have been successfully used include 2nd Skin™, Op-Site, and Bioclusive Pads®. <h3>Conclusion</h3> The suction below-knee prosthesis, while an excellent option for some patients, may for others be the triumph of valor over reason. Should the decision be made to proceed with suction, both the prosthetist and patient must be completely aware of the long and difficult route involved. There will be obvious changes in the residual limb following initial fit which will require socket adjustment and refabrication over an extended period. There will probably be the need for some experimentation with materials and fabrication methods to arrive at an optimum fit for the patient. However, once these factors have been resolved, the results of a well-fit suction socket will be a marked improvement in patient comfort, satisfaction, and in a prosthesis that the patient "feels" is more a part of his person. If, on the other hand, suction is not a goal, the Total Surface Bearing casting and modification techniques that support a suction fit are entirely valid for every below-knee fitting regardless of the socket interface or method of suspension. In the view of the authors, these improvements over more traditional methods of below-knee prosthetics have been long overdue. Clearly, the superiority of Total Surface Bearing has been established and undoubtedly is the most important dividend of the research and education on suction below-knee fittings. <h3>Suggested Readings</h3> <ul> <li> Roberts, Ruth, "Suction Socket Suspension for Below-Knee Amputees," Archives Physical Medicine and Rehabilitation, Vol. 67, March, 1986, pp. 196-199. </li> <li><a href="poi/1978_01_003.asp"></a> <a href="poi/1978_01_003.asp">Grevsten, S., "Ideas on Suspension of Below-knee Prosthesis," Prosthetics Orthotics International, 2, 1978, pp. 3-7.</a> <a href="poi/1978_01_003.asp"></a></li> <li> Grevsten, S., "Patellar Tendon Bearing Suction Prosthesis Clinical Experiences," (Uppsala) J. Medical Science, 82, 1977, pp. 209-220. </li> <li> Grevsten, S. and L. Marsh, "Suction-type Prosthesis for Below-Knee Amputees: Preliminary Report," Artificial Limbs, 15, Spring, 1971, pp. 78-80. </li> <li> Pearson, J.R., S. Grevsten, B. Almby, and L. Marsh, "Pressure Variation in Below-Knee, Patellar Tendon Bearing Suction Socket Prosthesis," J. Biomechanics, 7, 1974, pp. 487-496. </li> <li><a href="cpo/1984_03_004.asp"></a> <a href="cpo/1984_03_004.asp">Murphy, E., "Sockets, Linings, and Interfaces," Clinical Prosthetics and Orthotics, Vol. 8, No. 3, Summer, 1984, pp. 4-10.</a> <a href="cpo/1984_03_004.asp"></a></li> <li> Schuch, M. and A.B. Wilson, "The Use of Surlyn® and Polypropylene in Flexible Brim Socket Designs for Below-Knee Prostheses," Clinical Prosthetics and Orthotics, Vol. 10, No. 3, Summer, 1986, pp. 105-110. </li> <li> Kay, H. and J. Newman, "Report of Workshop on BK and AK Prostheses," Orthotics and Prosthetics, Vol. 27, No. 4, December, 1973. Abrahamson, M., et al., "Improved Techniques in Alginated Check Sockets," Orthotics and Prosthetics, Vol. 40, No. 4, Winter, 1987, pp. 63-67. </li> <li> Pritham, C, "Suspension of the Below-Knee Prosthesis: An Overview," Orthotics and Prosthetics, Vol. 33, No. 2, June, 1979, pp 1-20. </li> <li> Holley, Teresa, "The Suction BK Prosthesis," UCLA Prosthetics Education Program term paper, 1984. </li> </ul> References: <ol> <li>Murphy, E., "Lower Extremity Components," Orthopaedic Appliance Atlas, Vol. 2, J.W. Edwards, 1960.</li> <li>Radcliffe, C.W. and J. Foort, The Patellar-Tendon-Bearing Below Knee Prosthesis. University of California, Berkeley, Biomechanics Laboratory, 1961.</li> <li>Grevsten, S., The Patellar Tendon Bearing Suction Prosthesis. 1977 Functional Studies, Doctoral Thesis, University of Uppsala, Sweden.</li> <li>Bedouin, Leo, personal communication, Dan Muth Company San Francisco, California, 1981-March, 1987.</li> <li>Friestadt, Ake, "The Swedish Suction BK Prosthesis," presentation at UCLA Advanced below-knee Prosthetics Seminar, October, 1984. Contact Een Holmgren Co., Uppsala, Sweden.</li> <li>Murphy, E.F., "The Fitting of Below Knee Prostheses," Klopsteg PE, Wilson PD (eds), Human Limbs and their Substitutes, New York, McGraw Hill, 1954, pp. 693-735.</li> <li><a href="cpo/1986_02_093.asp">Sabolich, J. and T. Guth, "Below Knee Prosthesis with Total Flexible Socket: Preliminary Report," Clinical Prosthetics and Orthotics, Vol. 10. No. 2, Spring, 1986, pp. 93-99.</a></li> <li>Kristinsson, O., "The ICEROSS System," lecture at UCLA Advanced Below-knee Prosthetics Techniques Seminar, Fall, 1986. Contact: Ossur hf. Reykjavik, Iceland.</li> <li>Holmgren, G., "The Patellar Tendon-Bearing (PTB) Suction Prosthesis," Disability, Strathclyde Bioengineering Seminars, August, 1978, MacMillian Press, Chapter 47.</li> <li>Grevsten, S. and U. Eriksson, "Stump-Socket Contact and Skeletal Displacement in Suction Patellar Tendon Bearing Prosthesis," J. Bone and Joint Surgery, 56, 1974, pp. 1692-1696.</li> <li>Fillauer, C, "A P.T.B. Socket with a Detachable Medial Brim," Orthotics and Prosthetics, Vol. 25, No. 4, December, 1971, pp. 26-34.</li> <li>Gleaves, J.A.E., Moulds and Casts for Orthopedic and Prosthetic Appliances, Charles C. Thomas Publishers, Springfield, Illinois, 1972.</li> <li>Tranhardt, T., "Trimlines for Prosthetics," lecture to California Association of Prosthetists and Orthotists, Lake Tahoe, California, Spring, 1978.</li> <li>McQuirk, A. and A. Morris, Controlled Pressure Casting for PTB Sockets (Teaching Manual), Hangers, Roehamptom Lane, London, England, 1982.</li> <li>Hayes, R., "A Below-Knee Weight Bearing, Pressure Formed Socket Technique," Orthotics and Prosthetics, Vol 29, No. 4, December, 1975, pp. 37-40.</li> <li>Stokosa, J., "Prosthetics for Lower Limb Amputees," in Haimovici, H., Vascular Surgery, Norwalk, Connecticut, Appleton Century-Crofts, 1984.</li> <li>Vinnecour, K., "Clinical Below Knee Prosthetics," lecture at UCLA Prosthetics Education Program Advanced below-knee Symposium, Fall, 1983.</li> <li>Cascade Orthopedics, Chester, California.</li> <li>Staats, Timothy, "Advanced Prosthetics Techniques for Below-Knee Amputations," Orthopedics, 8, 1985, pp. 249-258.</li> <li>IPOS Manual, "Below Knee Supracondylar Flexible Socket," IPOS-USA, Niagara Falls, New York, 1982.</li> <li>Koniuk, W., "A Pure Silicone Below-knee Socket Liner," lecture at American Academy of Orthotists and Prosthetists at San Francisco, California, Winter, 1986.</li> <li>Mr. Peyton Massey, New Life Laboratory, Santa Monica, California.</li> </ol> *Judd Lundt, B.S., A.E. Prosthetics-Orthotics Education &Research at the UCLA Division of Orthopedic Surgery, 1000 Veteran Avenue, 22-56 Rehabilitation Center, Los Angeles, California 90024. *Timothy B. Staats, M.A., CP. Prosthetics-Orthotics Education &Research at the UCLA Division of Orthopedic Surgery, 1000 Veteran Avenue, 22-56 Rehabilitation Center, Los Angeles, California 90024. Page Number(s) 118 - 130 Year 1987 Volume 11 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1987_03_118/1987_03_118-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_03_131.pdf Text Any textual data included in the document <h2>Upper-Extremity Prosthetics: Considerations and Designs for Sports and Recreation</h2> <h5>Bob Radocy <a style="text-decoration: none;">*</a></h5> The population of upper-extremity amputees, including congenitally limb-deficient persons, in the United States and abroad is placing increased demand upon the profession for improved prosthetic designs and devices which will allow its members to participate competitively in sports and recreation activities.<a></a> Recreation trends indicate that these demands will most likely increase. Until recently, prosthetics did not directly address the needs of the sports-oriented amputee. Prosthetic designs focused on domestic and vocational needs and did not necessarily target the criteria necessary to perform in the vigorous environments of sports or recreation. Over the years, select prosthetists working with individual amputees have developed "one of a kind" sports devices for their patients. These devices sometimes proved adequate, but most were never made available commercially. Two commercially available sports terminal devices have been available for many years: the Baseball Glove Attachment and the Bowling Attachment.<a></a> Recently, other specialized prosthetic devices have become available to meet the sports-minded amputee's needs. These are the SUPER SPORTs,<a></a> Amputee Golf Grip,<a></a> and the Ski Hand.<a></a> Additionally, new variations in the designs of body-powered terminal devices are allowing amputees to participate in many sports activities without the need for specialized aids or radical modifications.<a></a> The measure of performance by the amputee in any activity, as always, depends upon proper limb design. Socket design, materials, alignment, and components all play a vital role in any amputee's ability to perform competitively. Another important factor is the amputee's physical condition. The prosthesis, no matter how well designed and constructed, cannot supplement atrophied muscle, limited range of motion, or inadequate strength. Sports prosthetics begins with the evaluation of the need and of the capacity of the amputee being served. A physical therapist and potentially a clinic physician will be important components in the rehabilitation of an amputee wishing to become active in sports and recreation. Exercise and conditioning with or without a prosthesis will be required as a preliminary step for an amputee who wishes to excel without injury in sports. Exercise can take multiple forms. Proven exercise techniques exist. Isometric, isotonic, and passive and active resistance all have specific goals and methods. Education is required so that the amputee is knowledgeable about how to proceed with an exercise program and to determine the objectives, i.e. is muscle hypertrophy (bulk) required for strength or is muscle endurance more appropriate? Additionally, how are flexibility and range of motion impacted? Preprosthetic exercise may be required or desired. Weight harnesses<a></a> (Figs. 1, 2, and 3) rather than strap or cuff weights are a better way to approach exercise without a prosthesis. A properly designed harness will prevent weight slippage during exercise and will enable many variations of upper-extremity conditioning (Figs. 4, 5, and 6). Figures 1, 2, and 3. Weight harnesses, rather than strap or cuff weights, are a better way to approach exercise without a prosthesis. Figures 4, 5, and 6. A properly designed harness will prevent slippage during exercise and will enable many variations of upper extremity conditioning. Bilateral exercise using a dumbbell on the non-affected side is important to maintain muscle balance and reduce spinal stress. A full length mirror aids the amputee in viewing him or herself in order to correct postural deficiencies or extraneous movements to optimize resistance exercise efforts. Certain weight machines also allow for non-prosthetic exercise, but exercise will be limited to specific muscle groups (Figs. 7, 8, 9, and 10). Complete upper-body conditioning will be most effectively accomplished while wearing a prosthesis. Furthermore, exercise while wearing a prosthesis will help condition the residual limb to the skin stresses and shears a prosthesis will create when under load. Modern exercise equipment systems, such as Nautilus, Hydra-Fitness, and Universal, are available virtually everywhere in YMCAs, community recreation centers, health and sports clubs. A planned program for the amputee can be structured by professional instructors to the amputee's goals. Free weights are another alternative or can complement a weight conditioning program with the convenience of low cost and home use. Equipped with a proper terminal device (Fig. 11), an arm amputee can safely handle dumbbells or barbells in weight training. Figures 7, 8, 9, (above) and 10 (right). Certain weight machines also allow for non-prosthetic exercise, but exercise will be limited to certain muscle groups. Figure 11. Amputee lifting dumbbell with a terminal device. Proper conditioning balanced by flexibility achieved through passive stretching, aerobics or any number of alternatives will result in the range of motion and strength an amputee will need for high performance in sports and recreation. A regular conditioning program will especially enhance the use of body-powered prostheses which require activation through body-controlled movements. Sound limb design, mentioned previously, is a major component in an amputee's performance potential. Lightweight yet strong prostheses are ideal, but strength should not be sacrificed just to achieve reduced weight. Socket design is dictated to a certain extent by stump configuration, but it is the author's belief that, if at all possible, a supra-condylar socket should be used.<a></a> Supra-condylar sockets with all their variations (Muenster, Bock, etc.) have evolved rapidly with advances in electromechanical limbs. A supra-condylar socket need not be unduly restrictive, and such a limb allows for less complicated harnessing. Carbon fiber and acrylic resins are two materials which lend well to the lightweight but high strength prosthetic objectives. Socket padding,<a></a> whether fully or partially lined, aids in protecting the condyles, olecranon, and distal residual limb end from trauma. If adequately reinforced, ISNY<a></a> style sockets may prove to be applicable for sports as well, but the published data on below-elbow applications is scarce. In addition to padding, the author recommends a heavy residual limb sock or two regular weight socks for most sports activities. Highly absorbent terry lined socks (designed for athletic footwear) are excellent. A polypropylene sock can be used effectively as a liner if heavy perspiration is a problem. An adjustable excursion harness,<a></a> such as the modified Northwestern (Fig. 9) which allows for excellent range of motion and terminal device control, can be applied, although other designs will work. Rapidly adjustable excursion is a plus for actuation of voluntary closing terminal device systems and in sports where gross motion of the arms is required, i.e. archery, golf, baseball, etc. Cable efficiency may also be targeted for consideration. Several experienced amputees known to the author wax the stainless steel cables before assembly into the cable housing. The wax is clean and reduces cable to cable housing friction, thus improving efficiency. Alignment of the prosthesis on the residual limb also requires consideration, depending upon the amputee's sports needs. Preextended, as opposed to pre flexed, socket designs have useful applications in sports. They allow for full elbow extension while limiting flexion only slightly and usually not unacceptably. Wrist alignment is also of consequence and affects the manner in which the prosthesis torques on the residual limb when load is applied. It is important to emphasize the need for prosthetists to be concerned with dynamic forces on the prosthesis. A mere static fitting with a check socket will not suffice because it doesn't accurately duplicate what will occur in the definitive prosthesis. A secondary fitting session with a foamed, but unlaminated, prosthesis donned and the chosen wrist unit and terminal device in place can determine the optimum alignment of the components. Changes can be made accordingly and retested so that the definitive prosthesis will fit correctly. Testing the prosthesis in this manner will also determine if undesirable trim lines exist in the socket or whether extended padding is required. A supra-condylar fit socket on short residual limbs can cantilever on the epicondyles and cut in proximal to the olecranon when the prosthesis is loaded distally making it impossible to carry any significant load (Fig. 12). Extending the trim line can direct pressures to the back of the humerus instead of into the joint. Figure 12. A supra-condylar fit socket with an undesirable trim line. Two other techniques which can aid in creating a more suitable sports prosthesis are external padding and suspension sleeves. Nylon covered neoprene rubber, such as a diver's wet suit material, is readily available and makes an excellent "stretch to fit" cover for a prosthesis (Fig. 13). Thicknesses from 3 mm to 1/4" are available. The material provides a good cushion for contact sports, helps reduce limb trauma during a fall, and the thicker materials have enough bouyancy to float a prosthesis. This technique has satisfied the requirements for a padded prosthesis in several school systems around the country. Figure 13. Nylon covered neoprene rubber, such as a diver's wet suit material, is readily available and makes an excellent "stretch to fit" cover for a prosthesis. Suspension sleeves can improve a supracondylar fit, especially when using a passive recreational device where the cable is absent or does not play a role in prosthetic suspension. Both latex and neoprene sleeves designed for below-knee amputees are available and can be modified for upper-extremity use simply by cutting them down in length (Fig. 14). The advantages of using a commercially available below-knee sleeve is that angulation for a joint is already built in. The author prefers neoprene due to its durability. Both cause increased perspiration within the socket. Designed properly, a neoprene prosthetic cover can function as a suspension sleeve as well. Figure 14. Both latex and neoprene sleeves designed for below-knee amputees are available and can be modified for upper extremity use. The remainder of this article will focus on modifications for specific sports and recreation to which the author has been exposed either directly or indirectly. In some cases, the solutions are simple; in others, performance dictates a more complex technical solution. Photographs and drawings have been used as often as possible rather than the written descriptions to illustrate a modification, device, or technique. Activities are dealt with alphabetically for convenience sake. <h3>Archery</h3> Modern archery equipment is easily adaptable to certain types of terminal devices. Fig. 15 illustrates how a bow riser (handle) can be wrapped with consecutive layers of rubber, foam, and bicycle inner tube to create a durable, functional bow grip.<a></a> A chuck or pin can be used to jam the thumb of the terminal device closed around the riser or the amputee can just "hold on" as illustrated by Fig. 16.<a></a> Performance capabilities are exemplified by the amputee archer in this photo. He is a skilled hunter who has harvested three deer in a four year period. Figure 15. A bow riser (handle) can be modified to create a functional bow grip. Figure 16. An amputee can simply hold on to the bow as shown. <h3>Basketball, Soccer, Volleyball, and Football</h3> Until recently, aids for amputees in ball-sports were limited to padded hooks, cosmetic hands, and custom one-of-a-kind terminal devices. Although these devices were useful, they rarely provided the type of high performance characteristics the sports-minded amputee required to compete successfully. One possible answer or solution is now available. The SUPER SPORTs devices, sized for all ages, are designed specifically for ball-sports and other rigorous recreations in which hand/wrist flexion/extension is needed. Additionally, they absorb shock as well as store and release externally applied energy (Figs. 17, 18, and 19). SUPER SPORTs are passive, not cable activated, but are helpful in catching and ball control when used in opposition to an anatomical hand or another device. SUPER SPORTs combined with padded arm covers create a safe, effective prosthesis for sports, such as football, basketball, and soccer in which interpersonal contact is inevitable. Figures 17, 18 and 19. The SUPER SPORTs devices sized for all ages, designed specifically for ball sports and other rigorous recreations in which hand/wrist flexion/extension is needed. <h3>Bicycling, Tricycling, and Motorcycling</h3> Bicycling or tricycling has proven to be an aggravation for amputees equipped with conventional style hooks. Lack of adequate gripping strength and finger shapes have hampered performance. Presently, however, children and adults equipped with newer style voluntary closing terminal devices (Figs. 20 and 21) can control two or three wheeled cycles as well as their two-handed peers. No modifications are required except when hand brakes are present. Front and rear brakes can be actuated from a single hand lever. Brake pressure must be regulated so that braking forces are always applied to the rear wheel first for safe handling. Your local bicycle shop can usually solve hand brake complications. Figures 20 and 21. Children and adults equipped with newer style voluntary closing devices can control two or three wheeled cycles as well as their two handed peers. Special adapters have been designed for or by individuals interested in competitive bicycle racing (Fig. 22).<a></a> The prototype illustrated is simple and is designed for safety to "quick disconnect" or "break away" at certain levels of force. Figure 22. Special adapter for use in bicycle racing. Motorcycling is a natural extension of bicycling. Again, hand brakes and, in this case, a clutch hand lever complicate the situation. Unilateral amputees missing their left hands can shift and clutch with one hand with practice. Brakes again can be combined. A single foot lever is practical for driving dual master cylinders for hydraulic brakes. The rear wheel braking must occur first however. A local motorcycle mechanic or custom motorcycle shop can provide ideas or adaptations and modifications to standard equipment. <h3>Canoeing and Kayaking</h3> The author's experience with conventional terminal devices proved frustrating during these types of recreation. Split hook finger shapes did not adequately adapt to a paddle or oar. Lack of prehension inhibited the bilateral arm function required for these activities. Locking type terminal devices should never be used in water sports activities. Figs. 23 and 24 illustrate how new technology and minor modifications to paddles can overcome problems in canoeing. Figures 23 and 24. New technology and minor modifications to paddles can overcome problems in canoeing. Kayaking (Fig. 25) with a double-bladed paddle requires only coordination and practice. Rubber rings on the paddle which are used to keep water off the central shaft work equally well in preventing terminal device slippage. Figure 25. Kayaking with a double-bladed paddle requires only coordination and practice. Gross arm movements, such as paddling or rowing, inherently activate voluntary closing devices and keep them closed. Rowing using an oar and oar lock can be enhanced by adding a stop or flange to the oar handle to prevent the terminal device from inadvertently pulling off during a power stroke. <h3>Dance/Floor Exercise and Gymnastics/Tumbling</h3> Activities, such as dance, tumbling and floor exercise gymnastics, have been treated similarly to ball sports in the past due to a lack of specialized terminal devices that were readily available. Padded hooks, cosmetic hands and some custom pedestal style terminal devices have been applied to attempt to satisfy the amputees' needs for balanced bilateral function. Fig. 26 illustrates how the SUPER SPORT terminal devices can be applied to satisfy these specialized recreation niches. Figure 26. SUPER SPORT terminal devices can be applied to satisfy specialized recreation niches. <h3>Fishing</h3> Fishing is a sport and pastime everyone has access to and should be able to enjoy. Amputees using split hooks who wish to have improved control of reels might want to consider the Ampo Fisher I<a></a> which adapts to their prosthesis and reel (Fig. 27). Figure 27. Amputees using split hooks may want to consider the Ampo Fisher I which adapts to their prosthesis and reel. Another alternative for the high level amputee is the Royal Bee Electric Retrieve Fishing Reel system (Fig. 28).<a></a> Figure 28. The Royal Bee Electric Retrieve Fishing Reel systems. Amputees equipped with voluntary closing terminal devices do not require many modifications to fish. A handle modified with some rubber inner tube or tape is usually all that is required to operate a spinning or bait casting reel, due to the improved prehension of these types of terminal devices (Figs. 29 and 30). Figures 29 and 30. A handle modified with some rubber inner tube or tape is usually all that is required to operate a spinning or bait casting reel. Casting with a prosthesis is awkward due to lack of wrist flexibility. Amputees usually control the pole with their natural hand then switch hands to reel or reel with the terminal device. Most reels are available in left and right handed models to suit various physical conditions. Fly fishing poses more of a challenge due to the two-handed dexterity required in handling the fly line. One alternative is the Fly Fishing Reel for Amputees<a></a> (Figs. 31 and 32). This system has been used successfully, although the author feels there is still a need for improved alternatives. Figures 31 and 32. The Fly Fishing Reel for Amputees. Automatic fly reels have been experimented with unsuccessfully due to the difficulties involved in "pulling out line" to wind up the return spring in these reels. Additionally, it was discovered that the spring force was only sufficient to pull in slack line, not with line under drag or a fish engaged. <h3>Golf</h3> Due to its popularity, golf has rules (USGA 14-3/15) regarding artificial limbs established by U.S. Golfing Association for tournament play. Variations in golf aids have evolved over the years primarily as individual designs to suit specific amputee's needs. Recently, however, a device called the Amputee Golf Grip (AGG)<a></a> has been introduced. The AGG is a standardized manufactured product which meets the USGA requirements (Figs. 33 and 34). The device is somewhat similar to the Robin-Aids Golfing device<a></a> (Figs. 35 and 36). Both devices utilize a flexible member to attach to the prosthesis and do not require club modification. They allow for complete wrist/club flexion and extension. The Amputee Golf Grip also allows for unrestricted rotation. Figures 33 and 34. The Amputee Golf Grip is a standardized manufactured product which meets the USGA requirements. Figures 35 and 36. The Robin-Aids golfing device. Other attempts to produce a functional aid should also be noted. One custom device is designed to have clubs attach directly to the prosthesis (Fig. 37).<a></a> Similarly, another model, the Atkins Golf Aid,<a></a> also attaches into the end of the club, but uses a ball-socket swivel. The swivel allows for a limited degree of wrist/ club, flexion/extension, and complete rotation. Figure 37. A custom device designed to have clubs attach directly to the prosthesis. The author has tried several devices and prefers those that do not require club modification and which provide for total flexion/extension/rotation at the wrist/club interface. This allows for a complete back swing and smooth follow through capability. It is important to note that certain of these designs function more easily with one hand than another and must be played cross-handed for opposite side amputations. <h3>Guns/Hunting</h3> Almost any amputee can redevelop the skills necessary to handle a firearm safely with some simple gun modification. In many cases, a standard military sling can prove useful for handling a rifle. Another technique is to add a ring to a forearm sling mount which can then be grasped or engaged with a terminal device. Improved control can be created by adding a custom pistol grip to the forearm of the rifle or shotgun (Figs. 38 and 39). This modification will even allow for the safe operation of pump style shotguns or rifles. Consult with your local gunsmith for help in this regard as he has the knowledge and the tools to perform the modifications correctly. Figures 38 (above) and 39 (left). Improved control can be created by adding a custom pistol grip to the forearm of the rifle or shotgun. Terminal devices can be used to trigger guns as illustrated in Fig. 40, but practice is obviously important. Figure 40. Terminal devices can be used to trigger guns, but practice is obviously important. Other modifications/aids like the Blevin's gun yoke (Fig. 41) illustrate what inexpensive devices amputees have designed for themselves to regain access to a favorite recreation. Figure 41. The Blevin's gun yoke illustrates what inexpensive devices amputees have designed for themselves. Persons with higher level amputations, multiple leg/arm amputations, strokes, or paralysis resulting in para or quadreplegia can also participate in shooting and hunting. Many states have now legalized hunting from parked vehicles to aid severely disabled sportsmen. Additionally, devices such as the SR-7721 (Fig. 42) or home-made Para-Quad Shooting System<a></a> (Fig. 43) offer capabilities not easily accessed in the past. Figure 42. The SR-77. Figure 43. The Para-Quad shooting system. One final design illustrates how an over and under shotgun can be modified to shoot one handed (Fig. 44). Figure 44. An over and under shotgun modified to shoot one-handed. <h3>Hockey</h3> A terminal device for hockey<a></a> (Fig. 45) developed in Canada is an ingenious aid for the hockey enthusiast. It is composed of an adjustable tension ball socket which fits with an adaptor onto the end of a hockey stick. The design allows for the stick to pivot under external force and quick release/flex during a fall. The original model pictured was custom designed for the young hockey player, but if modified with stronger materials, it would be applicable to adults as well. Figure 45. A terminal device for hockey developed in Canada. <h3>Mountaineering</h3> Mountaineering is a less accessible, less popular sport for most of the population, but it does attract enthusiasts and disabled persons. Figs. 46 and 47 illustrate the author during a technical climbing training session. Voluntary closing devices, because of their ability to grasp rope and control gripping force, have proved useful to mountaineering. Instruction and guidance by professional climbing instructors is a must, and "safety first" procedures are always dictated. Figures 46 and 47. The author during a technical climbing training session. <h3>Music</h3> Information and devices to aid amputees playing instruments is scarce. Recently, however, information on a new guitar prosthesis was published in Canada<a></a> (Fig. 48). Dan Roy, the guitarist, in conjunction with specialist Armand Viau have developed a prosthesis which allows Roy to use his shoulder to strum the guitar. The arm is lighter than a conventional prosthesis and can hold a guitar pick. Figure 48. A new prosthesis which enables guitarists to strum their instrument using their shoulders. Figures Figs. 49 and 50 illustrate how some newer terminal devices, such as the ADEPT,<a></a> have proved to be viable solutions for children wishing to "play" musician. Figures 49 and 50. Newer terminal devices, such as the ADEPT, have proved to be viable solutions for children wishing to "play" musician. <h3>Photography</h3> Custom photography and camera adapters have been fabricated for years. Now a device called the Amp-u-Pod<a></a> (Fig. 51) is a standardized, manufactured product which has proved to be an extremely effective aid for the amputee photographer. Designed to replace the amputee's regular terminal device, the Amp-u-Pod mounts directly to the prosthesis and adapts to any 35mm, movie, or video camera equipped to receive a tripod. Figure 51. The Amp-u-Pod has proven to be extremely effective for amputee photographers. <h3>Sailing</h3> Amputees are less restricted in this recreation, but handling rope lines and other types of sailing gear can place demands on the sailor to have two-handed capabilities. Fig. 52<a></a> illustrates a triple amputee who found a GRIP<a></a> terminal device to be one of his best assets for sailing. Figure 52. A GRIP terminal device used for sailing. <h3>Snow Skiing</h3> Amputees have experimented with a number of ways to attach a ski pole to a prosthesis with little functional success. The Ski Hand<a></a> (Fig. 53) is the first standardized manufactured terminal device designed specifically for skiing. Available in varying sizes, the amputee force fits the Ski Hand over a ski pole after removing the standard hand grip. The Ski Hand proved worthwhile for cross-country skiing where upper-body strength is required for propulsion. During downhill skiing, the author found the device of less advantage due to the shallow angle to which the pole enters the hand. The pole basket had a tendency to drag in the snow and was therefore more difficult to control. Novice skiers, however, will find the Ski Hand useful because it enhances maintaining balance and getting up after a tumble. Figure 53. The Ski Hand. <h3>Swimming</h3> Swimming for many upper-limb amputees requires no aid whatsoever. However, for those individuals who wish to perform better or compete in the water, several devices have evolved as custom, one-of-a-kind solutions. The Viau-Whiteside Swimming Attachment<a></a> (Fig. 54) and the P.O.S.O.S./Tablada Swimming Hand Prosthesis<a></a> (Figs. 55 and 56) are two with which the author is most familiar, although others may exist. Figure 54. The Viau-Whiteside swimming attachment. Figures 55 and 56. The P.O.S.O.S./Tablada Swimming Hand Prosthesis. The Tablada hand is flat rather than curved to prevent submarining of the prosthesis during pre-stroke arm extension (Australian Crawl) in order to generate greater stroke volume. Additionally, note that the Tablada system uses a prosthesis which is close to actual anatomical arm length, whereas the Viau system has a shortened forearm section. Both utilize a pre-flexed, rigid elbow design. The Viau arm was designed primarily for back stroke swimming and may therefore account for the curved terminal device shape which would not hamper this style of swimming. The author is also aware of the use of SUPER SPORT devices for swimming, especially for children unaccustomed to the water. Pistoning of the prosthesis can be one of the most common occurrences during swimming. A suspension sleeve can aid in eliminating this action. An additional consideration related to swimming and skin or scuba diving is that the prosthesis is not as buoyant as the body and can seem heavier than normal in water and sometimes will impair performance. <h3>Water-Skiing</h3> Water-skiing can be an extremely dangerous recreation if not approached with caution. The author suggests the following rules of good judgment if water-skiing is on an amputee's wish list of recreational pursuits. First, don't ever lock onto a ski rope handle with any terminal device or use a terminal device which requires a cable and harness system. Second, use a ski rope equipped with a single handle. Third, wear a self-suspending, condylar socket that can be twisted free of under stress. A suspension sleeve will aid support but not impair release of the socket due to the flexibility of the material. Fourth, have a neoprene arm cover for the prosthesis which will float the arm in the water if it comes off. Fifth, always wear an approved floatation vest. The Water Ski Hook<a></a> (Fig. 57) is a simple solution to water skiing that has proved safe when set up and used properly. The Ski Hook should be mounted on the prosthesis in a canted position and tightened into place so that it cannot rotate freely. The shallow hook design provides support, yet will twist off a ski rope handle. Should a fall occur where twisting off is impaired, the supra-condylar socket can be "torqued off" the arm and save the amputee's shoulder from potential trauma. Figure 57. The Water Ski Hand is a simple solution to waterskiing problems. Another solution to prevent injury is to have the tow rope attached to the boat with a quick release, or equipped with a second handle (for small children only) and always manned by an observer/handler. Should the amputee skier go down, the observer can release the rope instantly, preventing injury. The Ski Seat<a></a> (Fig. 58) and E-Ski<a></a> illustrated in Fig. 59 are viable answers for the high level bilateral amputee and the paraplegic or quadraplegic who wishes to enjoy the thrill of skiing. The sled is custom constructed and has two skis. The E-Ski, a newer device, has only one ski and a cage seat. Figure 58. The Ski Seat. Figure 59. The E-Ski. <h3>Wind Surfing</h3> Wind surfing is a relatively new recreation which combines aspects of sailing, surfing, and hang gliding. Load coordination and balance compounded by the need to grasp, maneuver, and rapidly let go of a cylindrical boom as well as uphaul a rope with mast and sail in tow are some of the obstacles the amputee windsurfer faces. A prototype voluntary closing wind surfing terminal device is illustrated in Figs. 60 and 61. Other considerations should include special adjustable harnesses and cable systems for ocean or cold water sailing. Salt accumulation can foul cable function and negate terminal device operation. Wet suits, due to their tight elastic fit, will also interfere with cable function if the cable is worn inside the suit. The harness and cable system must be designed to fit on the outside of the wet suit for unrestricted terminal device operation. Leather on the prosthesis or harness should be avoided, as well as hardware which corrodes. Performance wind surfing is a physically and mentally demanding sport, and the amputee needs to be cautious and prepared to participate safely. Figures 60 (above) and 61 (right). A prototype voluntary closing wind surfing terminal device. <h3>Summary</h3> The varied demands of sports and recreation create a multitude of factors which impact the design, construction, and use of a sports prosthesis. Physical fitness and conditioning, prosthetic design and materials, harness styles, and terminal devices all have roles in determining whether an amputee can engage in a sports activity successfully and safely. New improved prosthetic devices and designs will continue to evolve to meet these varying demands. Communication between professionals is important in order to share information on the improvements which are made. Designs for high performance limbs and devices for sports and recreation may well pave the way for improved prosthetic technology as a whole. An open mind, a fresh outlook, an understanding attitude, as well as the patience and willingness to experiment and develop, will inevitably lead to a brighter future for the disabled in sports and recreation. References: <ol> <li>Chadderton, O.C., C.A.E., "Survey: Consumer Interests," The Fragment, Winter, 1986, Vol. 151, pp. 29-31.</li> <li>Robinson, W.D., B. Pflanz, B. Watkins, and A. Viau "Recreational Limbs AMPUTATION III," The War Amputations of Canada, April, 1986, pp. 19-33.</li> <li><a href="poi/1986_03_129.asp">Mensch, G. and P.E. Ellis, "Running Patterns of Transfemoral Amputees: A Clinical Analysis," Prosthetics and Orthotics International, 1986, Vol. 10, pp. 129-134.</a></li> <li>Products and trade names of Hosmer-Dorrance Corporation, Campbell, California.</li> <li>Products and tradenames of T.R.S., Inc. of Boulder, Colorado.</li> <li>Product and tradename of Recreational Prosthetics, Inc., North Dakota.</li> <li>Radocy, R., "Sports Designs for Upper Extremity Amputees," a symposium presentation at the National Sports Prosthetics and Orthotics Symposium, U.C.L.A. Prosthetics/Orthotics Education Program, October, 1985.</li> <li>"Bow Modifications Serve Amputees," Archery World, February, 1987, p. 22.</li> <li>Weight harnesses designed and tested by Bob Radocy, T.R.S., Boulder, Colorado {not commercially available}.</li> <li>Radocy, B. and Randall D. Brown, "Technical Note: An Alternative Design for a High Performance Below-Elbow Prosthesis," Orthotics and Prosthetics, 1986, Vol. 40, No. 3, pp. 43-47.</li> <li>Billock, John N., "Northwestern University Supracondylar Suspension Technique for Below-Elbow Amputations," Orthotics and Prosthetics, December, 1972, Vol. 26, No. 4, pp. 16-23.</li> <li>Berger, N., et al, "The Application of ISNY Principles to the Below-Elbow Prosthesis," Orthotics and Prosthetics, Winter, 1985/86, Vol. 39, No. 4, pp. 10-20.</li> <li>Radocy, Bob, "The Rapid Adjust Prosthetic Harness," Orthotics and Prosthetics, 1983, Vol. 37, No. 1, pp. 55-56.</li> <li>Courtesy of Bill White, bilateral amputee using two GRIP terminal devices, Waterford, Pennsylvania.</li> <li>Courtesy of Kent Barber & Bill Dalke, Prototype bicycle aid not commercially available. Inquiries to T.R.S. of Boulder, Colorado.</li> <li>Courtesy of Bassamatic, Inc. of Canton, Ohio.</li> <li>Courtesy of Royal Bee Corporation, Pawhuskas, Oklahoma.</li> <li>Courtesy of Robin-Aids Prosthetics of Vallejo, California.</li> <li>Courtesy of The War Amputations of Canada, Ottawa, Ontario.</li> <li>Tradename and product of Innovation Research Corporation, Milwaukie, Oregon.</li> <li>Courtesy of SR-77 Enterprises, Inc. of Chadron, Nebraska.</li> <li>Courtesy of R.F. Meyer's photograph of R. Wityczak, a triple amputee.</li> <li>Courtesy of Carmen Tablada, CP., Professional Orthopedic Systems of Sacramento, California.</li> <li>Ski Seat, Mission Bay Aquatic Center of San Diego, California.</li> <li>E-Ski, Courtesy of E.S.C.I. of Gretna, Louisiana.</li> <li>Courtesy of the Rehabilitation Centre for Children, Winnipeg, Manitoba, Canada.</li> </ol> *Bob Radocy Bob Radocy is President, TRS, Inc. 1280 28th St., Suite 3, Boulder, CO. 80303-1797 <div style="width: 400px;"></div> Page Number(s) 131 - 153 Year 1987 Volume 11 Issue 3 Figure 2 FIGURES 4,5,&6 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-02.jpg Figure 3 FIGURES 7,8,9,& 10 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-03.jpg Figure 4 FIGURE 11 ttp://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-04.jpg Figure 6 FIGURE 13 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-06.jpg Figure 7 FIGURE 14 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Needs Revision-See Trello Figure 8 FIGURE 15 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-08.jpg Figure 1 FIGURES 1,2,& 3 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-01.jpg Figure 5 FIGURE 12 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-05.jpg Figure 9 FIGURE 16 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-09.jpg Figure 10 FIGURE 17,18,19 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-10.jpg Figure 11 FIGURE 20 & 21 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-11.jpg Figure 12 FIGURE 22 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-12.jpg Figure 13 FIGURE 23 & 24 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-13.jpg Figure 14 FIGURE 25 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-14.jpg Figure 15 FIGURE 26 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-15.jpg Figure 16 FIGURE 27 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-16.jpg Figure 17 FIGURE 28 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-17.jpg Figure 18 FIGURE 29 & 30 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-18.jpg Figure 19 FIGURE 31 & 32 http://www.oandplibrary.org/cpo/images/1987_03_131/1987_03_131-19.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Upper-Extremity Prosthetics: Considerations and Designs for Sports and Recreation Creator An entity primarily responsible for making the resource Bob Radocy * https://staging.drfop.org/files/original/6766332bd317d916ca9a238f35743f60.pdf 2b25dd44f3fa9c14c3be1eeea1a6e844 https://staging.drfop.org/files/original/d5809008a88d66f392efb83a15c98e08.jpg cea990994c7ba243100b8aa3d793d549 https://staging.drfop.org/files/original/d15c4c4e078acbf08e329fb7d2ff3af6.jpg e21aeea4c8203c21cdeedf3e3ec18a7d https://staging.drfop.org/files/original/e80eda1cd3d59fed9f1e0f8852d89735.jpg 56bc08198994bcfc62ee59886d6cf543 https://staging.drfop.org/files/original/5c659ce3f575c3d39ed5ff983405f233.jpg 4196cf554d53ae48ff899b8a51c5f98d https://staging.drfop.org/files/original/4471076f5da8b14d5f383cfef89e77da.jpg 876943b0c3cb1adfe8d456633ea0deb5 https://staging.drfop.org/files/original/7c3a2e144e4bf74065eb614cc24fbc5a.jpg 6efc62a9627b6315da3ef4380c5b8897 https://staging.drfop.org/files/original/7021a0f992d9834c3826a5c1214833c8.jpg ac3f65dc469a2e5b4a83a58c293a1a31 https://staging.drfop.org/files/original/e00bf130dfa52ef46f528d2fdcc21d5a.jpg c5b7c3acf44d1a4edfde62205f5d406e https://staging.drfop.org/files/original/d8cb5c3a16381e1b972ccb339401ad23.jpg a3120f6ef46cc75bdc38ef387740cf62 https://staging.drfop.org/files/original/a746e158f57a6b359bd86178f753b692.jpg 51ffece8c90f2b03a122eb8e92ae3406 https://staging.drfop.org/files/original/69d23ce53227fa4c6a63c9be1e86399a.jpg c51ef4d9e33a90542ed1ab043e4cf346 https://staging.drfop.org/files/original/cf39f04ba9b82003e7d927e8bb478bd8.jpg 4525cdf1a7773f0d3cc0e843b33286f9 https://staging.drfop.org/files/original/05b9623006627347d7649027077c6775.jpg c4d0ddcbb9a3c19966e715953a0b6324 https://staging.drfop.org/files/original/5797c5b8c05087206ffbbd354701687c.jpg ba564008cd8af45856b50ffd5983cfa0 https://staging.drfop.org/files/original/0649b32d8d71675a737acb669446e101.jpg ad21f50147be20e5771cb0b30ecbda1d Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_03_154.pdf Text Any textual data included in the document <h2>Energy Storing Feet: A Clinical Comparison</h2> <h5>John Michael, M.Ed., C.P.O. <a style="text-decoration: none;">*</a></h5> The human foot is an exceedingly complex structure. The pair contain 52 separate bones, dozens of intrinsic muscles, and scores of extrinsic ones. The feet are composed of multiple layers of ligaments, fascia, and muscle, and contain numerous interrelated articulations. In combination with the ankle complex, the foot provides the dual functions of support and propulsion. Paradoxically, this is accomplished by combining the diametrically opposite characteristics of flexibility and rigidity as the foot adapts to the gait cycle.<a></a> Despite hundreds of historical attempts to imitate this remarkable structure, very few designs have ever achieved widespread acceptance. Within the last three years, however, four new foot components have become commercially available—all in the previously unheard of class called "energy storing" designs. These intriguing new developments will be discussed in chronological order, summarizing our experience at Duke. <h3>Seattle Foot™</h3> In 1978, Bernice Kegal of the Prosthetics Research Study in Seattle published a paper entitled "Functional Capabilities of Lower Extremity Amputees,"<a></a> and noted that a major prosthetic limitation in sports activities was the inability to run. The vigorous amputee athlete was competing despite the components rather than because of them. The Prosthetics Research Study, in cooperation with engineers from Boeing aircraft, began developing a prosthetic foot specifically designed to store energy and release it at push off: the Seattle Foot™. First introduced in 1981 at a course in modern prosthetic rehabilitation presented by the American Academy of Orthopedic Surgeons, the Seattle Foot™ was later field tested by hundreds of Veterans Administration clients. Today, it should be widely acknowledged as the stimulus for the current explosion of new concepts in this area. The design specifics have varied over the past few years as the concept was refined. Originally, the keel was a fiberglas multi-leaf design, somewhat similar to an automobile suspension spring. The key concept was that as the patient increased his cadence, stiffer portions of the spring came into play. Various exotic materials were considered, including titanium, but were clinically impractical.<a></a> The commercial version first became available in October, 1985 and consisted of a Delrin bolt block and integral keel, with Kevlar® toe pad (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-01.jpg">Fig. 1</a>). The entire structure is contained in a lifelike injection-molded polyurethane shape. To date, over 8,000 Seattle™ feet have been used in the United States.<a></a> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-01.jpg">Figure 1. Seattle Foot™ note cantilevered plastic spring keel to store energy (Courtesy MIND).</a> Although patient acceptance has generally been good, several technical difficulties have been noted with this design. During the VA field-testing, catastrophic failure of the plastic keel occurred in some cases. This has been greatly reduced in the commercial version, provided the proper keel configuration is selected using the manufacturer's guidelines. Because of ongoing problems with failure of the flexible rubber toes at the keel tip, the polyurethane composition has recently been reformulated for more tear resistance.<a></a> About one third of our feet at Duke have failed in the forefoot, although all were replaced under manufacturer's warranty. We have experienced no catastrophic failures whatsoever in our series. The "Life-Molds," although very natural in appearance, have presented some difficulties. The first is that the forefoot is fairly wide and often difficult to fit into dress shoes, particularly narrow widths. In addition, there is no uniformity in dimensions from size to size, or even between left and right in the same size. For example, if a patient returns requesting a foot one size smaller since purchasing tighter shoes, and a 26cm foot is substituted for a 27cm foot, the prosthesis has been inadvertently shortened by 5mm (1/4"). Also, the stark contours of the original "Life-Molds" can be difficult to blend into the prosthetic ankle at the retromalleolar area, and are too muscular for some patients. The recently available "Ladies Molds" have effectively addressed the problems noted above. Redesign of the male version is underway, and is expected to achieve similar results. The Delrin keel has also been a source of problems. Because it is very slippery, inadvertent rotation and loss of toe out has occurred. Since drilling and pinning the bolt block would significantly increase the risk of breakage, the manufacturer recommends bonding the foot to the ankle block or endoskeletal adapter with hot-melt glue. This has eliminated problems with loss of toe out in our series at Duke, although we still experienced occasional problems with the keel "slipping" completely out of the polyurethane shell for active walkers. Problems have also been reported with occasional bolt breakage, and speculation regarding cold creep of the plastic has been voiced. The manufacturer supplies special bolts, locktite, and torque specifications to address this issue. We have experienced no bolt problems at Duke. Finally, this is the heaviest solid ankle design commercially available. Although most patients have no apparent difficulties, some find the weight objectionable. One volleyball player, in particular, rejected the foot for jumping activities, even though she found it excellent for jogging and similar sports. Despite the technical difficulties noted, our experience at Duke has generally been favorable. Patients often comment on the "lively" step permitted by the cantilevered spring design. We particularly favor this component in the smaller sizes (26cm and below), as the incidence of breakage seems reduced. One unilateral hip disarticulation amputee commented that the more active push off "lets me pass someone in a crowd for the first time since I became an amputee."<a></a> <h3>Flex-Foot™</h3> At the same time the Seattle Foot™ was being developed, an independent collaboration between a plastics engineer and a young research prosthetist-amputee resulted in creation of the Flex-Foot™. This lightweight graphite composite structure offers a radically different approach. All are hand made from a computer-generated design specific to each individual patient. Data such as weight, activity level, and residual limb characteristics determine the specific orientation and thickness of reinforcement fibers. Ultra high pressure, high temperature molding insures the greatest possible strength to weight ratio, but requires several weeks for fabrication. Although this is a very costly approach, it does permit fitting the widest range of individuals. The chief restriction is that a minimum of five inches is required from the end of the residual limb to the floor, and seven inches or greater is preferred. Thus, the Flex-Foot™ is not suitable for small children, Symes and similar amputations, and very long below-knee residual limbs.<a></a> Unlike any other component currently available, Flex-Foot™ utilizes the entire distance distal to the socket for function. Since it stores energy throughout its entire length rather than just within a four inch keel, this results in a very responsive and resilient component. It also significantly improves the mass distribution of the prosthesis (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-02.jpg">Fig. 2</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-02.jpg">Figure 2. Flex-Foot™, showing full-length composite strut for energy return (Photo courtesy Flex-Foot, Inc.).</a> Most multi-functional feet bolt onto the prosthesis at the ankle block, and are heavier than a conventional SACH foot. With the weight concentrated at the distal end, the limb swings as if it were a sledgehammer. Overcoming the inertia of this mass in order to propel it through space consumes energy, and the patient perceives it as "heavy." The Flex-Foot™, however, is more akin to an inverted sledgehammer. The bulk of the weight is in the socket and attachment cone, with the rest uniformly distributed in the pylon. This is analogous to holding the head of the sledge and swinging the handle through space. Even if the Flex-Foot™ prosthesis weighs nearly as much as the conventional limb, the patient finds it much easier to propel, and perceives it as "light." Actual weight savings of 10-15 percent are common, but patients typically perceive that the Flex-Foot™ weighs "half as much." Another advantage unique to the Flex-Foot™ is the ability to independently adjust the anterior and posterior lever arms. Overall stiffness is fabricated in at the factory, but tilting the pylon increases the anterior flexibility. Varying the length of the heel pylon independently controls its resistance. Conventional AP linear slide adjustments affect the resistances in the conventional manner: sliding the foot forward decreases posterior leverage while increasing the anterior resistance. Due to the complexity and magnitude of the inter-related alignment changes possible with the Flex-Foot™, we advocate use of a prototype prosthesis, at least initially. By dynamically aligning the new socket on a conventional foot using a conventional alignment fixture, mediolateral alignment and the quality of socket fitting can be easily evaluated and refined. Once these are satisfactory, the vertical transfer fixture can be used to permit substitution of the Flex-Foot™ pylon. A secondary dynamic alignment is then performed, permitting concentration on sagittal plane characteristics without being distracted by a multitude of adjustments in other planes. Although use of slow-motion video analysis has been of some value in refining the sagittal alignment, we strongly encourage an extended field trial prior to finishing the limb. Application of a PVC bag over the alignment fixture followed by several layers of fiberglass casting tape reinforcement will permit the patient to use the limb clinically for a week or two. Upon return to the laboratory, the fiberglass tape can be removed and the alignment further enhanced. As the patient becomes accustomed to the function of the Flex-Foot™, he will often prefer stronger anterior resistance. A knowledgeable physical therapist can be an asset at this stage, as the person must learn to shift his weight onto the Flex-Foot™ throughout stance phase and "ride it into toe off" in order to achieve maximum benefit from its push off characteristics. Casting tape should be reapplied and the field trial continued. Only when the patient returns, needing no additional alignment changes, can it be assumed the alignment is optimized, permitting transfer and finishing to proceed. A comprehensive fabrication manual is provided by the manufacturer,<a></a> and the instructions should be followed explicitly, particularly regarding reinforcement of the attachment cone. Tremendous stresses are concentrated where the resilient pylon meets the rigid socket, and structural failures of the lamination can occur if improperly fabricated. Cosmetic finishing is difficult and time-consuming, but results in a finished structure that is highly water resistant since the foam provided is used in life preserver construction. If immersion is anticipated, a final sealing coat of Lynadure or other flexible "skin" is recommended. Although our series is small, we have experienced no failures with the Flex-Foot™ system, even on very large and very active individuals. One high school athlete, who destroyed SACH and SAFE feet two or three times per year, has been playing varsity football with the Flex-Foot™ for two seasons without incident. The manufacturer reports an overall failure rate of less than four percent with over 2,500 units in the field. Most failures occurred where the heel pylon bolts attached to the anterior pylon. One common denominator has been a sudden increase in the patient's activity level after being fitted with the Flex-Foot™. A highly active individual (or one who has recently gained weight) using a pylon originally designed for standard duty applications is at risk, so the prosthetist must anticipate the ultimate stresses that will be applied.<a></a> The recent announcement of a "Modular Flex-Foot™" (MFF) represents an effort to expand the usefulness of the Flex-Foot™. Available in standard configurations, these pre-made pylons can be supplied within two weeks. The heel lever arm bolts through the forefoot rather than the highly stressed ankle area, to enhance durability. A refined attachment system permits easier socket replacements, which should encourage application to more recent amputees. And, limited alignment refinements are possible even after permanent attachment to the socket, via Otto Bock "Modular" components or the "pylon connector" (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-03.jpg">Fig. 3</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-03.jpg">Figure 3. Modular Flex-Foot™ (MFF), showing improved socket and heel attachment designs.</a> We believe the cost and complexity of the Flex-Foot™ can be justified due to the degree of function offered. A competitive volleyball player reported her vertical leap nearly doubled when using the Flex-Foot™, and its low inertial drag made activities less tiring.<a></a> A severely debilitated geriatric amputee, who ambulated with a cane due to impaired balance, claimed he could walk "twice as far before my wind gives out" after fitting with the Flex-Foot™.<a></a> And a 47 year old nurse completed the New York Marathon's 26 mile race on the Flex-Foot™ one hour thirty-two minutes more quickly than with a conventional design.<a></a> Hard data to buttress these anecdotal reports are very limited at this time. A motion analysis conducted at the University of Illinois suggests that the Flex-Foot™ allows a more normal range of motion than the SACH foot, even at normal cadences.<a></a> Several centers are reportedly conducting oxygen consumption studies in an effort to verify claims of lowered energy consumption, but none are yet published. Although most Flex-Foot™ prostheses have been used for unilateral and bilateral below-knee amputees, a significant percentage have been applied to above-knee amputees as well, and some hip disarticulation fittings have been completed.<a></a> Our experience at Duke has been chiefly at the below-knee level. Although higher level amputees would benefit greatly from reduced energy consumption, the addition of a passive knee mechanism may dissipate some of the potential return and bears further study. <h3>Carbon Copy II</h3> The Ohio Willow Wood Company introduced the original all-plastic SACH foot a decade ago called the "Marvel" foot. After its demise due to the availability of lighter and more durable feet from other suppliers, they embarked on a research and development project for what they termed the "next generation" of solid ankle feet. A few years ago, Mauch Laboratories approached Ohio Willow Wood to design a foot shell for Mauch's hydraulic ankle. This lead to the development of life-molds, a special micro-cellular polyurethane elastomer blend, and engineering of a carbon composite keel. The result was Carbon Copy I, a relatively rigid shell whose function comes primarily from the ankle mechanism. Development continued, and in May, 1986, Carbon Copy II was introduced as the latest entry into the energy storage arena. In many ways, it represents the synthesis of some of the best attributes of previous designs. This is a conventional solid ankle design, available with three durometers of heel cushion for simulated planter flexion. The keel, however, is a unique dual structure: a rigid posterior bolt block plus flexible anterior deflection plates. The bolt block is a special ultralight reinforced Kevlar/nylon design which recently won the plastic composite industry's "National Award of Excellence" for innovative engineering. A fiberglass/epoxy attachment plate resists deformation by both ex-oskeletal and endoskeletal ankle blocks, while very low density Styrofoam fills the cavities and prevents infiltration of the heavier polyurethane elastomer which forms the outer shell. The anterior deflection plates provide two-stage resistance at heel off. In normal walking, the thin primary deflection plates (which run to the PIP joints of the toes) provide a gentle energy return. At higher cadence or during more vigorous activities, the auxiliary deflection plate provides additional push off. A Kevlar™ glide sock prevents the plate from knifing through the elastomer shell (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-04.jpg">Fig. 4</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-04.jpg">Figure 4. Carbon Copy II; note rigid bolt block plus dual flexible carbon fiber deflection plates (Photo courtesy Ohio Willow Wood Co.).</a> The exterior design shows a similar attention to practical detail. The contours are lifelike, but not as starkly detailed as the Seattle Foot™. Rather, the veins and retromalleolar undercuts are softened into a more practical "humanoid" configuration. The forefoot width is a bit wider than conventional SACH feet, but less than the Seattle Foot™ version (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-05.jpg">Fig. 5</a>). Fitting narrow width shoes can sometimes be a problem. <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-05.jpg">Figure 5. (Dorsal view, L to R) STEN foot, Carbon Copy II, Seattle Foot™ note retromal-leolar contours and forefoot width.</a> The plantar surface is where the Carbon Copy II contour is most unique. Broad and flat (with a full-width carbon composite plate similar to Flex-Foot™), it is shaped to fit the shoe last. Analogous to a well-posted UCBL foot orthosis, this congruence between device and shoe offers maximum mediolateral stability (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-06.jpg">Fig. 6</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-06.jpg">Figure 6. (Plantar view, L to R) Seattle Foot™, STEN foot, Carbon Copy II; the flatter configuration enhances me-diolateral stability within the shoe.</a> Finally, all these practical details are contained in a package that is extremely lightweight. Significantly lighter than the conventional SACH foot, Carbon Copy II is actually slightly lighter than a geriatric "litefoot." Currently available only in adult male sizes, Carbon Copy II should be available in female sizes in the near future. Some practitioners report that the small keel sizes are noticeably suffer than their full-sized counterparts. In response to that observation, Ohio Willow Wood is retooling for a shorter keel block as well as narrower deflection plates for the women's style, which will initially be offered only in a 10mm (3/8") heel height. We have experienced no failures whatsoever with Carbon Copy II thus far, even for very vigorous applications. The manufacturer reports sales of over 2,000 feet, with known failures in nine cases. Seven were rubber tears at the tips of the toes (reportedly from one particular manufacturing run), plus one split deflection plate and one broken rivet.<a></a> If this early reliability continues, this may be one of the most durable prosthetic feet available. The only other problem noted is insufficient threads on the Otto Bock titanium endoskeletal foot bolt, which can be identified by its bright blue color. Placing one or two spacer washers under the head of the bolt allows it to be tightened firmly without running out of threads. One of the key design criteria for this foot was versatility, and we have found it suitable for many levels of amputation—including unilateral and bilateral below-knee, unilateral above-knee, hip disarticulation and hemipel-vectomy, as well as above-knee/below-knee bilaterals. Overall, the Carbon Copy II and Seattle Foot™ seem to offer similar function to the patient, and the wholesale cost is comparable. At least in the larger keel sizes, most patients have preferred the Carbon Copy over the Seattle Foot™, due to lighter weight and the two-stage resistance. In the smaller keel sizes, the difference is less pronounced, and many prefer the responsiveness of the Seattle design. In general, we consider both Carbon Copy and the Seattle Foot™ design to be good, moderately responsive energy storing designs. <h3>STEN Foot</h3> STEN Foot is one of the simplest designs in prosthetic feet. Externally, it uses the familiar Kingsley foot molds and rubber. This means it is the easiest design to fit in a variety of shoe styles, and comes in the greatest selection of sizes and heel heights: from a child's 18cm keel to an adult's 30cm, including women's widths as well. Soft, medium, or firm heel durometers are available as well.<a></a> Slightly heavier than a conventional SACH foot, the STEN Foot differs in its dual articulated keel. In addition to a metatarsal-phalangeal articulation, it also features a tarsal-metatarsal articulation, thus permitting a smoother, more gradual roll-over than a solid SACH keel (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-07.jpg">Fig. 7</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-07.jpg">Figure 7. STEN foot; note dual keel articulations and double reinforced belting (Illustration courtesy Kingsley Manufacturing).</a> Although the name stands for "STored EN-ergy" foot, it is our clinical impression that it does not accomplish this goal as effectively as the previous designs. The "keel bumpers" are directly analogous to the toe bumper in an old-fashioned wooden foot; both seem more to dissipate than to return energy. We view the STEN Foot as an additional flexible keel design, similar to the SAFE foot, permitting a smoother roll-over and somewhat greater forefoot supination and pronation than the more rigid SACH design. Since it is lighter than the SAFE foot, fits the shoe more readily, and is available in a broad range of heel heights and sizes, it may offer some advantages. Compared to a SACH foot, patient response has been predominantly favorable. Most preferred the smoother, "softer" roll-over it offers. Some higher level amputees complained of a slight increase in the tendency for the prosthetic knee to "buckle," although this could usually be minimized by plantarflexing or moving the foot more anteriorly. Reliability was a significant problem with early versions of this design, which sometimes failed catastrophically due to rupture of the plantar belting beneath the midfoot articulation. This resulted in a sudden loss of forefoot resistance, causing the amputee to stumble. When three of our initial seven STEN Feet failed in this fashion, we stopped using this component. It has since been redesigned with double belting reinforcements. The manufacturer reports that 3,000 feet have been sold, with no belting failures whatsoever since the reinforcement was added. With the new design, the overall failure rate from all causes is currently under one percent.<a></a> At a recent Academy conference, Richard Carey, CP. reported on over 80 successful applications of the reinforced version of the STEN Foot, and suggested it is particularly appropriate for the new amputee as the softer rollover may facilitate gait training.<a></a> This also might allow an easier transition to a more sophisticated design later, since the flexible keel is a common characteristic of all current "energy storing" feet. <h3>Other Designs</h3> Although not a brand new design, the SAFE foot (Stationary Ankle Flexible Endoskeleton) has recently been advertised as "the original energy storing foot." In our view, this may be stretching the point, since we believe the flexible keel serves primarily to dissipate energy as it accommodates to irregular surfaces. The SAFE foot can be viewed as a solid ankle version of the multi-axis concept, and we consider it an alternate to the well-known Greissinger foot. Both provide significant transverse rotation as well as inversion and eversion, in addition to some degree of plantar flexion and dorsiflexion.<a></a> The SAFE foot has the advantage of requiring no maintenance and being moisture and grit-resistant, while the Greissinger permits independent selection of the plantar flexion and other resistances. We summarize the SAFE foot as an "accommodative" design. It is probably unparalleled for use on uneven surfaces, and many amputees report an increase in residual limb comfort because it absorbs much of the shock of everyday walking. But aggressive racquet sportsmen have complained that it takes a fraction of a second to "wind up" before permitting push off, thus lowering their score. Perhaps the SAFE foot and other soft keel designs should be viewed as offering increased shock absorption and comfort at the expense of responsiveness in a competitive situation. <h3>Clinical Ranking</h3> There are currently no accepted definitions of what constitutes an "energy storing" prosthetic foot. In fact, there is currently no hard data to demonstrate any energy savings at all, despite numerous anecdotal reports. Yet, there is a need to have some means of evaluating and ranking the various designs, to add some measure of rational justification for clinical use of a given component. In reviewing slides of a unilateral below-knee amputee playing competitive volleyball, it was noted that her vertical leap appeared to be noticeably higher with the Flex-Foot™ than with the Seattle Foot™. This difference is likely due to the amount of "spring return" inherent in the components, and may represent one plausible criterion to rank their effectiveness. To test this hypothesis, a simple "pogo stick" apparatus was constructed which permitted interchange of various prosthetic feet (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-08.jpg">Fig. 8</a>). A non-amputee subject was instructed to jump on the pogo stick for ten hops, trying to attain as much altitude as possible. It is believed that this measures the spring potential of the component as if it were loaded by body weight at midstance. Since the subject's feet both remained firmly on the foot pegs and did not contact the ground, this was felt to be more accurate than measuring unilateral amputees jumping, where the sound limb could partially compensate for the component's deficits. <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-08.jpg">Figure 8. Pogo stick device used to test vertical spring capabilities of various feet.</a> Using frame-by-frame slow motion video analysis, the amount of ground clearance was measured to the nearest centimeter (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-09.jpg">Fig. 9</a>). This was not intended to be a controlled study, but rather a simple preliminary investigation; no quantitative judgments should be drawn from this data. Nevertheless, the trends were consistant over multiple trials, and are summarized in <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-10.jpg">Fig. 10</a>. <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-09.jpg">Figure 9. Frame-by-frame video analysis of ground clearance in centimeter increments.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-10.jpg">Figure 10. Ground clearance after vertical leap using pogo stick apparatus; 175 pound male subject, men's size 10 feet.</a> It is interesting to note that <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-10.jpg">Fig. 10</a> coincides with our subjective clinical ranking of the effectiveness of these designs. Patients given the choice between the SACH and STEN foot, for example, generally chose the more flexible STEN, but patients perferred the Carbon Copy II or Seattle Foot™ to the STEN, because the spring keels "felt more natural." Given the choice between Flex-Foot™ and other designs, the choice was generally for the more responsive composite system. Furthermore, the ranking also reflects the degree of sophistication of the design, and the relative wholesale cost from the manufacturer (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-11.jpg">Fig. 11</a>). The weight of the components was less straightforward. The inexpensive designs increased in weight as they increased in complexity, weighing progressively more than a conventional SACH foot. However, the two most expensive energy storing designs—Flex-Foot™ and Carbon Copy II—resulted in a lighter prosthesis than a SACH configuration (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-12.jpg">Fig. 12</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-11.jpg">Figure 11. Relative wholesale costs for prosthetic foot mechanisms.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-12.jpg">Figure 12. Weight of men's size 10 foot components, not including ankle block.</a> <h3>Summary</h3> Thanks to the efforts of the Prosthetics Research Study in Seattle, the concept of energy storing prosthetic feet has been widely disseminated.<a></a> Although it is fashionable to claim such benefits, no clear definition of the characteristics required has been established. The author suggests that the ability to leap vertically is one simple measurement of the "springiness" of a component, while reduced oxygen consumption during a measured task would be a more precise definition of an energy-conserving component. All current designs seem to have merit, and have been successfully utilized clinically (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-13.jpg">Fig. 13</a>). Although limited, the Duke experience has been summarized as a first step toward more clearly delineating the indications and contraindications for each design (<a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-14.jpg">Fig. 14</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-13.jpg">Figure 13. "Energy storing" feet through April 1987, Duke University experience.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-14.jpg">Figure 14. Clinical comparison of prosthetic feet</a>. The conventional SACH foot remains the most widely used design in North America, due to its low cost and reliability. In sports applications, it is particularly well suited for sprinting, since the rigid keel digs into the track, permitting rapid acceleration.<a></a> Multi-axis feet (Greissinger and SAFE) accommodate uneven terrain and dissipate some of the shocks of ambulation, thereby increasing skin comfort. They have been widely used by amputee athletes, although the softer keel resistance may increase the lag between sudden movements. Except for limiting transverse rotation, the STEN foot offers similar function, and may be worth considering for the novice amputee in particular. The Seattle Foot™ and Carbon Copy II are solid ankle devices that attempt to store energy via a spring keel design. They have been well received for a variety of amputation levels, and seem particularly well suited for joggers and weekend athletes. Flex-Foot™ represents the maximum in energy storage potential, and can be individualized for a wide range of applications. It is by far the best design for vertical jumping, thereby lending itself to such sports as volleyball. It has also performed well for long distance running, as well as vigorous sports in general. Finally, all these components have more widespread application than originally assumed. A more flexible forefoot permits an easier roll-over. For the geriatric individual, even a modest decrease in the effort required for walking can offer a substantial improvement in ambulatory potential. The more debilitated the person, the more important the weight and responsiveness of the foot component become. Virtually any lower limb amputee could benefit from the enhanced functioning that a sophisticated prosthetic foot can offer. Although none of these designs will turn the amputee into Superman, each can add a significant dimension to the degree of restoration that can be offered. Jan Stokosa, CP., has noted that although conventional prosthetic limbs restore mobility rather effectively, many patients feel their function has not been restored, so long as vigorous activities remain difficult or impossible to achieve.<a></a> By increasing our collective experience with the components under discussion and pooling our impressions in forums such as this, it is hoped that we can more closely approach that elusive goal: complete functional prosthetic restoration for every amputee. <h3>Appendix</h3> SAFE Foot, Campbell-Childs, Inc., 105 East First Street, P.O. Box 120, Phoenix, Oregon 97535. Flex-Foot™, Flex-Foot, Inc., 14 Hughes, B-201, Irvine, California 92714. STEN Foot, Litefoot, SACH, and Single Axis Feet, Kingsley Manufacturing Company, P.O. Box CSN 5010, Costa Mesa, California 92628. Carbon Copy II, Ohio Willow Wood Company, 15441 Scioto Darby Road, P.O. Box 192, Mount Sterling, Ohio 43134. Greissinger, Single Axis, & SACH Feet, Otto Bock Industries, Inc., 4130 Highway 55, Minneapolis, Minnesota 55422. Seattle Foot™, Model & Instrument Development, 861 Poplar Place South, Seattle, Washington 98144. References: <ol> <li>Beckman, Clarence, personal communication, May, 1983.</li> <li>Brooke, Steve, Marketing Manager, Model Instrument and Development, Inc., personal communication, April, 1987.</li> <li>Burgess, et al., "The Seattle Prosthetic Foot-A Design For Active Sports: Preliminary Studies," Orthotics and Prosthetics, Volume 37, Number 1, pp. 25-32.</li> <li>Burgess, et al., "The VA Seattle Foot," Rehabilitation Research and Development-Progress Reports 1984, Veterans Administration Publications, 1984, p. 5.</li> <li>Campbell, J. and C. Childs, "The S.A.F.E. Foot," Orthotics and Prosthetics, Volume 34, Number 3, 1980, pp. 3-17.</li> <li>Carey, Richard, "The STENFOOT," Continuing Education Course 1-87, American Academy of Orthotists and Prosthetists, Portland, Oregon, March, 1987.</li> <li>Enoka, et al., "Below-Knee Amputee Running Gait," American Journal of Physical Medicine, Volume 61, Number 2, 1982, pp. 66-84.</li> <li>"Flex-Foot™ Fitting and Alignment Procedure," Flex-Foot Inc., 19600 Fairchild, Suite 150, Irvine, CA 92715.</li> <li>Fosberg, Robert, President of Flex-Foot, Inc., personal communication, April, 1987.</li> <li>Graves, J. and E. Burgess, "The Extra-Ambulatory Concept As It Applies To the Below-Knee Amputee Skier," Bulletin of Prosthetics Research, Fall, 1973, pp. 126-131.</li> <li><a href="cpo/1982_04_001.asp">Hittenberger, Drew, "Extra-Ambulatory Activities and the Amputee," Clinical Prosthetics and Orthotics, Volume 6, Number 4, 1982, pp. 1-4.</a></li> <li>Hittenberger, Drew, "The Seattle Foot," Orthotics and Prosthetics, Volume 40, Number 3, 1986, pp. 17-23.</li> <li>Kegal, Bernice, et al., "Functional Capabilities of Lower Extremity Amputees," Archives of Physical Medicine and Rehabilitation, Volume 59, 1978, pp. 109-120.</li> <li>Kegal, et al., "Recreational Activities of Lower Extremity Amputees: A Survey," Archives of Physical Medicine and Rehabilitation, Volume 61, 1980, pp. 258-264.</li> <li>Klenerman, Leslie, The Foot and Its Disorders, Blackwell Scientific Publications, London, 1976, p. 19.</li> <li>"A Material Change for Prosthesis," The Orange County Register, October 31, 1985, Sec.E, p. 12.</li> <li>Martin, Jeffrey, Marketing Director, Ohio Willow Wood Company, personal communication, April, 1987.</li> <li>Michael, J.W., "Prosthetic Feet for the Amputee Athlete," Palaestra, Volume 2, Number 3, 1986, pp. 37-41.</li> <li>Miller, Enoka, et al., "Biomechanical Analysis of Lower Extremity Amputee Running." Final Report to Veterans Administration. Contract Number V5244P-1540/VA Hospital, New York, 1979.</li> <li>Nobbe, Carol, personal communication, September, 1984.</li> <li>Rauch, Colleen, personal communication, November, 1986.</li> <li>Sethi, M.P., "Vulcanized Rubber Foot for Lower Limb Amputees," Prosthetics and Orthotics International, Volume 2, Number 3, 1982, pp. 125-136.</li> <li>Stokosa, Jan, "Total Surface Bearing in Lower Extremity Prosthetics," Region II-III Assembly, American Orthotic & Prosthetic Association, Atlantic City, New Jersey, April, 1986.</li> <li>Truesdell, James, president, Kingsley Manufacturing Company, personal communication, April, 1987.</li> <li><a href="cpo/1987_01_055.asp">Wagner, J., et al., "Motion Analysis of SACH vs. Flex-Foot™ in Moderately Active Below-Knee Amputees," Clinical Prosthetics & Orthotics, Volume 11, Number 1, 1987, pp. 55-62.</a></li> </ol> *John Michael, M.Ed., C.P.O. John W. Michael, M.Ed., C.P.O., is Assistant Clinical Professor and Director of Prosthetics &Orthotics at Duke University Medical Center. <div style="width: 400px;"></div> Page Number(s) 154 - 168 Year 1987 Volume 11 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1987_03_154/1987_03_154-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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Title A name given to the resource Energy Storing Feet: A Clinical Comparison Creator An entity primarily responsible for making the resource John Michael, M.Ed., C.P.O. * https://staging.drfop.org/files/original/3f041b7c947e529153fa28232c237ff9.pdf d1f852ea47d629b46c047b9ae3e541ec https://staging.drfop.org/files/original/730b7c386610ac5066f7d34810d6e1cb.jpg 5d4cfcb9a11c6bdca221c13237a938da https://staging.drfop.org/files/original/7833aeed5e0f5b304177a2c2f4041545.jpg 8933a2daac139a455663a0839530e760 https://staging.drfop.org/files/original/3b3ef544eebe463014069b1f9f559617.jpg 49669d1ea09bc77fd63e098e093c5229 https://staging.drfop.org/files/original/1f0783dbf17ee81abcf3918ec110bc1a.jpg 3e6547ec9784789f1cd9426bc2316851 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_03_169.pdf Text Any textual data included in the document <h2>The O.K.C. Above-Knee Running System</h2> <h5>John Sabolich, B.S., C.P.O. <a style="text-decoration: none;">*</a></h5> For many years, above-knee amputees have been trying to run step over step rather than using the hop and skip running gait typified by Terry Fox in his run across Canada. This type of locomotion is still biomechanically defined as walking since it still contains a double support phase when both feet are touching the ground simultaneously. True running has no period of double support. One reason that above-knee amputees have had to run in this manner is that the lower shank does not accelerate forward fast enough for true running due to inertia. While the thigh segment quickly flexes about the hip, the foot tends to stay in place, causing the knee to flex beyond a desirable position and resulting in what is commonly referred to as "excessive heel rise." This excessive heel rise causes a delay in getting the foot-shank complex to move into extension which complicates the amputee's basic problem of not having active control of the knee. It seems that the harder the amputee tries to flex his hip, the worse the heel rise becomes. The O.K.C. system strives to solve these problems. It consists of a cable-housing arrangement (similar to that on a below-elbow prosthesis) that travels behind the hip joint and anterior to the knee axis (<a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-1.jpg">Fig. 1</a>). The proximal end of the cable is attached to a belt similar to a Silesian bandage by a short piece of elastic webbing and Dacron tape which is adjustable via a 4-bar buckle. The distal end of the cable is fixed to the proximal anterior shank section of the prosthesis. <a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-1.jpg">Figure 1. Lateral views of prosthesis showing path and attachment points of the OKC running cable.</a> When the hip joint starts to flex, just at the moment of "running toe off," tension in the cable causes a dynamic extension moment at the knee. In other words, power is being transferred to the knee joint directly from the action of hip flexion. When the thigh is fully flexed, the tension in the system is at its maximum. This turns out to be very desirable biomechanically, since the knee needs to be fully extended at heel strike. The O.K.C. system therefore supplies a dynamic force to the shank, much as the quadriceps does in the normal human leg during running (<a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-2.jpg">Fig. 2</a>). <a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-2.jpg">Figure 2. Running sequence showing action of the cable system.</a> It has been our experience that it is easier to start using this system on children running on grass and advance to adults later for two reasons. First, children are not afraid to try to run, especially when the practitioner tells them they are now capable of it. Second, due to lower stresses in the system, the prosthetist can use conventional upper extremity cable and housing components that are readily available rather than specially made cable and hardware which are needed for adults. It has been noted that some children are able to remove the cable after a few months, (much as training wheels on a bicycle) and still do a fair job of running step over step. They gain confidence from the system and use it to fine tune their running capabilities. However, it has been our experience that when truly fast running is required as in competitive events, the patient prefers the O.K.C. System. Parents report that their children like to keep the system in place at all times since it gives them a natural dynamic quadriceps effect. However, some adults prefer to remove the O.K.C. System for normal locomotion. For adult running, we have found that special aircraft grade cable and terminal ends are required due to the increased stresses in the system. It has also been discovered that monofilament fishing line (300-500lb. test line) works quite nicely as the coefficient of friction between the cable and housing is reduced. A plastic housing such as polypropylene tubing (commonly used in air conditioner drains) works best with this monofilament. An extension aid of surgical tubing or elastic webbing augments the O.K.C. System and provides another method of fine tuning the system. Some competitive runners also like to use a flexion limiter with the system. This consists of a 3/4" thick piece of PE-LITE® at the back of the knee joint which does not allow the knee to flex completely. This flexion limiter acts as a compressive stop which tends to bounce the knee into extension and swings out of the way during normal walking. A variety of other methods of limiting flexion can be used. To our knowledge, the first above-knee amputee to ever run step over step on an above-knee prosthesis was in March, 1982 utilizing an O.K.C. System. Since that day, many adults who enjoy competitive running or just sports in general have been fit. The shortest residual limb fit successfully with the O.K.C. System was on a 17 year old above-knee male with a 2 7/8" femur. The longest have been knee disarticulation amputees. <a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-3.jpg">Figure 3. Series of photographs taken from video screen.</a> It is easier to implement this system if the patient is using an exoskeletal prosthesis, since the cable and housing have a natural surface to ride and sit on. However, we have placed several on endoskeletal systems with a little creative rigging (<a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-4.jpg">Fig. 4</a>). It is also possible to laminate a track directly into the thigh portion of the prosthesis which eliminates the need for housing. However, this sometimes causes excessive breakage unless a section of housing is extended distally to reduce the bending radius distally about the knee. <a href="http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-4.jpg">Figure 4. OKC running cable on an endoskeletal prosthesis. Aircraft cable and terminal ends were used in fabrication.</a> Sitting can be a problem unless the cable or monofilament is placed in such a way as to allow the cable and housing to move posterior to the knee during sitting. This prevents the creation of a knee extension moment, which could be bothersome during sitting. Last, we have found it most helpful that the heel portion of the prosthetic foot be soft enough to provide very easy planer-flexion so as to lessen the tendency for the knee to be forced into flexion by the ground reaction force at heel strike. *John Sabolich, B.S., C.P.O. John Sabolich, B.S., C.P.O, is president of Sabolich Orthotic Prosthetic Center, 1017 N.W. 10th Street, Oklahoma City, Oklahoma 73106. Page Number(s) 169 - 172 Year 1987 Volume 11 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_03_169/1987_03_169-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. 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Above-Knee Running System Creator An entity primarily responsible for making the resource John Sabolich, B.S., C.P.O. * https://staging.drfop.org/files/original/bd8676bd2ae282b639f2399c6de321e3.pdf ffb53e28db8f2fc150a90906e09d5a19 https://staging.drfop.org/files/original/b5b98ec26d73edf01c22777a6f4f5372.jpg 2970dc2423a7e01f1bb92f8ceb1a1354 https://staging.drfop.org/files/original/bb57324218f589f3d313b6eacad77646.jpg 39967dc29d987500fb2008de8d00e469 https://staging.drfop.org/files/original/9f4e8fe4f15db8a5f8ba4d01ee1a70be.jpg 27a0ccb1ddc4f295ced948da5496ca58 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1987_03_173.pdf Text Any textual data included in the document <h2>Below-Knee Waterproof Sports Prosthesis with Joints and Corset</h2> <h5>Alfred W. Lehneis, CP. <a style="text-decoration: none;">*</a></h5> This article is concerned with the development of a waterproof below-knee prosthesis with knee joints and corset, utilizing the supracondylar/suprapatellar (SC/SP) suspension socket. A case report is described below. The patient had a below-knee amputation due to traumatic injury with a resultant amputation length of the tibia of approximately 1" (<a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-1.jpg">Fig. 1</a>). This patient currently wears a PTB type socket with leather thigh corset, polycen-tric joints and an SC/SP suspension socket, thus, no auxilliary suspension was necessary (<a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-2.jpg">Fig. 2</a>). He was doing well with this design in all activities of daily living, but desired a waterproof prosthesis for boating. <a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-1.jpg">Figure 1. Length of tibia is approximately 1".</a> <a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-2.jpg">Figure 2. Patient currently wears a PTB type socket with a leather thigh corset.</a> In developing the waterproof design, the following components were utilized: Kingsley beachcomber foot, Otto Bock polycentric stainless steel knee joints, and a corset fabricated from 4mm Subortholen thermoplastic. Closures were 1" dacron straps with virgin nylon buckle closures used on scoliosis type body jackets. The fitting and fabrication of the prosthesis was as follows: the patient was casted (including the thigh) and the cast modified, using standard procedures for SC/SP suspension, an insert was fabricated from Pelite™, and the socket was fabricated with acrylic resin and carbon/glass reinforcements, especially at the side bar attachment sites. After fabrication of the socket, the socket was foamed up and set-up on a Staros-Gardner coupling and aligned atop the beachcomber foot. The bars were then attached directly to the socket (not over the foam build-up), and the area over the bars filled with fiberglass/resin putty. The thigh bars were contoured to the modified cast, over which the Subortholen thermoplastic had been molded and attached to the corset. The patient was then fitted and aligned in the usual manner, but while wearing topsider type boating shoes. After optimum alignment was achieved, the Staros/Gardener coupling was transferred out. This can be accomplished on a horizontal transfer device. The prosthesis was then shaped to the patient's tracing and measurements and reduced to accommodate the lamination thickness. The sole of the foot is then removed and a woman's nylon is pulled over the entire prosthesis, followed by the PVA sleeve. A lamination of one carbon-glass and two nylons without pigment is performed. After the lamination is set, the laminated shell is split longitudinally on the posterior aspect (<a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-3.jpg">Fig. 3</a>), taken off the prosthesis, and taped back together to retain its shape. <a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-3.jpg">Figure 3. The laminated shell is split longitudinally on the posterior aspect.</a> The shaped portion of the prosthesis is cut to allow for a 3" ankle block and the socket is cut at the base. The foam between the ankle and socket is now eliminated (<a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-3.jpg">Fig. 3</a>). The foam ankle block and the foam at the base of the socket can be sealed with a resin-silica mix to prevent water penetration. The laminated shell should be sealed with tape on the outside, and the seam should be sealed on the inside with Siegelharz. The socket and ankle block can then be bonded to the laminated shell. Once this is set, the outer shell should be sanded for a second lamination, and approximately 1" of the proximal socket and distal ankle block perimeter should be exposed (<a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-3.jpg">Fig. 3</a>). The prosthesis is then filled with sand through the hole at the bottom of the ankle block. The hole is then sealed with play dough. Lay-up of the prosthesis consists of six alternating layers of nylon and nyglass. Two pieces of polypropylene with 120° arcs (<a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-3.jpg">Fig. 3</a>) should be placed between the joints and the socket after the first two layers to allow attachment of the joint clevis after lamination. These pieces are removed after lamination. The foot drain hole is then reopened to release the sand. A second 1/2" hole should be drilled posterior and distal to the socket end to allow air to enter and escape the inner hollow of the leg. This allows water to enter and escape the foot drain hole and prevent bouyancy of the prosthesis. The thermoplastic corset is finished with a polyethylene tongue and dacron strap closures as described earlier. When assembling the prosthesis, bonding of the foot should be as recommended by Kingsley, Mfg. or using Devcon two-part epoxy. <h3>Acknowledgments</h3> The author gratefully acknowledges the technical contribution of Roger Losee, CO., and Robert Wilson, M.S., for the illustration in <a href="http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-3.jpg">Fig. 3.</a> *Alfred W. Lehneis, CP. Alfred W. Lehneis, CP., is with Lehneis Orthotics and Prosthetics Associates in Roslyn, New York. Page Number(s) 173 - 175 Year 1987 Volume 11 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_03_173/1987_03_173-2.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_03_173/1987_03_173-3.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Below-Knee Waterproof Sports Prosthesis with Joints and Corset Creator An entity primarily responsible for making the resource Alfred W. Lehneis, CP. * https://staging.drfop.org/files/original/02e028e3e75d48a51464d262823def1c.pdf d29d6d36d9bfa48369439bb49c9a0cc0 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_04_199.pdf Text Any textual data included in the document <h2>The Basis of Orthotic Management in Quadriplegia</h2> <h5>John H. Bowker, M.D. </h5> Statistics indicate that there are 150,000-200,000 spinal cord injured persons in the United States.<a></a> Each year, approximately 10,000 newly injured are added to this figure. About 80% are males under the age of 40 years, while slightly more than half (53%) are quadriplegics, with low cervical injuries being most common.<a></a> In recent years, improved medical management has led to an increase in post-injury life expectancy in spinal cord injury to a probable 30 to 40 years.<a></a> This ever-increasing national prevalence of spinal cord injury poses major problems in rehabilitation, several of which will be addressed in this issue of Clinical Prosthetics and Orthotics. When the spinal cord team first confronts a person with a cervical spine injury, the first two priorities are preservation of life itself and prevention of further damage to the spinal cord and spinal nerve roots. Immobilization of the neck, followed by traction-reduction of vertebral malalignment, is carried out concomitantly with physiologic stabilization. Special studies, including magnetic resonance imaging, are then done to determine the need for immediate surgical relief of extrinsic pressure on the cord due to residual vertebral malalignment and/or fragments of bone or intervertebral disc. Intraoperative imaging with ultrasound further aids in the identification and removal of fragments causing extrinsic pressure. The preservation or restoration of function of just one nerve root by precise surgery of this sort can make the crucial difference between a modicum of independence and total dependence in self-care. Depending on the specific injury and the surgeon's preference, stabilization of the spine may be accomplished by means of a halo external fixation system alone or by internal fixation with wires and bone grafts, supplemented by an orthosis. In either case, stabilization will expedite the rapid mobilization of the patient. At this point, a decision can be made regarding the appropriateness of orthotic fitting. A brief mention has been made of the functional significance of each residual cervical nerve root in the quadriplegic. This may be further elaborated upon as follows: <ul> <li>Fourth cervical root (C-4): innervates the diaphragm, allowing independent breathing.</li> <li>Fifth cervical root (C-5): innervates the deltoid and biceps/brachialis, providing shoulder abduction/flexion and elbow flexion, respectively.</li> <li>Sixth cervical root (C-6): innervates the radial wrist extensors, permitting wrist dorsiflexion and a passive opposition of thumb and fingers by "tenodesis effect" of the finger flexors.</li> <li>Seventh cervical root (C-7): innervates the triceps, wrist flexors and finger extensors, allowing elbow extension, wrist volar flexion, and finger extension, respectively.</li> <li>Eighth cervical root (C-8): innervates the finger flexors, allowing a gross grasp.</li> <li>First thoracic root (T-1): innervates the intrinsic muscles of the hand, resulting in complete hand function, including grip and a precise thumb to finger pinch.</li> </ul> It is important to note three features of this progressive classification to develop a clearer understanding of its relative limitations. Firstly, many muscles are supplied by two roots. The root associated with a given muscle in the list above is that which primarily innervates that muscle. The preservation of the next lower root provides not only an additional distal function, but also greater strength in the muscle just above, due to the activation of additional motor units by this secondary nerve root. Again, this argues for preservation of every possible root. Secondly, preservation of root function is often asymmetrical. For example, a quadriplegic may have a functional level of C-5 on one side and C-6 on the other. In this case, an orthotic prescription for one side will be totally inappropriate for the other. Thirdly, with nerve fiber (axon) regrowth, improvement in strength of a given muscle may occur over time. Occasionally, even the next higher root may recover as well. Monitoring by repeated muscle testing can thus lead to a progressive change in orthotic prescription. The occupational therapist, by virtue of her close daily contact during the rehabilitation process, is often the first team member to note these changes. To aid in the prognosis of muscle return, it is now possible, by advanced biofeedback techniques, to find functioning motor units in muscles considered "paralyzed" by conventional muscle testing techniques. Following identification of working motor units, it may be possible to strengthen them with bio-feedback-directed exercise. This often results in the addition of another useful upper limb function with or without the help of an orthosis. Before an upper limb orthosis can be used, the quadriplegic must be positioned so that visual feedback allows contact between a partially insensate hand and the object to be manipulated. A properly designed and carefully fitted wheelchair can, therefore, be considered the basic orthosis for the quadriplegic. Lateral trunk supports or a corset may also be essential for functional sitting posture, freeing the upper limbs from supporting the trunk. Throughout the process of rehabilitation, the orthotist should work closely with all members of the team, but especially the occupational therapist, physical therapist, psychologist, and physician if acceptance and use of orthotic devices is to be achieved. Successfully fitted orthoses are useful not only for self-care, but can also play a major role in achieving the ultimate goal of rehabilitation, the return to gainful employment. Many types of electronic devices, including computers, are manipulated more easily with an orthosis. In conclusion, it is hoped that this issue will be helpful in not only delineating the unique role of the orthotist in the care of the quadriplegic, but equally importantly, in demonstrating the need for communication and cooperation among all team members, if we are to offer optimum care to our patients. References: <ol> <li>DiVivo, M.J., Fine, P.R., Maetz, H.M., and Stover, S.L., "Prevalence of Spinal Cord Injury: A Re-estimation Employing Life Table Techniques," Archives of Neurology, 37:1980, pp. 707-8.</li> <li>Eisenberg, M.G. and Tierney, D.O., "Changing Demographic Profile of the Spinal Cord Injury Population: Implications for Health Care Support Systems," Paraplegia, 23:1985, pp. 335-343.</li> <li>Green, B.A., Callahan, R.A., Klose, K.J., and DeLa-Torre, J., "Acute Spinal Cord Injury: Current Concepts," Clinical Orthopaedics and Related Research, 154:January-February, 1981, pp. 125-135.</li> <li>Young, J.S., Burns, P.E., Bowen, A.M., and McCut-chen, R., Spinal Cord Injury Statistics: Experience of the Regional Spinal Cord Systems, 1982, pp. 13-14.</li> </ol> Page Number(s) 199 - 200 Year 1987 Volume 11 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 The Basis of Orthotic Management in Quadriplegia Creator An entity primarily responsible for making the resource John H. 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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_04_201.pdf Text Any textual data included in the document <h2>The Team Approach to Orthotic Management in Quadriplegia</h2> <h5>Wayne R. Rosen, CO. <a style="text-decoration: none;">*</a> Janie J. McColey, O.T.R. <a style="text-decoration: none;">*</a> John H. Bowker, M.D. <a style="text-decoration: none;">*</a></h5> This article presents the approach to orthotic intervention in quadriplegia taken at the University of Miami/Jackson Memorial Rehabilitation Center. To begin, it must be emphasized that quadriplegia implies not only loss of walking, but also loss of normal use of the hands. Since our hands are the tools with which we sustain life, a major goal of rehabilitation must be to restore the ability to independently carry out common activities of daily living such as feeding, grooming, and manipulation of devices which may allow resumption of educational and vocational goals.<a></a> As health care professionals in the rehabilitation field, we must be aware of advances in technique and equipment which can enhance the ever-increasing life span of this young population whose educational, economic, and social progress has been so severely curtailed.<a></a> The role of the orthotist and occupational therapist as members of the rehabilitation team is to address this very underemphasized problem of upper limb management. When the spinal cord team is first asked to evaluate and treat a newly injured quadriplegic patient, they must take into consideration all aspects of care, not just those in their individual areas of specialization. During the acute medical phase, the emphasis is on preserving life and preventing further neurological damage. At this stage, there is little concern for joint positioning or splinting. After life-threatening problems have been addressed, however, prompt management of the upper limbs is of primary importance if we are to avoid joint stiffness and/or deformity which would interfere with the progression of rehabilitation.<a></a> This approach to the upper limbs involves a number of basic methods: frequent joint range of motion, limb positioning with and without positioning devices (temporary and permanent), dynamic orthoses (temporary and permanent), and externally powered orthoses. In our facility, spinal cord injured patients are initially placed on Roto-Rest beds. These beds, with their continuously alternating side-to-side motion, have proven to have a positive effect on the respiratory, renal and circulatory systems, as well as providing skin protection for the S.C.I. patient.<a></a> There is, however, potential for loss of glenohumeral and scapular mobility with its use for extended periods. We have currently adapted the bed so as to allow positioning of the shoulders in abduction and external rotation, alternating with the usual adduction and internal rotation. This change of shoulder position has been included in our regular routine of joint range of motion and should reduce the pain and stiffness that often interferes with arm placement and coordination.<a></a> Elbow flexion-forearm supination deformity is another potential problem, especially in C5 quadriplegics.<a></a> This may be managed by positioning the elbow in extension and pronation between range of motion sessions. The use of thermoplastic elbow-extension splints (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-01.jpg">Fig. 1</a>), bivalved casts (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-02.jpg">Fig. 2</a>), or serial casting (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-03.jpg">Fig. 3</a>), will assist the therapist in maintaining proper position. Functional hand position should be maintained with the use of a resting hand splint (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-04.jpg">Fig. 4</a>) or a functional long opponens splint with C-bar and lumbrical bar (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-05.jpg">Fig. 5</a>), to avoid the development of a flat "simian" hand. <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-01.jpg">Figure 1. Elbow Control Orthosis.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-02.jpg">Figure 2. Bivalved plaster cast.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-03.jpg">Figure 3. Serial casting (Plaster of Paris).</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-04.jpg">Figure 4. Thermoplastic resting splint.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-05.jpg">Figure 5. Long opponens with MCP extension stop.</a> Once the patient is medically stable, he is able to begin a more active phase of rehabilitation, including the use of functional orthoses, if appropriate. His response to this whole process depends largely on the success of the first few days, which in turn depends on how the treatment team constructs the patient's first experiences of sitting, trunk balancing, and functional arm placement. Only when control of these factors is satisfactory will it be appropriate to introduce orthoses for function. This becomes a critical point in time for the patient and therapist, because two possible approaches to future functional activities exist. The first approach is based on the use of adaptive devices which will allow some patients to perform specific functions such as self-feeding and oral-facial hygiene. However, it is our feeling that even at this early stage, multipurpose temporary functional orthoses must be introduced if definitive orthoses are to play a useful part in the patient's life. Therapists should be prepared to fabricate and properly fit a training orthosis, which will allow the patient reasonable options in developing his functional goals.<a></a> The following chart provides guidelines for management techniques according to the level of remaining neurologic function. Many of the orthotic options listed in the "Recommended Management" column are from the N.Y.U. Upper Extremity Orthotics Manual.<a></a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-07.jpg">Chart, Chart (cont'd)</a> The guidelines listed above have been generally accepted throughout the world as the rational basis for orthotic intervention. The following variables, however, must receive equal consideration before an orthosis can be successfully fit to a patient. Locality The patient should reside not only reasonably close to a facility capable of adjusting his orthosis, but should have accessible transportation available if a problem arises. Cost Sufficient funds must be allocated to cover not only the initial cost of the orthosis prescribed but also maintenance and replacement as necessary.<a></a> Gadget Tolerance The patient must have the patience to don and doff the orthosis or he will discard it because it "takes too long to apply." He may then actually prefer to sacrifice his independent performance of intricate manual tasks by either choosing a less effective piece of adaptive equipment or relying on another person for assistance. We, as practitioners, must monitor the attitude of a candidate to be sure that the function of the orthosis will be greater than the perceived inconvenience of wearing it.<a></a> Dominance The hand preferred prior to injury for writing and activities of daily living will usually be maintained as the dominant hand. This hand should be fit initially and the patient's progress monitored with specific activities before fitting the nondominant hand. Specific activity usage will determine whether or not the second orthosis is indicated.<a></a> Vocation/Avocation The patient's ability to perform fundamental activities of daily living is basic to maximum restoration, but it is equally important to determine additional intended uses of the orthosis, both vocationally and avocationally (i.e., manual work, desk work, telephone answering services). These data will help determine the type of materials suitable for fabrication or even the type of orthosis that would best suit the individual's needs.<a></a> Psychological/Familial Roles Assessment of the patient's psychological status is vital in establishing a treatment plan. Psychological make-up of the individual can play a very large role as to whether or not the patient will accept an orthosis. In this regard, cosmesis may play as important a role as function when dealing with a person's already altered body image. Psychological intervention is necessary to assist the patient through the stages of denial, anger, and depression to final adaptation. Indeed, the team members may need help in dealing with their own value systems regarding quality of life in relation to long term disability. The personalities of the patient and family members, as well as those of the orthotist and occupational therapist, play important roles in rehabilitation after a spinal cord injury. An air of confidence emanates from professionals who are comfortable and confident with the task at hand. This confidence can be passed on to the patient, who will in turn become comfortable and confident with the orthosis being fitted. Too often, however, therapists and orthotists are not comfortable with the intricacies of fabricating upper limb orthoses, leaving the patient at a disadvantage as he begins his rehabilitation process, in that he may not be made aware of all the options available, but rather only those preferred by the professionals. Therefore, it is necessary to assemble a team of practitioners who are well versed in all aspects of their respective specialties so as to not hinder the patient in an already stressful situation. Family support is also extremely important as a reinforcement of professional recommendations. Clear, concise instructions should be given to the patient and family members in order to increase the effective use of the orthosis.<a></a> Economics Since most orthotists in private practice cannot afford the luxury of skill maintenance for the small part of orthotic practice represented by upper limb orthotics, the majority of these devices are being made in an institutional setting, where an orthotist and occupational therapist on staff service the needs of quadriplegics. More time and energy can then be devoted, with less concern for monetary return, to fabrication and fitting of a complex device such as a wrist-driven prehension orthosis. Being on-site means quicker response time to the patient with no travel time for the practitioner, which also means that more time can be spent actually working with the patient as the need for adjustment arises. The expertise afforded by a qualified and skilled team of practitioners to the patient can only help an already trying and difficult situation.<a></a> Through a team approach to orthotic evaluation of the spinal cord injured patient, the best orthosis for that individual should be provided. That does not necessarily mean the most complex or expensive orthosis. It means that, given a specific clinical picture, an orthosis is chosen based on all the factors previously discussed. The purpose of setting standards and guidelines is to increase the success rate of our patients, in allowing them every opportunity to return to a meaningful lifestyle. When this occurs, we as practitioners have done our job and can consider the input of our specialty a success. Conversely, our failures have a negative effect on both the patient and the practitioner. For the patient, it becomes a setback in that his hospital stay may be extended or, more importantly, the potential for independence may be lost because of rejection of the orthosis. For the practitioner, it may be not only a time of second-guessing, but a learning experience at the patient's expense. Our approach to fitting of functional orthoses is as follows. All candidates for wrist driven prehension orthoses are initially fitted by the occupational therapist with a temporary training orthosis, namely the Rehabilitation Institute of Chicago (R.I.C.) tenodesis splint (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-06.jpg">Fig. 6</a>). The patient then trains for a period of time determined by the therapist. Once he has mastered this device, he can be fit by the orthotist with a definitive orthosis. The choice at our facility is the Engen wrist-driven prehension orthosis (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-09.jpg">Figure 7</a>, <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-10.jpg">Fig. 8</a>, and <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-11.jpg">Fig. 9</a>). We feel this device best suits our needs because of ease of fit, adjustability, and cosmesis.<a></a> The occupational therapist trains the patient to use his orthosis for activities of daily living, including the important function of self-catheterization of the bladder.<a></a> By virtue of thorough training, we feel the acceptance rate of orthoses is increased. <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-06.jpg">Figure 6. R.I.C., Tenodesis (temporary) splint with wrist extended and fingers apposed.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-09.jpg">Figure 7. Wrist-driven prehension orthosis with wrist in neutral position and fingers open-Ranchos Los Amigos type.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-10.jpg">Figure 8. Wrist-driven prehension orthosis with wrist extended and fingers apposed-Engen type.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-11.jpg">Figure 9. Wrist-driven prehension orthosis (Modified N.Y.U.-I.R.M. system).</a> Unfortunately, our success rate with the Externally Powered Prehension Orthosis (EPPO) has not been as favorable as that of the wrist driven type (<a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-12.jpg">Fig. 10</a>). Two-thirds of all EPPOs that have been fit at our institution have not been used long-term. The feedback from our patients is that they were trained throughout the long rehabilitation process to adapt with the aid of special equipment and then, just prior to discharge, given a brace to replace the adaptive equipment. The patient who spent four to six months in the rehabilitation facility would have perhaps a week to learn to function with his new orthosis. It is hardly surprising that, in most cases, the orthosis was discarded in favor of the adapted equipment with which they were familiar. The problem has been, that for high cervical injuries, a training version of an externally powered prehension orthosis does not exist. This problem could be solved by development of a training EPPO in which the components could be reused on different patients. The only parts of the orthosis that would need to be custom-made would be the hand shells. The cost to the patient for these would be minimal and in the long run we could save the patient the cost of a very expensive "closet trophy" if he proved to be a poor candidate. We have initiated this project as a joint effort of the Occupational Therapy Department and the Department of Orthotics. <a href="http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-12.jpg">Figure 10. Externally powered prehension orthosis.</a> <h3>Summary</h3> The fabrication and fitting of functional upper limb orthoses in quadriplegia requires close team work, especially between the orthotist and occupational therapist if the ultimate goal of acceptance of the orthosis as a useful aid to activities of daily living is to be achieved. We feel strongly that quadriplegics with wrist extensors should be fitted early with a functional training orthosis rather than supplied with activity-specific adaptive equipment. A confident, caring attitude on the part of the occupational therapist and orthotist can also do much toward achieving this goal. For quadriplegics with shoulder and elbow motion but no wrist extension, a training version of an externally powered prehension orthosis is badly needed for evaluation prior to ordering a definitive device. Success in the fitting of complex orthoses such as these requires almost unlimited "gadget-tolerance" on the part of the practitioner, if not the patient. The ultimate professional responsibility is to be equipped with both the manual skills and the objectivity to introduce all available options to our patients for their acceptance or rejection. References: <ol> <li>Abrahams, D., R.D. Shrosbree, and A.G. Key, "A Functional Splint for the C5 Tetraplegic Arm," Paraplegia, 17:2, July, 1979, pp. 198-203.</li> <li>Allen, V.R., "Follow-up Study of Wrist-Driven Flexor-Hinge-Splint Use," The American Journal of Occupational Therapy, 25:8, 1971, pp. 420-422.</li> <li>Becker, D., M. Gonzalez, G. Amilcare, F. Eismont, and B. Green, "Prevention of Deep Venous Thrombosis in Patients with Acute Spinal Cord Injuries: Use of Rotating Treatment Tables," Neurosurgery, 20:5, 1987, pp. 675-677.</li> <li>Berard, E., J. Depassio, N. Pangaud, and J. Landi, "Self Catheterization: Urinary Complications and the Social Resettlement of Spinal Cord Injured Patients," Paraplegia, 23, 1985, p. 386.</li> <li>DeVivo, M.J., P.R. Fine, H.M. Maetz, and S.L. Stover, "Prevalence of Spinal Cord Injury: A Re-estimation Employing Life Table Techniques," Archives of Neurology, 37, 1980, pp. 707-708.</li> <li>Eisenberg, M.G. and D.O. Tierney, "Changing Demographic Profile of the Spinal Cord Injury Population: Implications for Health Care Support Systems," Paraplegia, 23, 1985, pp. 335-343.</li> <li>Fishman, S., et al., The Upper Extremity Orthotics Manual, New York University Post-graduate Medical School.</li> <li>Lamb, Jr., C.R., A.J. Booth, and M.E. Godfrey, "Flexor Hinge Splint: Modification to Allow Radial Deviation," Archives of Physical Medicine and Rehabilitation, 55, July, 1974, pp. 322-323.</li> <li>Meyer, C.M.H., R.D. Shrosbree, and D.L. Abrahams, "A Method of Rehabilitating the C6 Tetraplegic Hand," Paraplegia, 17, 1979-80, pp. 170-175.</li> <li>Nichols, P.J.R., S.L. Peach, R.J. Haworth, and J. Ennis, "The Value of Flexor Hand Splints," Prosthetics and Orthotics International, 2, 1978, pp. 86-94.</li> <li>Patterson, R.P., D. Halpern, and W.G. Kubicek, "A Proportionally Controlled Externally Powered Hand Splint," Archives of Physical Medicine and Rehabilitation, 52:9, September, 1971, pp. 434-438.</li> <li>Spieker, J.L. and B.J. Lethcoe, "Upper Extremity Functional Bracing: A Follow-Up Study," The American Journal of Occupational Therapy, 25:8, 1971, pp. 398-401.</li> <li>Stauffer, E.S. and V.L. Nickel, "Control Systems for Upper Extremity Function in Traumatic Quadriplegia," Paraplegia, 10, 1972, pp. 3-10.</li> <li>Yarkony, G.M., L.M. Bass, V. Keenan, III, and P.R. Meyer, Jr., "Contractures Complicating Spinal Cord Injury: Incidence and Comparison Between Spinal Cord Centre and General Hospital Acute Care," Paraplegia, 23, 1985, pp. 265-271.</li> <li>Zrubecky, G. and M. Stoger, "The Orthosis for Restoration of Prehensile Function in Tetraplegics," Paraplegia, 11, 1973, pp. 228-237.</li> </ol> *John H. Bowker, M.D. John H. Bowker, M.D., is Professor and Associate Chairman of the Department of Orthopaedics and Rehabilitation at the University of Miami School of Medicine and Medical Director of the University of Miami/Jackson Memorial Rehabilitation Center in Miami, Florida. *Janie J. McColey, O.T.R., is the Supervisor of Occupational Therapy, Spinal Cord Unit at the University of Miami/Jackson Memorial Rehabilitation Center in Miami. *Wayne R. Rosen, CO. Wayne R. Rosen, CO., C.P.E.D., is Chief Orthotist, Department of Prosthetics and Orthotics at the University of Miami/Jackson Memorial Rehabilitation Center, 1611 N.W. 12th Avenue, Miami, Florida 33136. <div style="width: 400px;"></div> Page Number(s) 201 - 209 Year 1987 Volume 11 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-05.jpg Figure 6 CHART http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-07.jpg CHART CONT. http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-08.jpg Figure 7 FIGURE 6 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-06.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 FIGURE 7 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-09.jpg Figure 9 FIGURE 8 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-10.jpg Figure 10 FIGURE 9 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-11.jpg Figure 11 FIGURE 10 http://www.oandplibrary.org/cpo/images/1987_04_201/1987_04_201-12.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource The Team Approach to Orthotic Management in Quadriplegia Creator An entity primarily responsible for making the resource Wayne R. Rosen, CO. * Janie J. McColey, O.T.R. * John H. Bowker, M.D. * https://staging.drfop.org/files/original/1191469674a4152e921228b656aa1dfe.pdf d08f2c16efeb47cb114ce1f919ffdaed 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_04_210.pdf Text Any textual data included in the document <h2>Orthotic Management of the Surgically Stabilized Spine in Quadriplegic and Paraplegic Patients</h2> <h5>Michael MacMillan, M.D. <a style="text-decoration: none;">*</a> E. Shannon Stauffer, M.D. <a style="text-decoration: none;">*</a> Daryl G. Barth, C.P.O. <a style="text-decoration: none;">*</a></h5> Recent developments in the diagnosis and understanding of spinal dysfunction have affected both surgical and orthotic management of post-traumatic spine instability. The diagnosis of spinal instability has been clarified by clinical study of its natural history and by application of advanced imaging techniques.<a></a> Biomechanical studies have defined the role of each vertebral component in maintaining structural stability.<a></a> Surgical techniques and instrumentation for treating this problem have also evolved rapidly. These advances have resulted in an improved approach toward operative management of spinal instability. First, because the outcome of spinal injury can be more accurately predicted, surgery can be elected earlier for disorders that certainly would fail with nonoperative management. Surgery systems are available which maximize their effect in both obtaining and maintaining optimal spine positions. These reliable instruments have allowed surgeons to apply operative stabilization to a wider range of spine problems. Therefore, the orthotist is presented with an increasing number of patients who have undergone surgical stabilization and require postoperative immobilization. The purpose of this paper is to review the rationale for surgical treatment of traumatic spine disorders. This review will identify both the neurological and mechanical factors which must be addressed. Some of the instrumentation systems available and a few of their advantages and disadvantages will be examined. Finally, five separate areas of the spine will be identified and the special orthotic considerations in each region reviewed. The primary concern in all injuries to the spine is the neurologic status of the patient. There are three general categories of neurologic injury for which reduction and stabilization of the spine improves recovery.<a></a> The first group includes the Brown-Sequard, anterior cord, and posterior cord syndromes. These are collectively known as incomplete cord syndromes. Stabilization of the spine in the presence of these lesions can significantly improve neurologic recovery in a majority of cases. The second class of neurologic injury which is benefited by stabilization is nerve root compression at the cervical level. The recovery of a single nerve root at the cervical level dramatically improves the function of the patient for the rest of his life. This recovery can be facilitated by stabilization. The final lesion helped by internal fixation is the progressive neurological deficit. Often motion at a site of neurologic damage aggravates the injury. Surgical stabilization can reduce irritation and promote recovery. Thus, irrespective of the integrity of the spine, surgery can be indicated for neurologic conditions alone. However, loss of structural integrity can itself be an indication of operative treatment. If an area of bony disruption has resulted in significant deformity or has compromised the spine's ability to resist further deformity, surgical stabilization may be indicated. Authors have established guidelines for angulations and displacements to define this instability, but in all cases the final diagnosis of instability is largely clinical.<a></a> Pain at an area of compromised stability may also be an indication to reduce and stabilize a lesion. However, again the final determination is made on clinical grounds. If internal fixation of the spine is indicated, the subsequent step is the selection of an instrumentation system and postoperative immobilization method for that patient. In dealing with quadriplegic and paraplegic patients, a major concern is skin insensitivity. Although postoperative cast immobilization provides the most rigid support and protection, it also presents the highest risk for skin and wound complications. It is generally agreed that orthoses which can be removed once or twice a day for skin inspection are best suited for neurologically impaired individuals.<a></a> The dilemma the surgeon faces is how to mobilize the patient as soon as possible after surgery, yet not use the rigid protection of casts. The solution to this problem has been the development of more rigid internal fixation systems for the spine. Ultimately, the characteristics of the spinal column disruption determines the choice of instrumentation. Flexion, compression, and distraction are the three major mechanisms of spinal injury. Rarely does one force occur totally independent of the others. Usually one force is predominant with variable effect of the other two. The instability resulting from each of these forces, the instrument techniques used to counteract each of the deforming forces, and finally how the postoperative orthosis is also used to counter the mechanism of injury will be discussed. Fractures which result primarily from flexion often involve crushing of the vertebral body anteriorly and distraction of the posterior elements. Generally speaking, instrumentation systems to correct this problem rely on three-point bending to reduce the fracture and maintain position. The Harrington system uses a single hook at either end of a rod to effect leverage against the kyphus and create an extension force. A long rod is required for this, so that excessive force is not generated under the single hook. In order to shorten the length of the rod and improve fixation, other systems have developed methods for attaching the rod to every segment over which it passes. The Luque, Wisconsin, and Cotrel-Dubosset instruments are examples of this segmental type fixation. These systems have three advantages over Harrington rods. By fixing the rod to each segment over which it passes, the large leverage force necessary to reduce the deformity is evenly distributed over several segments. This reduces pull-out failure. Because this force is distributed evenly, it is possible to reduce the total number of segments stabilized by the rod, thus preserving spinal motion segments. And finally, these segmental fixation systems are significantly more stable, which helps promote bony fusion of the injured segment. Another method of obtaining three-point reduction while improving instrument fixation is the use of transpedicular screws for placement of the hardware. This system uses a short plate placed over the vertex of the kyphus, and then screws placed through the plate are firmly anchored to the uninjured vertebra above-and-below the fracture. As the screws are tightened, the kyphus is slowly reduced. These devices involve the least number of normal vertebral segments to achieve reduction. They are exemplified by Steffee and Roy-Camille plates. The segmentally fixed rods and transpedicu-larly anchored plates described above have excellent immediate stability. The major requirement of the postoperative orthosis is to reduce the stress on the implant by preventing repetitive forward bending of the patient. Orthotic requirements for Harrington rods systems are more demanding. With only single hook attachment, Harrington rods require an orthosis which generates a supplementary three-point bending force to reduce the possibility of hook pull-out. Because there are multiple unfixed segments where fusion is expected to occur, postoperative mobilization should be rigid enough to prevent non-unions from rotation and side-bending movements. In fractures where axial compression is the major deformity, the vertebral body can burst both anteriorly and posteriorly. To reduce the fracture, an instrumentation system capable of distracting vertebral segments is chosen. Again, Harrington rods can be used in this situation. They have a hook in one end that can be ratcheted against the rod to distract and pull apart the segments above and below the crushed vertebra. Segmental wiring alone is ineffective in reducing vertebral body burst fractures. However, many surgeons first use Harrington rods to counteract the compressive force, then use wires attached to the rod at every level to get the advantages of segmental wiring. This combination is lightly referred to as "Harri Luque." Plates anchored to the spine with transpedicular screws are incapable of generating a distracting force. An experimental Swiss system attaches a threaded distractor to the spine with screws and can be used to distract burst-type fractures. Orthoses cannot effectively counteract an axial load, or the results of the compressive mechanism of injury. Therefore, the orthosis is used exclusively to protect the implants from stress while the bone graft is consolidating. Again, the orthosis is most clearly indicated when Harrington rods are the only instruments maintaining the reduction. These single hook rods are subject to dislodgement if excessive bending or torsional forces are encountered. The loss of structural integrity resulting from distraction injuries has different implications in the diagnosis and treatment of this instability. While flexion and compression forces generally cause anterior bony collapse, distraction injuries tend to cause posterior ligament disruption. Since the injury is a traumatic tearing of ligaments and discs, the instrumentation is used to compress or pull the separated segments together. In the thoracolumbar spine, hooks enclose the vertebrae above and below the site of injury and are connected by a threaded rod. Turning of the rod slowly approximates the hooks and reduces the deformity. However, this type of injury predominantly occurs in the cervical spine. In this location, wires are usually used to draw the separated segments together. Because of the ineffectiveness of ligamentous healing, bone graft fusion is used in conjunction with internal fixation. Postoperative orthotic management in this situation is more complementary than supplementary. Whereas the internal fixation stabilizes in flexion, it offers little resistance to extension. Therefore, the orthosis should emphasize stability in extension. For the sake of completeness, orthotic management after anterior spinal decompression and fusion should also be mentioned. When this procedure is performed, most of the affected vertebra is removed and replaced with a block of iliac bone graft. Present anterior spine instrumentation uses a threaded rod attached to the spine with screws to afford stability. Control of motion in all planes by the orthosis is required in this clinical situation. The previous section dealt with the indications and techniques of spinal internal fixation, with emphasis on the role of postoperative orthotic management. Next, five regions in the spine and some specific orthotic requirements for each will be identified. Particular emphasis will be placed on whether a specific injury requires an orthosis to restrict or only to reduce intervertebral motion. When an orthosis restricts intervertebral motion, less than ten percent of normal motion is possible at that segment with the orthosis in place. An orthosis which restricts motion is used when either no or minimal internal fixation is used to provide stability. When up to 30% of motion at an intervertebral segment is possible while wearing an orthosis, the orthosis is said to only reduce intervertebral motion and not restrict it. A reduction orthosis is indicated to protect inherently stable fractures or spines internally stabilized secondary to surgery. The first anatomic area to be discussed is the upper cervical spine. In this area, instability can result from fractures of the atlas, from fractures of the odontoid process, and from disease processes such as rheumatoid arthritis and tumors. Orthoses generally are inadequate in restricting intervertebral motion between the occipito-atlanto-axial segments. Therefore, for virtually any upper cervical disorder requiring restriction of intervertebral motion, application of a halo and vest is indicated.<a></a> One possible exception is the SOMI brace, which can be used to effectively restrict instability from ruptures and attrition of the transverse ligament of the atlas.<a></a> The second anatomical area is the lower cervical spine. This extends from C3 through T1. Restriction of motion in this region is required in at least three situations. One is a flexion injury which compresses the vertebral body anteriorly and disrupts ligaments posteriorly. A second need for restriction is for extension injuries which avulse both the anterior longitudinal ligament and the intervertebral disc. A final situation is postoperative management of lower cervical fusions in which no internal fixation is used. In these situations, a cervicothoracic four-poster device should be used. If only reduction of intervertebral motion is required, then application of a Philadelphia collar is all that is necessary. The usual clinical situation needing reduction of intervertebral motion is immobilization after posterior cervical stabilization with wires. The third anatomical region lies between T3 and T10. The thoracic region possesses the most inherent stability of the entire spine. For this reason, the bracing requirements are minimal. If no internal fixation is performed, the stabilization afforded by the thoracic cage need only be supplemented by a thoracolumbosacral orthosis (TLSO) to ensure maintenance of position. Segmental type operative fixation is especially suited for the thoracic spine. When this is performed, often no postoperative orthosis is required. Postoperative immobilization is still required in the thoracic spine when Harrington instrumentation is employed. In the fourth region, the thoracolumbar junction, the use of orthotic management is dependent on whether or not surgical stabilization is performed and if so, which instruments are used. In this area, from T11 through L3, the typical fracture occurs from a combination of flexion and compression forces and is termed a "burst" fracture. Nonoperative management of this lesion relies on bracing to create an extension moment to reduce the amount of collapse during healing. Operative treatment has a combined goal: to reduce and hold the fractured segments while leaving mobile as many normal lumbar segments as possible. For this reason either segmentally attached rods or transpedic-ularly applied plates are used in this area. Since these systems possess significant inherent stability, the TLSO provides effective postoperative immobilization. This orthosis has been demonstrated to be effective for the upper lumbar spine.<a></a> The final anatomical area, the lumbosacral spine including L4, is least subject to traumatic fractures. It does, however, present some interesting challenges to obtaining effective immobilization. Operative treatment in this area should also preserve as many mobile lumbar segments as possible. With L4 fractures, the lumbosacral articulation can often be maintained. However, the more rare L5 fractures usually require fusion to the sacrum. Because of the need for short but extremely rigid spinal instrumentation, systems using transpedicular fixation are favored for lumbosacral fusions. Although this fixation method is rigid, the high stresses at the lumbosacral junction dictate that external immobilization be used, especially if two level fusions are attempted. The TLSO has almost no ability to immobilize the lumbosacral motion segment. Therefore, the use of a one-half spica cast is recommended for use after lumbosacral surgery.<a></a> In summary, the role of orthotics in the postoperative management of spinal instability is critical. Because the lack of normal sensation precludes the use of casts in quadriplegics and paraplegics, the proper fabrication and application of an orthosis is essential. Knowledge of the original fractures forces, as well as an understanding of the principles of operative stabilization, can assist the orthotist in managing the postoperative immobilization of the injured spine. References: <ol> <li>Denis, F., "Spinal Stability as Defined by the Three-column Spine Concept in Acute Spinal Trauma," Clin Ortho, 189, 1984, pp. 65-76.</li> <li>Sances, A., J.B. Myklebust, D.J. Mainman, S.J. Larsen, J.F. Cusick, R.W. Jodat, The Biomechanics of Spinal Injuries. CRC Critical Reviews in Biomedical Engineering 11(1), 1984, pp. 1-65.</li> <li>Stauffer, E.S., "Neurologic Recovery Following Injuries to the Cervical Spinal Cord and Nerve Roots," Spine, 9(5), 1987, pp. 532-3.</li> <li>White, A.A., M.D. Panjabi, I. Posner, W.T. Edward, W.C. Hayes, "Spinal Stability: Evaluation and Treatment," AAOS Instructional Course Lectures Volume XXXIV. The Spine. Chapter 23. CV Mosby, St. Louis-Toronto-Princeton, 1985.</li> <li>Dickson, J.H., D.R. Harrington, W.D. Erwin, "Results of Reduction and Stabilization of the Severely Fractured Thoracic and Lumbar Spine, "J Bone and Joint Surg, 60A(6), 1978, pp. 799-805.</li> <li>Bradford, D.S., B.A. Akbarnia, R.B. Winter, E.L. Seljeskog, "Surgical Stabilization of Fracture and Fracture Dislocations of the Thoracic," Spine, 2(3), 1977, pp. 185-196.</li> <li>Johnson, R.M., D.L. Hart, E.F. Simmons, G.R. Ransby, W.O. Southwich, "Cervical Orthoses," J Bone and Joint Surg, 59A(3), pp. 332-339.</li> <li>Fidler, M.W., "The effect of four types of support on the segmental mobility of the lumbosacral spine," J Bone and Joint Surg, 65A(7), 1983, pp. 963-7.</li> </ol> *Daryl G. Barth, C.P.O. Daryl G. Barth, C.P.O., is Assistant Director of Orthotic and Prosthetic Services for the Division of Orthopaedics and Rehabilitation at Southern Illinois University School of Medicine. *E. Shannon Stauffer, M.D. E. Shannon Stauffer, M.D., is Professor of Chairman of the Division of Orthopaedics and Rehabilitation at Southern Illinois University School of Medicine. *Michael MacMillan, M.D. Michael MacMillan, M.D., has a Spinal Fellow with the Division of Orthopaedics and Rehabilitation at Southern Illinois University School of Medicine in Springfield, Illinois. Page Number(s) 210 - 214 Year 1987 Volume 11 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 Orthotic Management of the Surgically Stabilized Spine in Quadriplegic and Paraplegic Patients Creator An entity primarily responsible for making the resource Michael MacMillan, M.D. * E. Shannon Stauffer, M.D. * Daryl G. Barth, C.P.O. * https://staging.drfop.org/files/original/15815c49a6adce1760436c8f5ae00753.pdf ccf779f3680911a29673df7262a2d03a 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_04_215.pdf Text Any textual data included in the document <h2>Mobility and Mobility Devices for the Spinal Cord Injured Person</h2> <h5>Samuel R. McFarland, MSME <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> In the dictionary, the preferred definition of mobility is "the quality of being movable."<a></a> A second definition, more sociological in scope, defines mobility as "the movement of people in a population, from place to place, or job to job, or social position to social position." The second concept captures the significance of mobility as it relates to the life of a spinal cord injured individual. Spinal cord injury is a condition that most commonly affects young, physically active adults who have already established a social pattern in their lives. Certainly, spinal cord injury (SCI) causes impairment of movement, but more importantly, it may constrain a person's capacity for self-di-rected, purposeful movements, which are important to almost all activities. Much of the medical rehabilitation of a SCI patient involves therapeutic interventions aimed at increasing the range, strength, and coordination of body movements that have been impaired by an insult to the central nervous system. To fully appreciate the scope of mobility impairments encountered by SCI patients, we must examine the entire spectrum of activities that can be affected by limitations of movements. Independence, social and personal interactions, career development, and access to public facilities are some of the freedoms that can be adversely affected by mobility impairment.<a></a> A thorough discussion of the methodology for reestablishment of mobility for SCI patients must include topics such as therapeutic interventions, orthotic appliances for stabilizing and enhancing the performance of musculoskeletal components, devices for extending the range or speed of movements, and substitutions for lost or severely limited functions. This article will not dwell on therapy, which is more appropriate for other authors, nor on orthotic appliances, since that subject is covered well in the accompanying articles on spinal stabilization and upper limb orthotics. Rather, it will attempt to represent some of the mobility considerations that are common to SCI and to discuss the application of products and techniques associated with ameliorating movement limitations. For the sake of simplifying the myriad array of details that can be covered under the general heading of mobility, this article will survey a sequence of activities that start with static support of the body and proceed to increasingly more complex movements in terms of range, speed, and energy demand. The author admits to a bias toward devices and technologies, which will be reflected in the discussions that follow, but he wishes to emphasize his belief that the only successful technical solution to a mobility problem is the one that integrates well with other rehabilitation interventions and withstands the test of time and use by the patient. Simplicity, cosmetic design, and reliability are essential to the immediate and long-range acceptance of adaptive technology by the user.<a></a> <h3>Background</h3> Spinal cord injury commonly results in permanent paralysis of some of the large and powerful skeletal muscles of the body. The location of the injury along the spine correlates roughly to the cumulative amount of paralysis that results. The closer the injury site is to the head, the greater the involvement. Trauma incurred at the spinal column can affect the transmission of the nerve signals to all parts of the body served by the injury site and beyond. However, functional deficits incurred by SCI are almost always incomplete, meaning seldom is there complete loss of function or bilateral symmetry of effects below the site of the injury (lesion). For the sake of this paper, however, it will suffice to consider only two general types of functional paralysis: paraplegia and quadriplegia. Impaired voluntary control of skeletal muscles is not the only significant impediment resulting from SCI. Other organ functions can be affected as well. Bowel elimination, bladder voiding, sexual function, sweating, bone strength, and peripheral vascular circulation can all be altered in response to spinal cord insult. A common and troublesome side-effect is involuntary contraction of a muscle, spasm. Not only is the motor function of a nerve network affected, but also the sensory aspect. The combination of loss of sensation and reduced tissue blood circulation resulting from everyday bumps and pressures incur a high risk of undetected soft tissue damage. In insensate tissues, such seemingly minor injuries can easily progress into massive tissue death in the form of a decubitus ulcur. "Decubiti" are immensely threatening to a spinal injured person, not only because of the irreversible tissue damage, but also due to the extensive time loss and expense incurred in the treatment. All of these conditions must be kept in the forefront of planning for mobility and will be mentioned from time to time in the text that follows. <h3>Transfer</h3> The initial and simplest tasks of SCI mobility begin with rising from a reclining position, from which seated tasks, ambulation, or wheeled mobility can proceed. If starting from a bed, the person must first be able to sit up. A paraplegic or quadriplegic with good shoulder strength, may be able to sit up without assistance. Some may prefer to use an overhead handle, often called a trapeze, or a looped strap, to pull up into a sitting position. Sometimes a hospital type bed, with a powered drive to the articulated back section, can raise the person to a sitting position from which he can turn and let his legs off the bed in preparation for standing. A standing transfer, even with an attendant assisting is desirable because the weight is borne on the legs, but not by the attendant or a transfer device. If the legs are capable of supporting body weight, with or without bracing, the person may develop greater independence. When the quadriplegic or high paraplegic is not able to stand without braces, the transfer from a sitting position to another seat is somewhat more complicated because of the physical strength required to lift the body, change levels between sitting surfaces, and traverse the distance. Transfer aids foster independence and supplement the work of an attendant. For wheelchair transfers, it may be helpful to use a sliding board (also called a "transfer board"), a short length of wood or rigid artificial material that bridges the gap between two sitting surfaces, such as the bed and wheelchair. A paraplegic, and some low level quadriplegics, can momentarily life his weight and move in short, sideways increments from one surface to another. A strong and active paraplegic will probably vault by pushing downward with his hands or swing from an overhead handle, in lieu of being burdened with a transfer board. Even a person who cannot transfer himself can be aided by sitting on a piece of sturdy fabric which may be pulled sideways across the sliding board by an attendant. If a sliding transfer is not possible, a person can be lifted while sitting in a fabric hammock by a mechanical patient lift that incorporates an electrical motor or hydraulic jack mechanism to provide the lifting force. The hammock is attached overhead to the lifting device which is usually operated by an attendant. Some can be self-operated if appropriate fail-safe or emergency mechanisms are built in to compensate for equipment failure. Elaborate custom installations of overhead tracks can allow a person to be transported from bedroom to bathroom and beyond. Overhead lifts are also available for transferring from a wheelchair into a car, but with the advent of van adaptations, they are losing acceptance among users. The lifting and sliding principles used in transfer aids are applied in many products used in home and institutional settings, especially in the bedroom and bathroom. A common application of the sliding-lifting principle is the bathtub transfer aid, a device used to help a person transfer safely into the bathtub and lower himself into the tub for bathing. Some products are completely passive, incorporating a sliding pathway for the user to traverse across the tub rim. Some are powered seats, often driven by faucet water pressure, that raise and lower the seated occupant relative to the tub bottom. A more expensive form of lifting aid for the home is the vertical shaft home elevator that is used to give mobility between vertically separated living areas. Installation usually requires alterations to the structure of the building. A somewhat less expensive approach, where applicable, is the stairway elevator, which can be added to an existing staircase. Available as a chair for ambulatory persons and a platform for wheelchair riders, it typically follows the path and incline of the stairs and usurps a portion of the walking path. The least expensive adaptation for moving between levels, especially from outside, is the ramp. Ramps have been well defined in standards produced by the American National Standards Institute.<a></a> Outdoor elevators that are added on, rather than built into a building, usually called porch lifts, are made primarily for wheelchair users where ramp construction is impractical and a landing platform can be placed next to an outer door. Home elevators of all forms are usually sold and custom-installed by specialty vendors that are associated with vendors of other mobility aids. <h3>Standing Aids</h3> Paraplegics and quadriplegics, although unable to stand unassisted, can derive both physiological and psychological benefits from standing.<a></a> Being able to stand allows a wheelchair user to reach work surfaces and interact with standing people at their level. There are static devices, called standing frames, that hold a person in a standing position by binding him to an upright, rigid structure. The user must pull himself up from a seated position into the device and secure the binding straps or close and latch a supporting gate. The manipulations involved may require the assistance of another person. A more complicated device that allows more independent operation by the user is the mobile Stander that uses a power source to raise the person to a standing position and support him there. This principle has been incorporated into two forms of wheeled mobility. In the one form, the person may move slowly around for short distances on smooth surfaces after he rises to the standing position by controlling an electrically powered drive mechanism. In the other form, the assistive force standup mechanism has been added to a wheelchair. When the occupant is standing, the device is immobile. When the occupant is seated, it functions as a regular wheelchair. Another standing device, but one that provides a modicum of mobility is the swivel walker, or "parapodium," that is used by a very few paraplegic adults. <h3>Ambulation</h3> Walking is the most common form of mobility for humans and the mode most desired by people who have limitations that diminish or eliminate their ambulation abilities. Where there is any possibility of a mechanism to regain the ability to walk or move about in a standing posture, even if it is slow and requires great expenditure of energy, a person often prefers to ambulate rather than use wheeled mobility. Even temporary standing, without walking, can be used to enable a person to get through narrow entry ways, such as toilet compartments, bathrooms, and closets. The desire to remain upright has sustained the development and application of torso and leg braces, standing aids, and even artificial stimulation of paralyzed muscles by externally supplied electrical signals. At a lesion level around high thoracic, the instability of the torso suggests that ambulation may be less secure and more demanding of energy than wheeled mobility. <h3>Stability</h3> One of the more important considerations in assuring the fullest functional mobility of the SCI patient is stabilizing the proximal parts of the body in order to facilitate the most controlled movements of the distal portions. The person fitted with the finest of upper limb orthoses or supplied with the most elaborate vehicle control system will be substantially incapable of adequate performance if the body is not appropriately stabilized. Securing the proximal portions of the body is a critical consideration and can easily be both underestimated and overdone. It is quite common that a patient will be trained to substitute certain spared muscle functions for those that have been impaired. If a substitute muscle is occupied with stabilizing the torso, it will be effectively unavailable for its substitute function. Similarly, if the proximal base of distal limb segments has been too severely confined, the distal functions will be limited. In general, the SCI patient will be concerned with use of the upper body for control and work tasks, so the primary concern should be focused on providing a secure base for the torso, while retaining a sufficient range of upper body motion to allow the arms and hands to perform functional tasks. These principles will be restated more specifically in the sections that follow. <h3>Wheeled Mobility</h3> When walking is not an option, or when the upper limits of speed and range of ambulation are too low for the mobility needs of the person or the occasion, the indicated mobility aid is the wheelchair or any one of a variety of wheeled devices. The basic, most familiar form of the wheelchair is a shiny, tubular metal, open-framed structure that has four wheels, two small casters in front and two large drive wheels in the rear. Details of implementation vary slightly, but the design remains essentially the same from brand to brand. They are intended to fit an average sized person, withstand heavy use with minimal maintenance, and be propelled primarily by an attendant. A wheelchair produced for these purposes is known in the industry as a commodity wheelchair and is intended for temporary use by any one person but repeated use by many people. This is the type of wheelchair that insurance companies and government-based reimbursement programs provide for nursing home and convalescent use. Chronic users of wheelchairs should not use a commodity chair, but should be guided toward the use of a prescription wheelchair, which looks similar to the commodity chair, but is available in a variety of dimensions that can be more carefully sized to the user and embodies some optional features that better suit the demands of everyday, independent usage. Prescription wheelchairs tend to be lighter in weight, more durable, and offer less resistance to rolling than the commodity type because of the use of more specifically suitable materials and components and more exacting tolerances in their manufacture. Available options include variations in wheel and tire size and type, variable seating dimensions and configurations, removeable armrests and footrests, and selection of frame and upholstery material and color.<a></a> The diameter of the wheel and type of tire affect the maneuverability, rolling resistance, and riding comfort. Hard rubber or polymeric tires offer less rolling resistance than pneumatic tires, but transmit more of the shock of pathway irregularities to the rider than the softer, pneumatic tires. Similarly, small diameter wheels offer less inertial resistance to rolling than larger diameters, but the greater curvature imparts higher impact forces to the rider and inhibits movement over rough surfaces. For a chronic user, a wheelchair should be very carefully sized and the components and accessories selected to assure efficiency of operation, postural support, and prevention of medical complications of disability. In general, a wheelchair should be as narrow as possible without pressing against the hips, thereby allowing the greatest freedom of access through narrow passageways and the maximum of mechanical advantage for propulsion and control. The back height should provide good postural support, but minimize interference with the arms during a propulsion stroke. Low level, active paraplegics may prefer a very low back to maximize freedom of arm and upper body movements. The height of the seat bottom is governed by three dependent variables; arm access to the pushrims, footplate clearance above the ground, and even distribution of the sitting load along the underside of the thighs and buttocks (taking the compressed thickness of any cushion into consideration).<a></a> The wheelchair seat cushion is a crucially important accessory component for a person who does not have sensation in the lower body and legs.<a></a> A cushion is intended to help distribute the gravitational loading forces of the occupant over the broadest possible area of the sitting surface and minimize the point pressure that occurs near the bony prominences of the pelvis and hips. There are many types of cushions that utilize a broad variety of materials and configurations, such as polyethylene foam, air and fluid-filled pillows, and semirigid and custom contoured devices. Each design has proponents who claim it is the best universal solution to the problem of pressure sores (decubitus ulcers), a major health problem for paralyzed persons with diminished or absent sensation. Since the formation of de-cubiti is related to many factors, such as pressure distribution and duration, temperature, moisture, diet, activity level and seating geometry,<a></a> it follows that no cushion can serve as a universal preventative measure. However, it is generally accepted by clinicians and users that there is a type of cushion best suited to each individual and careful selection for each person is important. It has also become increasingly more common for wheelchair seating experts to recommend that the hammock-style seat be replaced with a rigid member to provide a solid support structure for the type of cushioning material that is chosen. Hammock seats tend to wrap around the buttocks, creating a squeezing and shearing force pattern that tends to restrict tissue circulation. Also, the hammock is inherently unstable as a support for a high center of mass. The prescription wheelchair has recently undergone a rapid evolution in materials and design, resulting in lighter weight, smoother operation, greater durability and a change of image for the user. Wheelchairs are now offered in a mosaic of materials, colors, frame styles, and applications.<a></a> Largely because of the demand and innovations arising from the wheelchair sports movement, a new breed of daily use wheelchair has been developed and the market has accepted it with enthusiasm and buyer support. The new breed of wheelchair, now being labelled the "ultralight," embodies higher performance materials and design innovations including radial, rather than crossed (bicycle style) spoke patterns, aluminum alloy rims and hubs, die cast metal or injection molded polymeric wheels, adjustable position (fore/aft and up/down) and angle of axles, rigid (non-folding) and take-apart frames, and designer colors in anodized and polymeric finishes. The new product is less medical in appearance, more energy efficient to use, and more reliable and durable to the user. Although most of these changes have been directed at the manually propelled wheelchair for active adult paraplegics, some of the same innovations are beginning to be applied to powered chairs as well. The addition of mechanisms that propel the vehicle using electric motor power has provided a means of independent mobility for previously dependent users with quadriplegia. The most commonly used powered wheelchairs are supplied from the manufacturer as an integrated product that combines conventional frame and seating design with motorized propulsion. The power drive wheelchair (also called "electric" and "battery powered") was originally the result of relatively minor design improvements to the basic tubular metal wheelchair. Beginning in the early 1970s, the concept of a wheeled device, especially for severely disabled users, was reexamined by designers in North America and Europe. The result of that scrutiny was a proliferation of design ideas and clinical studies, some of which have resulted in commercially viable products. Out of that innovation revolution, stimulated in part by government supported research programs and workshops,<a></a> have come significant changes in propulsion and control of the electrically powered vehicle, an understanding of the health and performance benefits of carefully seating and positioning the occupant, and two new distinctly different types of powered vehicles. The first thrust of innovation dealt with obtaining new control modes for the user who could not operate the conventional joystick controller. One of the most common modifications of the powered wheelchair, and most important to the independence of the user, is the relocation or other alteration of the operator control device (typically an electromechanical joystick). It is now possible, with the purchase of options from the wheelchair manufacturer, or modifications developed by separate suppliers, for a severely impaired person to drive a powered wheelchair using any available physical movement on the body, including the head, chin, eyes and feet. It is also possible now to control a powered wheelchair with oral modulation of the breath and pneumatically powered electronic switching (the "sip and puff" control). The second most noteworthy trend in the redesign of the basic vehicle has been the separation of the seating function from the vehicular function. Conventional wheelchairs had been designed so that the chassis of the vehicle and the frame supporting the seat were the same. Therefore, changing the seat meant changing the total unit. The current focus on separating the functions has freed the vehicle designers and body positioning designers to pursue independent courses of study, resulting in both improved vehicle performance and enhanced comfort and health for the user. Scientific knowledge of the biomechanics and physiology of the wheelchair occupant is now being more appropriately applied to the development of specialized seating systems that position the body statically, and periodically reposition it, to promote improved vascular circulation and breathing, pressure relief and posture, leading to greater comfort, health, and prolonged periods of functional independence for the user.<a></a> An entirely different form of vehicle, the powered cart, has also been developed during the past decade, primarily for people who are ambulatory, but limited in speed and range of ambulation. The cart does not look like the basic wheelchair, rather a scaled-down, one person version of the familiar golf cart. Intended primarily for public use by less severely disabled people, the cart is available in a variety of three and four-wheel versions with either tiller or joystick control. People who might otherwise use ambulatory aids or manually-propelled wheelchairs may choose a cart to gain greater speed, range, and (in some models) rough terrain travelling capabilities. Use of the cart should be confined, however, to areas where motor vehicles are not likely to travel. On the road travel for wheelchair users should be limited to persons riding in specially adapted automobiles, trucks, and buses. <h3>Adapted Motor Vehicles</h3> As a passenger or as an operator, a spinal cord injured person can greatly extend his range of travel by using a motor vehicle. The motor vehicle, whether a passenger car, a truck, or a mass transit vehicle, presents some significant impediments to use by an SCI person and typically must be modified to accommodate him. The impediments can be roughly grouped into three categories: access, securement, and control. In order to safely and comfortably use a motor vehicle, a person must be able to get into (and out of) the vehicle, be seated comfortably and secured against any hazards that are presented by vehicle motion, and, if feasible, he must be able to exercise guidance or accessory control over the vehicle. Access to the vehicle is the pivotal concern, for if the individual cannot enter the vehicle, securement and control functions are moot. Entry into a vehicle is affected by the size and shape of the doorway, the height and slope of the ground just outside the vehicle, and the amount of time consumed in the boarding process; these parameters can be effectively controlled with an adapted personal vehicle. Mass transit vehicles, which are designed to quickly transport large numbers of people, present a great challenge to people who use ambulation aids and wheelchairs because transit systems typically operate on hurried schedules and boarding occurs in tight spaces. Access to busses, trains, and airplanes is a problem if the person cannot enter the vehicle where it is normally available for boarding without displacing other passengers or delaying the route schedule. Despite these conflicts, many of the modern mass transportation systems have incorporated accommodations for mobility limited people and their mobility devices.<a></a> Older systems are typically not accessible and not feasible for retrofit. Personal vehicles and small busses for groups of mobility impaired people, however, can be selected and effectively adapted with structural modifications and add-on products. Personal vehicles are more adaptable. Many people prefer to use a passenger sedan, rather than a van or bus, simply because it is smaller and less costly to own and operate. Paralyzed people, except for those who ride power drive wheelchairs, can get into a sedan without using special access equipment, but may need a little more time than able-bodied people. They must learn to be selective about the place on the sidewalk, at the curb, or in the garage where they board, because the height and slope of the ground often affect the ease of boarding. Generally desirable features in a car include a tall, wide door opening, a door that swings open to a large angle, and a seat at chair height with firm padding and low friction upholstery. A broad driprail or handle located overhead near the door opening can give a person something to hold or pull against during the transfer process. Large interior leg space is important, especially to someone who wears a long leg brace. Seating is only part of the access problem, since once the person is seated, the mobility aid must be stowed. A crutch or cane can be stowed inside the car, but a walker may be too bulky unless it is the type that folds up for storage. A wheelchair creates a special problem which will be discussed later. The person who can enter a passenger car, even with difficulty, may find entry to a van or bus to be impossible because the height of the seat from the ground is typically too great to enable direct sitting from outside the van. The person must enter the van before sitting. Van seats more nearly resemble a chair in height and attitude, so they are more accommodating to a mobility impaired person than the seats of a passenger car, but the height of the entry step on a van is as much an impediment to an ambulatory SCI person as stairsteps in a building. Even if he can surmount the stepwell and get inside, he cannot stand upright either for sitting or moving about, unless the roof has been extended. On vans that have been modified for a raised roof, the side or rear cargo doorway is also modified to give more head clearance to people entering and leaving the passenger area. To accomplish the transition from ground level to the level of the van floor, both ambulatory people and wheelchair users can be aided by a ramp or a platform lift. The ramp is the least expensive access device and offers the most trouble free service, but another person is needed both to deploy it into operating position and to assist the user while he is traversing the bridge. The lift, though more expensive, is frequently preferred over the ramp. For attendant operation, a lift carries the load, thereby reducing the labor and risk of injury. Unlike a ramp, certain types of lifts can be self-operated by a passenger in a wheelchair. There are two general designs of platform lifts: the folding lift (also called flop-out) and the swinging lift (also called rotary). A lift of the folding type consists of a platform for supporting and carrying the passenger and an electromechanical or electrohydraulic power mechanism that provides the lifting force. Deployed for operation, it unfolds outward to a horizontal attitude ready for moving the passenger between the floor and ground levels. The folding lift is usually offered in semi or fully automatic operating modes. The semi-automatic version raises and lowers under power while an attendant provides the controlling function as well as the stowage operation (opening/closing doors and folding/ unfolding the platform). The more complicated, and more costly, fully automatic version is further equipped with switches and drive mechanisms that allow the user to control the entire process independently. Typically, the installation of a fully-automatic lift is accompanied by the installation of a powered door opener and an external lift access control panel to complete the total system of components that provide the user with a capability for independent access to the vehicle. The swinging lift is almost always provided in a fully-automatic configuration. The platform travels vertically outside the opened cargo door between ground and vehicle floor levels. At the floor level, the platform swings (rotates) about a vertical axis into the vehicle and remains there for its stowed position, thereby limiting the available floor space inside the vehicle. This type of lift is somewhat less expensive to purchase and is lighter in weight than the folding type, but typically will not accommodate a full-sized powered wheelchair or cart. Many users of wheelchairs can transfer to the automobile or van seat without assistance. Often the transfer is aided by the sliding across a transfer board and sometimes by pulling up on an overhead handle or wriststrap. Each person must develop his own transfer technique based on the spatial geometry of the opened doorway, the location of the seat and vehicle interior appointments, and the nature of his physical ability. The transfer process will also vary with the vehicle being used and nature of the trip. Use of a taxicab, rental car, or a friend's car presents a greater challenge because of the variability of vehicle type, many of which are not suitable to the individual wheelchair user. After transferring themselves into the car, passengers (or drivers) of sedan-type vehicles must load the wheelchair into the car or park it at the debarkation point before they can close the door. If an attendant (or cab driver) is present, the chair can be placed in the trunk, in the back seat, or on a special rack attached to the back bumper. The independent wheelchair user must either stow the wheelchair (folded or dismantled) inside the car behind the front seat or on the roof outside. Strong and agile paraplegics can usually fold the chair and pull it inside. Those who are less able sometimes use a rooftop carrier to stow the chair. A passenger who transfers to a seat inside a van (a desirable practice from the standpoint of safety) can usually tether the empty wheelchair next to him inside the van, making it readily accessible for re-transfer and exiting the vehicle. Access to the vehicle seat does not complete the process of safely preparing for travel. The passenger should be secured. With many SCI people, safety securement is more than a crash protection mechanism, because they may have insufficient upper body strength to withstand common vehicle accelerations. A seatbelt or over-the-shoulder harness can be very important for both purposes. When an ambulatory person is seated in a vehicle, he can almost always use the conventional safety restraint belt for passenger security. So can a wheelchair user who is able to transfer from the wheelchair to the vehicle seat. When a wheelchair user cannot transfer, he should use some form of restraining device. As a general rule, both the wheelchair and its occupant should be restrained (separately) by a vehicle structural member. Many designs of restraining devices have been tried and tested by researchers and manufacturers. To date, only two relatively satisfactory approaches have been produced. In one, the wheelchair is permanently fitted with an additional structural subassembly which serves to reinforce the structural integrity of the wheelchair and engage a mating assembly that is securely anchored to the frame of the van. Though demonstrated to be an impact resistant combination,<a></a> this approach has the disadvantage of restricting a passenger to the use of a van that carries the mating structure and of imposing additional weight on the routine mobility of the wheelchair, demanding additional propulsive energy from either the arms of the occupant or the batteries of the power system. A second approach separately tethers the wheelchair and the wheelchair occupant to the vehicle structure, using belts. The tethering operation is virtually impossible for a wheelchair user to perform independently and is time-consuming even for an attendant. Some of the restraint devices that are provided for wheelchairs, however adequate to the task for wheelchairs of the basic design, will not engage certain forms of wheeled mobility aids at all. Passengers using such non-standard aids must often travel unrestrained. Many SCI people can be adapted to driving.<a></a> Although they may lack the leg and arm function required to operate the pedals and steering wheel, they may employ specialized products called automotive adaptive controls (also called hand controls and foot controls). Such devices transfer the locus of driving control from its conventional position in the vehicle to a location and configuration that can be operated effectively by parts of the body that are functionally able to handle the task. If the feet are not able to operate the throttle or brake pedals, a mechanical linkage can be added to transfer the input to a hand-operated lever. For most products, the throttle and brake are combined into a single lever. Since the hand-control completely occupies one hand with starting and stopping, the other hand must do all the steering. If that hand is limited in strength, common to quadriplegics, a steering wheel spinner may be needed to assure constant hand contact with the wheel throughout its rotational circuit. Spinners are available in a variety of configurations, depending on the nature of the hand disability. Other adaptive devices take the form of extensions of vehicle control levers, shafts, and pedals (such as turn signal, gear selector, steering column, throttle, brake, and emergency brake) that improve the mechanical advantage, extend the locus of activation, or transfer the operation to the opposite side. Hand controls typically do not prevent another person, who is not disabled in driving function, to drive the car since the conventional controls remain intact, having been added-to rather than replaced. Just extending and relocating the application of forces is sometimes inadequate to enable a quadriplegic to drive. Where conventional power assisted steering and braking requires more force than the driver can exert, it is possible to further reduce the force or range of movement required to operate the controls by performing a more extensive modification of the vehicle control components. Reduced effort steering, throttle, and brake conversions diminish the force the driver must supply. Since the driver who needs force amplification is unable to operate the vehicle without the modification, the complete reduced-effort system should be supplied with backup power that will sustain hydraulic and vacuum reserves, even if the engine (the primary source) fails. With the use of a reduced-effort system, the mechanical advantage of a large diameter steering wheel and extended lever arms is no longer needed, so the range of movement of the input controls can be reduced to accommodate limitations in upper extremity movement. A small diameter steering wheel, even one that is repositioned through universal joints and angular drives (so-called "horizontal steering"), extends the possibility of driving to people with even greater limitations of limb movement. As with all mobility aids, professional help with selection and training is very important to the ultimate successful application of automotive adaptive aids. Specialized assessment and training facilities have been established in conjunction with major rehabilitation centers worldwide. The staff of these centers typically includes a therapist, a driver trainer, and an equipment specialist who combine their expertise to provide the disabled driver candidate with comprehensive assessment, equipment selection, vehicle modification, and driver training.<a></a> In some areas, the vendor of vehicle adaptive equipment and modifications is responsible for the recommendation of products and services, but the more comprehensive clinical team approach seems to be more objective. <h3>Conclusion</h3> Helping to attain mobility for the spinal cord injured individual is a multiparameter equation. Mobility is key and essential to almost all aspects of the process of rehabilitation and return to active life postinjury. Many products and technologies are available to help extend the residual capabilities of the patient. A team approach to mobility assessment, prescription, and training will greatly encourage the development of a system approach that can lead to a well integrated plan for the user. References: <ol> <li>Axelson, Peter W., Dennis Gurski, and Ann Lasko-Harvill, "Standing and Its Importance in Spinal Cord Injury Management," Proceedings of the Tenth Annual Conference on Rehabilitation Technology, San Jose, California, June, 1987, pp. 477-479.</li> <li>Bolton, Michael, "The Ann Arbor Transportation Authority's Experience," Proceedings of the National Workshop on Bus-Wheelchair Accessibility, Seattle, Washington, May 7-9, 1986, U.S. Urban Mass Transportation Administration, DOT-1-87-11, pp. 2-16-2-21.</li> <li>Brubaker, Clifford, Ph.D., "Fitting a Person with a Chair," Clinical Supplement No. 2, "Choosing a Wheelchair System," Journal of Rehabilitation Research and Development, Veterans Administration Rehabilitation Research and Development Service, Baltimore, Maryland (in press).</li> <li>Crase, Nancy (editor), "Fourth Annual Survey of the Lightweights," Sports 'N Spokes, 11:6, March/April, 1986, pp. 19-30.</li> <li>Hobson, Douglas A. and Elaine B. Treffler, "Towards Matching Needs with Technical Approaches in Specialized Seating," Proceedings of the Seventh Annual Conference of the Rehabilitation Engineering Society of North America, June, 1984, Ottawa, Canada, pp. 486-488.</li> <li>Luce, Thomas P., The Handicapped Driver's Mobility Guide, American Automobile Association, Traffic Safety Department, Falls Church, Virginia, 1984.</li> <li>McFarland, Samuel R., "Personal Licensed Vehicles for Disabled Persons," Paraplegia News, 36(6), June, 1982, pp. 33-38.</li> <li>McFarland, Samuel R. and Lawrence A. Scadden, "Marketing Rehabilitation Engineering," SOMA, Engineering for the Human Body, 1:2, American Society of Mechanical Engineers, New York, July, 1986, pp. 19-23.</li> <li>Phillips, Lynn, Peter Axelson, Mark Ozer, M.D., and Howard Chizeck, Spinal Cord Injury, A Guide for the Patient and Family, Raven Press, New York, New York, 1987.</li> <li>Proceedings of the National Symposium on "Care, Treatment and Prevention of Decubitis Ulcers," Sponsored by the Paralyzed Veterans of America, Washington, D.C, November, 1984.</li> <li>Schneider, Lawrence W., Ph.D., "Sled Impact Tests of Wheelchair Tie-Down Systems for Handicapped Drivers," Project Report, University of Michigan Transportation Research Institute, Ann Arbor, 1985.</li> <li>"Specifications for Making Buildings and Facilities Accessible to and Usable by Handicapped People," ANSI Standard No. A117.1-1980, American National Standards Institute, New York, New York.</li> <li>The American College Dictionary, Random House, New York, New York, 1967, p. 780.</li> <li>Wheelchair III, Report of a Workshop on "Specially Adapted Wheelchairs and Sports Wheelchairs," Sponsored by the Veterans Administration Rehabilitation Research and Development Service and the Rehabilitation Engineering Society of North America, LaJolla, California, September, 1982.</li> <li>Wilson, A. Bennett, Jr., Wheelchairs, A Prescription Guide, Rehabilitation Press, Charlottesville, Virginia, 1986.</li> <li>Zacharkov, Dennis, Wheelchair Posture and Pressure Sores, Charles C. Thomas, 1984.</li> </ol> *Samuel R. McFarland, MSME Samuel R. McFarland, MSME, is Director of Rehabilitation Engineering at the National Rehabilitation Hospital, 102 Irving Street, N.W., Washington, D.C. 20010. Page Number(s) 215 - 224 Year 1987 Volume 11 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 Mobility and Mobility Devices for the Spinal Cord Injured Person Creator An entity primarily responsible for making the resource Samuel R. McFarland, MSME * https://staging.drfop.org/files/original/d7bbda5fa4a94c9b44ad420c291a651d.pdf 1fbf7ce3189a6a47e65af6fd71c3f8d6 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_04_225.pdf Text Any textual data included in the document <h2>Psychological Aspects of Spinal Cord Injury</h2> <h5>Katharine S. Westie, Ph.D. <a style="text-decoration: none;">*</a></h5> Spinal cord injury (SCI) is a massive assault to the psyche as well as the body. Within moments, a person who had been active and independent becomes immobilized, loses control of bowel, bladder, sexual and other bodily functions, and is dependent on others to meet the most basic needs. The instantaneous effects of the injury result in total disruption of the victim's life, and the beginning of a life-long psychological adjustment process. Optimal emotional adjustment is imperative to the recovery and rehabilitation process, due to the tremendous psychological energy and motivation required for a SCI patient to learn self-care, independence, and psychosocial coping skills. <h3>Theories of Psychological Adjustment</h3> Psychological adjustment to SCI has been conceptualized in terms of three major models. The first is referred to as the "stages" theory, and is derived from the well known work on grieving done by Lindeman and Kubler-Ross.<a></a> This theory proposes that individuals adjusting to losses, such as SCI, experience certain psychological stages in the readjustment process. These include (1) shock and denial, (2) depression, (3) anxiety, (4) anger, (5) "bargaining," and (6) adaptation. In using this model, it is important to understand that not all patients go through all stages, that a patient may go through a stage more than once and that stages are not necessarily experienced in a given order. This model is helpful in recognizing these emotional responses as a normal, healthy, and appropriate part of adjustment to SCI. The second model is referred to as the "developmental" theory. It is derived from Er-ikson's work on psychosocial stages of development, from infancy to adulthood.<a></a> As applied to SCI, the developmental theory assumes that the trauma results in a natural regression, followed by a reworking of some developmental tasks previously mastered in childhood, starting with (1) basic trust, (2) autonomy, and (3) initiative. Physically and emotionally, SCI patients must progress through tasks of infancy and childhood again. Like infants, they initially may be unable to verbally communicate, need to be fed and moved, have no bowel and bladder control, and are totally dependent. As they progress through rehabilitation, they relearn childhood tasks such as rolling, feeding, developing a bowel and bladder routine, mobility, and other basic activities of daily living. They experience the adolescent task of separation from parental figures as they work toward the independence of adulthood. The rehabilitation program can be seen as facilitating attainment of these developmental landmarks. The third model, the "individual differences" theory, proposes that adjustment is primarily related to individual differences in patients' premorbid personalities. These models provide three different approaches to understanding psychological adjustment to SCI. However, they need not be seen as mutually exclusive. In fact, when used together, they provide a more complete picture of SCI patients' complex adjustment process. <h3>Psychological Responses of Staff</h3> Rehabilitation professionals working with SCI may find that certain patients elicit grieving responses in them, similar to those of their patients. When staff members identify with or become emotionally attached to patients, they may find themselves experiencing symptoms of depression, anger, or even denial. Highly motivated staff may also find it difficult to cope with noncompliance of depressed or angry SCI patients. Occasionally, when staff members' goals for resistant patients are not met, they may blame themselves for perceived failures or subconsciously direct anger and frustration toward patients. Although these are normal emotional responses, they may interfere with staff members' well-being and effectiveness. When situations such as these occur, consultation with the rehabilitation psychologist can provide the staff member with behavioral management techniques and enhance personal coping skills and insight. Professionally facilitated groups designed to provide peer support, teach stress management skills, and prevent "burnout" are also recommended. <h3>Head Injury in SCI</h3> Closed head injury (CHI) frequently accompanies traumatic SCI, though it often goes unrecognized. The reported incidence of head injury in SCI ranges from 10% to 58%.<a></a> Recent studies indicate that neuropsychological deficits are common among SCI patients.<a></a> Morris, et al. state that 50% of all SCI patients may be expected to exhibit evidence of CHI and some degree of cognitive impairment.<a></a> Even mild head injuries can significantly affect cognitive and emotional functioning, especially during the first months post-injury. The most prominent areas of cognitive dysfunction following CHI are in learning, memory, and speed of information processing, all important to learning of new skills in rehabilitation settings.<a></a> Thus, patients' ability to acquire new knowledge may be greatly diminished at the precise time that intense demands to learn are placed on them.<a></a> CHI-related behaviors such as poor social judgment, poor frustration tolerance, impulsivity, emotional lability, perseveration, difficulty in initiating behavior, decreased mental stamina, fatigability, and irritability are often misperceived by staff as enduring premorbid personality traits. Neuropsychological testing can enhance patient and staff insight into the effects of CHI and facilitate treatment planning. <h3>Psychological Treatment Approaches in the Rehabilitation Setting</h3> Though the primary responsibility for psychological care of the SCI patient is assigned the psychologist and social worker, other rehabilitation professionals on the interdisciplinary team play an important role. Sensitivity to the patients' emotional status allows for treatment planning and interaction that maximizes physical and psychological rehabilitation. Ideally, psychological rehabilitation begins in the Intensive Care Unit (ICU) soon after injury. At this time, many SCI patients are intubated and unable to verbally communicate. They often experience disorientation, depression and anxiety, sensory and sleep deprivation, and perhaps the temporary delusional and hallucinatory state known as "ICU psychosis." This is a critical time for team members to offer emotional support, establish a communication system and determine what the patient wants to know. Some need extensive information about their injury and care in order to best cope with fears and anxiety. Others clearly want to delay knowing more about their condition. Most welcome reassurance that their emotional responses and concerns are normal and accepted. As the patient progresses through acute care into the rehabilitation setting, regularly scheduled psychotherapy sessions can facilitate the adjustment process. The psychologist can help the team understand the patient's stage of adjustment, and provide consultation on behavioral management approaches. Emotional responses dealt with by psychotherapy include a range of ego defenses, most commonly repression and denial. It is important to recognize that these defenses protect the psyche from material too traumatic to deal with consciously, thereby preventing decompensation. In this regard, denial and repression are adaptive, and indeed may be the reason SCI patients are able to function in the stressful rehabilitation situation so soon post-injury. Typically, as denial decreases over time, depression, anxiety, and anger increase. How these emotions are expressed depends largely on the patient's premorbid personality style. Normal emotional responses to SCI may be manifested in behaviors which impede progress in the rehabilitation setting. For instance, depression may cause psychomotor slowing, decreased motivation, and social withdrawal. Anxiety may create psychogenic somatic symptoms and poor concentration. Anger may result in noncompliant or destructive behavior. Psychotherapy can help via reinforcing adaptive coping skills and teaching new coping strategies. The psychologist may also work with the interdisciplinary team to develop behavioral modification programs, based on learning theory, to decrease these behaviors. Contingency management and behavioral "contracting" are most frequently used in rehabilitation settings. Approaches emphasizing positive reinforcement to "shape" desired behaviors are particularly effective.<a></a> Although such programs may be time-consuming initially, they can rapidly decrease maladaptive behavior and ultimately increase the patient's sense of control and self-esteem. Psychological treatment of SCI often includes group psychotherapy, which is an excellent method to both maximize patient learning and efficiently use therapist time. Patient groups can provide emotional support, peer role models, teach new coping skills, and decrease social discomfort. Likewise, multiple-family group psychotherapy is a powerful and effective tool for facilitating family adjustment to SCI.<a></a> Family members experience similar emotional responses to the patient and similarly benefit from psychological intervention. If not included in the team effort, a well-meaning family member could inadvertently sabotage the independence-oriented rehabilitation approach, or be too psychologically distressed to provide the emotional or physical care the patient needs. Other issues which need to be routinely addressed by the psychologist, in conjunction with the rehabilitation team, are sexual adjustment, vocational rehabilitation and pain management training. Prevention of medical complications, particularly those which have significant behavioral/emotional components, need to be emphasized. An example is pressure sores, which often occur when depression and/ or substance abuse lead to poor self-care. <h3>Psychological Response to Orthotic Devices</h3> SCI patients' ability to emotionally adjust to orthotic devices (sometimes referred to as "gadget tolerance"), is related to type of orthosis, premorbid personality factors, and stage of emotional adjustment. Orthoses used to stabilize the spine after surgery sometimes become the "target" of patients' emotional distress. For instance, it is easier for the patient who is denying the seriousness of his SCI to blame pain and decreased function on the TLSO. Anger expressed toward an inanimate object is "safe," whereas anger directed toward family or staff may have negative repercussions. Insight into these psychody-namics can help the orthotist deal with constant requests for adjustments to orthoses, or anger responses of post-surgical SCI patients. Upper and lower limb orthoses used to increase independence elicit a variety of emotional responses. The potential for increased function often provides a major psychological "lift," enhancing patients' sense of competence and self-esteem. However, inclusion of psychological factors in the selection of candidates for orthoses is critical. Fitting a patient who is not emotionally ready for an orthosis will result in loss of time and a failure experience for all concerned. There are numerous reasons why SCI patients may resist orthotic devices, or are unsuccessful with them, including the following: Body image Many SCI patients value the fact that they look "normal" except for the wheelchair. The magnitude of disability may be "invisible." When orthoses are introduced, patients sometimes report that people stare at them more. Their sense of "being different" and social discomfort increases. For this reason, sensitivity to aesthetics is important in designing orthoses for this population. Independence-Dependence Conflicts In some patients, there are secondary gains in their dependent state, though they may not be consciously aware of this. For example, when an upper limb orthosis significantly increases independence in activities of daily living, the patient may experience withdrawal of valued reinforcers (e.g. time and attention from caregivers). This can lead to rejection of the orthosis. If significant others (family and staff) are willing to provide extra attention and reinforcement for the new independence behaviors, these issues usually resolve well. Self-Concept SCI patients may not integrate disability into their self-concept for some time. In one study, 130 SCI patients were interviewed about their dreams in order to examine subconscious content regarding self-perception. The authors found that 75% of these patients, injured less than one year, had never seen themselves in a wheelchair in dreams.<a></a> This is one illustration of the initial need of SCI patients to maintain an underlying self-image as nondisabled. Orthoses may conflict with this self-image in more recently injured SCI patients. Denial Orthoses may threaten patients' denial systems. Patients not yet ready to acknowledge the extent or permanence of their disabilities frequently reject orthoses. Alternatively, they may accept temporary orthoses, but reject definitive ones. Patients with self-image and denial issues benefit from psychotherapy and being given more time to adjust emotionally to their disability. They should be provided with information on obtaining recommended orthoses for the future. At the other extreme, patients sometimes build denial systems based on unrealistically high hopes for orthoses. For example, a patient using lower limb orthoses for ambulation may find they are not practical for use in valued pre-injury activities. This could lead to breaking down of denial and increased depression or anger, which may temporarily create decreased motivaton or rejection of the orthoses. Clear communication, emphasizing realistic expectations before introducing orthoses, may prevent some of these responses. Premorbid Personality Longstanding personality attributes (such as poor frustration tolerance, risk-taking behavior, and substance abuse) and stage of adjustment (especially depression) can lead to poor self-care resulting in pressure sores or poor follow-through in any activities requiring sustained effort. Attention to psychological factors in selecting candidates for orthoses is the most important factor in preventing these problems. <h3>Summary</h3> Spinal cord injury results in an overwhelming physical and emotional adjustment process. By understanding emotional responses, and applying them in treatment planning and interaction with patients, rehabilitation professionals can greatly enhance the psychological adjustment of SCI patients. References: <ol> <li>Bond, M.R., "Neurobehavioral Sequelae of Closed Head Injury," in I. Grant and K.M. Adams (Eds.), Neuropsychological Assessment of Neuropsychiatric Disorders, New York: Oxford University Press, 1986, pp. 347-371.</li> <li>Davidoff, G., J. Morris, E. Roth, and J. Bleiberg, "Cognitive Dysfunction and Mild Closed Head Injury in Traumatic Spinal Cord Injury," Archives of Physical Medicine and Rehabilitation, 66, 1985, pp. 489-491.</li> <li>Dunse, C, R. Eichberg, and D. Deboskey, "The Incidence of Neuropsychological Deficits in the Spinal Cord Population," paper presented at the Third Annual Houston Conference on Neurotrauma, Houston, Texas, February, 1987.</li> <li>Erikson, E.H., Insight and Responsibility, W.W. Norton, 1964.</li> <li>Hoffman, Loren L., "Auditory-Verbal Memory Abilities Following Traumatic Spinal Cord Injuries: A Comparative Study," doctoral dissertation, Georgia State University, 1987.</li> <li>Kubler-Ross, Elisabeth, On Death and Dying, New York: MacMillan Publishing Company, Inc., 1969.</li> <li>Lindenmann, Erick, "Symptomatology and Management of Acute Grief," American Journal of Psychiatry, 101:143, September, 1944.</li> <li>Morris, J., E. Roth, and G. Davidoff, "Mild Closed Head Injury and Cognitive Deficits in Spinal-Cord-Injured Patients: Incidence and Impact," Journal of Head Trauma Rehabilitation, 1(2), 1986, pp. 31-42.</li> <li>Rohren, K., B. Adelman, J. Puckert, B. Toomey, B. Talbert, and E. Johnson, "Rehabilitation in Spinal Cord Injury: Use of a Patient-Family Group," Archives of Physical Medicine and Rehabilitation, 61, 1980, pp. 225-229.</li> <li>Taylor, G.P., and R.W. Persons, "Behavior Modification Techniques in a Physical Medicine and Rehabilitation Center," The Journal of Psychology, 74, 1970, pp. 117-124.</li> <li>Westie, K.S., and J. Evans, "Self-Perception as Disabled in Dreams of Spinal Cord Injured Persons," paper presented at American Psychological Association Convention, New York, 1987.</li> <li>Westie, K., and W. McKeon, "Multiple-Family Group Psychotherapy in Treatment of Spinal Cord Injury Families," paper presented at American Association of SCI Psychologists and Social Workers Convention, Las Vegas, Nevada, November, 1987.</li> <li>Wilmot, C.B., D.N. Cope, K.M. Hall, and M. Acker, "Occult Head Injury: Its Incidence in Spinal Cord Injury," Archives of Physical Medicine and Rehabilitation, 66, 1985, pp. 227-231.</li> </ol> *Katharine S. Westie, Ph.D. Katharine S. Westie, Ph.D., is Director of Clinical Psychology for the Spinal Cord Injury Service at the University of Miami/Jackson Memorial Rehabilitation Center in Miami, Florida. Page Number(s) 225 - 229 Year 1987 Volume 11 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 Psychological Aspects of Spinal Cord Injury Creator An entity primarily responsible for making the resource Katharine S. Westie, Ph.D. * https://staging.drfop.org/files/original/d473917f5c93279c86fec167ec3e6f8d.pdf 52522a97179122f2dab8aa3dded039d2 https://staging.drfop.org/files/original/cd42d129793a2e44547062aae35b954c.jpg 7fa5af2ce6f8ad613bc3161879335a63 https://staging.drfop.org/files/original/bb210c41d31ba6d69894ab5f0678324e.jpg b4f8eac8a1df5167a5581f3d8051bb22 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_04_230.pdf Text Any textual data included in the document <h2>The Relationship Between Orthotics and Gainful Employment of the Disabled</h2> <h5>J.E. Yourist, Ph.D. <a style="text-decoration: none;">*</a> Z.A. Latif, Ph.D. <a style="text-decoration: none;">*</a> S.T. Layton, Ph.D. <a style="text-decoration: none;">*</a> J.H. Bowker, M.D. <a style="text-decoration: none;">* </a></h5> <h3>Statement of Problem</h3> Physical and sensory disabilities restrict individuals from functional access to the environment.<a></a> Since our environment is best suited to the average person, losses such as these represent formidable barriers to fruitful interactions with the environment and society. Of special significance in this regard is the ability to function productively in gainful employment. National statistics reveal that the unemployment rate among the disabled is tenfold that of the general population (70% versus 7%).<a></a> Barring all other variables, this statistic reflects that our environment is especially inaccessible to the disabled. There are several factors which contribute to this serious unemployment problem.<a></a> Notable among these is the fact that the disabled are unable to return to work due to "access" deficiencies caused by the nature of their disability. In this sense "access" means to bridge the barriers to the environment imposed by physical or sensory disability (<a href="/files/original/bb210c41d31ba6d69894ab5f0678324e.jpg">Fig. 2</a>). This paper deals with the probable relationships between adaptive devices and employment/economic opportunities for the disabled. <h3>Probable Solutions to Access Deficiencies</h3> Appropriate solutions to these "access" problems can be complex, but all necessitate the use of orthotic or adaptive devices. Typically, these devices will aid the disabled to achieve a level of performance that, at best, approaches that of the able-bodied person. The primary device for the severely disabled remains the wheelchair which, when appropriately prescribed and adapted, provides mobility throughout the workplace and good sitting posture for proper interface with tools at the workstation. A stand-up chair allows the worker to utilize a standard file cabinet and reach objects on higher shelving. Quadriplegics can manipulate keyboard sticks either with wrist-driven flexor-hinge orthoses if C-6 function is present or with the use of a universal utensil holder for those with C-5 function. The advent of high-technology electronic devices such as computers and robots has greatly expanded the horizons of the severely disabled in the workplace. These devices, which are cost and energy efficient, can transform minimum physical energy into tangible and impressive work events. A simple example is that of a quadriplegic operating a microcomputer by activating a switch by a "sip and puff" device or speech-recognition software and hardware. For the purpose of this discussion, it is necessary to focus on the relevance of these devices to independent living and the achievement of gainful employment for the disabled. A behavioral model for task performance may be considered which allows the definition of the necessary device required to achieve a particular task. <a href="/files/original/cd42d129793a2e44547062aae35b954c.jpg">Fig. 1</a> is a schematic representation of the performance of a common task by an able-bodied individual. In this illustration, an intent or desire to perform a particular task is first identified.<a></a> After assessing the person's inherent capabilities and resources, the activity can then be performed. Consequently, the immediate environment is altered, a purposeful response is made, and the consequences are appreciated. <a href="/files/original/bb210c41d31ba6d69894ab5f0678324e.jpg">Fig. 2</a> depicts the same task presented to a disabled individual. This schematic is altered to demonstrate the physical and/or sensory barriers to completing a similar task.<a></a> A disabled person may have a desire to perform this task, but may not have the same inherent capabilities or the resources as the able-bodied counterpart. At this juncture, "access" deficits to the environment become obvious. An adaptive device is required to facilitate the fulfillment of this task. One might expect the appreciation factor to be much higher compared to the able-bodied person. <h3>Improvement of Function</h3> For many years orthoses have been successfully fitted to restore and sustain the ability to carry out common activities of daily living. These biomechanical devices have improved the ability of the disabled person to perform such physical tasks as sitting, walking reaching, and grasping. Functionally, many of these activities are no different than those found in the current workplace. Those disabled persons previously employed in manual labor or manufacturing jobs would probably be displaced from their previous employment. This is due, in part, to the fact that conventional orthoses have definite limitations in their ability to replace the physical potential of the able-bodied. Therefore, till now, the highly disproportionate number of unemployed disabled persons does not indicate a positive correlation between employment and the use of traditional orthoses or adaptive devices. However, the emergence of microcomputer technology during the last decade has provided new potential for more effective use of these devices. Furthermore, the microcomputer can be regarded as both a biomechanical accessibility device and an employment tool which can be utilized for physical and economic rehabilitation. <h3>The Change in Definition of Work</h3> Our global economy is rapidly evolving from an "industrial" to an "information" age.<a></a> Jobs are becoming more knowledge-based with increasing dependence on computer technology as the sole productivity tool.<a></a> Indeed, the management of information is being realized as a central resource or commodity for jobs. Consequently, demand for manual labor is being steadily replaced by a demand for workers who can effectively manage information. In the coming decade, more than 50 percent of all jobs in this country will be found in high technology based information management. The personal computer is the principal instrument used in these jobs.<a></a> These events are quite beneficial to those who are physically disabled, because the labor market will depend in a large degree on mental rather than physical capabilities. Coinciden-tally, the tool used in these new jobs is the same tool that can be used to access the environment: the microcomputer. Economic Rehabilitation Even in view of recent economic and technological developments, the question of the high ratio of unemployment among the severely disabled remains a serious and complex problem. In most cases, the severely disabled are displaced from their previous careers and require intensive rehabilitation to re-enter the job market. This implies that rehabilitation is certainly not complete until educational/retraining and economic goals are met to achieve financial independence. Therefore, complete rehabilitation is defined here as the process by which a person who is disabled and unemployed, can be physically and, more importantly, functionally and economically rehabilitated. This can only be achieved through a comprehensive program which includes not only conventional strategies of physical and occupational therapy, but vocational diagnostics, vocational counselling and retraining, and lastly, job placement. MEED (Microcomputer Education for the Employment of the Disabled) Appropriate vocational diagnostics and job retraining are key elements in successful economic rehabilitation. In most instances, this training has been inadequate, frequently resulting in supported job placement. Such a disincentive is often compounded by the possible loss of government-subsidized unemployment benefits and health care coverages. Therefore, at the University of Miami, we have developed an economic rehabilitation program based on high-technology called MEED, or Microcomputer Education for Employment of the Disabled. MEED was conceived from the federal Projects With Industry (PWI) model to pilot a high-technology approach to rehabilitative training. It is a microcomputer-based training and placement program for the severely disabled, teaching information management skills which are necessary for competitive employment in business. This training is comprehensive, job-targeted, and cost-effective. <h3>Other Causes of High Unemployment</h3> Although access barriers are keeping many disabled persons from the workplace, their high rates of unemployment certainly reflect a minimal relationship between employment and adaptive devices. These devices may promote job function, but may not significantly increase the chance of that person acquiring a job. Many other factors come into play, especially the social issues facing disabled individuals and the marketability of their job skills. Other factors also contribute, including: first, unavailability of suitable retraining programs; second, chronic health problems; and third, government-established major work disincentives, such as disability payments. <h3>Conclusions</h3> In our judgement, feasible vocational retraining approaches are needed. They must be designed to equip disabled individuals with marketable skills which are necessary for competitive employment. Partnerships among several sectors of the community are essential to make these efforts a success. These include academia, government, business and industry, and the rehabilitation and health-care communities. Conventional orthoses will play a significant role in complementing the function of high technology devices. For example, various splints and universal utensils will improve computer keyboard access and function. However, technology holds the key to the future of economic rehabilitation. We believe that the computer, particularly the microcomputer, is central to achieving this goal. The microcomputer is not only a valuable business productivity tool, but is also a vehicle through which a severely disabled individual can "access" his environment. In a sense, the microcomputer itself can be viewed as an orthotic or adaptive device. It is an extension of not only the body, but also the mind. So, in the "information age," the microcomputer is assuming a pivotal role in improving the quality of life for the able-bodied as well as, and even more importantly, for the physically disabled. References: <ol> <li>DeJong, Gerben, and Lifchez, Raymond, "Physical Disability and Public Policy," Scientific American, June, 1983, vol. 248, no. 6, pp. 40-49.</li> <li>Bowe, Frank, Ph.D., "Making Computers Accessible to Disabled People," Technology Review, January, 1987, pp. 54-59.</li> <li>Jaffee, David, "High Technology and New 'Access Devices'" from lecture and written material at High Technology Education for Employment of Disabled Conference, Miami, Florida, March, 1987.</li> <li>Harris and Associates, Inc., The ICD Survey of Disabled Americans Bringing Disabled Americans into the Mainstream, March, 1986.</li> <li>Spencer, William, M.D., "Technology and Rehabilitation," lecture at Symposium on Computers in Medical Care and Education, Washington, D.C, October, 1986.</li> <li>Cornish, Edward, "The New Industrial Revolution: How Microelectronics May Change the Workplace," Careers Tomorrow, C. Norman, 1983, pp. 26-35.</li> <li>Cornish, Edward, "Careers with a Future: Where the Jobs Will Be in the 1990s," Careers Tomorrow, M. Cetron andT. O'Toole, 1983, pp. 10-19.</li> </ol> *J.H. Bowker, M.D. John H. Bowker, M.D., is a professor and Associate Chairman of the Department of Orthopaedics and Rehabilitation at the University of Miami Schools of Medicine. He is also the Medical Director of the University of Miami/ Jackson Memorial Rehabilitation Center in Miami, Florida. *S.T. Layton, Ph.D. S.T. Layton, Ph.D., is Associate Director of the MEED Program at the University of Miami School of Continuing Studies. *Z.A. Latif, Ph.D. Z.A. Latif, Ph.D., is Assistant Professor in the Department of Medicine and Consultant to the MEED Program at the University of Miami School of Medicine. *J.E. Yourist, Ph.D. Jay E. Yourist, Ph.D., is Assistant Professor in the Department of Medicine and the Director of the MEED Program at the University of Miami Schools of Medicine and Continuing Studies, P.O. Box 016960, Miami, Florida 33101. Page Number(s) 230 - 234 Year 1987 Volume 11 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1987_04_230/1987_04_230-1.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 2 http://www.oandplibrary.org/cpo/images/1987_04_230/1987_04_230-2.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 The Relationship Between Orthotics and Gainful Employment of the Disabled Creator An entity primarily responsible for making the resource J.E. Yourist, Ph.D. * Z.A. Latif, Ph.D. * S.T. Layton, Ph.D. * J.H. Bowker, M.D. * https://staging.drfop.org/files/original/00aef4cd6df4fe2afbe93e23bb1aa9a0.pdf 27266064d8bfe3c96f4086c7204d1b26 https://staging.drfop.org/files/original/08880a20a3c0f8fd3794a62b5e39233d.jpg 79a06756e4f898cff5eebb111185d355 https://staging.drfop.org/files/original/f314fd85de1bb9acb2edfc3629026582.jpg 38d5c67d49c718680e501e2c20e483ff https://staging.drfop.org/files/original/56dbb5a30ba120dc374233660a6d08f2.jpg 66064d3a55ad5117af2b25623bc9cc92 https://staging.drfop.org/files/original/2d2151c41c8d769207ce1150be49de3c.jpg a9ad2494375193603f1088dc4f80b52f https://staging.drfop.org/files/original/35ce4605762acb542ff3e5cfb0953f88.jpg 338a3e36c40cb57d3a465aa7b51a0fed https://staging.drfop.org/files/original/1a6880facfd5db40696e5d6d3e54f5c7.jpg 9f7281a6ee94e4e07aa0cb3a096b65a9 https://staging.drfop.org/files/original/0cb44f1af50f82e37a10bcf6655eef8f.jpg d39462496db66313910dd49940ae4454 https://staging.drfop.org/files/original/1568f3bda968608839fa654316c6fcdf.jpg 751c90e73f3344c1b5bd104bcd06bcde 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_04_235.pdf Text Any textual data included in the document <h2>Mechanical Comparison of Terminal Devices</h2> <h5>James D. Corin, M.S. <a style="text-decoration: none;">*</a> Teresa M. Holley, CP. <a style="text-decoration: none;">*</a> Rodney A. Hasler, M.E. <a style="text-decoration: none;">*</a> Richard B. Ashman, Ph.D. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> Considerable controversy has developed over the appropriateness of fitting "functional hand" prostheses to juvenile and adolescent amputees. This controversy is further enhanced by the cosmetic advantages of functional hands over the more traditional hook terminal devices. Conversely, experience has shown the hook terminal devices to offer greater functional control. Prosthetists often feel obliged to fit the amputee with a more functional terminal device, while the amputee often wishes to relinquish some function for cosmesis. Because the functional hands available today do not approach the necessary control, and because hooks are so uncosmetic, a significant percentage of upper limb amputees tend not to wear their prosthesis. The fundamental question presented to the prosthetist in fitting an amputee is how much function can be gained with a particular device. If function is defined simply as prehension grip force and grip width, the next question is whether an amputee can fully operate the particular device completely and comfortably. To date, very little objective data has been available on the comparison of terminal devices. Hence, prescription principles on the part of most prosthetists have been somewhat subjective. Quantitative force and excursion are not usually critical in fitting low level amputees; but the strength adolescents, juveniles, and higher level adult amputees can induce, becomes quite variable. The study presented here is an objective comparison of several terminal devices for mechanical function. The measured parameters were prehension grip force, grip width at full open, excursion range, and the excursion force required to fully open the terminal devices. <h3>Methods</h3> Test Protocol All test data presented here was accomplished on a MTS-858 universal materials testing machine. With this hydraulically powered machine, a piston-like cross-head can be positioned accurately, while loads created on the test specimens are monitored. The degree of sophistication of this machine is not critical to the test protocol. Any testing apparatus can be used as long as displacement and created force can be measured accurately. Two different tests were performed on each terminal device at each of the different tension settings available. The first test will be referred to as the excursion test. Here, the cross head and load cell of the test machine were attached to the cable actuator of the terminal device (<a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-01.jpg">Fig. 1</a>). The terminal device itself was mounted rigidly to the machine base. The result of this test was a plot of excursion of the cable actuator against the tensile force generated in pulling the cable (<a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-02.jpg">Fig. 2</a>). The rate of pull was constant at 4" per minute and, because of this slow rate, loading was considered to be static. The plots of excursion force verses excursion of the cable actuator were all of the same general form. <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg">Fig. 3</a> shows generalized force versus excursion plot. To present the actual loading curves for each device tested would have taken considerable space, therefore, for each device the only parameters that were tabulated are "A," "B," "C," "D," and "E." The portion of the curve up to "A," "C," represents the pre-loading of the terminal device. Excursion of the cable up to this point does not significantly move the appendages of the terminal device and is primarily due to slack in the system. The pre-load force "C," is the force necessary to overcome preloading of the spring or bands. The force constant "D," of a particular terminal device is the slope of the loading curve between the end of preloading and full open excursion of the cable. The full open excursion of the cable actuator is the distance "B," while the force required to fully open the device is labeled "E." It should be noted that with the five parameters, an estimation of the excursion-load curve of a particular device can be reconstructed. It should also be noted that the tabulated excursion parameters were measured by pulling the terminal devices open. If one was to continue to plot force versus excursion while the device was allowed to close, one would find much lower forces for a given excursion. This hysterisis in the loading curve is due primarily to friction. The loading curves are presented, rather than the unloading curves, because this is the manner in which the devices are operated. <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-01.jpg">Figure 1. A 2.5" U.N.B. STEEPER set up for excursion testing on the MTS-858 universal machine.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-02.jpg">Figure 2. Experimental plot of excursion force vs. excursion travel on a 2.5" U.N.B. STEEPER terminal device. Notice that at 0.45" the characteristics of the curve changes. This is the point (A,C) at which the hand just begins to open.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg">Figure 3. Generalized version of excursion force vs. excursion with parameters indicated.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg">A-Pre-load excursion (inches)</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg">B-Full opening excursion (inches)</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg">C-Pre-loading force (lb.)</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg">D-Force constant in loading (lb./in.)</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg">E-Total excursion force at full open (lb.)</a> The second test performed was to assess the prehension gripping forces that are created with each device. With the hand in a horizontal position, the base of the test machine was attached to the thumb, or one hook half, with a cable. The phalanges, or other hook half, were attached to the cross head and load cell of the test machine via a cable (<a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-04.jpg">Fig. 4</a>). The prosthesis was started in the full open position. A plot of grip force verses grip width was created by allowing the device to close at a constant rate of 4" per minute (<a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-05.jpg">Fig. 5</a>). From these plots, the parameters "G," "H," and "I," were calculated for use with the generalized graph (<a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-06.jpg">Fig. 6</a>). It should be noted that the plotting direction of these curves was opposite to those discussed in Figures 2 and 3. Since the hand was started full open, maximum prehension grip force "I" and the full open grip width "F" are plotted first. The force plotted here represents the force created by the device upon its own closing. The force necessary to pull the appendages open would be greater than this force, due to friction. In <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-06.jpg">Fig. 6</a>, "G" is referred to as the initial prehension force. This is the force created just prior to the grip closing completely. Also, the prehension grip force constant, "H" is the slope of the unloading curve between fully open and closed positions of the terminal device. With the parameters "F," "G," "H," and "I," an approximate reproduction of prehension grip force verses grip width can be created. <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-04.jpg">Figure 4. A 2.5" U.N.B. STEEPER set up for prehension grip testing on the MTS-858 universal machine.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-05.jpg">Figure 5. Experimental plot of prehension grip force vs. grip width for a 2.5" U.N.B. STEEPER. This plot was started with the hand full open, a 2.25" grip width, and 2.5 lb. grip force. The steep slope at approximately 0.4" is where the inner locking mechanism activates. The hand is essentially closed at this time.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-06.jpg">Figure 6. Generalized version of prehension grip force vs. grip width, with parameters listed.</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-06.jpg">F-Full opening grip width (inches)</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-06.jpg">G-Initial prehension grip force (lb.)</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-06.jpg">H-Prehension grip force constant (lb./in.)</a> <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-06.jpg">I-Total prehension grip force (lb.)</a> <h3>Results</h3> Table I lists the measured parameters derived from the two tests of 33 terminal devices. Of the 12 parameters listed, the first nine were described previously in the test protocol section. The J-th parameter is the number of different devices tested of each type. When more than one device was tested of a particular type, results were averaged. The criteria for testing most of the devices was based on local availability. The ratio of maximum prehension grip force to excursion force is often called the efficiency of a terminal device. The K-th parameter is the measured efficiency. The last parameter, listed as "L," is that of the work required to open the terminal device by pulling the actuator cable. Work is defined as the excursion force times excursion length and is measured by calculating the area under the force-excursion curve. This parameter can be estimated to reasonable accuracy by considering the area under the generalized force-excursion curve (<a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg">Fig. 3</a>). The work, or area under this curve can be calculated as: work = (1/2)*(A*C) + (B-A)*C + (1/2)*(E-C)*(B-A) <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-08.jpg">Table I. Values measured from hook and hand type terminal devices.</a> <h3>Description of Terminal Devices Tested</h3> The following list of terminal devices corresponds to the device number of Table I. <ol> <li> CAPP regular spring, center pull, nylon cabled </li> <li> CAPP soft spring, center pull, nylon cabled </li> <li> HOSMER SSS-555, 1 band, steel cabled </li> <li> HOSMER SSS-555, 2 bands, steel cabled </li> <li> HOSMER SSS-555, 3 bands, steel cabled </li> <li> HOSMER 10P, 1 band, steel cabled </li> <li> HOSMER 10P, 2 bands, steel cabled </li> <li> HOSMER 10P, 3 bands, steel cabled </li> <li> HOSMER 10X, 1 band, steel cabled </li> <li> HOSMER 10X, 2 bands, steel cabled </li> <li> HOSMER 10X, 3 bands, steel cabled </li> <li> HOSMER 12P, 1 band, steel cabled </li> <li> HOSMER 12P, 2 bands, steel cabled </li> <li> HOSMER 88X, 1 band, steel cabled </li> <li> HOSMER 88X, 2 bands, steel cabled </li> <li> HOSMER 88X, 3 bands, steel cabled </li> <li> HOSMER 99X, 1 band, steel cabled </li> <li> HOSMER 99X, 2 bands, steel cabled </li> <li> HOSMER 99X, 3 bands, steel cabled </li> <li> U.N.B. STEEPER, 2.0" w/glove, nylon pull </li> <li> U.N.B. STEEPER, 2.25" w/glove, tension #1 (softest), nylon pull </li> <li> U.N.B. STEEPER, 2.25" w/glove, tension #2, nylon pull </li> <li> U.N.B. STEEPER, 2.25" w/glove, tension #3, nylon pull </li> <li> U.N.B. STEEPER, 2.50" w/glove, steel cabled </li> <li> U.N.B. STEEPER, 2.75" w/glove, steel cabled </li> <li> HOSMER SIERRA, gloved, steel cabled </li> <li> HOSMER ROBINS-AIDS, soft-mechanical, gloved, steel cabled </li> <li> HOSMER BECKER-IMPERIAL, gloved, steel cabled </li> <li> HOSMER, #201 gloved, steel cabled </li> <li> HOSMER, #301 gloved, steel cabled </li> <li> HOSMER, #401 gloved, steel cabled </li> <li> OTTO-BOCK, 6.75", gloved, steel cabled </li> <li> OTTO-BOCK, 7.75" gloved, steel cabled </li> </ol> <h3>Discussion</h3> General trends in the measured parameters become evident on closer examination of <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-08.jpg">Table I</a>. Organization of these tables is such that devices with numbers less than 20 were hook type terminal devices, while those with numbers 20 and over were functional hands. Preload excursion, parameter "A," can be thought of as the excursion necessary to take up slack in the system. Some functional hand units require as much as 1/2" of excursion before any opening occurs. Full opening excursion, parameter "B," and the total excursion force necessary to open the terminal device, parameter "E," are self explanatory. If an amputee cannot generate either the excursion or the necessary force, a different terminal device should be considered. It should be noted that children usually have trouble operating a device with an excursion force greater than ten pounds. The pre-loading force "C" and the force constant "D" are useful parameters in assessing the function of a terminal device when the amputee can marginally create the forces and excursion necessary for full opening. In marginal cases, large pre-loading forces will limit the function of a device. For example, although the UCLA CAPP, device number one, only takes eight pounds to open fully, a patient must be able to create at least 4.5 pounds to start the device in motion. Without regard for the pre-load, one might incorrectly think that four pounds of excursion force would open the device halfway. A terminal device with a high pre-opening excursion (more prominent in hands) could be used on an amputee with good strength initially, but might have weakness toward the end of the excursion range. This is particularly true for higher levels of amputation which rely more on scapular abduction and less humeral flexion. Another important factor to note is the grip performance of the terminal devices. Here the full open grip width "F" and maximum prehension grip force "I" are the important notable values. The parameter that includes both grip and excursion is "K," the ratio of maximum grip force to excursion force. This term was measured to be greater than 0.40 for all of the hook type devices examined, and less than 0.40 for the functional hands. Some hooks revealed efficiencies as high as 0.70. It should be noted that the ratio of maximum grip force to excursion force can be calculated from the geometry of a particular device and is independent of the spring or rubber band tension. The measured results show this to be the case, in that parameter "K" did not significantly vary when spring tensions or the number of rubber bands were changed. Measured efficiencies for the functional hands were, in general, less than hook terminal devices. This consistent discrepancy is due largely to friction in the mechanics of the internal hinges within the hands in addition to glove attachments. The final parameter "L" which is the total amount of work required to operate the terminal device is also of extreme importance. Hands compare more favorably to hooks because on a general basis hands require less excursion than hooks for full opening. This is an important factor for children as well as higher levels of amputation, because of less available excursion. Plotting maximum prehension grip force against total excursion force, the relative performance between hooks and hands can be compared (Fig. 7). For clarity, the hand device numbers were plotted with a preceding dash. For any particular excursion force, it can be easily seen that grip force is greater for the hook devices. The devices 7, 8, 10, 11, and 19, were particularly good performers, which required excursion forces less than 15 pounds, and created prehension grip forces greater than seven pounds. In light of this comparison, it should be challenging for terminal device designers to come up with functional hand devices that approach the efficiencies of hooks. <a href="http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-07.jpg">Figure 7. Graph of prehension grip force vs. excursion force for all terminal devices. Note that all hand terminal devices have a preceding dash.</a> <h3>Conclusions</h3> This comparison of terminal devices is only preliminary in that many more terminal devices have yet to be analyzed. Furthermore, the number of devices tested was very small. In spite of these limitations, the best protocol allowing comparisons between the different terminal devices was felt to be objective and reflect the relative performance of different devices. <h3>Acknowledgments</h3> This research was funded by the King Foundation, Dallas, Texas and the Research Fund of Texas Scottish Rite Hospital for Crippled Children. We wish to also thank Hosmer Dorrance and Liberty Mutual for the donation of their terminal devices. *Richard B. Ashman, Ph.D. Texas Scottish Rite Hospital for Crippled Children, 2222 Welborn Street, Dallas, Texas 75219. *Rodney A. Hasler, M.E. Texas Scottish Rite Hospital for Crippled Children, 2222 Welborn Street, Dallas, Texas 75219. *Teresa M. Holley, CP. Texas Scottish Rite Hospital for Crippled Children, 2222 Welborn Street, Dallas, Texas 75219. *James D. Corin, M.S. Texas Scottish Rite Hospital for Crippled Children, 2222 Welborn Street, Dallas, Texas 75219. Page Number(s) 235 - 244 Year 1987 Volume 11 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-01.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-05.jpg Figure 7 TABLE I http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-08.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Assigned to Expert Review Figure 8 FIGURE 7 http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-07.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-02.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1987_04_235/1987_04_235-06.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 Mechanical Comparison of Terminal Devices Creator An entity primarily responsible for making the resource James D. Corin, M.S. * Teresa M. Holley, CP. * Rodney A. Hasler, M.E. * Richard B. Ashman, Ph.D. * https://staging.drfop.org/files/original/d634f72b53fee3270263d6b02eee78a9.pdf 081468a627be053883d0d2c0f57e0d81 https://staging.drfop.org/files/original/47c2da3bfe365d19dab934e665f66a7e.jpg c6870a13ba528d9a08b712870f181aef https://staging.drfop.org/files/original/021188ebcef7da90fd31f98828fa6492.jpg 219db07046fc7f9d39d4657d7c82b990 https://staging.drfop.org/files/original/33a23ce6e5de3913d0478c534f7aba36.jpg 3883d5d385c53d064fdf6a5ccd89ca18 https://staging.drfop.org/files/original/603316446d9d314a4586a444cf9f0a22.jpg 4ba8c8779644110430c42c63360db0e7 https://staging.drfop.org/files/original/18b9b43af4d8e97b8ba3e0f2828c3ef6.jpg bd974c771438f676134eb68427186558 https://staging.drfop.org/files/original/105098f81ea7edb2a091dcd0415eed6a.jpg 2f4c92856ae0e6562aebe32d5d1bf29c https://staging.drfop.org/files/original/dedd8fa68f49c7b3bcc8c3e82b8efa92.jpg a5d2d0752fc526c58c0bc3a2c08f9417 https://staging.drfop.org/files/original/e592dc5785c3e7b7ec28c9077eaa7fef.jpg 07a87e00f96d255cf1334360f01727ca https://staging.drfop.org/files/original/a8cce387b55b45e6a667c49df89ae308.jpg 5bb5287ac69b8ef9966416fdcca3aab3 https://staging.drfop.org/files/original/ca2b3ffb8c94001e703bdd917b139e04.jpg 69f9c2b5942f12823da5914a0873a1b3 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1985_01_002.pdf Text Any textual data included in the document <h2>Historical Aspects of Powered Limb Prostheses</h2> <h5>Dudley S. Childress, Ph.D. <a style="text-decoration: none;">* </a></h5> <h3>Introduction</h3> People involved in work on powered limb prostheses may wonder if the history of this field is important. My answer is that one can learn a lot from history. Nevertheless, Hegel has said, "What history teaches us is that men never learned anything from it." Unfortunately, it sometimes does seem true in prosthetics that we have not always profited from past experiences. Too many aspects of the work are never published, and the multidisciplinary nature of the field produces papers in a broad spectrum of journals that are difficult to track. Books on the field are, unfortunately, not numerous. The brief history that follows is by no means complete, and since some of it involves years that are within readers' memories, I apologize in advance for omissions that anyone may consider significant. The history is intended to entice readers to look more deeply into historical issues. It is also intended to give some perspective on the field and to dispel notions that powered prostheses are only recent developments of "bionic man" research. Wilson<a></a> has written a brief history on external power of limb prostheses and the handbook by Spaeth<a></a> contains an introductory chapter on this subject. Brief surveys are included in papers (e.g. Childress<a></a> or Bottomley et al.<a></a>) Powered limbs have existed for some seventy years. This roughly corresponds with the history of powered hand tools and other powered technical devices used so widely in modern society (e.g. airplanes, automobiles, etc.). This is not surprising since technology in most fields tends to mirror the state of technology generally. The history of powered limbs is also comparable in length with the history of an identifiable field known as "limb prosthetics." I have chosen to consider the history of powered prostheses from a hardware viewpoint and from the viewpoint of important meetings and events. Control approaches, another viewpoint, are considered but not emphasized. Also, the perspective is from America. <h3>Prologue (1915-1945)</h3> The first powered prosthesis, of which I am aware, was a pneumatic hand patented in Germany in 1915.<a></a> A drawing of an early pneumatic hand is shown in <a href="/files/original/47c2da3bfe365d19dab934e665f66a7e.jpg">Fig. 1</a>. <a href="/files/original/021188ebcef7da90fd31f98828fa6492.jpg">Fig. 2</a> shows a drawing of what I believe to be the first electric powered hand. These drawings were published in 1919 in Ersatzglieder und Arbeitshilfen (Substitute Limbs and Work Aids).<a></a> This German publication illustrates the importance of history in prosthetics, containing ideas that are still being discovered today. Although the book Treatise on Artificial Limbs by A.A. Marks, published in 1901, does not contain anything about powered limbs, it too illustrates the importance of history in the field because many ideas put forward in it are also quite modern. <a href="/files/original/47c2da3bfe365d19dab934e665f66a7e.jpg">Figure 1</a>. Early compressed-gas powered hand (Perhaps the first powered prosthesis component). From Ersatzglieder under Arbeitshilfen (Limb Substitutes and Work Aids) 1919. <a href="/files/original/021188ebcef7da90fd31f98828fa6492.jpg">Figure 2.</a> Early electric hand component (Perhaps the first electric hand mechanism). From Ersatzglieder und Arbeitshilfen (Limb Substitutes and Work Aids) 1919. Powered limbs were probably not used to any significant extent between the World Wars, but CO2 powered limbs were used by Weil as early as 1948.<a></a> Development work continued at Heidelberg during the 1950's under Marquardt,<a></a> and the Otto Bock Company became involved with the work about 1962. Laboratories at Munster and Hannover were also involved in this early work that led to clinical applications of gas powered prostheses. Part of Germany's prominent position in the prosthetics field can be traced to their early commitment to development work in the entire field of prosthetics. Kiessling<a></a> was the major U.S. investigator involved with CO2 powered limbs. Of course, the McKibben muscle<a></a> was developed in the U.S., but has been used mainly in orthotics. The first, as far as we know, myoelectric prosthesis was developed during the early 40's by Reinhold Reiter, a physicist working with the Bavarian Red Cross. He published his work in 1948<a></a> but it was not widely known and myoelectric control was destined to be "rediscovered" in England, in the Soviet Union, and perhaps other places during the 1950's. Economic conditions in Germany after World War II prevented the work on myoelectric control from being continued there. <a href="/files/original/33a23ce6e5de3913d0478c534f7aba36.jpg">Fig. 3</a> shows a picture of the first myoelectric hand prosthesis which was probably used around 1943. The system was controlled by a vacuum tube amplifier and was not portable. The hand was a modified Hüfner Hand that continued a control electro-magnet. The system was heavy, large, and not battery operated; the idea was to use it as a special prosthesis at a work station. Reiter hoped that further development could make it portable. <a href="/files/original/33a23ce6e5de3913d0478c534f7aba36.jpg">Figure 3.</a> Electric powered hand used by Reiter in development of first myoelectric prosthesis (Circa 1943). It consists of a Hüfner Hand in which a control magnet has been built. From Grenzgebiete der Medizin (Frontiers of Medicine) 1948. It is an interesting coincidence that the results of the first experiments with myoelectric control were published in 1948, the same year in which the development of the transistor was announced. Practical myoelectrically controlled prostheses required the transistor and its subsequent refinements. Although Reiter conceived and developed the idea of myoelectric control in the early 1940's, others had the same idea later and apparently independently. The late Professor Norbert Weiner of Massachusetts Institute of Technology is reported to have suggested the concept around 1947. Berger & Huppert<a></a> presented the idea in 1952. Battye, Nightingale, and Whillis<a></a> at Guy's Hospital in London developed a myoelectric control system for a powered prosthesis in 1955 in what was for many years thought to be the first demonstration of this principle. That they were not first in no way detracts from their accomplishment. Soviet scientists were apparently the first to use transistors in a myoelectrically controlled prosthesis. The so-called Russian Hand<a></a> was the first semi-practical myo-electrical limb to be used clinically and was sold (although not widely used) on a license basis for application in Great Britain and in Canada. <h3>The Early Years (1945-1967)</h3> As far as the United States is concerned, the year 1945 was a turning point in prosthetics. In January 1945, military personnel, surgeons, prosthetists, and engineers met in Chicago (Thorne Hall, Northwestern University) to consider what should be done about limb prosthetics. This meeting is recognized as the beginning of the prosthetics research and development program by the U.S. government. This program ultimately resulted in the establishment of the Committee on Prosthetics Research and Development (CPRD) of the National Research Council which guided work in the field for over twenty-five years. The post-war years saw tremendous advances in limb prosthetics in general, although powered prosthesis development was slow. During the period 1946-1952, Alder-son, with the support of IBM and the Veterans Administration, developed several electric-powered limbs.<a></a> These IBM arms were impressive engineering achievements for the time, but they were somewhat difficult for amputees to use. The Vaduz hand, developed during the early post-war period, appears to have been a prosthesis ahead of its time and one that contained antecedents of today's electric hands. A German team headed by Dr. Edmund Wilms settled in Vaduz, Lichtenstein after World War II to continue their prosthetic hand development work. They wanted to create a hand controlled by the muscles of prehension, which would operate on a portable power source. The hand they created is shown in <a href="/files/original/603316446d9d314a4586a444cf9f0a22.jpg">Fig. 4</a>. It has been described by Wilms.<a></a> This hand had a gear shifting mechanism to enable it to obtain high gripping force from an electric motor while also having reasonable finger velocity. This is a principle used in current Otto Bock hands. The hand used a unique controller in which a pneumatic bag inside the socket detected muscle bulge through pneumatic pressure, which in turn operated a switch-activated position servomechanism to close the voluntary-closing electric hand. This principle foreshadows the concept of extended physiological proprioception (EPP) introduced by Simpson<a></a> (<a href="/files/original/18b9b43af4d8e97b8ba3e0f2828c3ef6.jpg">Fig. 5</a>). The complete system is shown in <a href="/files/original/105098f81ea7edb2a091dcd0415eed6a.jpg">Fig. 6</a>. <a href="/files/original/603316446d9d314a4586a444cf9f0a22.jpg">Figures 4a and 4b.</a> Two views of the mechanics of the Vaduz Hand. Note position and force feedback links that connect to the inner transducer. This connects to an outer transducer (a bladder) adjacent to the residual limb in the socket. This voluntary-closing hand was activated by muscle bulge. It operated as a position servomechanism. It contained a gear shifting mechanism and a current cut-off mechanism. From Bulletin of Prosthetics Research, BPR 10-6, 1966. <a href="/files/original/18b9b43af4d8e97b8ba3e0f2828c3ef6.jpg">Figure 5.</a> Diagram of control circuit for Vaduz Hand. Muscle bulge compresses the outer transducer, which causes expansion of the inner transducer, moving the spindle upward. This activates the switches that close the hand. A link with the output moves the switch assembly along so that the hand stops when the link movement corresponds with spindle movement. Force feedback opens the closing limit switch at some force level when the hand meets an object. This conserves battery power. From Bulletin of Prosthetics Research, BPR 10-6, 1966. <a href="/files/original/105098f81ea7edb2a091dcd0415eed6a.jpg">Figure 6.</a> View of complete Vaduz system. Note similarity of myoelectric systems. From Bulletin of Prosthetics Research, BPR 10-6, 1966. Lucaccini, Kaiser & Lyman<a></a> evaluated the Vaduz Hand. The center at the University of California at Los Angeles, under Lyman's direction, also evaluated the Alderson-IBM arm, the Heidelburg Pneumatic Prosthesis, and other externally powered systems, as well as conducting many control studies of their own. After 1953, the Vaduz Hand was marketed from Paris and consequently was sometimes called the French Hand. It apparently was difficult to keep in optimal mechanical adjustment, but it must be considered as one of the most important ancestors of today's electric hands, and a hand that contained many novel and intriguing concepts. It was available through the mid-sixties. The Russian Hand and Vaduz Hand were followed by an English Hand developed around 1965 by Bottomley.<a></a> This was the first myo-electrically controlled hand that exhibited proportional control (<a href="/files/original/dedd8fa68f49c7b3bcc8c3e82b8efa92.jpg">Fig. 7</a>). This prosthesis also contained several novel features for that period of time, such as internal force and velocity feedback and a unique myoelectric signal smoothing principle called "autogenic backlash," which produced a more or less consistent direct current (DC) output from the fluctuating myoelectric signal while not sacrificing time response. <a href="/files/original/dedd8fa68f49c7b3bcc8c3e82b8efa92.jpg">Figure 7.</a> View of myoelectric hand developed by Bottom-ley in England. Note the two external packages on the table, battery on left and electronics on right. This was the first myoelectrically controlled hand that had proportional control. From Science Journal article by R.N. Scott, March 1966. The Russian Hand (<a href="/files/original/e592dc5785c3e7b7ec28c9077eaa7fef.jpg">Fig. 8</a>), Vaduz Hand, and Bottomley Hand were single-function devices and non-adaptive. During the early 1960's Tomovic suggested an adaptive, multi-articulated hand with rudimentary sensory qualities. This resulted in the Belgrade Hand.<a></a> Although this hand was not used clinically to any great extent, it was used extensively in research laboratories and has had influence on robotic hand developments. In 1965, a Swedish research group began work on an electric hand which was adaptive and which had multiple functions (two types of grasp, wrist flexion-extension, and supination-pronation). This became known as the SVEN-Hand<a></a> (<a href="/files/original/a8cce387b55b45e6a667c49df89ae308.jpg">Fig. 9</a>). It also has been used extensively in research, particularly regarding multi-function control<a></a> and concepts employed in it are utilized today in Swedish developments. <a href="/files/original/e592dc5785c3e7b7ec28c9077eaa7fef.jpg">Figure 8.</a> Photograph of Russian Hand. This was the first myoelectric hand that was transistorized and portable (Circa 1959). The external battery pack is shown in the center of the photograph. The electronic package is beneath the battery. The battery charger is at left. Note the long electrode wires and the prosthesis suspension straps. From Science Journal article by R.N. Scott, March 1966. <a href="/files/original/a8cce387b55b45e6a667c49df89ae308.jpg">Figure 9.</a> Photograph of the SVEN-Hand. This was one of the first multifunctional, adaptive, myoelectrically controlled hand prostheses. Congenital amputations caused by the drug Thalidomide resulted in expanded interest in powered prostheses in the 1960's. Pneumatic systems by Otto Bock (hand, hooks, wrist rotators, and elbows) were fitted successfully, particularly in Germany by Marquardt,<a></a> to many children born without limbs. However, pneumatic systems never caught on well in the U.S. probably because of difficulties with the compressed gas. Cannisters of gas were expensive and difficult to maintain and distribute in the U.S. American laws also required steel cannisters, which added to weight. Pneumatic systems have low energy storage densities and this meant that multiple cannisters were required, particularly to supply the energy needs of adult prostheses. On the other hand, these systems have actuators that are light in weight, which are easily controlled, and which have natural compliance properties that keep them from being rigid. Electric power can be stored more cheaply, more safely, and with greater density than gas power. Also, the control possibilities made possible by electronic circuits have given electrical systems an advantage. Unfortunately, the actuators (electric motors and gear mechanisms) tend to be heavy and may result in prostheses that are noisy and naturally non-compliant. They also have zero efficiency when activated in the stalled condition. Some of the negative aspects of electrical actuators have been overcome electronically in today's powered prostheses. Electro-Hydraulic systems may be used in the future because they have the potential advantage of developing high torque in small actuators. However, cost factors for the special hydraulic mechanisms needed, along with technical problems, have restricted development work in this area thus far. Early work was conducted in Canada.<a></a> The Edinburgh arm has been converted to hydraulic power at a couple of centers in the U.K. Research work on multifunctional limb prostheses flourished in the United Kingdom during the 1960's and early 1970's. Most notable among the developments were the Hendon Arm<a></a> and the Edinburgh Arm.<a></a> Both were pneumatic, multi-functional limbs. Simpson used a position servomechanism control principle that he called extended physiological proprioception (EPP), a principle which enables control of multiple functions without excessive mental load on the user. This control technique has been shown to be a better information link between the body and prosthesis than "velocity" controllers.<a></a> The Edinburgh Arm, which was pneumatic, worked in spherical coordinates from the shoulder and was controlled by protraction-retraction and elevation-depression of the two shoulders. If the arm was fitted on the right side, then elevation of the right shoulder elevated the hand about the shoulder joint. Protraction of the right shoulder moved the hand more distant from the shoulder (in a radial direction). Protraction of the left shoulder moved the hand medially, and elevation of the left shoulder supinated the hand. The wrist was linked to the shoulder and elbow so as to maintain attitude of the hand during shoulder or elbow motion. This made it possible to hold a glass of water without worrying too much about spilling the contents during arm movements. Carlson<a></a> has called this kind of joint coupling, "kinematic coupling." Opening and closing the hand or terminal device of the arm was controlled by a switch through some other motion of the body. The arm was complex and difficult to keep functional on active children but the control was remarkable. Children operated its multiple functions naturally, without much training, and seemingly without too much mental load. <a href="/files/original/ca2b3ffb8c94001e703bdd917b139e04.jpg">Fig. 10</a> shows the mechanism. Less complex (and less functional) all-electric EPP-type controllers are now under study in the U.S. and Scotland. <a href="/files/original/ca2b3ffb8c94001e703bdd917b139e04.jpg">Figure 10.</a> Photograph of the mechanism of the Edinburgh Arm, developed by D.C. Simpson. This CO2-powered limb had four degrees of freedom (five if the terminal device was included) and kinematic coupling of the wrist to the elbow and the shoulder. It used spherical coordinates and was controlled by position servos that mechanically linked shoulder girdle position with prosthesis position. It is one of the most complete powered arms ever developed. Proceedings of meetings form an excellent historical record of powered prostheses. The first meeting of consequence in the U.S. concerning powered prostheses was held at Lake Arrowhead, California in 1960,<a></a> and was sponsored by the National Research Council. The second major meeting of this kind in the U.S. was held in Warrenton, Virginia in 1965<a></a> with considerable international input. Subsequently, the Committee on Prosthetics Research & Development (CPRD) held regular meetings related to applications of external power in limb prosthetics, and the reports of these meetings form a good record of U.S. activity in this field. Myoelectric control received a major boost in America through a 1966 symposium in Cleveland, Ohio (Case Western Reserve University) entitled "Myoelectric Control Systems and Electromyographic Kinesiology." Bottomley demonstrated his elegant myoelectric system at that meeting. The meeting was also attended by Professor Robert N. Scott of the University of New Brunswick. Scott headed a group that developed the first myoelectric control mechanism in North America.<a></a> A Yugoslavia-based conference, around 1963, called "External Control of Human Extremities" was followed by a similar conference in Dubrovnik, Yugoslavia and this international conference has been held there every third year since 1966. The Proceedings of the "Dubrovnik Conference," as it is often called, are a singular record of international developments in powered limb research and development since the early sixties. Three other symposia produced significant early publications. The symposium on "Basic Problems of Prehension, Movement and Control of Artificial Limbs"<a></a> organized in London in 1968 by the Institution of Mechanical Engineers contains a wealth of information on powered limbs. The "Dundee Conference" held in Dundee, Scotland in 1969 resulted in the book Prosthetic and Orthotic Practice.<a></a> It covers prosthetics generally but has a fair amount of material on powered prostheses. Finally, the Swedish conference of 1974<a></a> produced a book that concerned early research and development work on powered prostheses and orthoses. <h3>Growing Up (1967-1977)</h3> I have selected the decade of 1967-1977 as one of "growing up" because 1967 is about the time it became possible to purchase a powered prosthesis commercially in the United States, and it was approximately 1977 before powered upper-limb prostheses began to take on some real clinical significance (i.e. larger numbers of clients fitted). The Viennatone Hand was the first commercial system available in the U.S. This hand came about as a result of Otto Bock Orthopedic Industries, a German prosthetics company, and Viennatone, an Austrian hearing aid company with expertise in electronics. Shortly thereafter, Otto Bock developed their own myoelectric system and a new hand mechanism. The Viennatone and Otto Bock Hand mechanisms (both designed by Otto Bock) have been altered somewhat through the years, but their basic appearance and design principles remain essentially unchanged. In the early days of myoelectric control (e.g. 1968), the battery or battery and electronics had to be worn outside the prosthesis, usually in a chest pouch, on a clip at the waist, or on a band around the humeral section of the arm. The wires and connections required by this kind of configuration led to failures due to wire breakage. There was also electrical interference on occasion. In addition, the components outside the prosthesis were a nuisance to fit and to wear. In 1968, I was involved in fitting a college student with one of the first self-contained and self-suspended below-elbow prostheses.<a></a> The Viennatone Hand mechanism was used in conjunction with a myoelectric controller developed at Northwestern University. Self-containment and self-suspension are standard procedures for below-elbow prostheses today. The Veterans Administration Prosthetics Center (VAPC) modified the Viennatone Hand mechanism and packaged it with a modified version of the electronic system developed at Northwestern. The VAPC contracted for this system to be manufactured by Fidelity Electronics, Ltd. and this system was marketed for a period of time. An interesting electric powered hand of this period was the hand developed at the Army Medical and Biomechanical Research Laboratory.<a></a> This hand contained a "slip detector" in the thumb. The hand would grip to about 2 Lff at the finger tips. If the object to be held started to slip, the hand would automatically increase gripping force until slippage stopped. Schmidl<a></a> was actively fitting many upper-limb amputees with myoelectrically controlled, powered limbs during this period and he achieved clinical significance with powered limbs well before this happened in the U.S. His center in Italy was also involved early in fittings of multifunctional limbs. Three-state controllers are used to control electric elbow, electric wrist rotator and electric hand from three muscle electrode sites. The Italian group has been at the forefront of progress in the fitting of powered limbs. Engineers at Temple University-Moss Rehabilitation Hospital<a></a> were probably first to attempt multi-functional control of elbow, humeral rotation, and wrist using pattern recognition techniques on myoelectric signals from multiple muscle sites of the upper arm and shoulder. They had some laboratory success. Swedish scientists<a></a> did similar work to control multiple functions of the hand (rotation, flexion-extension, and prehension). The New Brunswick laboratory has played an active role in developing control methods for powered limbs in North America and is well known for three-state control design and development. They have also been active in research on sensory feedback<a></a> and the University of New Brunswick sensory feedback system is the only one available today, of which I am aware. Sensory feedback was examined by many research groups during the 1970's. I reviewed some of this work in an article appearing in the Annals of Biomedical Engineering.<a></a> In the late 1960's and 1970's much experimentation and development were engendered in the field of external electric power. The Japanese developed a myoelectric powered hand.<a></a> MIT scientists designed the Boston Arm,<a></a> the first myoelectrically controlled elbow. The Ontario Crippled Children's Centre (OCCC) Elbow, a switch-controlled electric elbow was also developed in the late sixties, and is still in use. A number of electric elbows, the Rancho Electric Elbow (from Rancho Los Amigos Hospital) the AMBRL Elbow (from the Army Medical and Biomechanical Research Laboratory), and the VAPC Elbow (from the VA Prosthetics Center) also made their appearance in this time period. The Boston Elbow, AMBRL Elbow, and Rancho Elbow were evaluated by the Committee on Prosthetics Research and Development (CPRD).<a></a> Subsequently, the Applied Physics Laboratory in association with Johns Hopkins University developed a powered unit<a></a> capable of pulling the cable of conventional cable-operated, body-powered prostheses. It could be controlled by other inputs, such as from skin motion sensors, which were used with several fittings for high-level arm amputees. The Boston Elbow was redesigned extensively to become the Liberty Mutual Powered Elbow,<a></a> available through Liberty Mutual Insurance Company. The Boston Elbow was also undoubtedly a stimulus to Jacobsen who did his graduate studies at MIT and who later developed the finely-crafted Utah Arm,<a></a> available through Motion Control, Inc. in Salt Lake City. Likewise this research at MIT influenced Hogan,<a></a> who today is developing an elbow in which elbow compliance is controlled by myoelectric signals. The VAPC elbow was manufactured by Fidelity Electronics and used to some extent by VA clients. It was controlled by the VAPC pull switch. The OCCC elbow (available through Electro-Limb in Toronto) has been a workhorse for many years. It, along with other elbows of its period, influenced Lembeck<a></a> in development of the NYU Elbow at New York University. This elbow is presently manufactured by the Hosmer Dorrance Corporation. The OCCC has been a leader in the fitting and development of powered limbs. It is interesting how influential children's prosthetics programs in Germany, Sweden, Britain, and Canada have been on the field of powered prostheses. This is partially the result of government sponsored research programs directed toward amputations caused by the drug Thalidomide. Besides the electric elbow, the Ontario group have made small electric hands available through Electro-Limb for many years and their new electric hand is the latest evolutionary result of their continuing development work in this area. Sorbye<a></a> in Sweden, pioneered the fitting of child amputees with myoelectric hands during the early 70's. His work stimulated the development of the Systemteknik Hand. His work also stimulated interest in the U.K. and an evaluation program there found myoelectric hand systems valuable for child amputees. This undoubtedly had an influence on the development of the Steeper child-sized hand. When Colin McLaurin was at Northwestern University in the early 1960's he developed a "feeder arm" for the Michigan Area Amputee Center (MAAC) in Grand Rapids, Michigan. It was a kinematically coupled limb, designed to enable children with bilateral amelia to eat. A single electric drive mechanism at the elbow moved the terminal device from plate to mouth in a mechanically predetermined fashion. Subsequently, McLaurin moved to OCCC and was responsible for many developments there. Later, Dr. Aitken of MAAC requested the Prosthetics Research Laboratory at Northwestern to re-design the "feeder arm." The Michigan Arm resulted, which was a simple arm with electric hook and electric elbow similar in shape and function to one of Simpson's early CO2 powered limbs. The electric terminal device for the Michigan Arm became commercially available through Hosmer Dorrance as the Michigan Hook. This was one of the first electric hooks to become commercially available. Of course CO2 powered hooks had been used for many years. Also, it should be noted that Bottomley<a></a> designed a unique CO2 powered hook in the 1960's that had many merits which were never exploited. The Michigan Hook was a stimulus for Lembeck at New York University to develop the Prosthesis Assist Device. Like the Michigan Hook and the earlier systems at Johns Hopkins, it pulls on a cable to open a voluntary-opening hook or hand against a resisting spring (e.g. rubber band). This form of electric power utilization in prostheses lacks control sophistication but has simplicity of design and operation. Electric-powered prosthetic hooks have generally been thought to be desirable, particularly by Americans in the prosthetics field. During the mid-seventies, the VAPC developed an electric hook.<a></a> A few years earlier, Northwestern had introduced the synergetic prehension concept and the Synergetic Hook.<a></a> The VA purchased 12 synergetic hooks and evaluated them on VA clients. However, only recently has there been interest in commercial development of this prehension device for interchangeable use with electric hands. Otto Bock developed the Greifer during the late 1970's. It is a novel prehension device that is interchangeable with the Otto Bock Hand. This device is valuable for persons engaged in heavy-duty activities. The commitment of Otto Bock Orthopaedic Industries, Inc. to the powered limb field cannot be overlooked in any historical review. Without availability of Otto Bock hands, wrist rotators, and electronic control systems, much research work in this field would have been stymied for lack of components. Of course, without available commercial components that were backed strongly by educational programs and literature, and by repair and maintenance, it would have been impossible for practicing prosthetists to serve their clients well. Needless to say, Otto Bock, through research, production, education, and product support has made an unparalleled contribution to development for almost a quarter century. <h3>The Present (1977-1984)</h3> The last seven years has been a period marked not by experimental powered fittings in a small number of research centers or elite institutions, but rather by the clinical use of powered limbs by prosthetists practicing all over the country. This "coming of age" was vividly evident at the education seminar entitled, "Current Clinical Concepts of Electrically Powered Upper-Limb Prostheses" in Chicago in September, 1984 and sponsored by the American Academy of Orthotists and Prosthetists. This seminar, convened within a few hundred yards of where prosthetics research was born in the U.S., was not a seminar of researchers or a seminar directed toward particular products or particular methods; it was a seminar of clinicians involved with powered-limb fittings. Undoubtedly, this meeting was a milestone in the history of powered prostheses in this country. An interesting aspect about this period has been the upsurge of clinical fittings of powered prostheses and the increase of commercially available powered components. At the same time, there seems to have been some reduction of research efforts in this area. It is an area that has received considerable attention over the last twenty-five years, and perhaps research is just gathering its breath for the next important push. Whatever the situation, the clinical results show that progress has been made. That this progress has been difficult and hard won with many setbacks, is an indication of the difficulty of the problem being addressed. Indeed, adequate replacement of the human hand and arm is one of the most difficult problems facing medical technology. <h3>Future Trends</h3> From a technical viewpoint there will probably be movement to smaller electronic systems that have extremely low quiescent power. This will enable small power sources to be used when they are coupled with highly efficient prehension devices. Consequently, it may be possible to fit myoelectrically controlled, electrically driven prehension devices to partial hand amputees. Availability of wrist function should make this kind of fitting very effective. This new possibility with technology, coupled with the new surgical reconstruction techniques for the hand, should open up many new possibilities for rehabilitation of partial hand amputees. There should be an increase in reliability and serviceability of powered limb systems. They will become more modular, as well as smaller and lighter. Electro-mechanical components will become more efficient and will have improved dynamic performance. That is, they will be faster and more responsive to the desires of the amputee. New prehension devices, interchangeable with hands and hooks, will be developed. Computer-based controllers will be used in artificial arms, particularly those for multifunctional control. The Utah Arm will probably be the first commercially available arm to contain a computer-based controller. Prosthetists will develop better suspension techniques that minimize or eliminate harnessing in powered limb fittings. They will also, through case studies, develop fitting principles that will enable the various components to be fitted components to be fitted effectively, used appropriately in combinations, and used creatively with body-power. I hope that new control strategies will become available which will enable arm amputees to use multifunctional prostheses without excessive mental load. When this may happen is difficult to predict. <h3>Summary</h3> I have attempted to put powered limb components available today into perspective from an historical viewpoint. None of the devices used today appeared "de novo." All have been influenced by historical events and concepts, the state of technology, and prosthetics practice. References: <ol> <li>Alderson, S.W., "The Electric Arm," Human Limbs and Their Substitutes, Eds. Klopsteg, P. and William, P., McGraw-Hill, 1954 (Reprinted by Hafner Press, 1969), Chapter 13.</li> <li>Almström, C, Herberts, P., and Caine, K., "Clinical Application Study of Multifunctional Prosthetic Hands," Report 2:77, Research Laboratory of Medical Electronics, Chalmers University of Technology, Göteborg, Sweden.</li> <li>Battye, C.K., Nightingale, A., and Whillis, J., "The Use of Myo-Electric Currents in the Operation of Prostheses," J. Bone & Joint Surg., 37B, pp. 506-510, 1955.</li> <li>Berger, N. and Huppert, C.V., "The Use of Electrical and Mechanical Muscular Forces for the Control of an Electrical Prosthesis," Amer. J. Occup. Ther., 6:110-14, 1952.</li> <li>Bottomley, A., "Myo-Electric Control of Powered Prostheses," J. Bone & Joint Surg., 47-B(3):411, 1965.</li> <li>Bottomley, A., "Design Considerations for a Prosthetic Prehension Device," Proc. of Intl. Symp. on External Control of Human Extremities, Dubrovnik 1966 (Published 1967), pp. 82-84.</li> <li>Bottomley, A., Kinnier Wilson, A.B., and Nightingale, A., "Muscle Substitutes and Myo-Electric Control," J. Brit. I.R.E., 26, pp. 439-448, 1963.</li> <li>Carlson, L.E., and Radcliffe, C.W., "A Multi-Mode Approach to Coordinated Prosthesis Control," Proc. of 4th Intl. Symp. on External Control of Human Extremities, pp. 185-186, Dubrovnik, 1972, (published 1973).</li> <li>Childress, D.S., "Closed-Loop Control in Prosthetic Systems: Historical Perspective," Annals of Biomed. Engr., Vol. 9, pp. 293-303, 1980.</li> <li>Childress, D.S., "Powered Limb Prostheses: Their Clinical Significance," IEEE Trans. Biomed. Engr., BME-20, No. 3, pp. 200-207, 1973.</li> <li>Childress, D.S., "An Approach to Powered Grasp," Proc. 4th Intl. Symp. on External Control of Human Extremities," pp. 159-167, Dubrovnik, 1972 (published 1973).</li> <li>Childress, D.S., and Billock, J.N., "Self-Containment and Self-Suspension of Externally Powered Prosthesis for the Forearm," Bull. Prosthetics Research, BPR 10-14, pp. 4-21, 1970.</li> <li>Dahlheim, W., Pressluft hand fur kreigsbeschädigte Industriearbeiter Z. komprimierte und flüssige Gase, German Patent (1915).</li> <li>Dorcas, D.S., and Scott, R.N., "A Three-State Myoelectric Control System," Med. Biol. Engr., Vol. 4, pp. 367-370, 1966.</li> <li>Doubler, J.A., and Childress, D.S., "Design and Evaluation of a Prosthesis Control System Based on the Concept of Extended Physiological Proprioception," J. of Rehab. Research and Development, 21:1, BPR 10-39, pp. 19-31, 1984.</li> <li>"Externally Powered Prosthetic Elbows-A Clinical Evaluation," Comm. on Prosthetics Research and Development (CPRD), Report E-4, National Academy of Sciences-National Research Council, 1970.</li> <li>Geddes, L.A., Moore, A.C., Spencer, W.A., and Hoff, H.E., "Electropneumatic Control of the McKibben Synthetic Muscle," Orthopaedic & Prosthetic Appliance J., 13, pp. 33-36, 1959.</li> <li>Herberts, P., Almström, C, Kadefors, R., and Lawrence, P., "Hand Prosthesis Control Via Myoelectric Patterns," Acta Orthopaedica Scandinavica, Vol. 44, pp. 389-409, 1973.</li> <li>Herberts, P., and Petersen, I., "Possibilities for Control of Powered Devices by Myoelectric Signals," Scand. J. Rehab. Med., 2:164-170, 1970.</li> <li>Hogan, N., Mechanical Impedance Control in Assistive Devices and Manipulators," Proc. of the Joint Automatic Controls Conf., San Francisco, Vol. 1, August, 1980.</li> <li>Jacobsen, S.C., Knutti, D.F., Johnson, R.T., and Sears, H.H., "Development of the Utah Arm," IEEE Trans. Biomed. Engr., BME-29, No. 4, pp. 249-269, 1982.</li> <li>Kato, I., et al., "Multifunctional Myoelectric Hand Prosthesis with Pressure Sensory Feedback System-WASEDA Hand-4P," Proc. 3rd Intl. Symp. on External Control of Human Extremities, pp. 155-170, Dubrovnik, 1969 (published 1970).</li> <li>Kessler, H.H., and Kiessling, E.A., "Pneumatic Arm Prosthesis," Am. J. Nursing, 65:6, 1965.</li> <li>Kobrinskii, A.E., Bolkhoivin, S.V., Voskoboini-kova, L.M., Joffe, D.M., Polyan, E.P., Slavictskü, Ya. L., Sysin, A. Ya., and Yakobsen, Ya, S., "Problems of Bioelectric Control," Proc. Intl. Fed. on Automatic Control Conf., pp. 1119-22, Moscow, 1960, (Butterworth, London, 1961).</li> <li>Lembeck, W., Personal Communication, 1984.</li> <li>Lucaccini, L.F., Kaiser, P.K., and Lyman, J., "The French Electric Hand: Some Observations and Conclusions," Bull. of Prosth. Research, BPR 10-6, pp. 30-51, 1966.</li> <li>Mann, R.W., "Cybernetic Limb Prosthesis," Annals of Biomed. Engr., Vol. 9, pp. 1-43, 1981.</li> <li>Marguardt, E., "The Heidelberg Pneumatic Arm Prosthesis," J. Bone & Joint Surg., 47-B:3, pp. 425-434, 1965.</li> <li>McWilliam, R., "Design of an Experimental Arm Prosthesis: Biological Aspects," The Basic Problems of Prehension, Movement and Control of Artificial Limbs, The Institution of Mechanical Engineers, Proc. 1968-69, Vol. 183, Part 3J, pp. 74-81, 1969.</li> <li>Montgomery, S.R., "Design of an Experimental Arm Prosthesis: Engineering Aspects," in The Basic Problems of Prehension, Movement and Control of Artificial Limbs, The Institution of Mechanical Engineer, Proc. 1968-69, Vol. 183, Part 3J, pp. 68-73, 1969.</li> <li>Prosthetic and Orthotic Practice, based on Dundee Conference of 1969, Ed. G. Murdoch, Edward Arnold Ltd., London, 1970.</li> <li>Rakic, M., "The Belgrade Hand Prosthesis," in The Basic Problems of Prehension, Movement and Control Artificial Limbs, The Institution of Mechanical Engineers, Proc. 1968-69, Vol. 183, Part 3J, pp. 60-67, 1969.</li> <li>Reiter, R., "Eine neue Electrokunsthand," Grenzgebiete der Medizin, 4:133, 1948.</li> <li>Salisbury, L.L., and Colman, A.B., "A Mechanical Hand with Automatic Proportional Control of Prehension," Med. Biol. Eng., Vol. 5, pp. 505-511, 1967.</li> <li>Schlesinger, G., "Der Mechanische aufbau der kunstlichen glieder," in Ersatzglieder und Arbeitshilfen, Borchardt, M., et al., Eds., J. Springer, Berlin, 1919.</li> <li>Schmidl, H., "The I.N.A.I.L. Experience Fitting Upper-Limb Dysmelia Patients with Myoelectric Control," Bull. of Prosthetics Research, BPR 10-27, pp. 17-42, 1977.</li> <li>Scott, R.N., Brittain, R.H., Caldwell, R.R., Cameron, A.B., and Dunfield, V.A., "Sensory Feedback System Compatible with Myoelectric Control," Med. & Biol. Eng. & Comp., Vol. 18, No. 1, pp. 65-69, 1980.</li> <li>Seamone, W., "Development and Evaluation of Externally Powered Upper-Limb Prosthesis," Bull. of Prosthetics Research, BPR 10-13, pp. 57-63, 1970.</li> <li>Simpson, D.C., "An Externally Powered Prosthesis for the Complete Arm," in The Basic Problems of Prehension, Movement and Control of Artificial Limbs, The Institution of Mechanical Engineers, Proc. 1968-69, Vol. 183, Part 3J, pp. 11-17, 1969.</li> <li>Sorbye, R., "Myoelectric Controlled Hand Prostheses in Children," Int. J. of Rehab. Research, Vol. 1, pp. 15-25, 1977.</li> <li>Spaeth, J. P., Handbook of Externally Powered Prostheses for the Upper Extremity Amputation, Charles C. Thomas, Springfield, 111., 1981.</li> <li>Stevenson, D.A., and Lippay, A.L., "Hydraulic Powered Arm Systems," in The Basic Problems of Prehension, Movement and Control of Artificial Limbs, The Institution of Mechanical Engineers, Proc. 1968-69, Vol. 183, Part 3J, pp. 37-44, 1969.</li> <li>"The Application of External Power in Prosthetics and Orthotics," Report of Conference at Lake Arrowhead, California, Publication 874, National Academy of Sciences, National Research Council, September, 1960.</li> <li>"The Basic Problems of Prehension, Movement and Control of Artificial Limbs," The Institution of Mechanical Engineers, Proc. 1968-69, Vol. 183, Part 3J, 1969.</li> <li>"The Control of External Power in Upper-Extremity Rehabilitation," Report of Conference held at Warrenton, Virginia, April, 1965, Publication 1352, National Academy of Sciences-National Research Council, 1966.</li> <li>"The Control of Upper-Extremity Prostheses and Orthoses," based on a conference held in Göteborg, Sweden, 1971, Charles C. Thomas, Springfield, Illinois, 1974.</li> <li>VAPC Research Report, Development (Components), Powered Hook developed by C. Mason, Bull. of Prosthetics Research, BPR 10-16, pp. 217-219, 1971.</li> <li>Williams, T.W., "Clinical Applications of the improved Boston Arm," Proc. Conf. on Energy Devices in Rehab., Boston (Tufts), 1976.</li> <li>Wilms, E., "Die Technik der Vaduzer Hand," Orthopädie Technik, 3, 7, 1951.</li> <li>Wilson, A.B., Jr., "Externally Powered Upper Prostheses," Newsletter . . . Prosthetics and Orthotics Clinic, Vol. 2, No. 1, pp. -4, 1978.</li> <li>Wirta, R.W., Taylor, D.R., and Finley, F.R., "Pattern-Recognition Arm Prosthesis: A Historical Perspective-A Final Report," Bull, of Prosthetics Research, BPR 10-31, pp. 8-35, 1978.</li> </ol> <div style="width: 400px;">*Dudley S. Childress, Ph.D. Dudley S. Childress, Ph.D. is Director of the Prosthetics Research Laboratory and Director of the Rehabilitation Engineering Program at Northwestern University, Room 1441, 345 East Superior Street, Chicago, Illinois 60611. </div> Page Number(s) 2 - 13 Year 1985 Volume 9 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-07.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 8 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1985_01_002/1985_01_002-10.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Historical Aspects of Powered Limb Prostheses Creator An entity primarily responsible for making the resource Dudley S. Childress, Ph.D. *