9 20 371 https://staging.drfop.org/files/original/75dc06cd0cb2f16f20c55049bd0bdbc7.pdf f76171ab4432c6a50cf6f259be7af891 https://staging.drfop.org/files/original/d81d51673f68ef5fe93f7930d455e5f8.jpg 7008a305e99a0abc591c52fc2411bb17 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_02_004.pdf Year 1954 Volume 1 Issue 2 Page Number(s) 4 - 7 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_02_004.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_02_004.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>The Objectives of the Lower-Extremity Prosthetics Program</h2> <h5>Howard D. Eberhart, M.S. <a style="text-decoration:none;">*</a><br /></h5> <p>Man depends upon his legs to support the body and to move it from place to place as occasion warrants. Since mobility is nearly indispensable to most human activities, the loss of part or all of a leg—through accident, war, or disease—imposes serious limitations and has always made a replacement of some sort more or less of a necessity. Accordingly, artificial legs of one kind or another have been made and used since the most ancient times. As a result of the long-continued effort, leg prostheses have undergone progressive, if slow, development through the centuries, so that many lower-extremity amputees have in the past been successfully restored to something resembling a normal life. With the advent of industrial development, and of improved tools and materials with which to work, the nineteenth century marked the appearance of many new lower-extremity devices and of new techniques in the medical treatment of amputations.</p> <p>Impetus provided by World Wars I and II gave rise to rapid advancement in all branches of technology and thus made possible a concerted attack on the problem of supplying the best possible artificial limbs. The term "lower-extremity prosthetics" has now come to mean the practice of rehabilitation of the leg amputee by providing him with an artificial limb that will restore lost functions to the greatest possible degree. But more than just the artificial leg is involved. The amputee himself is a most important part of the end-product, and amputees, like other people, are individuals with widely differing characteristics and abilities. Of course surgical procedures should be designed to secure a painless stump and to retain maximum function, and it would seem that the artificial leg, when properly fitted, should duplicate as closely as possible the normal activity of the lost part. Moreover, physical conditioning and gait training are both important phases of the whole rehabilitation process.</p> <p>This concept of lower-extremity prosthetics has developed during the years since the start in 1945 of the program of the Advisory Committee on Artificial Limbs, National Research Council. Initially, the primary objective was to develop improved devices, it being considered as obvious that, if a better prosthetic knee or ankle or foot could be devised, the amputee would benefit. Attempts to produce such items, however, made necessary the determination of functional requirements and thus immediately revealed the lack of necessary fundamental information. Basic research into the complicated phenomenon we call "locomotion" was therefore carried on simultaneously with the development of devices.<a style="text-decoration:none;">*</a> These investigations indicated a need for the application of basic mechanical principles to fitting and alignment of artificial legs. A three-pronged approach, all parts of which are complex and interrelated in various ways, has thus evolved. Basically, the three objectives are:</p> <ol> <li>To extend knowledge of the amputee, of lost and remaining functions affecting locomotion, and to collect information on the best possible medical treatment.</li><li>To improve fitting techniques and practices, including training, so that existing devices might be used with greater comfort and function.</li><li>To develop improved lower-extremity devices.</li></ol> <p>Relative emphasis on these three phases is shown in <b>Fig. 1</b>. Implied in such a program is the dissemination of information and techniques to those who serve the amputee. Many of the accomplishments to date are recorded, and fully documented with the report literature, in Klopsteg and Wilson's <i>Human Limbs and Their Substitutes </i>(McGraw-Hill, in press). In addition, various seminars and short courses for surgeons and prosthetists have been conducted throughout the program.</p> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <p class="clsTextCaption"><br /> Fig. 1. Trends in the lower-extremity prosthetics program, 1945-54, projected through 1956 </p> </td> </tr> </tbody></table> </td> </tr> </tbody></table><br /> <h3>Fundamental Studies</h3> <p>Detailed and comprehensive study of normal human locomotion is the basic key to improvement in all phases of the lower-extremity problem. Walking is to all appearances so natural and simple a process that it is difficult to conceive of its complexity. A knowledge of the behavior and the contribution of each anatomical part in providing the many services required of legs in normal use is essential to determine the functions that have been lost through amputation and the functions that still remain. The surgeon needs such information in order to provide the best amputation stump with maximum remaining function. The prosthetist must understand the limitations and potentialities of the amputee-prosthesis combination for optimum fitting, alignment, and adjustment. The designer needs detailed information on angles, displacements, velocities, accelerations, forces, energy requirements, and functions in order to improve existing devices and to develop new ones. And finally, the amputee himself has problems that require a fundamental approach. Causes and treatment of phantom or other pain, circulatory difficulties resulting from amputation, skin tolerance to pressure in areas never intended for such use, as well as the better understanding of the psychological problems of the amputee are examples of important areas of investigation.</p> <p>The objectives of the program of fundamental studies of the lower extremity may be summarized as:</p> <ol> <li>To study the phenomenon of locomotion in a sample of normal individuals and to analyze the results for use by the surgeon, the designer, and the prosthetist.</li><li>To develop design criteria for new or improved devices and as a basis for evaluating existing devices.</li><li>To develop an understanding of the compensatory mechanism of the human body and its ability to adapt itself to overcome functional deficiencies of its parts.</li><li>To provide a frame of reference for evaluating the degree of success obtained in replacing lost functions by means of an artificial leg.</li><li>To obtain information on the cause and possible treatment of phantom pain and other medical problems of the amputee.<a style="text-decoration:none;">*</a></li></ol> <h3>Development of Techniques of Fitting and Alignment</h3> <p>It appears obvious that, no matter to what degree an artificial leg is perfected mechanically, its effectiveness will depend upon the comfort afforded the wearer. Comfort is a function of the fit and alignment of the prosthesis.</p> <p>Although the artificial-limb industry has, through the years, developed reasonably successful techniques for fitting and aligning artificial legs, the results have been obtained mostly by trial-and-error methods; seldom have basic mechanical and anatomical principles been employed. It was found, for instance, that even among the most successful prosthetists there existed little agreement as to what constituted a satisfactory fit. For these reasons it appeared necessary to include in the lower-extremity program a project to develop fitting and alignment techniques based on sound scientific principles and to include, if necessary, the development of auxiliary tools and a study of materials and of methods of suspension.</p> <p>The study was launched with the following objectives in mind:</p> <ol> <li>To learn from the artificial-limb industry the procedures used in fitting and alignment of artificial legs.</li><li>To work with the industry in applying fundamental principles to the problem of fit and alignment and to formulate the guiding principles involved.</li><li>To develop mechanical aids to improve fit and alignment and to serve as tools to simplify shop operations.</li><li>To investigate and evaluate types of suspension as well as materials and methods used in socket fabrication.</li><li>To develop simplified methods of evaluating the amputee-limb combination-to be used as a check by the prosthetist, the surgeon, and the physiotherapist.</li><li>To improve methods of training the lower-extremity amputee in order to get better functional and more effective use of his prosthesis.</li></ol> <p>Out of this study have come such developments as the introduction of the above-knee suction socket and the University of California adjustable legs and alignment duplication jig. The study of fitting and alignment continues at the University of California, Berkeley Campus.</p> <h3>Development of Prosthetic Devices</h3> <p>New and improved devices have always been a major objective of the ACAL program. Great effort has been expended in this direction, often without the necessary or valid criteria. Although engineering designs can be made to accomplish nearly any specified function, the end result of any given design may be unsatisfactory if the specifications were unrealistic. The device may be too complicated, too heavy, uneconomical for the improvements obtained—or it may actually interfere with some service functions though improving others. Since the beginning of the ACAL research program, a number of outstanding industrial firms have engaged in development of devices. As a result of these activities, a great deal has been learned about what is possible—and about what <i>not </i>to do. Together with the fundamental studies, a body of knowledge has been developed to provide a realistic approach to design criteria. A number of devices based on this information are now in the development stage; they show promise for the future.</p> <p>Criteria for improved knee joints for above-knee amputees have undergone great changes as fundamental knowledge of locomotion has increased and as various knees, alleged to be improved ones, have been tested on amputees. Similarly, dependence of knee performance on ankle function, fit and alignment, training, and total coordination is becoming better understood. In the light of present knowledge, it seems clear that "super-devices" are not apt to be the solution to improved artificial legs and that considerations of natural appearance, minimum energy consumption, and simplicity of mechanism for maintenance and economy will in the end be the controlling factors. Of course no device should be made available for general distribution until it has been checked thoroughly for function, strength, maintenance requirements, life expectancy, and adaptability to different types of amputees. A complete testing program has there- fore been established under the direction of New York University to ensure the adequacy of each device approved under the program.</p> <p>Present objectives for the development of prosthetic devices may be stated as:</p> <ol> <li>To invent new mechanisms, improve and adapt existing mechanisms, and apply new materials so as to add functions, or to improve presently provided functions of prostheses, seeking in the end to provide better devices to meet the needs of every amputee type.</li><li>To perfect those functions involved in level walking, with the best possible solution for oilier services such as sitting down, walking on slopes and stairs, etc.</li><li>To adapt devices that take advantage of remaining functions in the amputee's stump.</li><li>To increase stability during the weight-bearing phase but to reduce the energy requirement during transition as well as during the entire cycle of walking.</li></ol> <h3>Clinical Study</h3> <p>Throughout the program, amputees have been fitted with experimental prostheses in order to conduct studies, trials, and tests of the equipment. Techniques and practices involved in fitting amputees are so varied, however, that some orderly means of investigating these areas became necessary. Accordingly, in 1952 a program of clinical studies was established under the project at the University of California, Berkeley, in space at the Artificial Limb Shop of the U. S. Naval Hospital at Oakland, California. Here an orderly approach can be made to a review and formulation of best practice in lower-extremity prescription, fabrication, fitting and alignment, and training in the use of the prosthesis. Complete documentation of each step in the process, as applied to a variety of amputee types, under the supervision of an advisory panel and with the cooperation of members of the limb industry in the San Francisco Bay-Area, will serve to close the gap between fundamental work in the laboratory and practice in the field. Besides this, it will serve to supply source material for the information of the various professions involved in physical rehabilitation of the amputee as well as to define areas where more information or new devices are required.</p> <p>In addition to establishing what is the best prosthetic practice, the objective of the clinical study is to develop, for distribution to each member of the rehabilitation team, including the amputee, information such as:</p> <ol> <li>Medical data for use by the surgeon in connection with amputee problems.</li><li>Criteria for use in proper prescription of a prosthesis.</li><li>Principles and practices of fabrication, fitting, and alignment of a prosthesis.</li><li>Suggested means of evaluating prosthesis and amputee, Including gait analysis, performance checks, and achievement tests for use by the prosthetist, the surgeon, and the physical therapist.</li><li>Suggested curriculum for training the amputee in the use of his prosthesis.</li><li>A comprehensive list of specific prosthetic appliances and devices, with descriptions of their individual characteristics and functions, for use in preparing prescriptions.</li><li>Suggested curriculum for training the prosthetist, the surgeon, and other members of the clinic team in lower-extremity prosthetics.</li><li>Data useful to the research and development laboratories in continuing their studies.</li></ol> <h3>Future Program</h3> <p>The investigation and development involved in a lower-extremity prosthetics program are complicated and time-consuming. And since it appears impossible to reach the ultimate goal of replacement of all functions that have been lost, the task must be considered as never-ending. For the immediate future it is contemplated that development of devices, the clinical study, fitting and alignment studies, and fundamental research will continue. The relative emphasis on each phase is projected on <b>Fig. 1</b> through 1956.</p> <p>As progress is reflected in the results of the clinical study, some means must be developed for effectively transmitting this information to orthopedic clinic teams throughout the nation. Whether this is to be accomplished periodically at a central location, or whether through field teams on a continuing basis, will depend to a large extent upon the results obtained in the clinical study during the coming year. Whatever method evolves, every effort will be made to ensure that any useful information is disseminated to the field as quickly and efficiently as possible.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">It should be noted that the work on phantom pain is applicable to both upper- and lower-extremity amputations.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Footnote</b></td></tr><tr><td class="clsTextSmall">A more logical and systematic approach, had there been sufficient time, might have been to postpone device development until the results of the basic work became available. But the urgency of amputee demands at the end of World War II made such an approach less desirable than the one adopted.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div><div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Howard D. Eberhart, M.S. </b></td></tr><tr><td class="clsTextSmall">Professor of Civil Engineering, University of California, Berkeley; member, Advisory Committee on Artificial Limbs, National Research Council; chairman, Lower-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Figure 1 http://www.oandplibrary.org/al/images/1954_02_004/May-1954OCRBatch1-1.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 Objectives of the Lower-Extremity Prosthetics Program Creator An entity primarily responsible for making the resource Howard D. Eberhart, M.S. * https://staging.drfop.org/files/original/708fa372e3aa806c06ea2cec87c6d54d.pdf 9a1fac5f9d62e7f6b1c6180a01f964f8 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_01_001.pdf Year 1954 Volume 1 Issue 1 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_01_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_01_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Artificial Limbs-Today and Tomorrow</h2> <h5>F. S. Strong, Jr. <a style="text-decoration:none;">*</a><br /></h5> <p>Ours is an age of scientific research and development in almost every field of human interest. Some work to make man live longer, to make him more comfortable, more mobile, more informed. Some devise ways to maim or destroy him. This report and others to follow will tell the story of those who strive to replace what war, accident, or disease have removed, or what nature simply failed to provide. This is concerned with what modern science and engineering skill can do today-and what may be expected in the future-for the person in need of a substitute for normally standard equipment-an artificial limb for a missing arm or leg.</p> <p>From the dawn of history men have contrived replacements for lost extremities, particularly the lower. The loss of an arm, while causing inconvenience, has not resulted generally in serious handicap. But without a leg, a man becomes immobilized. Thus, over the years there has come about a considerable development until today some of the better types of artificial legs afford reasonably satisfactory service, always provided they are well fitted and aligned by qualified prosthetists. The same has not been true of upper-extremity devices. And so when young men returned from World War II with missing limbs, while the lower-extremity amputee could expect a replacement of some merit, the man who needed an arm was definitely in trouble. As a matter of fact, the entire field of artificial limbs needed serious attention to bring amputee service more in line with the scientific and engineering progress which has become synonymous with America in the modern world.</p> <p>To meet this need, not only for the benefit of veteran amputees, but also to help all similarly handicapped individuals everywhere, a program was established at the end of the war under the sponsorship of the Armed Services and the Veterans Administration and was later implemented on a permanent basis by the Eightieth Congress through Public Law 729. This act authorizes the expenditure of $1,000,000 annually "to aid in the development of improved prosthetic appliances ..." and designates the Veterans Administration as the appropriate agency for the administration of the funds thus made available.</p> <p>The activities encompassed within the framework of these endeavors have come to be known as the Artificial Limb Program. And since the field, though serving less than a million persons, of whom only some 27,000 are veterans, involves the cooperation of several scientific disciplines as well as various organizations both civil and military, a special structure had to be contrived for successful operation. This was done through a contract between the Veterans Administration and the National Academy of Sciences, by means of which an Advisory Committee on Artificial Limbs of the National Research Council has been established for general supervision and coordination, and through other contracts between the Veterans Administration and various educational and industrial organizations for research and development. In addition the Surgeons-General of the Army, Navy, and Air Force, and the Chief Medical Director of the Veterans Administration, have made available the services of certain laboratories and personnel in further support of the over-all program. While in the early stages of this undertaking, it was necessary to proceed generally on a broad front in order to explore and define the complete problem so that at one time as many as sixteen contracts were in force, at present the number has been reduced to three only, and an operational structure has been evolved through which a long-range plan can be followed with reasonable hope of success</p> <p>The word "prosthetics" has been found a convenient term to define the general field of amputee service. Since the problems of replacement in the lower extremity are quite different from those in the upper, the field is divided into two parts. Lower-extremity research and development are centered at the University of California, Berkeley Campus, while upper-extremity studies are similarly covered at the University of California at Los Angeles, all under a contract between the Veterans Administration and the University. Assisting in lower extremities is the Oakland Naval Hospital Artificial Limb Department while the Army Prosthetics Research Laboratory at Walter Reed Army Medical Center cooperates in the development of artificial arms and terminal devices Finally, through a contract with New York University, and with the cooperation of the VA Prosthetic Testing and Development Laboratory in New York well-defined methods of testing and field application assure that devices and techniques developed under the program are, before acceptance, in fact useful improvements in amputee rehabilitation.</p> <p>For general technical guidance in these two branches, standing committees, in lower- and upper-extremity prosthetics respectively, have been constituted, each composed of specialists in the fields of medicine, engineering, prosthetics, and the like, and each under the chairmanship of the leader of the appropriate University of California research project. These groups meet annually, or more frequently if necessary, to review progress, define requirements, and recommend action to the Advisory Committee on Artificial Limbs, to the artificial-limb industry, or to others interested in amputee rehabilitation problems. In addition smaller research and development panels have been appointed from these technical committees to supervise current activities between meetings of the larger groups. In this work, definite transition procedures have been adopted for orderly progress from the inception of ideas for improved devices and techniques to their final application in the limbshop or rehabilitation clinic.</p> <p>By these methods the results of some eight years of research and development are now being channeled as directly as practicable to the service of amputees, rather than indirectly merely through the issuance of reports or through publication in scientific journals. In order that physicians, prosthetists, rehabilitation specialists, insurance carriers, and other interested individuals and organizations may be informed of advances in this field as promptly as possible, this series of reports is being undertaken. While the Advisory Committee on Artificial Limbs has previously issued monthly progress reports on a limited basis to those immediately concerned, and although the various contractors and governmental laboratories associated with the program have contributed reports and other data on specific subjects, this will be the first organized attempt to disseminate timely information to a broad list of individuals and institutions interested in the rehabilitation of the amputee. This is being done in furtherance of the intent of the Congress which, in Public Law 729, authorizes the Administrator of Veterans' Affairs "to make available the results of his investigations to private or public institutions or agencies and to individuals in order that the unique investigative materials and research data in the possession of the Government may result in improved prosthetic appliances for all disabled persons."</p> <p>In offering these reports to the reader who has not been in a position to follow recent progress in this field as unfolded through the Artificial Limb Program it can be stated that the views and information to be set forth in this and Subsequent issues are the result of long and objective study by specialists in the various branches of science and engineering involved. These findings, therefore, can be accepted with considerable confidence as indications not only of the present state of the art but also as to future trends And where these findings may appear at variance with previous traditional concepts or the writings of earlier authorities, it can be said simply that the field of prosthetics is even today largely uncharted and untraversed-that it is a field where the marvels of modern science and engineering have yet to leave their mark.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>F. S. Strong, Jr. </b></td></tr><tr><td class="clsTextSmall">Executive Director, Advisory Committee on Artificial Limbs, National Research Council.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Artificial Limbs-Today and Tomorrow Creator An entity primarily responsible for making the resource F. S. Strong, Jr. * https://staging.drfop.org/files/original/30b4b4710a8911bc0aea77a638feabd8.pdf d94353f2854ff602c0f9346f778e7e3d https://staging.drfop.org/files/original/ff9bbaad1957b97f9dbdb9a80193dba9.jpeg fafe36c6b4d258417e6f680dddb9b70e https://staging.drfop.org/files/original/571e595fe827f4f47a6bcb256a5c41d3.jpg 293e8f412cb4574591640035f63316e5 https://staging.drfop.org/files/original/6cf829e905f2e447ba594e3384850a62.jpg 4550835e4a6000c414e01462ccfa5217 https://staging.drfop.org/files/original/add90ab6d50a34714b20dca5c661b095.jpg f6b8c5082ce320e83340172ce97d6143 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1979_01_001.pdf Text Any textual data included in the document <h2>Instep Strap</h2> <h5>Richard Rosenberger&nbsp;<a style="text-decoration: none;">*</a><br />Charles H. Pritham <a style="text-decoration: none;">*</a></h5> <p>Ankle-foot orthoses are prescribed for a variety of reasons, but chief among them is the control of undesirable positions of deformities, the most common being equino-varus. Gravity alone will cause the ankle-foot complex to adopt the equino varus position, but spasticity or contracture of the triceps surae can only complicate the situation.</p> <p>A conventional metal ankle-foot orthosis, with either a single or double uprights, can be effective in combating this deforming position, but success depends on proper construction and application of the orthosis. While in most instances the shoe is strong enough, in the presence of severe spasticity it is necessary to reinforce the shank of the shoe lest it break down at the anterior edge of the tongue and thus allow the shoe and foot to adopt a position of equinus. To properly control the foot the shoe should fit snugly when laced up. This latter point can be difficult to achieve and it is not uncommon to find that the heel has ridden up in the shoe. It may be necessary to prescribe a high-top surgical boot with undesirable economic and cosmetic side effects that weigh against use of the orthosis, as does the stipulation, when necessary, that the orthosis be worn at night. It is unconventional, uncomfortable, inconvenient, and unsanitary to wear shoes to bed.</p> <p>The situation with unmodified plastic ankle-foot orthoses is much the same, although it is somewhat easier to apply the orthosis properly than is the case with the shoe. For this reason it has proven popular to modify the basic orthosis by the addition of straps in various configurations. The attraction of this course of action should be obvious. First it makes it possible to don the orthosis and maintain the desired position without a shoe, and thus eliminates the need for expensive high-top surgical boots and it is practical to wear the orthosis in bed. The clear view afforded by these orthoses (as well as the translucency of polypropylene when used) and the strap makes it easy to secure the foot in the proper position before donning the shoe, which obscures the view. Moreover, the use of an instep strap makes the selection of a proper shoe even less critical than it is with the unmodified ankle-foot orthosis. While selection of proper heel height is unaffected, the instep strap allows the use of loose floppy shoes and slippers. This can be important for people who must get up at night or who desire to use the orthosis at poolside.</p> <p>In the hospital the use of an orthosis modified by an instep strap allows ambulation to proceed with an ordinary bedroom slipper while a proper shoe is being obtained. Frequently, delays can be encountered in obtaining shoes, with needless extension of the hospital stay.</p> <p>What is less clearly appreciated is the proper positioning of the strap. For our purposes in this instance the shin-foot complex can be considered as two arms, the tibia and the foot, set at right angles to each other and articulating at the ankle. In combating equinus the orthosis imposes two anteriorly directed forces, one at the top edge of the orthosis, and the other at the metatarsal heads. If unopposed by an anterior third point the leg will ride up in the orthosis, pivoting about these two points with the ankle moving forward. In effect, the leg bowstrings about the two most extreme points. To be maximally effective and comfortable the third force should be as far as possible from the two end points so as to develop the maximum resistance with the minimum force and thus minimum pressure under the strap. In the ordinary course of events this third force is provided by the lace closure of the shoe over the oblique instep of the foot. Since this surface is oblique the force provided normal to this surface can be resolved into two right-angle forces, each of which opposes one of the two anteriorly directed forces of the orthosis. If an accessory strap is added in this bony area it is likely to prove uncomfortable owing to the relatively small area underneath it and the fact that it is positioned too far distally to oppose the anterior motion of the tibia with minimum force. Moreover, if a shoe is worn over it the additional bulk in the shoe is likely to prove undesirable. Conversely, if the strap is added proximal to the malleoli it will be in good position to control the tibia but inadequate to affect the foot.</p> <p>Unless opposed by a second strap or the shoe, equinus is likely to occur and since anterior motion of the tibia is prevented all the motion is likely to occur in a proximal direction with the malleoli riding up and shear taking place under the strap.</p> <p>Following the foregoing analysis then, it seems logical to locate the strap at the deepest point of the radius connecting the oblique dorsal surface of the foot and the vertical tibia, roughly equidistant to the ankle mortice and the subtalar joint. In this position the instep strap is as far as possible from each of the two end points, well positioned to control motion in each segment, and free of the lace area of the standard low-quarter shoe. Instep straps have been used in this configuration a number of years now and, contrary to expectations, irritation under the strap in this relatively unpadded area has not been a problem. This can be attributed, in part, to the fact that the strap is well placed to develop maximum torque with minimum pressure. It is, of course, possible to pad the strap if so desired.</p> <h3>Method</h3> <p>Two methods of adding the strap have proven successful. In one the strap and a narrow loop are riveted to the orthosis on either side along the intended line of force. In the second two slots are cut in the material of the orthosis if the orthosis extends far enough anteriorly to permit it. One end of a Velcro strap is passed through one of the slots and sewn back on to itself. The free end of the strap can then be passed through the other slot and placed back on itself to secure the orthosis. In each case a flexible tape measure can be used to measure the proper length of strap and to plan the proper points of attachment (<b>Fig. 1</b>, <b>Fig. 2</b>, <b>Fig. 3</b>, and <b>Fig. 4</b>). This procedure can be done either over the positive model or the involved extremity itself and a strap can be added at any time.<br /><br /><strong><a href="/files/original/ff9bbaad1957b97f9dbdb9a80193dba9.jpeg">Fig. 1</a>. A tape measure is used to locate the position of the rivet hole for attaching the Velcro strap. This can be done on the patient or around the positive model.</strong></p> <strong><a href="/files/original/571e595fe827f4f47a6bcb256a5c41d3.jpg">Fig. 2</a>. Similarly, a tape measure is used to plan the location of the slots to be cut in the orthosis.</strong><br /><br /><strong><a href="/files/original/6cf829e905f2e447ba594e3384850a62.jpg">Fig. 3</a>. Appearance of the Velcro strap and metal loop once they are riveted to the orthosis. Normally, of course, the patient would be wearing a stocking. The metal loop should be located further posterior so as not to impinge on flesh.<br /><br /><a href="/files/original/add90ab6d50a34714b20dca5c661b095.jpg">Fig. 4</a>. The Velcro strap attached to an orthosis through slots cut in the orthosis. Excess material has been cut away from around the slots to present a neat and finished trimline.<br /></strong><br /> <h3>Summary</h3> <p>A rationale for the use of an accessory strap to control equino-varus in an orthosis without the shoe is given. Some thoughts about its placement and descriptions of two methods of attachment are also given.<br /><em><b><br />Charles H. Pritham&nbsp;<br /></b></em><em>Director, Orthotics and Prosthetics Rehabilitation Engineering Center, Moss Rehabilitation Hospital, Philadelphia, Pennsylvania<b><br /><br />Richard Rosenberger <br /></b>Director, Prosthetics and Orthotics Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia<b><br /></b><br /></em></p> Page Number(s) 1 - 3 Year 1979 Volume 3 Issue 1 Figure 2 http://www.oandplibrary.org/cpo/images/1979_01_001/1979_01_001-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1979_01_001/1979_01_001-3.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/1979_01_001/1979_01_001-4.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1979_01_001/1979_01_001-1.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 Instep Strap Creator An entity primarily responsible for making the resource Richard Rosenberger * Charles H. Pritham * https://staging.drfop.org/files/original/2004b9922067489189c4d3ae92485e41.pdf b5adf4cefb2c7793eaa0d0c236efe080 DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout http://www.oandplibrary.org/al/pdf/1954_02_001.pdf Year 1954 Volume 1 Issue 2 Page Number(s) 1 - 3 Text Any textual data included in the document <table><tbody><tr><td> <table> <tbody><tr> <td> <table> <tbody><tr> <td> <table> <tbody><tr> <td><a href="al/pdf/1954_02_001.pdf"></a></td> <td></td> <td><p><b><a href="al/pdf/1954_02_001.pdf">View as PDF</a></b></p></td> </tr> <tr> <td><p class="clsTextSmall">with original layout</p></td> </tr> </tbody></table> </td> </tr> </tbody></table> </td> </tr> </tbody></table> </td></tr></tbody></table> <h2>Limbs in Limbo</h2> <h5>Herbert Elftman, Ph.D. <a style="text-decoration:none;">*</a><br /></h5> <p>To stand on his feet and to walk with his legs wherever his heart desires are natural rights guaranteed to man by his own constitution. Heads may plan and hands may build, but only where legs and feet have brought them. Loss of the lower limb is therefore a major catastrophe.</p> <p>When loss of leg occurs, replacement becomes the primary hope. Ages past, an unknown man hobbled forth from his cave in search of a willow; with one of its limbs adopted as his own, he walked back with majesty. Since then the stage of history has resounded with the staccato echo of countless amputees marching with peg-leg, grit, and gumption.</p> <p>Rapid perfection of limb construction was to be anticipated after these early ventures had focused human ingenuity upon the problem. To the superlative talent which mankind has shown in the production of machinery both intricate and sturdy, the building of a mechanical leg would appear to offer little difficulty. Why is it, then, that artificial limbs have so generally belonged to the limbo of things undeserving either of unstinted praise or of utter condemnation? Failure of artificial legs to satisfy our hopes results less from the imperfection of their mechanisms than from the extravagance of our expectations. People who do not expect a glass eye to see or a prosthetic hand to play the piccolo are disappointed when an artificial leg squeaks while dancing the polka. Man has never commanded clear appreciation of his means of locomotion. From time to time he has been ecstatic about the eye and the liver, the heart, the brain, the hand. Legs have been referred to most frequently as symbols of neighboring functions, so lightly have their own merits been regarded.</p> <p>Why is the performance of the lower extremity so much less spectacular than that of the upper? Independence of the upper limb from obligation to the rest of the body allows it to indulge in ornamentation of movement, so impressive to the eye. The lower limb, sandwiched between the ground and the torso, must ever be responsive to the needs of the body as a whole. It cannot choose to support some parts of the body and not others or to walk with the body through only portions of each step. The intricacy of function of knee and ankle does not exhibit itself in capricious movements but excels when it modulates countless disturbing factors so that no tremor mars the stark simplicity of normal locomotion.</p> <p>No one can rightly expect an artificial limb to take over completely the functions of its predecessor unless it is endowed with an equivalent of muscular and nervous control. Difficult as it is to provide substitutes for bones and joints, such provision is simplicity itself compared with the incorporation within the prosthesis of its own control. Although considerable progress has been made in the field of decelerating mechanisms for lower-extremity prostheses, the leg amputee must still use his own resources when he needs to supply energy or to exercise discretion.</p> <p>The contribution which the amputee makes to the over-all prosthetic result far exceeds that of acting as a model for exhibiting the achievements of inventors. It is he who must finish creation of the new locomotor mechanism by reshaping the pattern of his muscular activity and establishing alertness to new sensory cues. The success of the artificial leg depends on how thoroughly it becomes a part of the form and the function of the amputee after he has blended its metal, wood, and plastic with his muscle and perception. It is only appropriate that the new mechanism, having superseded the natural limb, should contribute to amputee gait that special accent which identifies the supernatural walk.</p> <p>The complexity of human motion makes it inevitable that fundamental improvement in leg prostheses must come slowly, since it is based on factors so numerous that no one individual can comprehend them all. In addition to the profession of engineering, there is needed the cooperation of the physician, the physicist, the physiologist, the physiotherapist, the prosthetist, and the psychologist-to list them in alphabetical order—so that the patient may get the total care he deserves.</p> <p>The problems which need attention are of different degrees of complexity and must be approached by different methods. Choice of materials, details of construction, and provisions for repair require less consideration of the over-all characteristics expected in the rehabilitated amputee than do problems of fit and socket shape. More general considerations must be weighed in projects concerned with alignment, basic design of mechanisms, and evaluation of performance. For these there should be a conscious choice of a realizable objective, the attainment of which requires integration of man and machine into a functional unit.</p> <p>All of these are practical problems amenable to increasingly useful solutions year by year, provided we do not surrender to the impatience of those who must have the answer to the question of the century today and of the millennium tomorrow. It is necessary to preserve clear vision of long-term objectives, although some members of every team find the environment more familiar when details arise.</p> <p>Had trial-and-error and serendipity been able to produce truly satisfactory lower limbs, we would not still be waiting for such. It was left for the National Academy of Sciences-National Research Council to initiate the development of artificial limbs on a modern basis by creating the Committee on Prosthetic Devices and, later, its successor, the Advisory Committee on Artificial Limbs. By carefully balancing the fundamental and the practical in their program, these Committees have laid a firm basis for some progress today, much more tomorrow.</p> <p>This is the key to the future in lower-extremity prosthetics. Used wisely, it will allow us eventually to rescue the limb problem from limbo and to provide the amputee of the future with a fitting legacy.</p> <br /> <div style="width:400px;"><table style="background:#003399;"><tbody><tr><td><table><tbody><tr><td style="text-align:left;padding:3px;"><table><tbody><tr><td class="clsTextSmall" style="border-bottom:1px #666666 solid;"><b>Herbert Elftman, Ph.D. </b></td></tr><tr><td class="clsTextSmall">Associate Professor of Anatomy, College of Physicians and Surgeons, Columbia University; member, Lower-Extremity Technical Committee, ACAL, NRC.</td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></div> Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Limbs in Limbo Creator An entity primarily responsible for making the resource Herbert Elftman, Ph.D. * https://staging.drfop.org/files/original/ae05e878bd64c3dbd3b2584c3a8af1c3.pdf 908af03ad8cb34c07750c64b92d97c44 https://staging.drfop.org/files/original/eff05f3ff73679cc3aa9f244a0b01ee1.jpeg edfa643666b367de3ccf1505947074ee https://staging.drfop.org/files/original/45c3082ce4cd40c92baa03e02c966b83.jpg 673473bd1e41e590c4e9c60e9599e2fc https://staging.drfop.org/files/original/6e9b5d4a5957258a4958635acfc8fbda.jpg 682e526dd8cd44af055581f51d3543b0 https://staging.drfop.org/files/original/29254ec4552c6b302e11d7249167147b.jpg 5872069631752d0d3d9eb1f39bd37b76 https://staging.drfop.org/files/original/be009fdace4d2d0fce8a7757ab25edf7.jpg fc1c45950fcf019e826c6035112ac38e https://staging.drfop.org/files/original/a8017df2f33ae779bbc361ad9d87e7ee.jpg f72d46285c6e66bf702f8dc9c651e66b https://staging.drfop.org/files/original/51d4491374c4e678089f6cdf6c27afae.jpg f51626e0ef82b0a4dfb1ee8ab4693ced https://staging.drfop.org/files/original/822789265194f5be4e60727bb55d3108.jpg 4499acf3c75535c673217cfa36745c01 https://staging.drfop.org/files/original/20bbec62ad79b83acbdb384867dd8dfe.jpeg e67daa763e1a8051b264102cc6bd4c8b https://staging.drfop.org/files/original/df0e494105bf2580379ea0532148fd6e.jpeg 821ac6be13efc72dd02bf99301f354ec https://staging.drfop.org/files/original/56713088198c8c2e3e4a0e824e14d79b.jpeg efa1d6a37f55c3e4ec5ba5c6f99c1555 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1981_04_005.pdf Text Any textual data included in the document <h2>Knee Orthoses: Biomechanics</h2> <h5>Charles H. Pritham, C.P.O.&nbsp;<a style="text-decoration: none;">*</a></h5> <p><i>Derived from a lecture given at the ISPO Lower Limb Orthotics Course, Dallas, Texas, March 9-13, 1981.</i></p> <p>Irrespective of etiology, deformities of the knee can be divided into three broad categories: angular (genu valgum, genu varum, genu recurvatum), rotary (internal, external rotation of the tibia relative to the femur), translatory (anterior/posterior subluxation of the tibia relative to the femur). They can be further categorized as either flexible (secondary to flaccid musculature and/or ligamentous and capsular laxity) or fixed (secondary to spastic musculature and/or ligamentous and capsular tightness). For a variety of reasons orthotics has traditionally devoted the majority of its attention to cases of angular deformity and coped with instances of rotary or translatory deformity only secondarily as they arise as complications of angular deformity. For that reason, then, the majority of discussion will focus on this aspect of the situation.</p> <p>Viewed in the frontal plane (the case is the same in the sagittal plane) with the body aligned so that the weightbearing line coincides exactly with the mechanical axis of the leg (<a href="/files/original/eff05f3ff73679cc3aa9f244a0b01ee1.jpeg"><b>Fig. 1</b></a>), there is no tendency for the knee to bend into either genu valgum or genu varum. If the weightbearing line deviates to one side, a bending moment or torque is created (<a href="/files/original/45c3082ce4cd40c92baa03e02c966b83.jpg"><b>Fig. 2</b></a>) that causes a change in angle (angle of deformity, 0) of the femur relative to the tibia. The bending moment can be quantified by multiplying the deforming force (body weight, W) times the perpendicular distance (x) from the line of action to the center of rotation. As body weight is essentially constant, any increase in angle of deformity will lead to an increase in distance x and an increase in the deforming moment. In real life this tends to create a vicious circle since the deformity is resisted by the capsular and ligamentous elements on the opposite side of the knee. The stress is greatest on those elements farthest away from the center of rotation, as they are best positioned by virtue of their longer lever arm to oppose the deforming force. When the stress becomes intolerable, they yield, and the load falls on elements less strategically placed. As the angle of deformity increases, distance x increases, the deforming moment increases, and a compromised knee is jeopardized further. To correct this situation and prevent further damage, it is necessary to introduce a corrective moment and reduce the angle of deformity.</p> <strong><a href="/files/original/eff05f3ff73679cc3aa9f244a0b01ee1.jpeg">Fig. 1</a>. Lower limb positioned so that weightbearing axis falls through the mechanical axis of the limb.</strong><br /><br /><strong><a href="/files/original/45c3082ce4cd40c92baa03e02c966b83.jpg">Fig. 2</a>. As the weightbearing axis deviates to one side a bending moment or torque is created</strong><br /> <p>This corrective moment is created by a three-point pressure system (<a href="/files/original/6e9b5d4a5957258a4958635acfc8fbda.jpg"><b>Fig. 3</b></a>). For the laws of equilibrium to be satisfied, the forces acting on each side of the structure must be equal, and the clockwise moments acting about the center of rotation must be equal to the counterclockwise moments. The farther forces H and A are from the center of rotation, the smaller they can be, due to increased lengths of their lever arms a and b. Force K can seldom be applied directly at the center of rotation (<a href="/files/original/29254ec4552c6b302e11d7249167147b.jpg"><b>Fig. 4</b></a>), as the anatomical structures vary in their ability to tolerate the pressure. It may very well prove necessary to locate force K some distance from the knee and apply it as two sub-elements, S and I. K would be equal to the sum of the two and vary in point of application according to their relative strength. As K moves away from the center of rotation (<a href="/files/original/be009fdace4d2d0fce8a7757ab25edf7.jpg"><b>Fig. 5</b></a>), it increases the bending moment acting in one direction or another, and if the laws of equilibrium are to be satisfied, the opposing moment will have to increase in magnitude, leading to an increase in total force on the limb. <a href="/files/original/a8017df2f33ae779bbc361ad9d87e7ee.jpg"><b>Fig. 6</b></a> summarizes the discussion thus far. It should be noted that any orthosis fabricated to satisfy these conditions must be strong enough to do so without yielding or bending as the old pattern of the vicious circle (<a href="/files/original/45c3082ce4cd40c92baa03e02c966b83.jpg"><b>Fig. 2</b></a>) will assert itself. Yet another factor to be taken into account is the familiar relationship of pressure, force, and area (<a href="/files/original/51d4491374c4e678089f6cdf6c27afae.jpg"><b>Fig. 7</b>)</a>. The need to satisfy these conditions and thus reduce the total force exerted must be, of course, balanced with the desire not to encumber adjacent joints, and to keep the orthosis as cool and light as possible.</p> <strong><a href="/files/original/6e9b5d4a5957258a4958635acfc8fbda.jpg">Fig. 3.</a> Three-point pressure system acting about the knee.</strong><br /><br /><strong><a href="/files/original/29254ec4552c6b302e11d7249167147b.jpg">Fig. 4</a>. Force K acting as two sub-forces, S and I.</strong><br /><br /><strong><a href="/files/original/be009fdace4d2d0fce8a7757ab25edf7.jpg">Fig. 5.</a> As force K moves away from the knee the total force on the limb increases.</strong><br /><br /><strong><a href="/files/original/a8017df2f33ae779bbc361ad9d87e7ee.jpg">Fig. 6.</a> A summarization of criteria necessary to minimize the force on the limb.</strong><br /><br /><strong><a href="/files/original/51d4491374c4e678089f6cdf6c27afae.jpg">Fig. 7.</a> The relationship of pressure to force and area.</strong><br /> <p>Another way to tackle the problem is to use a weightbearing brim (<a href="/files/original/822789265194f5be4e60727bb55d3108.jpg"><b>Fig. 8</b></a>). This, of course, reduces the deforming force and thus the deforming moment. What is not so apparent is that it might very well change the length of the lever arm x and reduce the bending moment. If some of the body weight is borne medially on an ischial seat, it would tend to shift the line of action of the body weight medial to its usual course through the head of the femur. This phenomenon is at work when a KAFO with a quadrilateral brim is used in cases of gluteus medium lurch. It might very well have implications in cases of genu varum and genu valgum. In the sagittal plane (<a href="/files/original/20bbec62ad79b83acbdb384867dd8dfe.jpeg"><b>Fig. 9</b></a>), a similar situation is identified in the UCLA Functional Long Leg Brace<a></a>. Moving the line of action of the weight line anterior by virtue of the load on the Scarpa's Triangle, a knee extension moment is generated. Knee extension is further aided by the intimate fit of the quadrilaterial brim and a firm fit of the foot in the shoe which produces a distractive effect on the leg, straightening it, as would pulling on opposite ends of a rope.</p> <strong><a href="/files/original/822789265194f5be4e60727bb55d3108.jpg">Fig. 8.</a> Use of a weightbearing brim creates a proximally acting force, R, that counteracts weight, W.</strong><br /><br /><strong><a href="/files/original/20bbec62ad79b83acbdb384867dd8dfe.jpeg">Fig. 9.</a> Forces applied to the higher anterior wall of a quadrilateral brim tend to move the weightbearing axis anterior to the head of the femur, and the knee center.</strong><br /> <p>Subluxation of the tibia (such as might occur due to the pull of the quadriceps secondarily to ligamentous laxity in cases of genu valgum in arthritis, a situation described by Smith, et al.<a></a>), can be corn-batted by separate force couples acting on the femur and the tibia (<a href="/files/original/df0e494105bf2580379ea0532148fd6e.jpeg"><b>Fig. 10</b></a>). This is a feature of the University of Michigan Arthritic Knee Brace.</p> <strong><a href="/files/original/df0e494105bf2580379ea0532148fd6e.jpeg">Fig. 10.</a> Use of force couples acting on the femur and tibia to prevent anterior subluxation of the tibia relative to the femur. The force system would be reversed in an instance of posterior subluxation. A system of force couples is subject to the same sort of analysis and criteria as a three-point pressure system.</strong><br /> <p>In the absence of direct action on the skeleton, control of rotation is more problematical. As the proximal portion of the shin is triangular, considerable rotational control can be achieved as in the PTB prosthesis, the spiral ankle-foot orthosis (AFO), and the hemi-spiral AFO. Purchase about the condyles of the femur and the patella can be achieved, but is compromised by the necessity for unencumbered knee flexion. It is, of course, possible to use a quadrilateral brim to gain a purchase on the proximal structures, but any prosthetist will be glad to regale his orthotist companion with tales or rotary instability in above-knee prostheses. The last alternative is a frictional coupling between the soft tissue and broad elastic straps as in the Lenox Hill Derotation Orthosis (<a href="/files/original/56713088198c8c2e3e4a0e824e14d79b.jpeg"><b>Fig. 11</b></a>). As considerable slack must be taken up in the soft tissues, 20 degrees of motion at the surface may result in only 10 degrees of motion of the femur about its axis. Moreover, the efficacy of even the best such measures is called into question considering the magnitude of the bending moment generated by the action of the center of gravity about the long axis of the leg and comparing it with the moments that can be induced about the same axis by the maximum tolerable force acting at the surface of the leg.</p> <strong><a href="/files/original/56713088198c8c2e3e4a0e824e14d79b.jpeg">Fig. 11.</a> Schematic cross-section of a limb, on the left, with the skin (outer circle) connected to the bone (middle circle) by soft tissue (radiating rippling lines) and acting about the center of rotation (innermost circle). The broad vertical line is for reference. As rotary forces (arrows) are applied, on the right, the force is transmitted from the skin to the bone by the soft tissue. As slack in the soft tissue must be taken up it becomes apparent that the bone moves less than the skin.</strong><br /> <p>In conclusion, some of the biomechanical factors involved in the function of knee orthoses are reviewed. Due consideration of these factors, the anatomical structures involved, and the intended purpose of the orthosis at the time of prescription should inevitably lead to a more functional orthosis.</p> <p><b>References:</b></p> <ol> <li><em>Final Report, Functional Long Leg Brace Research</em>. University of California, Los Angeles. Prosthetics/Orthotics Education Program, March 30, 1971.</li> <li>Edwin M. Smith, M.D., Robert C. Juvinall, M.S.M.E., Edward B. Correll, M.S.M.E., and Victor J. Nyboer, M.D., "Bracing the Unstable Arthritic Knee," <em>Archives of Physical Medicine and Rehabilitation</em>, Vol. 51, No. 1, Jan. 1970, pp. 22-28, and 36.</li> </ol> <div style="width: 400px;"><em><br />*<b>Charles H. Pritham, C.P.O. </b> Formerly Director, Prosthetics and Orthotics Laboratory, Rehabilitation Engineering Center, Moss Rehabilitation Hospital, Philadelphia. Presently Branch Manager, Snell's of Louisville.</em></div> <div style="width: 400px;"><br /><br /></div> Page Number(s) 5 - 7 Year 1981 Volume 5 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-01.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-02.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-03.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-04.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-05.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-06.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-07.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/1981_04_005/1981_04_005-08.jpg Figure 9 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-09.jpg Figure 10 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-10.jpg Figure 11 http://www.oandplibrary.org/cpo/images/1981_04_005/1981_04_005-11.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Knee Orthoses: Biomechanics Creator An entity primarily responsible for making the resource Charles H. Pritham, C.P.O. * https://staging.drfop.org/files/original/9efbf424d1bfe2b5b84fe13f0d2fd516.pdf 0bcf1c41627ab178388a24b6e69db174 https://staging.drfop.org/files/original/9811319d59776c370a44ed906f991cfd.jpeg 00380d4a6a0059f69700b9ea0c517dc3 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1981_04_001.pdf Text Any textual data included in the document <h2>Rehabilitation Engineering and Prosthetics/Orthotics</h2> <h5>Anthony Staros, MSME, PE&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The words "Rehabilitation Engineering" are now commonly used to mean a paramedical practice which in its job characteristics and their demands, in the basic technical background needed, in its high activity level, and in its human service slant, is an extrapolation of professional prosthetics and orthotics. Prosthetics and orthotics are in fact very significant components.</p> <p>Rehabilitation engineering is defined as that broad discipline having as its ultimate objective the <i>application</i> of technology to enhance life's quality for the disabled. It includes subsidiary goals in research, development and education. But one doesn't need to be an engineer to <i>practice</i> rehabilitation engineering!</p> <p>With the recent advances in technical aids, prosthetics and orthotics included, there has been increasing need for those who currently serve the disabled with technology to expand the range of their commitment requiring a persistent demand for more knowledge. At the same time, there are counterpressures:—the potentially harmful low rates of increase in the numbers of practitioners. Fewer people are trying to do more while also needing more information for what they do. The effects that Government budget restraints will produce in this situation are difficult to predict, but clearly seen is that the pressures will be greater, that there will be real need for increased efficiency in all parts of society and more so for us committed to the delivery of high quality service to the disabled: increased productivity and more knowledge are conjointly required.</p> <p>Much of what rehabilitation engineering means in real practice is the selection of devices, the making of special systems, or the design of environments, and then the delivery of these, customizing them even further when necessary, and applying them to assist the disabled. Demanded is the achievement of independence through function and/or access with both comfort and control maximized. Training of the client is essential. These efforts are effected in a precise and deliberate process with full understanding of the patterns of disability presented and a substantial awareness of the personal wishes of the disabled person being served (and his/her family).</p> <p>Rehabilitation engineering includes aids fitted directly to the client as in prosthetics and orthotics, tools such as communication devices, and adaptations to environment, to work sites, to the home, or to the vehicles used to reach one or the other or to those mobility devices operated within an environment. Some of the technical aids may be very simple in design; most of those which are custom-made require biomechanically sound, creative, and often inventive approaches. The simplest may require the most creativity.</p> <p>In the rehabilitation engineering applications process, in supporting the physician's role in prescription or in the selection of aids and then in their application, the knowledgeable and interested prosthetist, orthotist, and therapist (physical, occupational, speech) can play the key roles. Especially <i>productive</i> and <i>cost effective</i> is the involvement of the skilled technician, an essential member of the rehabilitation engineering team. The team concept is crucial in that the knowledge needed comes out of the sharing of training and experience—and the creativity sought can usually come from the synergism in the group, especially including the client. The actual "making" although involving all to various degrees becomes the special province of the technician, with the "fitting" itself being a product of the team. The required contribution to benefit the patient will be a scenario of analysis and synthesis, idea and response, search and research, give and take, and then plain work.</p> <p>That which is rehabilitation engineering has been performed for many years, before it became stylish to use this expression to represent a special technology. But there is now in place an acceleration in the development of new technology in products and processes, many so recent that they are not known to members of the rehabilitation team who received preparatory training or post-graduate courses years earlier. Even now the newer information needed is not obtained in structured formats. Pathways should be constructed for each member of the team to broaden his/her own discipline to include constantly updated knowledge about all technology necessary for his/her personal professional contribution to the rehabilitation engineering team. And not to be overlooked is that the payers for services need to be instructed on the cost benefits of rehabilitation engineering.</p> <p>We recommend that these professionals (the prosthetist, orthotist, and therapist) have their own societies' publications and conferences include the information about the advance in rehabilitation engineering. They should also participate in those societies which meld the team, the <i>Rehabilitation Engineering Society of North America</i> and the <i>International Society for Prosthetics and Orthotics</i>, thereby advancing the practice of rehabilitation engineering through contacts with the other team members. Special seminars need to be structured for the 3rd party payers.</p> <p>In the team, or even in the individual practices, the added knowledge about rehabilitation engineering aids can only benefit. If the prosthetist or orthotist fitting a patient with an <i>upper-limb</i> deficit relates his fitting in part to the vehicle controls the disabled person may need to use, shouldn't he or she be knowledgeable about such controls and their installation? Beyond that, shouldn't both (prosthesis or orthosis <i>and control</i>) be "installed" under such professional supervision? Yet still, in this decade of rapidly advancing technology and of certification of those who dispense it, ordinary automobile repair garages install hand controls for licensed vehicles for disabled drivers. Why not the orthotist or prosthetist overseeing his/her technician?</p> <p>There are often frustrating limits to the mobility which can be provided in lower limb orthotic or prosthetic care. Under what circumstances does one use a wheelchair as a supplement or as a last resort? How is it selected? In what way should it be modified if at all? What kind of buttock and trunk support are required? Here the prosthetist, the orthotist, and the therapist should be involved for aren't these the professionals who can be and should be closely associated with wheelchair prescription and modification? In a national workshop held in 1978, WHEELCHAIR I,<a style="text-decoration: none;">*</a> mention was repeatedly made about the need for a "wheelchairist", a person to be concerned exclusively with wheelchair prescription and fitting. If prosthetists, orthotists, and therapists are indeed responsible for other aids for mobility, why not then the wheelchair? Isn't a functioning rehabilitation engineering team the "wheelchairist" sought?</p> <p>From the clinic team setting or from the counselor's desk, the usual site for the final selection and customization of technical aids and then their application is not unlike a prosthetics/orthotics laboratory, there blessed with talented technician support. In a recent paper,<a style="text-decoration: none;">*</a> we recommended that the prosthetics/orthotics profession develop the practice of rehabilitation engineering:</p> <p>"Recommended is that prosthetics and orthotics, with their foundation in clinical technology, constitute the basis for the establishment and certification of a broadly based rehabilitation engineering capability in the United States. Indeed, it would be well for prosthetists and orthotists to start expanding their scope to include the other technical aids in rehabilitation engineering and in collaboration with other members of the rehabilitation team, especially the orthopedic surgeon, provide the means for a wider coverage in the delivery of technology to restore independence and function to many handicapped individuals who are not now receiving the full, broad spectrum services they deserve."</p> <p><a href="/files/original/9811319d59776c370a44ed906f991cfd.jpeg"><b>Figure 1</b></a></p> <p>Is there then really need for the engineer, the graduate of a formal engineering curriculum to be the <i>applier</i>, the "clinical" practitioner of rehabilitation engineering? The rehabilitation <i>engineer</i> has a role: in design, development, research, and perhaps in management. The prosthetist, orthotist and therapist especially with technician support, as a team and as individuals can and should respond to the total technical needs of the patients presented to them; rehabilitation engineers should identify with the other (consulting) members of the medical-technical professional structure in the overall rehabilitation effort. To be called on only in the case of <i>special</i>, more complex problems, the engineer should be mostly involved in leading generalized design and development efforts, these to include others of the team as well.</p> <p>Total need, as the prosthetist, orthotist, and therapist well know, includes "tender loving care," this in the past demonstrated by the experiences of these professionals in analyzing then defining the problems of the disabled. For patients with the severer disabilities, those requiring broader rehabilitation engineering efforts, good practice requires more of such empathic yet deliberate reasoning to seek solutions: devices which yield function in a real sense and are more than just tolerated, used for their novelty, or accepted to please someone else. Seating, wheelchair designs, licensed vehicle modifications, electrical stimulation for pain relief or function, and home and job modifications are all parts of an armamentarium which spans the spectrum from modifications to the shoe to those to the motorcar, for mobility; from a mouth stick to a robotic system, for independent "prehensile" function; from a simple word-display board to synthetic speech, for communciation.</p> <p>Then, do we really need to cultivate large numbers of graduate engineers for rehabilitation engineering practices (other than for the employment of some smaller number in research and development)? Yes, if the prosthetist/ orthotist does not accept the alternative recommended: proper management of his/her practice integrating it with those of other team members and with the very significant role of their skilled technicians who become key constituents in that practice.</p> <p>Apparently some prosthetists and orthotists see an expanding future. The excellent document describing the professions of prosthetics and orthotics and recently published by the American Academy of Orthotists and Prosthetists<a style="text-decoration: none;">*</a> refers to the directions being taken by its professions, based for now on "bionics" referring specifically to automatic control of knee function and myoelectric control of powered upper-limb prostheses. These are presented as steps toward encompassing more and more technology, components of a rehabilitation engineering commitment. In fact the logo of this publication (shown here) presents the transition from orthotics and prosthetics to rehabilitation engineering over a natural pathway (or track) for growth.</p> <p>The essential initiatives now have to come from the current practitioners. In fact they could also abdicate their "clinical" role to the rehabilitation engineering equipment dealers!</p> <b>Footnote</b>The Academy brochure can be ordered from the National Office for $1.25 each.<b><br /><br />Footnote</b> Staros, A. and G. Rubin, The Orthopedic Surgeon and Rehabilitation Engineering in Orthopedics, March/April 1978, Volume 1/Number 2, Charles B. Slack, Inc., Thorofare, N.J.<br /><br /><b>Footnote</b> Moss Rehabilitation Hospital (REC) Wheelchair I; Report of a Workshop sponsored by RSA and VAPC, Dec. 6-8, 1977, Philadelphia, Pa.<br /><br /><em><b>*Anthony Staros, MSME, PE </b> Director, VA Rehabilitation Engineering Center New York, N.Y.</em><br /> <div style="width: 400px;"><br /><br /></div> Page Number(s) 1 - 3 Year 1981 Volume 5 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 1 http://www.oandplibrary.org/cpo/images/1981_04_001/1981_04_001-1.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 Rehabilitation Engineering and Prosthetics/Orthotics Creator An entity primarily responsible for making the resource Anthony Staros, MSME, PE * https://staging.drfop.org/files/original/eb7af921f4b32f8e97132e548f88898b.pdf b3171ca328eee50b5195df04b2d0c788 https://staging.drfop.org/files/original/8b668143ca8ff4ec00d38bdaca0e8295.jpeg 8099103e73990942586441d921a16c1c https://staging.drfop.org/files/original/3bb0ef66a8d97b487e2406e04dfe528a.jpg 657f28db4b18efbba8fdf19ced12aefc https://staging.drfop.org/files/original/c874cf9cf5f6cd93cbfd7caefebfdb17.jpg 3a422d3bde70187bd6eacbad0b5b61bd https://staging.drfop.org/files/original/8ae5ce0e382f544320be566569a2f206.jpg e3914b13228afa24f44648b12154099a Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1981_03_007.pdf Text Any textual data included in the document <h2>Feedback For Electrically Powered Prostheses And Orthoses</h2> <h5>Warren Frisina, B.E. (in M.E.)&nbsp;<a style="text-decoration: none;">*</a><br />James A. Reeve, B.S. (in E.E.)&nbsp;<a style="text-decoration: none;">*</a></h5> <p style="font-size: 60%;"><i>All rights reserved © Warren Frisina 1981</i></p> <p><i>This research was supported by the National Institute of Handicapped Research under the designation of New York University Medical Center as a Research and Training Center.</i></p> <p>Basically, pressure feedback systems for upper limb electrically powered prostheses consist of sensors about the prehensile area, electronic processing circuits, and actuators that contact the body. Sensors require careful installation and tend to be vulnerable to damage. Processing circuits leave that much more delicate equipment to coordinate. Actuators sometimes unduly complicate construction and fitting.</p> <p>The system to be described here makes use of the characteristic current response of an electric motor encountering a load—current increases in proportion to the load. This response is directly employed as the combined feedback/actuating signal. It is sent to a miniature direct current electric motor⁴ (<a href="/files/original/8b668143ca8ff4ec00d38bdaca0e8295.jpeg"><b>Fig. 1</b></a>). The top of <b>Fig. 1</b> shows three Micromo motors and the bottom of the figure, the assembled unit. On the shaft of the motor an eccentric mass is mounted. (Several such masses are shown on the right of <b>Fig. 1</b>). This causes the motor to vibrate in proportion to the motor speed (motor speed is proportional to current). When this motor is rigidly mounted to virtually any portion of a prosthesis, the entire prosthesis will vibrate in turn (<a href="/files/original/3bb0ef66a8d97b487e2406e04dfe528a.jpg"><b>Fig. 2</b></a>). Thus, the entire surface of the skin in contact with the prosthesis receives feedback information. The units installed thus far in patients' below-elbow myoelectric prostheses have been fixed at the distal end of the socket with a hose clamp which has been laminated to the socket (<a href="/files/original/c874cf9cf5f6cd93cbfd7caefebfdb17.jpg"><b>Fig. 3</b></a>).</p> <p>The feedback motor can be installed in virtually any electrically powered prosthesis by putting it in series with the drive motor(s). So that most of the current flows to the drive motor(s) and to avoid overloading the small feedback motor, a resistor of approximately three ohms is placed in parallel with the feedback motor. In order to fine tune the system, it would be convenient to have this resistor be of the variable type.</p> <p>This system has been applied to myoelectric prostheses for seven patients at the Institute of Rehabilitation Medicine, New York University Medical Center. It is being applied explicitly for force feedback. But it appears to serve for position feedback as well, since the prosthetic hand unit and glove offer resistance to the drive motor as the hand opens, i.e., the greater the opening, the higher the vibration frequency. The hardness or, more importantly, brittleness, of objects could also possibly be determined by the sensing of rate of change of vibrations, i.e., vibration rate of change for a hard object like an egg is greater than that for a soft object like a paper cup. There have been no controlled studies as yet to verify these possible benefits.</p> <p>A variation of the principle has been applied in the laboratory to an electric arm orthosis tried by a C-4 lesion quadruplegic patient. The feedback motor is either clipped to the user's lapel (<a href="/files/original/8ae5ce0e382f544320be566569a2f206.jpg"><b>Fig. 4</b></a>) or to the back of his wheelchair.</p> <p>Another orthotic variation of the principle was tried in the laboratory by replacing the feedback motor with a flashlight-type light bulb to provide proportional visual feedback. Brightness of the bulb is proportional to pressure at the desensitized finger tips when used with an electrically-driven prehension orthosis.</p> <em><b>*James A. Reeve, B.S. (in E.E.) </b> Project Engineer, Orthotics &amp;Prosthetics, IRM, NYU Medical Center.</em><br /><br /><em><b>*Warren Frisina, B.E. (in M.E.) </b> Formerly Associate Research Scientist, Orthotics &amp;Prosthetics, Institute of Rehabilitation Medicine, NYU Medical Center</em><br /> <div style="width: 400px;"><br /><br /></div> Page Number(s) 7 - 8 Year 1981 Volume 5 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1981_03_007/1981_03_007-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1981_03_007/1981_03_007-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1981_03_007/1981_03_007-3.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 4 http://www.oandplibrary.org/cpo/images/1981_03_007/1981_03_007-4.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Feedback For Electrically Powered Prostheses And Orthoses Creator An entity primarily responsible for making the resource Warren Frisina, B.E. (in M.E.) * James A. Reeve, B.S. (in E.E.) * https://staging.drfop.org/files/original/fdb824053cd07dc56b8a0f9bb5710f77.pdf 040eee9523be02600597ae2e21998310 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1981_03_005.pdf Text Any textual data included in the document <h2>Editorial: Tightening The Loops On Sensory Feedback</h2> <h5>John Lyman, Ph.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Ma Bell's radio and TV ad theme, "reach out and touch someone", appeals to everyone. It represents contact with those sensitive, often sentimental, emotional connections we have with our environment and the people and things that we value. In real life, it is only one's voice and the feedback of the voices of our familiar compadres that makes situations comparable to the telephone company ad warm and real. We all know the experience. What makes it work?</p> <p>Many years of experience in the serious pursuit of possible answers to this question, and its broader implications concerning the role of sensory feedback in shaping human performance, have brought us only a few answers on which we can count. Mostly, we only know that the importance of sensory feedback varies greatly with specific situations, and that the role of the senses is very complex because of two-way filter interactions with the central nervous system. We do know quite a lot about the specifics of the sensory receptors themselves. It is, however, the manner in which the patterns of sensory stimuli provide information for processing by the spinal cord and higher levels that is clinically provocative.</p> <p>With specific reference to limb amputees, everyone agrees that to achieve functional unity with a prosthesis, there must be some form of awareness established by the wearer about the capabilities of the prosthesis. How reliably does it respond to the amputee's command? Does it react predictably to each familiar environmental situation so that the wearer has an accurate mental model of what to expect? Getting a wrong number does not reach out and touch the expected connection. After too many wrong numbers or too much noise in the connection, one tends to lose that warm feeling of predictable expectation. This appears to be the case in the matter of the state-of-the-art with sensory feedback in limb prosthetics.</p> <p>We have long known that the primary source of sensory feedback for limb prosthesis wearers was an "open loop" mental model of the space occupied by the prosthesis, its dynamic control features and pressure patterns on the stump-all modulated by visual, and sometimes auditory, information from both the prosthesis and its situational environment.</p> <p>To date, except for blind amputees where any feedback from the environment is helpful, we have not been able to definitively establish whether or not specialized sensors located on the prosthesis itself could effectively communicate signals to the wearer that would significantly enhance task performance. Experimental results have, for the most part, been marginal and frustrating, both scientifically and clinically.</p> <p>Despite many disappointments, especially in terms of immediately useable clinical benefits, our knowledge base has been substantially broadened, mostly concerning the scope and complexity of factors that realistically must be brought under control. For example, in the biological model of a limb, it is known that receptor density for cutaneous and kinesthetic senses (pressure, pain, thermal, etc.) may reach several hundred per square millimeter. These high receptor densities provide precise patterns of environmental information. They generate functionally important physiological and psychological adjustments of information flow rates. Refined movement may require highly defined sensory patterns to optimize the available muscle capability of the normal limb. The stability and continuity of these patterns is identified with the integrative function of the central nervous system. The distortion of the patterns by modification from disease, or by total physical destruction, requires laying down new cognitive adaptations. These adaptations can only reach a degree of approximation to the original system. The extent of the sensory side of the approximation is dependent on the capability for sensory input that remains or is replaced. Substitution of one pattern of signals for another depends on achieving a common coding scheme. Whatever scheme is achieved, it must be compatible at both the input and output sides of the person-prosthesis loop. Missing or distorted patterns are functionally reconstructed into new channels, both by means of the "software" of the brain, and substitution of sensors. When the sensations are natural, e.g., from the surface of a stump, the sensors available probably were not previously used for primary information about the location of and forces on the limb in space. New cognitive patterns must be brought into association. These new patterns may only provide part of the information previously presented, or the information provided may not be relevant. Thus, there may be a permanent substantial loss of skill.</p> <p>The original, natural, learning process in the intact person seems to make use of whatever sensory function is available to provide a pliable, plastic motor output capability. This is subject to refinement of precision according to criteria set genetically (e.g., walking), or learned according to environmental and personal, i.e., cognitive set standards for performance. "Normal" gait for a leg prosthesis wearer, "smooth," "coordinated" delivery of a fork full of food by an arm amputee, may have to come to mean something different, cognitively, than these actions for the non-amputee.</p> <p>For the amputee, complex situational vectors are set up by a combination of motor deficits and sensory deficits. This makes it especially difficult to independently assess the role of sensory feedback in task performance. For example, direct observations of the role of the senses is confounded by factors such as the transmission precision of the power train, by dynamic stability properties of the structural interface between the stump and the socket, and by task complexity, e.g., climbing stairs, rotating a door knob, etc. A simple analog would be to try to observe the role of sensory feedback in the performance of a non-amputee who was trying to write with a pencil that had the tip attached to a soft, compliant, rubber-like shaft. The capricious relationship between the tip of the pencil and the writer would make interpretation of the performance associate more closely with the hardware interface between the writer and his task than with the properties of the writer's sensory-motor system.</p> <p>To function with maximum effectiveness, the communications channels, as well as the energy (power) transfer channels, must be locked intimately and reliably together in both the relationship of time, e.g., minimum transmission time-lag, and geometric positions. It seems probable that sensory information, to be effective, must have a tight, reliable, one-to-one superposition with a tight, reliable motor output system.</p> <p>It is, thus, our view that perhaps a major reason for not being able to obtain clear-cut experimental results with artificial sensory feedback techniques for limb prostheses is that the linkages between the subsystem interfaces have usually been excessively "loose." The messages in both directions are garbled. As the requirement for task precision increases, the effects of loose communication links become increasingly evident. Softness of fit between the prosthesis and the flesh of the stump, for example, generates uncertain messages in both directions. The "reach out and touch" is a spongy approximation, a sensory haze at the cognitive level.</p> <p>The bad news is that in the prevailing situation, where direct bone attachments have not reached a level of development suitable for standard clinical practice, the tightening of sensory feedback loops and feed-forward loops seems to be inherently limited in promise. The good news is that with each year, the background research and technology is progressing to significantly more sophisticated levels, achieving denser, more accurate and less power-consuming transducer arrays for picking up the tactile features of the environment. As has often been the case before in the history of important prosthesis development, much of the technology for sensory augmentation is to be found in other applications, in this case, industrial automation and robotics. When, as will happen sooner or later, art and technology reach out and come together, the parts of the limb-prosthesis system will indeed, touch-with feeling.</p> <em><b>*John Lyman, Ph.D. </b> Professor and Chair, Engineering Systems Department Head, Biotechnology Laboratory, UCLA, Los Angeles, CA 90024</em><br /> <div style="width: 400px;"><br /><br /></div> Page Number(s) 5 - 6 Year 1981 Volume 5 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Editorial: Tightening The Loops On Sensory Feedback Creator An entity primarily responsible for making the resource John Lyman, Ph.D. * https://staging.drfop.org/files/original/971d394bd3cab6b56131702cf9304cfc.pdf f2823830773aab477c31ef87b7ef4503 https://staging.drfop.org/files/original/19d63adbf4fba399327be2d43c975736.jpeg ddab110728e3ce26e0c64c15d5a8fee2 https://staging.drfop.org/files/original/5f71f091dd01239060dbc584eb8435a2.jpg 06f5cd1d15bf80197630f436ea40479a Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1981_03_001.pdf Text Any textual data included in the document <h2>Prosthetic Sensory Feedback Lower Extremity</h2> <h5>Frank W. Clippinger, M.D.&nbsp;<a style="text-decoration: none;">*</a><br />James H. McElhaney, Ph.D&nbsp;<a style="text-decoration: none;">*</a><br />Maret G. Maxwell, Ph.D.&nbsp;<a style="text-decoration: none;">*</a><br />David W. Vaughn, C.P.O.&nbsp;<a style="text-decoration: none;">*</a><br />Grace Horton, R.P.T.&nbsp;<a style="text-decoration: none;">*</a><br />Linda Bright, R.N.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>This is a progress report of a Duke University research project involving sensory feedback from lower extremity amputation prostheses.</p> <p>It has been assumed for many years that replacement of sensory function in prosthetic limbs was a nearly impossible task. Developments in electronics have made possible small amplifier systems and usable transducers, but the basic difficulty remains that of getting the signals into the central nervous system in a fashion that is interpretable, comfortable, consistent, and convenient.</p> <p>The problem has not been ignored and the obvious routes-auditory signal, electrical stimulation of intact skin, mechanical stimulation, and developments leading to solving the skin barrier with compatible percutaneous materials have been explored.</p> <p>From 1969 to 1975, this laboratory developed the mechanism to produce sensation from upper limb prosthetic terminal devices. This system was built around the concept of proportional peripheral nerve stimulation by means of a surgically implanted, induction coupled radio receiver-pulse generator, driven by an external amplifier and transmitter that relayed frequency modulated signals, controlled by a strain gauge transducer in the terminal device.</p> <p>The conclusions from this study were:</p> <ol> <li> <p>The system is feasible and signals can be interpreted with reliability relative to the stimulating activity.</p> </li> <li> <p>The brain interprets the signal as coming from the normal peripheral distribution of the nerve stimulated.</p> </li> <li> <p>Signal threshold and nerve excitability does not deteriorate with time, at least in this application.</p> </li> <li> <p>The implanted device is reliable, and durable, there having been no implant failures in twelve years.</p> </li> </ol> <p>In 1975, a grant was received from the National Cancer Institute to apply this technique to the lower limb amputee. This study is to determine whether sensory feedback, in addition to that provided normally from the stump-socket interface and terminal knee impact, useful or advantageous.</p> <p>To date, 21 patients have been fitted with a lower extremity sensory feedback system, including below knee, above knee, and hip disarticulation amputees. The majority of these have been cancer patients.</p> <p>The new amputee from malignancy presents a special problem. It is difficult to subject a person recently amputated for cancer to another surgical procedure to insert a stimulator implant. In addition, the amputation is followed by months of chemotherapy during which time wound healing is compromised and the patient does not feel well. Emotional factors must be considered also.</p> <p>For this reason, it was necessary to develop a noninvasive system as well as the implanted nerve stimulator. After a brief unsuccessful trial with a skin vibrator, the auditory route was selected.</p> <p>The electronic systems of both the implanted and auditory devices are similar. The system consists of a set of strain gauges which measure anteroposterior and mediolateral bending moments incorporated into the below knee segment of the prosthesis utilizing an endoskeletal unit developed by the Department of Bioengineering at Duke, hybridized with Ottobock endoskeletal prosthetic components.</p> <p>In addition to the strain gauges, a pressure activated piezo-electric crystal is imbedded in the heel of a SACH foot. This is activated on heel strike.</p> <p>When the weight is balanced in mid stance or when the prosthesis is unloaded, as with the patient sitting, there is no signal produced by any of the transducers. The system is designed to provide proportional feedback as soon as weight is biased in any direction.<br /><br /><a href="/files/original/19d63adbf4fba399327be2d43c975736.jpeg"><strong>Figure</strong></a></p> <p>For the implant system, the signal to the nerve is frequency-modulated with the frequency of stimulus increasing from 0 to 90 Hertz proportionate to the load. With frequencies greater than 90 Hertz, a decrease in signal or complete loss of signal has been experienced routinely. Voltage is adjusted to a level that is comfortable for the patient. Threshold in these patients has varied between .5 and .9 volts.</p> <p>The implanted receiver is identical to that used in the upper limb project except that four electrodes are placed around the sciatic nerve in the buttock rather than the two that were used for the median nerve in the upper limb project. The receiver is placed subcutaneously in the lower abdominal wall and the antenna is taped to the overlying skin. Only two electrodes are stimulated and the pair which produces the best response is selected. Electrode orientation is important and this is a compromise. The alternative would be to do the surgery with the patient awake which has obvious disadvantages.</p> <p>In all patients, an interpretable signal was produced although the mental imaging, which was 90 percent correct in the upper limb, has been haphazard in the lower. No patient has reported that the stimulus or the mental image produced was uncomfortable, unpleasant, or confusing, however.</p> <p>The auditory system uses the same external transducer unit, but the signal is fed to a hearing aid earpiece placed behind the ear without blocking the external auditory canal.</p> <p>In that the end result of any sensory feedback is a subjective response, it is difficult to determine its effect in scientific terms.</p> <p>A gait laboratory has been developed to analyze walking with and without the sensory feedback system. This provides computer-assisted analysis of force plate and segmental accelerometer data. This facet of the study has just started and at the moment, insufficient data analysis is available to be meaningful.</p> <p>It is felt, however, that the subjective individual patient response will actually be more helpful in the long run. This is "quality of life" response and is voiced as statements like: "I can walk out in the driveway at night without worrying", "I feel better about going downstairs", "I can play basketball better with it turned on", "I can control the accelerator on my car far better".</p> <p>Not all the subjects have found the system useful. <b>Table I</b> outlines the patients who have had the sensory feedback systems and their outcome. Most of those who have abandoned it, however, have had the auditory unit.<br /><br /><strong>Table I</strong></p> <img src="/files/original/5f71f091dd01239060dbc584eb8435a2.jpg" h3="" />Conclusions <ol> <li> <p>Sensory feedback systems in lower extremity amputees appear to have advantages. How much better the amputees are is still under investigation and whether the system is cost effective is still not determined.</p> </li> <li> <p>The auditory system is somewhat confusing and cumbersome. It may end up being a good training apparatus but not appropriate for long term use.</p> </li> <li> <p>The electronics package in the below knee segment of the prosthesis presents some problems related to the cosmetic cover which has to allow frequent access for adjustment and battery changes. An attempt is underway at present to replace the instrumented pylon with an instrumented ankle bolt.</p> </li> <li> <p>Investigation is still needed to determine exactly what information is useful. Knee position, for instance, may be more useful information than the direction and magnitude of loading.</p> </li> </ol> <em><b>*Linda Bright, R.N. </b>Department of Surgery, School of Medicine, Department of Medicine, Department of Biomedical Engineering, School of Engineering, Duke University, Durham, N.C.</em><br /><b><br /><em>*Grace Horton, R.P.T. </em></b><em> Department of Surgery, School of Medicine, Department of Medicine, Department of Biomedical Engineering, School of Engineering, Duke University, Durham, N.C.</em><br /><br /><em><b>*David W. Vaughn, C.P.O. </b> Department of Surgery, School of Medicine, Department of Medicine, Department of Biomedical Engineering, School of Engineering, Duke University, Durham, N.C.</em><br /><br /><em><b>*Maret G. Maxwell, Ph.D. </b> Department of Surgery, School of Medicine, Department of Medicine, Department of Biomedical Engineering, School of Engineering, Duke University, Durham, N.C.</em><br /><br /><em><b>*James H. McElhaney, Ph.D </b> Department of Surgery, School of Medicine, Department of Medicine, Department of Biomedical Engineering, School of Engineering, Duke University, Durham, N.C.</em><br /><br /><em><b>*Frank W. Clippinger, M.D. </b> Department of Surgery, School of Medicine, Department of Medicine, Department of Biomedical Engineering, School of Engineering, Duke University, Durham, N.C.</em> Page Number(s) 1 - 3 Year 1981 Volume 5 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1981_03_001/1981_03_001-1.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/1981_03_001/1981_03_001-2.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Prosthetic Sensory Feedback Lower Extremity Creator An entity primarily responsible for making the resource Frank W. Clippinger, M.D. * James H. McElhaney, Ph.D * Maret G. Maxwell, Ph.D. * David W. Vaughn, C.P.O. * Grace Horton, R.P.T. * Linda Bright, R.N. * https://staging.drfop.org/files/original/3737624fef3a56640de26ee5e3002198.pdf 15dcba40ce0ee64a88813bdb9436da11 https://staging.drfop.org/files/original/90b09bc05fe9f54eac7fb5d364a84b1c.jpeg bf517f01325ef5bfd382d9f9221d3ade https://staging.drfop.org/files/original/f21dd604b9586a00f2668ad4a7c12771.jpg 6fb57a7aca27799becfcbf804eeb70ed Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1981_01_006.pdf Text Any textual data included in the document <h2>Cross-Diagonal Closure Of Pelvic And Spinal Appliances</h2> <h5>Louis Ekus, CO&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The pelvic region with its numerous bony prominences, subcutaneous structures, and varied contours, has long been a useful site for the stabilization of many different orthoses and prostheses. The Milwaukee orthosis, body jackets, prostheses for hemipelvectomy and hip disarticulation amputees, to name a few, often maintain high internal forces as components of complex three-point pressure systems. Due to the nature of these devices, the internal forces are often quite different on the patient's opposing sides. Most practitioners are already aware that when the differences in the forces from right to left sides becomes large enough, relative motion of the two sides of the appliance becomes a difficult problem. This motion, in the superior or inferior direction in the frontal plane, causes skin breakdown, irritations, torsional stress on the devices and, thus, provides less than optimal function. In hip disarticulation and hemipelvectomy prostheses, "pumping" can be attributed to a great extent to the lack of the closures to maintain effective apposition of the two sides of the socket. The cross-diagonal closure is one way of dealing with this undesirable movement effectively.</p> <p>When the attachment points of closure straps are placed horizontally across from one another, as in conventional practice, the long axis of the straps is perpendicular to the direction of the relative movement between the two sides. A large amount of this motion can then occur with little increase in the distance between these points. This fact, in addition to the high degree of compression and migration of the tissue in the pelvic region, contributes greatly to the problem. In this case, the unwanted action can take place due to a lack of increased tension on the closure straps at the onset of the motion. However, if the points are placed so that the long axis of the straps will <i>not</i> be perpendicular to the direction of movement, the distance change between these points per unit of motion is much greater.<a style="text-decoration: none;">*</a> This will cause a rapidly increasing tension on the straps, hence restricting additional movement.</p> <p>Each strap in the cross will restrict translation in one direction; motion in the other direction will bring the attachment points closer together, and the strap will loosen. Application of the cross introduces a strap for the limitation of motion in both directions (<a href="/files/original/90b09bc05fe9f54eac7fb5d364a84b1c.jpeg"><b>Fig. 1</b></a>).</p> <p>When applied to prostheses, a visible difference in the amount of relative motion possible could be noted between the conventional closure and the cross-diagonal closure (<a href="/files/original/f21dd604b9586a00f2668ad4a7c12771.jpg"><b>Fig. 2</b></a>). The appliances with the crossed type were no more difficult to don and doff than the corresponding conventional types. This closure is presented here because of the similarities in the pelvic sections of both prostheses and orthoses along with the similarities in the problems that accompany each. The cross-diagonal closure may be utilized as an important new method of optimizing increased effectiveness and patient comfort.</p> <b>Footnote</b> This physical phenomenon is explained trigonometrically by the fact that the difference in the sine functions of a one degree (1°) change (0° to 1°) near the horizontal is much larger than the difference in the sine function of a one degree (1°) change near the vertical (89° to 90°).<br /> <div style="width: 400px;"><br /><em><b>*Louis Ekus, CO </b> Currently medical student at the School of Medicine, Universidad del Noreste, Tampico, Mexico; formerly a staff orthotist, Institute of Rehabilitation Medicine, New York University Medical Center.</em></div> <div style="width: 400px;"><br /><br /></div> Page Number(s) 6 - 6 Year 1981 Volume 5 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1981_01_006/1981_01_006-1.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/1981_01_006/1981_01_006-2.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 Cross-Diagonal Closure Of Pelvic And Spinal Appliances Creator An entity primarily responsible for making the resource Louis Ekus, CO * https://staging.drfop.org/files/original/5482be4ae060a01e68f831179c03541a.pdf c4183c71a23a893c1ee48207ff643511 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1981_01_005.pdf Text Any textual data included in the document <h2>Editorial: Orthotics For Spinal Deformity - 1980 View</h2> <h5>Robert B. Winter, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Thirty-three years ago the Milwaukee brace made its first appearance, originally designed as a postoperative immobilizing and corrective device. Soon thereafter, it began to be used as a non-operative treatment method for both scoliosis and kyphosis. Between 1950 and 1970, the brace was gradually improved and the system of non-operative treatment became more refined, with more knowledge of the indications and contraindications.</p> <p>In Europe in the 1960's and in North America in the 1970's, a wave of new braces appeared, all attempting to control spinal curvatures without surgery. The corset Lyonnaise, the Riviera brace, the Pasadena brace, and finally the Boston brace and the Wilmington jacket were all basically "underarm" orthoses, although most could be extended up to a neck ring for special circumstances.</p> <p>The "underarm" orthoses were, of course, more aesthetically&nbsp;pleasing to the child, but there was considerable controversy as to whether they could achieve the same quality of curve control as was achieved by the Milwaukee brace.</p> <p>About this time, i.e. 1975, relatively long-term studies of the Milwaukee brace experience began to appear, not just what the curve was at the time of brace stoppage, but what was happening to those curves five and ten years later. It became increasingly apparent that there was a wide spectrum of brace results, even when ideal circumstances of brace manufacture, curve selection, and patient cooperation existed. The average result was a curve the same at the end as at the beginning.</p> <p>Why then use an orthosis if there is to be no correction? The answer is obvious: to prevent progression. We have learned through experience that orthoses are not designed to make large curves permanently into small curves. Orthoses <em>are</em> designed to keep small curves small.</p> <p>Should all small curves, therefore, be braced? The answer is "no," since many small curves are nonprogressive and do not need treatment of any kind. An 18° thoracic idiopathic scoliosis in a pre-menstrual 13 year-old girl has a 63 percent chance of being nonprogressive without treatment and a 4 percent chance of spontaneously improving without treatment. There is only a 33 percent chance of her curve progressing, and therefore she needs treatment only if progression is well-documented.</p> <p>What kind of a brace is best? It depends on multiple factors as to which brace is best for which patient. All too often, proponents of a particular design will claim that their design is best and will solve all problems. As in all phases of medicine, there is a spectrum of diseases and a spectrum of solutions. The pendulum of enthusiasm swings first one way (the Milwaukee brace only), and then the other (underarm orthoses only), and finally settles in the middle.</p> <p>The current "middle ground" of orthotic management is best expressed by that sophisticated program in which the orthotist and orthopaedic surgeon work together to design an orthosis for the specific child's curvature problem. For a lumbar or thoracolumbar curve, they will use an orthosis that exerts correctional and stabilizing forces on the curve, but does not extend up to the neck, i.e., some type of underarm orthosis. If there is a decompensation problem, a trochanteric extension will be employed.</p> <p>If the curvature is in the thoracic spine, i.e., the apex is at T7, an orthosis is needed which will give a maximal effect at that area. The best orthosis is still the Milwaukee brace, regardless of whether the curve problem is a kyphosis or a scoliosis.</p> <p>Why is a Milwaukee brace best for such thoracic curves? It is best because it is designed to apply its forces in that area without negative effects on other areas. Those who suggest that an underarm orthosis can achieve the same result are looking only at the roentgenogram, not at the patient. It is of no benefit to create a "good looking" roentgenogram, if at the same time the patient has decreased lung function, permanent alteration of rib cage dimensions, skin sores, digestion problems, or any of the other secondary effects which improper bracing can create.</p> <p>In summary, we have reached a point of professional advancement in which children with progressive curvatures are being detected early enough to permit non-operative control (not "correction") by orthoses. We are sophisticated enough not to overtreat small curves, nor to attempt to orthotically treat curves needing surgery. We now have a wide selection of orthotic devices from which to choose for the individual patient and her or his specific curve problem. We must stop looking just at an anteroposterior roentgenogram and begin to look at the patient as a three dimensional individual. Finally, we must recognize defeat - sometimes the orthosis just doesn't work and the patient needs surgery.</p> <em><strong><b>*Robert B. Winter, M.D. </b></strong>Professor of Orthopedic Surgery University of Minnesota</em><br /> <div style="width: 400px;"></div> Page Number(s) 5 - 5 Year 1981 Volume 5 Issue 1 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Editorial: Orthotics For Spinal Deformity - 1980 View Creator An entity primarily responsible for making the resource Robert B. Winter, M.D. * https://staging.drfop.org/files/original/c14dfe270bafb90a2b20c29025446a0e.pdf ea4783b10f5c3a4d12c12442901d6cfc https://staging.drfop.org/files/original/e1c5e0817e16709456d081f6f415e65f.jpeg 25f2e057c93d0e69803ff76ac02699cb https://staging.drfop.org/files/original/b41bc35c2793e59d83d08621281b2157.jpg d5bfa6e4244d4b75c3af3ee1a2a68fca https://staging.drfop.org/files/original/38a21614eba81d206bc337aeb5d6e7fd.jpg b15d554896978844d9a1ee39e912bc50 https://staging.drfop.org/files/original/ab1b7ad80230fb3c67ffc6ab3131818b.jpg 382f8f76e28b2dde663fe0ef853f6e34 https://staging.drfop.org/files/original/4b05615aa03be409c03076b58f01516d.jpg d8571f4ee65ef85e91ebdfa64c11a806 https://staging.drfop.org/files/original/d44602f704718bd80028a10a39ab8557.jpg e1ed3363899743fe273d87b37d17f806 https://staging.drfop.org/files/original/aaeef9fb5c5bb12a4dd59e22be53a3c9.jpg 0f490c5304c88163f508047e5ba454cb https://staging.drfop.org/files/original/e0754e5e8e0d5cf1482166067833d458.jpg a89802e08f0b5c0fc15a0c44adff5e94 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1981_01_001.pdf Text Any textual data included in the document <h2>Scoliosis: Orthotic Management Concepts</h2> <h5>Edward P. Van Hanswyk, CO.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>The orthotic management of idiopathic scoliosis (<a href="/files/original/e1c5e0817e16709456d081f6f415e65f.jpeg"><b>Fig. 1</b></a>) over the years has employed a number of different orthotic systems. Included among them have been the Milwaukee and modified cervico-thoracolumbosacral orthoses (C.T.L.S.O.) as well as various prefabricated, modular, and custom fabricated thoracolumbosacral orthoses (T.L.S.O.).</p> <p>The prescription of any of the systems is dependent upon a number of variables, including the level and degree of curvature, the degree of rotation, the age and physical condition of the patient, and the degree of patient cooperation expected.</p> <p>No matter which system is selected, and no matter which set or combination of variables is present, there exists a number of orthotic management principles for consideration. The purpose of this paper is to outline these principles and theories, the similarities and differences presented by scoliosis, and orthotic management systems employed.</p> <p>In order to present these relationships, a number of somewhat original, and perhaps not so original, orthotic management concepts and theories are discussed. The theories include: 1. the reasons for reducing lumbar lordosis; 2. the idea and employment of a "righting reflex," both sagittal and coronal; 3. the concept of "costal distraction"; 4. the importance of axial alignment; and 5. a theory concerning the deviations of scoliosis, the creation of forces, and the force systems necessary for their control and correction.</p> <h3>Lumbar Lordosis</h3> <p>Historically, there has been an emphasis over the years on the reduction of lumbar lordosis (<a href="/files/original/b41bc35c2793e59d83d08621281b2157.jpg"><b>Fig. 2</b></a>) in the orthotic management of the spine, especially in the orthotic management of scoliosis with the C.T.L.S.O. and the T.L.S.O., for a number of reasons.</p> <ol> <li> <p>In the orthotic management of a lumbar or thoraco-lumbar scoliosis, flexion of the lumbar spine has a positive effect on scoliosis. The distraction that occurs between the thoracic spine and sacrum reduces lumbar scoliosis. The reasons presented for this "correction" include the release of the hip flexors and resultant pelvic tilt, and the stretch of the posterior longitudinal ligaments; the net result being an improvement of the lumbar scoliosis.</p> </li> <li> <p>When managing a lumbar curve in an orthosis with a corrective force from the posterior lateral direction in an attempt to reduce scoliosis and vertebral rotation by compressing of muscle bulge, it is necessary to provide an anterior counter-force to prevent an increase in lordosis.</p> </li> <li> <p>Recognizing that the thoracic and lumbar spine are interrelated, efforts to control lordosis with encasement and stabilization of the pelvis produce an opportunity for leverage and corrective forces, both inductive and direct, to be applied to the thoracic spine.</p> </li> </ol> <h3>"Righting Reflex"</h3> <p>The "righting reflex" (<a href="/files/original/38a21614eba81d206bc337aeb5d6e7fd.jpg"><b>Fig. 3</b></a>) is an example of an inductive force. When producing flexion of the lumbar spine, the kyphotic posture of the thoracic spine accentuates a forward flexion of the shoulder and head. The body's natural tendency to right itself over the center of gravity produces an extension or reduction in thoracic kyphosis. This sagittal plane reflex can be utilized in the orthotic management of Scheurmann's kyphosis and idiopathic scoliosis.</p> <p>Another "righting reflex" force developed is in the coronal plane. In double curves, thoracic and thoracolumbar, when the lumbar curve is reduced, causing a lateral shift of the head and shoulders, the body's natural tendency to right itself results in a reduction in thoracic scoliosis as well.</p> <p>In the orthotic management of scoliosis in a C.T.L.S.O., the "righting reflexes" can be planned as an adjunct to the direct counter-lateral and anti-rotational forces of the thoracic pad.</p> <p>In a T.L.S.O., this inductive extension is aided by a fulcrum created by the superior trim line of the orthosis. In theory, even though the length of the lever arm superior to the apex of the thoracic curve does not appear adequate for a significant force to be applied, the planned instigation of "righting reflex" forces is used to augment a lesser, direct force.</p> <h3>Axial Alignment</h3> <p>The encasement and stabilization of the pelvis provides the counter-force and leverage for direct force application to the thorax as well.</p> <p>Because of the rotational component present in scoliosis, axial alignment of the body, rib cage and pelvis is necessary. The direct force created by symmetric alignment of the pelvic and thoracic surfaces of the orthosis results in a direct anti-rotational corrective force. This is particularly applicable in the orthotic management of a thoracic curve in a T.L.S.O. Since the rotational component present in scoliosis is one variable that may preclude the use of a T.L.S.O., management of rotation in this system can be viewed as critical.</p> <h3>"Costal Distraction"</h3> <p>Another direct force advantage created by the encasement of the pelvis is "distraction." Stabilization of the pelvis and the "total contact" encasement of the lower rib cage in a T.L.S.O. produces an opportunity to maximize the distance between the pelvis and the rib cage, resulting in a distraction of the lumbar spine. The flattened abdominal surface induces lumbar flexion and also increases the intra-abdominal pressures, augmenting this force. The resultant costal-pelvis distraction is another planned, direct force in the orthotic management of lumbar scoliosis in a T.L.S.O.</p> <h3>Orthotic Management Goals</h3> <p>The concepts and theories presented might now be viewed in relation to orthotic management goals relative to scoliosis, specifically the evaluation of the various scoliosis deviations and the corrective forces available in the orthotic management system employed.</p> <p>In the normal spine, the muscles act antagonistically on either side to maintain a straight, neutral spine. The spine, rib cage, and pelvis are symmetrically related and supported by the musculature.</p> <p>In the scoliotic spine, as the vertebrae rotate and move laterally, the muscles lose their lever-arm advantage, and the spine, rib cage, and pelvis lose their symmetry. The orthotic management goals then become:</p> <ol> <li> <p>repositioning of the vertebrae, not only by direct forces, but also by inductive reflex forces.</p> </li> <li> <p>re-establishment of muscle levers and re-establishment of symmetry of the rib cage and between the rib cage and pelvis.</p> </li> </ol> <h3>Thoracic Scoliosis (Two Deviations)</h3> <p>In identifying the orthotic system to be used, the differences in scoliosis deviations should be recognized.</p> <p>Thoracic scoliosis (<a href="/files/original/ab1b7ad80230fb3c67ffc6ab3131818b.jpg"><b>Fig. 4a</b></a>) is seen as a two-deviational deformity, 1. a lateral deviation, the curve, 2. a rotational deviation, the rib prominence. Theoretically a three-directional force system is necessary for management of these deviations. The choice of C.T.L.S.O. or T.L.S.O. force systems depends, of course, on the variables outlined previously.</p> <p>In the three-directional force system C.T.L.S.O. (<a href="/files/original/4b05615aa03be409c03076b58f01516d.jpg"><b>Fig. 4b</b></a>), the forces include, 1. the counter-lateral force of the thoracic pad, 2. the anti-rotational force of the thoracic pad, and 3. the distractive force of the pelvic base opposed by the occipital portion of the neck ring.</p> <p>Certain thoracic curves can be managed also in a T.L.S.O. system: The two-deviational deformity of thoracic scoliosis managed with the lateral and anti-rotational force of the axially aligned surfaces of the orthosis, augmented by the righting reflex inductive forces, coronal and sagittal.</p> <h3>Lumbar Scoliosis (Three Deviations)</h3> <p>Thoraco-lumbar and lumbar curves (<a href="/files/original/d44602f704718bd80028a10a39ab8557.jpg"><b>Fig. 5</b></a>) are seen as a three-deviational deformity (<a href="/files/original/aaeef9fb5c5bb12a4dd59e22be53a3c9.jpg"><b>Fig. 6</b></a>). In addition to the lateral and rotational deviations there is usually a tendency toward lordosis. The asymmetry and loss of muscle levers and the shape of the lumbar vertebrae allow hyper-extension which contributes to a third deviation. It becomes necessary to incorporate a four-vector force system to manage this three-deviational deformity.</p> <p>The four-vector force system T.L.S.O. (<a href="/files/original/e0754e5e8e0d5cf1482166067833d458.jpg"><b>Fig. 7</b></a>) contains: 1. anti-lordotic, 2. lateral, 3. anti-rotational, and 4. costal distraction forces, all described earlier.</p> <p>In summary, understanding of the concepts and theories presented is necessary to provide the orthotic management system reflecting the re-positioning and forces required for appropriate correction.</p> <p><b>References:</b></p> <ol> <li>Van Hanswyk, Edward P., Hansen, Yuan, and Eckhardt, Wayne, A., "Orthotic Management of Thoraco-Lumbar Spine Fractures with a 'Total-Contact' TLSO," <i>Orthotics and Prosthetics Journal</i>, Vol. 33, No. 3, pp 10-19, September, 1979.</li> <li>Van Hanswyk , Edward P. and Bunnell, William P., "The Orthotic Management of Lumbar Lordosis and the Relationship to the Treatment of Thoraco-Lumbar Scoliosis and Juvenile Kyphosis," <i>Orthotics and Prosthetics Journal</i>, Vol. 32, No. 2, pp 27-34, June, 1978.</li> </ol> <div style="width: 400px;"><em><b>*Edward P. Van Hanswyk, CO. </b> Instructor, Department of Orthopedic Surgery, University Medical Center, SUNY, Syracuse, New York.</em></div> Page Number(s) 1 - 4 Year 1981 Volume 5 Issue 1 Figure 1 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-5.jpg Figure 6 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-6.jpg Figure 7 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-7.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 8 http://www.oandplibrary.org/cpo/images/1981_01_001/1981_01_001-8.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Scoliosis: Orthotic Management Concepts Creator An entity primarily responsible for making the resource Edward P. Van Hanswyk, CO. * https://staging.drfop.org/files/original/d1fa99c68ccb7ad17715ef0dc1dd6825.pdf 2673ebe4132713a88e1fc6bbbefeea96 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_04_007.pdf Text Any textual data included in the document <h2>Hydraulic/Pneumatic Knee Control Units A Prosthetist's Point of View</h2> <h5>Charles H. Pritham, CPO&nbsp;<a style="text-decoration: none;">*</a></h5> <p>As Mr. Wilson has demonstrated, the use of hydraulic and pneumatic control units had its genesis in the post World War II R &amp; D effort. The objective, of course, was to fit the returning veteran AK amputee with the best prosthesis technology could provide. Such amputees were young and physically fit, prime candidates to benefit from the advantages of advanced control units. The prime advantage, usually cited, is cadence responsiveness. As the patient walks at different rates, the control unit automatically adjusts to control heelrise and terminal swing impact. Constant friction knees can not duplicate this feature. All hydraulic and pneumatic units provide this feature and one, the Mauch S-N-S, provides stance phase control as well. This means that the unit provides enhanced knee stability in the early portion of stance phase to increase the patient's safety.</p> <p>In this mode, the S-N-S unit can be said to function in a fashion analogous to that of a conventional safety knee. In another mode, the function of the S-N-S can be likened to that of a simple manually locking knee. Two other knee control units, variants of Kingsley's Hydranumatic and USMC's Dynaflex, function in a similar fashion.</p> <p>The Hydracadence, in addition to swing phase control, also provides heel height adjustability and toe pick-up. Otto Bock has recently introduced a modular knee that includes a hydraulic swing phase control.</p> <p>As can be seen then, these are just a few of the variations available to the prosthetist and his patient. The principal advantages claimed for such control units are enhanced cosmesis and performance, and lower energy expenditure. Against these advantages, the disadvantages must be weighed. Bulk, size, and weight of some of the units preclude their use by many patients. The considerable expense of most, if not all, hydraulic and pneumatic control units rules out others. Moreover, the control units have been shown to be unreliable. Some patients derive satisfactory service from their units while other patients using the same brand unit are constantly having them replaced and repaired. As most of the units need to be factory serviced, the delay and expense of maintaining a unit under such circumstances can engender considerable frustration.</p> <p>Given these circumstances, the pool of available amputees for whom such advanced control units are suitable is a small proportion of the total AK population, and most closely resembles the patients for whom they were originally developed: young traumatic males; i.e. veterans. It must be borne in mind that this pool today represents a less important proportion of the amputee population than it did some 25 years ago. Statistics demonstrate that the majority of civilian amputees in the Western World are geriatrics who lose a leg due to arteriosclerosis and are as often as not female. Indeed, the very amputees who were originally provided hydraulic units by the VA are not getting any younger. The day will come for each of them when they, and the clinic teams who attempt to address their needs, must make a reappraisal of their prescription. So, the use of hydraulic/ pneumatic control units for a considerable portion of the amputee population can be ruled out. Not only that, but it is possible to be very skeptical in considering the suitability of such units for patients for whom it is theoretically ideally suited.</p> <p>Young, active traumatic amputees are probably, children aside, the hardest on their prostheses. Given the expense of purchasing and maintaining such a unit, does it make sense to fit an amputee with one if he is going to have more than average maintenance problems? Can he afford the time lost from work, interruptions in his daily life, and expense of repairs? Given the disproportionately rising cost of health care today, can society? Gait studies demonstrate that AK amputees walk slower than normal subjects and BK amputees because of increased energy expenditure. If this is so, is the prime advantage cited for hydraulic/pneumatic units, cadence response, relevant and worth the additional expense and problems? In another vein, given the aging nature of the population should further effort and money be devoted to developing newer and more sophisticated knee control units?</p> <p>In any event, it can be said that a prosthetist in attempting to formulate a solution to his patient's problems is confronted with a number of questions and a wide variety of devices all intended to perform the same function. It is also true that the prosthetist has little more than personal experience, hearsay, and the competing claims of the manufacturers to aid him in making his decision. The natural tendency on the prosthetist's part is to provide his patient with the most sophisticated unit possible, for all of us gain considerable satisfaction from doing so and from working with such units. The patient also wants the best prosthesis possible. The fact remains, however, that such tendencies must be resisted and both prosthetists and patient must make a realistic appraisal of the situation and logically weigh the pros and cons.</p> <b>*Charles H. Pritham, CPO </b> Technical Coordinator Durr-Fillauer Medical, Inc. Chattanooga, Tennessee Editor, C.P.O.<br /><br /> <div style="width: 400px;"></div> Page Number(s) 7 - 8 Year 1983 Volume 7 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Hydraulic/Pneumatic Knee Control Units A Prosthetists Point of View Creator An entity primarily responsible for making the resource Charles H. Pritham, CPO * https://staging.drfop.org/files/original/ea5cb965d7cc12d8d6b0c436964b44d9.pdf e5e3dd0a8d1c47e6d18a93f0e7dde31d https://staging.drfop.org/files/original/eb8ca65bd9a979fad277a91a57b0e631.jpeg 43dae3e86044e9e9337edfa12f8d523c https://staging.drfop.org/files/original/b99d31ef707acfb4cb39459306f929ae.jpg 1f0a63be299196ddf613145c782f8bb2 https://staging.drfop.org/files/original/fac91bdfc7e7039cf0393d7300667e49.jpg 4f4ff35f2fa8689775893928003e2f4d https://staging.drfop.org/files/original/17601e26a1ee85e6b6d571785e2d2278.jpg b0ffbc512dbf96e101590a70c9834f21 https://staging.drfop.org/files/original/3c565e3e3e82d1e16dd0bc2c8487a402.jpg edc1b0783e1722653e72676e255cecdc https://staging.drfop.org/files/original/f60360f716924225bb6b1b92e24d5971.jpg ccb584ca57daf2499edbf1d0c9c55314 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_04_004.pdf Text Any textual data included in the document <h2>Physical Therapy and Hydraulic Knee Units</h2> <h5>Bernice Kegel R.P.T.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Without a thorough understanding of the principles of operation and functional benefits engineered into the sophisticated hydraulic knee mechanisms, the therapist will be unable to help the amputee gain maximum benefits and use the system effectively. It is important that the prosthetist ascertain that the therapist knows what adjustability is incorporated into the prosthesis. Much of the adjustment will be done during dynamic alignment at the prosthetic facility, but modifications will need to be made as the patient gains confidence and his ambulation pattern improves.</p> <p>An understanding of the fundamental differences between hydraulic control and mechanical friction will help in training the amputee to take full advantage of the flexibility of hydraulic mechanisms. Amputees can walk over a wide range of cadences instead of being limited as with mechanical friction. There are two reasons for this. First, hydraulic friction increases with speed to balance the increase in kinetic energy of the prosthesis while mechanical friction remains essentially constant. The programmed hydraulic characteristics give little frictional resistance during initial extension and flexion but build to a peak at terminal flexion and extension. This helps to provide a natural appearing gait regardless of cadence. The stability of hydraulic systems permits alignment nearer the trigger point and thus results in less energy expenditure required for walking. If a patient has previously used a mechanical knee, he needs to be reminded that no exaggerated residual limb motion is necessary to gain adequate flexion and extension of his hydraulic prosthesis.</p> <p>For purposes of brevity, I will limit my discussion to gait training with one knee unit-the Mauch S-N-S (<b>Fig. 1</b>). The Mauch S-N-S knee unit can be set to provide 3 functions:</p> <strong><a href="/files/original/eb8ca65bd9a979fad277a91a57b0e631.jpeg">Figure 1</a>. Cutaway diagram of the Mauch Unit</strong><br /> <ol> <li> <p>Swing and Stance phase control.</p> </li> <li> <p>Swing phase control only.</p> </li> <li> <p>Manual knee lock.</p> </li> </ol> <p>A stirrup shaped lever near the top of the piston rod operates as a selector switch. When the lever is in the down position, swing and stance control are both operative. This would be the adjustment chosen for normal walking. The major advantage of stance control is that it offers the patient stumble recovery. If the prosthetic knee buckles, it will give way slowly enough that the patient should be able to regain his balance before falling. When training a patient with a conventional knee unit, he is taught to forcefully contract his hip extensors late in swing phase to accelerate the shank forward (with resulting terminal impact) to ensure extension of the knee at heel strike. Amputees wearing fluid-controlled mechanisms need not do this. The amputee should be instructed to swing his thigh forward, decelerate it, and end the movement with the residual limb pointing to the point on the ground where the heel should strike. The shank, aided by the built-in extension bias will swing forward smoothly, and at heel strike will be in full extension. With the stance phase control engaged, the prosthetic knee will be stable in the initial portion of stance phase without forceful extension of the hip musculature being necessary. The feature makes gait training markedly easier.</p> <p>It is extremely important during the end of stance phase on the prosthetic side that the hip be ahead of the knee and weight on the ball of the foot. This hyperextension moment is necessary to disengage the stance phase control momentarily and allow the knee to bend freely in swing phase. If the amputee does not exert this hyperextension for 1/10th of a second, he might experience difficulty in flexing the knee to begin swing phase. When walking on soft ground, it is even more important to exert this hyperextension moment.</p> <p>The benefits of stance control are also used when walking down stairs and ramps in a step-over-step manner. This ability to walk down steps in a step-over-step manner rather than one step at a time or by jack-knifing is one of the key advantages of the Mauch knee unit. The patient needs to be taught to place his prosthetic heel on the lower step with the forefoot extending beyond the edge of the step (<b>Fig. 2</b>). He is then told to flex his hip forward while simultaneously putting weight on the prosthetic leg. This will cause a controlled bending of the prosthetic knee. As the prosthetic knee yields, the sound leg is brought forward and placed on the lower step. If the patient has to wait for the prosthetic knee to bend, then stance phase resistance is too high and should be reduced. This activity is probably the most difficult to teach an amputee, especially if he has used a conventional knee unit in the past. This same technique is used for going down ramps. When walking up steps and ramps the same techniques are used as in conventional training.</p> <strong><a href="/files/original/b99d31ef707acfb4cb39459306f929ae.jpg">Figure 2</a>. Correct placement of the prosthetic heel</strong><br /> <p>When sitting down in a chair, the patient can either use the weight bearing resistance of the S-N-S unit to control the rate of sitting, or release the stance phase control and use the sound leg to control sitting rate in the same fashion as with a conventional knee unit.</p> <p>How quickly the knee bends under weight is determined by the stance adjustment screw, which is turned with a 22mm Allen wrench (<b>Fig. 3</b>). The adjustment is <i>extremely</i> sensitive with a range of only 120 degrees. Slowest bending and maximum stability is obtained with a full clockwise adjustment. Most patients like to start with a high degree of stability.</p> <strong><a href="/files/original/fac91bdfc7e7039cf0393d7300667e49.jpg">Figure 3.</a> Allen wrench inserted into the stance adjustment screw</strong><br /> <p>To eliminate stance phase control the patient is told to stand with his prosthetic leg behind his sound leg. With weight on the toe of his prosthesis, he pulls the selector switch lever up (<b>Fig. 4</b>). This mode would be used for bicycling and other activities needing a free swinging leg. Swing resistance is adjusted by moving the serrated cap. The verticle black line under the serrated cap is the extension resistance marker. When the black line is all the way to the right (4 o'clock) extension resistance is lowest, and all the way to the left (8 o'clock) is the maximum setting. A good resistance for beginning walking would be at 5 o'clock (<b>Fig. 5</b>).</p> <strong><a href="/files/original/17601e26a1ee85e6b6d571785e2d2278.jpg">Figure 4</a>. Eliminating the stance phase control.</strong><br /><br /><strong><a href="/files/original/3c565e3e3e82d1e16dd0bc2c8487a402.jpg">Figure 5</a>. Good resistance settings for beginning walking.</strong><br /> <p>The same serrated cap that adjusts extension resistance also adjusts flexion resistance. When the "H" in the word HYDRAULIC is over the line marker (regardless of the position of the line marker), flexion resistance is lowest. "K" over the marker indicates maximum resistance. A good resistance for beginning walking is at the "D" position (as shown in <b>Fig. 5</b>).</p> <p>To engage the knee lock, the selector switch is pulled into up position with the knee flexed and bearing no weight (<b>Fig. 6</b>). The knee may now be extended from this flexed position, but increased flexion is not possible.</p> <strong><a href="/files/original/f60360f716924225bb6b1b92e24d5971.jpg">Figure 6</a>. Engaging the knee lock.</strong><br /> <p>A right-legged amputee might choose to lock the prosthetic knee while driving and pressing the pedal by a forward motion of the hip. For standing at work for any length of time or while standing on a bus, the amputee could be taught to lock his knee.</p> <p>The Mauch S-N-S units have also been successfully used by bilateral amputees. The two units are likely to be adjusted differently because different residual limb lengths call for different resistance settings.</p> <p>The patient should be taught that the hydraulic unit may require servicing every one to two years. He should also be told that small amounts of air in the hydraulic system are no reason for concern. An automatic selfbleeding feature will eliminate the air after he walks a few steps, or if he bends the knees several times before applying the prosthesis. The leg should be stored upright with the knee fully extended so that air does not enter the hydraulic spaces.</p> <p><b>References:</b></p> <ol> <li>Kegel, B., Byers, J.L., "Amputee's Manual-Mauch S-N-S Knee." Medic Publishing Co., P.O. Box 1636, Bel-levue, WA 98009, 1977.</li> <li>Lewis, E.A., "Elements of Training with the Mauch S-N-S System for Above-Knee Amputees." Research and Development Division, Prosthetics and Sensory Aids Service, Veterans Administration, 252 Seventh Avenue, New York, New York 10001.</li> <li>Lewis, E.A. and Bernstock, W.M., "Clinical Application Study of the Henschke-Mauch Model A Swing and Stance Control System." <i>Bulletin of Prosthetics Research</i> Fall, 1968.</li> <li>Mauch, H.A., "Stance Control for Above-Knee Artificial Legs-Design Considerations in the S-N-S Knee." <i>Bulletin of Prosthetics Research</i>, Fall 1968.</li> <li>Knee Prostheses, Mauch Laboratories, Inc., 3035 Dryden Road, Dayton, Ohio 45439, January 1974.</li> <li>Murphy, E.F., "The Swing Phase of Walking with Above-Knee Prosthesis." <i>Bulletin of Prosthetics Research</i>, Spring 1964.</li> <li>Staros, A. and Murphy, E.F., "Properties of Fluid Flow Applied to Above Knee Prostheses." <i>Bulletin of Prosthetics Research</i>, Spring 1964.</li> </ol> <em><b>*Bernice Kegel R.P.T. </b> Seattle, Washington<br /><br /><br /></em> Page Number(s) 4 - 7 Year 1983 Volume 7 Issue 4 Figure 1 http://www.oandplibrary.org/cpo/images/1983_04_004/1983_04_004-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1983_04_004/1983_04_004-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1983_04_004/1983_04_004-3.jpg Figure 4 http://www.oandplibrary.org/cpo/images/1983_04_004/1983_04_004-4.jpg Figure 5 http://www.oandplibrary.org/cpo/images/1983_04_004/1983_04_004-5.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 6 http://www.oandplibrary.org/cpo/images/1983_04_004/1983_04_004-6.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Physical Therapy and Hydraulic Knee Units Creator An entity primarily responsible for making the resource Bernice Kegel R.P.T. * https://staging.drfop.org/files/original/c1dcd8002daf073f875a014ab93e6d77.pdf 9f6846fc84195173da86b474bf524650 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_04_003.pdf Text Any textual data included in the document <h2>Hydraulics and Above-Knee Prosthetics</h2> <h5>A. Bennett Wilson, Jr., B.S.M.E. <a style="text-decoration: none;">*</a></h5> <p>Some of the highlights in the history of the use of hydraulic systems in artificial legs might be useful in understanding the present status and influencing the future application of hydraulic principles in lower-limb prosthetics.</p> <p>One of the prime objectives of the designers of artificial legs for above-knee amputees is control of the knee joint, and, thus, the shank to provide the amputee with the means to stand and walk safely, efficiently, and gracefully. Sporadically since 1918, and possibly before, hydraulic principles were proposed as a means for locking or braking the knee to enhance safety, but none of these ideas seem to have reached a practical stage until after World War II.</p> <p>When the National Academy of Sciences (NAS) initiated a research program in limb prosthetics in 1945 at the request of the Surgeon General of the Army, surveys of amputees indicated that the above-knee amputees felt that their greatest need was a knee lock that would prevent stumbling. This "finding" prompted a number of designs in the United States that used hydraulic systems to provide knee locking or braking on demand. Concurrently, a team in Germany, Ulrich Henschke, a physician, and Hans Mauch, an engineer, developed a leg prototype that used a hydraulic lock activated by motion of the abdominal wall. After Dr. Henschke and Mr. Mauch moved to the United States at the invitation of the United States Air Force, they were encouraged by their host to continue development of their design, and they became active in the NAS Artificial Limb Program.</p> <p>During the 1940's, Mr. Jack Stewart, an AK amputee and inventor, devised, to meet his own needs, an above knee leg which used a hydraulic system to not only provide knee locking, but also to provide shock absorption at the heel, co-ordinated motion between knee and ankle joints, and adjustability of the height of the heel. Swing phase control was provided by hydraulic fluid being forced through a single orifice, a serendipitous sort of circumstance.</p> <p>About 1951, leaders in the research program came to the conclusion, based on data developed at the University of California, that perhaps, more important than control in the stance phase, is control during the swing phase. Mr. Mauch was requested to give high priority to the design of a mechanism that would provide control of the knee during swing phase so that the amputee could vary cadence without changing the friction control setting. At about the same time, it was recognized that the characteristics of a fluid flowing through an orifice had the possibility of providing automatically the change in resistance to knee flexion and extension needed to compensate for changes in the walking cadence.</p> <p>Using many of the same parts designed for the stance-control system as well as data provided by the University of California Biomechanics Laboratory concerning knee movements during swing phase, Mr. Mauch produced a unit with a number of orifices arranged to provide changes in resistance to rotation at the knee corresponding to the "normal." This design, known as the Model "B," after some years of testing and field use, was combined with the stance-control system to produce the Model "A," which when modified was marketed as the Henschke-Mauch S'n'S (Swing and Stance) knee unit. During the development of the Henchke-Mauch units several less complex hydraulic and pneumatic units were also developed by others and marketed commercially with some degree of success.</p> <p>During the early 1950's 18 units of the Stewart design known as the Stewart-Vickers Hydraulic Leg were evaluated by a team at New York University, who found good amputee acceptance, and recommended that the locking feature be eliminated since the cost could be reduced appreciably and the test subjects didn't seem to make use of that feature. This recommendation was followed by Mr. Stewart, who a short while later sold all rights to U.S. Manufacturing Co., who manufactured and marketed it as the Hydra-Cadence Leg. The Hydra-Cadence Leg has been a commercial success, but in spite of a great deal of experience, no one can be sure of the relative importance of its many features.</p> <p>The development of hydraulic mechanisms for artificial legs has been plagued by leakage and breakage, which is only natural in an effort that tries to arrive at the optimum compromise between cost, weight, and function. Whether or not this optimum has been achieved is not yet known. We do know, however, that active above-knee and hip-disarticulation amputees appreciate the swing-phase control function afforded by hydraulic mechanisms and that the present day costs are not prohibitive for a substantial number of amputees. No definitive studies have been made that would delineate the efforts of the various factors and features involved, singly or in combination. With the availability of 4-channel 24-hour physiological surveillance systems and other sophisticated instrumentation, such studies seem to be quite feasible now and certainly should be considered.</p> <p>For at least thirty years the need for voluntary control of the knee joint has been recognized, but until the advent of the microcomputer it was difficult to conceive of a practical method to accomplish this. When microcomputers became available, the first reaction of some designers was simply to add the microcomputer to present hydraulic systems, but these efforts failed most probably because the systems available were not designed for control by computer. At any rate, it would seem that the weight alone of present systems would make voluntary control impractical, and thus any project in this area should begin anew.</p> <p>At present, very little work seems to be going on in the area of voluntary control systems. Some work at the Massachusetts Institute of Technology has been reported for nearly a decade. More recently, the REC at Moss Rehabilitation Hospital started a project where pattern recognition techniques are used to obtain subconscious control of a knee mechanism by EMG signals about the hip joint, which shows a good deal of promise.</p> <p>Perhaps what we need most at this point is more information concerning the contribution of each variable, such as swing-phase control, stance-phase control, ankle action, weight, and weight distribution, singly and in combination, for designers of the next generation of above-knee legs. With the technology now available to us, this appears to be possible as well as practical.</p> <em><b>*A. Bennett Wilson, Jr., B.S.M.E. </b>Assistant Director, Rehabilitation Research and Training Center Dept. of Orthopaedics and Rehabilitation University of Virginia Medical Center Charlottesville, Virginia 22908.<br /><br /></em><br /> <div style="width: 400px;"></div> Page Number(s) 3 - 4 Year 1983 Volume 7 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Hydraulics and Above-Knee Prosthetics Creator An entity primarily responsible for making the resource A. Bennett Wilson, Jr., B.S.M.E. * https://staging.drfop.org/files/original/d387177f1743b2d3eb2e5fd8a7efd4c6.pdf 5152d646cade58bf58af3b450a7b5ac2 https://staging.drfop.org/files/original/cf533beb527fcd368a66e40b0251877b.jpeg 746bfce96a05847c161f7f8919e43c51 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_04_001.pdf Text Any textual data included in the document <h2>S-N-S Knees and the Bilateral A/K Amputee</h2> <h5>Gustav Rubin, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p>We have under our care at VAREC eleven adult male bilateral A/K <i>ambulators</i>. Ten of these use Swing and Stance (S-N-S) knees and one, a missionary to a remote area in Africa, was fitted with single axis knees because of the obvious need for simplicity in his special circumstances. Eight of our S-N-S users are active individuals, but two are household and limited community ambulators. As would be anticipated, all of our above-knee amputee ambulators are in good physical condition and strongly motivated. These were important aspects in prescribing prostheses. The S-N-S knees provided the amputees with the smooth gait characteristic of hydraulics, greater security, improved ease in reaching the sitting position, improved opportunity to recover from sudden stops or potential stumbles, better control when descending stairs, and the ability to lock one or both knees for negotiation of stairs. We have also found the S-N-S to be the sturdiest of the hydraulic units.</p> <p><b><a href="/files/original/cf533beb527fcd368a66e40b0251877b.jpeg">Image</a>: </b>A.H., an active bilateral A/K ambulator.<br /><br />No one of our amputee veterans demonstrates the potential of S-N-S knees better than A.H., injured in Vietnam at 21 years of age. A. H. was initially evaluated by the VAREC Clinic Team over one year later on Sept. 24,1970.</p> <p>A.H. sustained bilateral A/K amputations. The right A/K stump was eight inches in length and multiply scarred. The left A/K stump, partially covered by healed split thickness skin grafts, was seven and one-half inches in length. A.H. also sustained partial amputations of the fingers of both hands. The index and middle fingers of the left hand were amputated; on the right hand, the proximal phalanges of the fourth and fifth fingers and the first metacarpal of the thumb were retained. A.H. demonstrated that he was capable of grasping crutches with both residual hands. On the right he could come within an inch of opposing the first metacarpal to the fourth and fifth proximal phalangeal stumps. Opposition could be achieved on the left.</p> <p>A.H. was in excellent physical condition, very well motivated, without hip contractures, and with good muscle power of the trunk and residual extremities. He had been working out in his garage, which he had converted to a gym. When seen, he weighed 160 lbs. and indicated that his pre-amputation height was 6 feet, 1-1/2 inches (a height that was subsequently successfully reachieved at his request).</p> <p>The VAREC Clinic Team decided to prescribe bilateral A/K partial suction quad sockets with waist belt, rigid uprights and band, multiplex knees (to allow trial of several knee units "in the rough"), and, finally, a trial with first SACH feet, and then single axis feet. The S-N-S knee units and single axis feet were selected on the basis of A.H.'s performance with them.</p> <p>On May 13, 1971 A.H. walked to VAREC without a cane or crutches. After a subsequent trial with total suction and silesian belts he had to be returned to his original prescription, due to stump scarring.</p> <p>A.H. had been an accomplished skier prior to amputation and, on January 25, 1974, requested prostheses with which he could ski again. The clinic team notes of that date follows.</p> <p>"He has been informed that skiing will be dangerous. Nevertheless, he is anxious to try it, and, because of the morale factor and the intensity with which this patient wishes to ski, plus the fact that he was a skier prior to his leg amputations, the prostheses have been ordered." Outrigger ski poles with special adjustments for the hand grips were also prescribed.</p> <p>The first prescription was determined after another bilateral A/K skier was invited to visit the clinic team with his prostheses. That concept was copied and prostheses were supplied to A.H. with solid knees fixed at 45 degrees and correspondingly dorsiflexed feet. They were rejected shortly thereafter by A.H. since they allowed him to slide down only low slopes.</p> <p>The prostheses with S-N-S knees and single axis feet however, did allow him to actively ski. It is noteworthy that the most efficient position of his stumps, since he required strong abductor power for skiing, was found to be in sockets set up in almost twenty degees of abduction. Since the neutral position of the feet was more efficient for skiing the feet were not out-toed.</p> <p>A.H. proved his proficiency on skis (<a href="/files/original/cf533beb527fcd368a66e40b0251877b.jpeg">see photo</a>) by winning the handicapped Olympics in Norway in 1982. He has competed in numerous events in the U.S. and overseas and he reports that he can negotiate 40 slalom gates in 60 seconds.</p> <p>He has not been trouble free, however. The most serious of his problems occurred when a spur was removed from his left stump and overlying soft tissue breakdown occurred. Although this healed secondarily, the clinic team advised that the area be covered by adequate soft tissue. This was done and the amputee had no further difficulty. A.H. continues to be active and, in addition to skiing, sails his own boat.</p> <p>Not all amputees, however, follow the same road to successful ambulation. At one time, the clinic team believed they had two patients who had the potential and motivation to ambulate. The team provided prostheses but the patients became obese and gave up the effort. The rehabilitation of one, a triple amputee (BE on one side) was, unfortuntately, a notable failure.</p> <p><em><b><b>*Gustav Rubin, M.D. </b></b>FACS Chief, VAREC Special Clinic Team</em></p> <p><em>&nbsp;</em></p> Page Number(s) 1 - 2 Year 1983 Volume 7 Issue 4 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 1 http://www.oandplibrary.org/cpo/images/1983_04_001/1983_04_001-1.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 S-N-S Knees and the Bilateral A/K Amputee Creator An entity primarily responsible for making the resource Gustav Rubin, M.D. * https://staging.drfop.org/files/original/e1690cf1890c573375cb787032399988.pdf 87ee8a5abed800c76c98156dc2200899 https://staging.drfop.org/files/original/eabe930fc32847ec7e0d92434e7bc45f.jpeg b3f9edfdc10e1b362dba27c588c54d35 https://staging.drfop.org/files/original/4c55a6f8fb1adae4dd686d30f0e72e98.jpg 7ea898f965eb05a136608fe7f0fa85db https://staging.drfop.org/files/original/972fd80c1ddfa050d6812e2062ddeca8.jpg 3019cc6d45434da220cde813c997c009 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_03_010.pdf Text Any textual data included in the document <h2>Technical Note: A Cervical Orthosis Modification</h2> <h5>Paul Trautman, CPO&nbsp;<a style="text-decoration: none;">*</a><br />George Varghese, MD&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Recommending or prescribing the best possible cervical orthosis for a patient whose cervical vertebrae require support is a difficult task for an orthotist or physician.</p> <p>In recent years the plastazote® (Philadelphia) cervical orthosis has become a highly prescribed device for several reasons (<a href="/files/original/eabe930fc32847ec7e0d92434e7bc45f.jpeg"><b>Fig. 1</b></a>). Most importantly, the orthosis limits flexion and extension of the cervical spine as well as rotation between C-3 and C-7 and patients find it reasonably comfortable and accept wearing it. This is due, to some extent, to the fact that the low temperature, and easily moldable plastazote® conforms in time to the patient's contours. The better distribution of pressure and comfort for the patient may provide more relaxation of the para-cervical spinal <br /><br />Secondly, the Philadelphia cervical orthosis is relatively inexpensive compared to more rigid appliances. Thus, it is less costly to replace when it becomes contaminated or spoiled beyond cleansing.</p> <p>A third important feature is the ease of selecting and donning the device. Only two measurements, the length of the neck and the circumference of the neck are required. The orthotist is able to provide the item to the patient readily, and it is not necessary to maintain a large, costly inventory.</p> <p>In the Neurosurgery Intensive Care Unit of the University of Kansas' Bell Memorial Hospital, this cervical orthosis has become the orthosis of choice for treating head trauma patients. The posterior half of the collar can be slipped behind the patient's supported head and neck with a minimal amount of need to move the patient. The anterior half is easily put into place to complete the fitting.</p> <p>Since a number of ICU patients have required a tracheotomy it became necessary to modify the Philadelphia cervical orthosis. The design modification created by staff orthotist Wallace Whitney, CO is seen in <a href="/files/original/4c55a6f8fb1adae4dd686d30f0e72e98.jpg"><b>Fig. 2</b></a> and <b><a href="/files/original/972fd80c1ddfa050d6812e2062ddeca8.jpg">Fig. 3</a>.</b></p> <p>Since we do this modification fairly regularily we have made a plaster cast to preform the low temperature plastic (K-splint® or Orthoplast®) reinforcement piece. The original anterior strap is cut in the center, folded over and riveted to the plastic reinforcement piece and the collar. A hole (1 1/4 inch) for the tracheotomy tube is cut through the collar. A side effect is that the collar is made slightly more rigid which is often desirable for those patients.<br /><br /><em><b>*George Varghese, MD </b>Associate Professor, Department of Rehabilitation Medicine University of Kansas College of Health Sciences and Hospital Kansas City, Kansas</em></p> <p><em><b>*Paul Trautman, CPO </b>Director of Orthotics/Prosthetics University of Kansas College of Health Sciences and Hospital Kansas City, Kansas</em></p> <p><em>&nbsp;</em></p> <div style="width: 400px;"></div> Page Number(s) 10 - 11 Year 1983 Volume 7 Issue 3 Figure 1 http://www.oandplibrary.org/cpo/images/1983_03_010/1983_03_010-1.jpg Figure 2 http://www.oandplibrary.org/cpo/images/1983_03_010/1983_03_010-2.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 3 http://www.oandplibrary.org/cpo/images/1983_03_010/1983_03_010-3.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 Technical Note: A Cervical Orthosis Modification Creator An entity primarily responsible for making the resource Paul Trautman, CPO * George Varghese, MD * https://staging.drfop.org/files/original/cafa9b743d894ef8ac329dd049105439.pdf c5c3c6f8570f5611fb7f6c5a42f9907f https://staging.drfop.org/files/original/da8d8abfb620ef2e663567dd50bcc654.jpeg 1a03a7488c0c4c3a9df9bdbc0366fc44 https://staging.drfop.org/files/original/3f58c60474774ff9e63168d5ae29a02e.jpg 815138367afbe230364d1322051cddfe https://staging.drfop.org/files/original/3144aa6cc1e6fdbd0b6a2114007d029c.jpg 5b636b99ef116d0e221fdb299ac85bb1 https://staging.drfop.org/files/original/5d13bc560af79f59d4201f44574589b8.jpg c266285611b6774216497b8f21a83e26 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_03_008.pdf Text Any textual data included in the document <h2>Technical Note: Wrist Flexion Unit Modification</h2> <h5>Peter A. Ockenfels, CPO&nbsp;<a style="text-decoration: none;">*</a></h5> <p>Several years back we learned that a wrist flexion unit, be it the Homser FM 500, 300, 200, or the Pope Easy Flexion Wrist PW 4-6, has little value for bilateral above elbow or bilateral shoulder disarticulation amputees. The patient involved, a right true shoulder disarticulation and left humeral neck amputee, had been successfully fitted with bilateral prostheses. The term "successful" can only be used in terms that the patient felt comfortable, was able to flex his elbows to 90 degrees and 135 degrees, and able to open the terminal device with extended elbow 100 percent of full opening elbow flexion of 90 degrees, 80 percent, and at elbow flexion of 135 degrees, 50 percent. Both prostheses were harnessed with leg loops and the usual elbow lock controls. Wrist units were prescribed and incorporated into both forearms, but proved to be quite useless due to the fact that the patient was unable to activate the wrist units.</p> <p>To rectify the situation, the following modification was constructed. The trigger bar that activates the wrist flexion units is located medially on either wrist unit; therefore, an activating lever was designed and incorporated into the forearm (<a href="/files/original/da8d8abfb620ef2e663567dd50bcc654.jpeg"><b>Fig. 1</b></a>), so that the patient can trigger wrist flexion by pushing against a chair, his leg, or any other object (<a href="/files/original/3f58c60474774ff9e63168d5ae29a02e.jpg"><b>Fig. 2</b></a>). Extension of the wrist unit is achieved using the legs (<a href="/files/original/3144aa6cc1e6fdbd0b6a2114007d029c.jpg"><b>Fig. 3</b></a>). The trigger lever (<a href="/files/original/5d13bc560af79f59d4201f44574589b8.jpg"><b>Fig. 4</b></a>) is made of 1/8" aluminum and pivots on a 3/16 half-threaded rod, mounted in the sides (ant. and post.) of the forearm wall. The patient no longer uses his right SD prosthesis and has been converted to a special chest harness. The wrist flexion trigger mechanism has proven to be very successful, and the patient would not be able to accomplish many tasks of daily care without it.</p> <em><b><b>*Peter A. Ockenfels, CPO </b></b>American Orthotic &amp; Prosthetic Laboratory, Inc. Columbus, Ohio</em><b><b><br /><br /></b></b> Page Number(s) 8 - 8 Year 1983 Volume 7 Issue 3 Figure 2 http://www.oandplibrary.org/cpo/images/1983_03_008/1983_03_008-2.jpg Figure 3 http://www.oandplibrary.org/cpo/images/1983_03_008/1983_03_008-3.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/1983_03_008/1983_03_008-4.jpg Figure 1 http://www.oandplibrary.org/cpo/images/1983_03_008/1983_03_008-1.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 Technical Note: Wrist Flexion Unit Modification Creator An entity primarily responsible for making the resource Peter A. Ockenfels, CPO * https://staging.drfop.org/files/original/2a26fa46a936952d7346630a4fddeb3b.pdf 9bf1d7ad81311e350ca58227aa8ef3e4 https://staging.drfop.org/files/original/fd60ab108fc04d3ee3243e19fd78a73d.jpeg 12316de41cb85404fa07f030884d0bbd https://staging.drfop.org/files/original/b22d12eeac67c882c1a6ee06ab860780.jpg 5c959a25cd8c901d6983309deb9ae306 https://staging.drfop.org/files/original/7555fd7f9d24bef41fe4b95c8c319ccf.jpg aa82aa97958a91904276e94a5b918415 Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_03_005.pdf Text Any textual data included in the document <h2>Some Comments on Cervical Orthoses</h2> <h5>Augustus A. White, III, M.D.&nbsp;<a style="text-decoration: none;">*</a></h5> <p><i>The following was received past the deadline for the Spring C.P.O., for which it was intended. Because of the interest in the subject it addresses, we are printing these comments here. Anyone wishing to respond to the points the author raises may do so through letters to the editor. Our thanks to Dr. White for submitting his editorial.</i></p> <p style="margin-left: 10%;"><i>The Editor</i></p> <h3>Introduction</h3> <p>A classic history on the development of orthopaedic appliances, including some interesting material on cervical orthoses, has been written by J. W. Edwards (1952). A reading of this work quickly illustrates that many orthotic devices bear a striking resemblance to components of medieval armor. Particularly prominent in cervical orthotics is the work of Hugh Owen Thomas. This ingenious, chain-smoking, nineteenth century inventor developed a number of useful orthopaedic appliances, and is credited with the basic design of the cervical brace used today and known as the Thomas cervical collar.</p> <h3>Functions of Cervical Orthoses</h3> <p>Any cervical orthosis is really a device designed to apply forces to the cervical spine in order to control it in some way. The goal of that control is usually support, rest, immobilization, protection, or correction. The application of the forces restrains the normal or abnormal patterns of movement or alignment of the cervical spine. When the goal is to rest the spine, the device must assist or substitute for stabilizing muscle action. For example, a cervical collar may be used to prevent extension into a range that is painful or irritating to the patient. In another instance, the purpose of the orthosis may be to protect the vital spinal cord or nerve roots. This would be required when the spine has been rendered unstable by tumor, disease, surgery, or injury. A cervical orthosis can also function simply as a reminder and psychological "support." When the patient moves, he or she is made aware of the brace and therefore voluntarily restricts motion. In addition, the orthosis may provide warmth and physical support that is reassuring to the patient.</p> <p>After the physician makes a diagnosis, and elects to treat a particular problem with a cervical orthosis, it is helpful to identify the specific mechanical functions that are to be achieved with the orthosis (see <b>Table I</b>). Is the goal to support (rest), immobilize (protect), or correct the spine? It is helpful for the clinician to go through the process of determining which of various motions of the spine must be controlled. Is it flexion, extension, lateral bending, axial rotation, or some combination of these? By thinking through these questions, a more rational and precise orthotics selection can be made.</p> <strong>Table I. Systematic Analysis for the Selection of Orthoses</strong> <h3><img src="/files/original/fd60ab108fc04d3ee3243e19fd78a73d.jpeg" h3="" width="418" height="327" />Orthotics Evaluation Studies</h3> <p>Before discussing examples of cervical orthotics, it is helpful to review briefly the experimental work upon which we base our clinical recommendations. <i>In-vivo</i> cineradiography studies by Hartman and colleagues evaluated the effectiveness of immobilization of various orthotic devices on the cervical spine (Hartman et al. 1975). These studies compared five different cervical orthoses (Findings are shown in <b>Table II</b>). The investigators concluded that the motion that was most difficult to restrain was that between the occiput and C2.</p> <strong>Table II. Effectiveness of Cervical Spine Orthoses in Immobilization*<br /></strong><br /><img src="/files/original/b22d12eeac67c882c1a6ee06ab860780.jpg" p="" width="568" height="192" /><br />An evaluation of cervical braces by Johnson and colleagues placed normal subjects in different orthotic devices Johnson et al. 1977). Photographs and radiographs were used to determine differences in range of motion with and without the subjects wearing various orthoses (Findings are shown in <b>Table III</b>). It was found that by increasing the vertical length and the rigidity of a given cervical orthoses, there is improvement in its ability to control motion. In general, it was found that controlling lateral bending and axial rotation is more difficult than controlling flexion/extension. The most effective conventional braces are able to restrict C1-C2 flexion extension by only 45% or normal. The halo apparatus restricts the motion by 75%. <br /><br /><strong>Table III. Efficiency of Cervical Braces in Immobilization*</strong><br /><img src="/files/original/7555fd7f9d24bef41fe4b95c8c319ccf.jpg" p="" width="422" height="254" /><br />In summarizing this experimental data, the following generalizations are valid. The soft collar does little in the way of immobilizing the cervical spine. The rigidity of the components at the chin and the occiput are the main elements in restricting motion. As one adds shoulder or thoracic fixation to the various conventional cervical collars, the immobilizing capacity of the orthosis is increased. When the added chest support is actually fixed to the thorax, the immobilizing efficiency is further improved.<br /><br /> <h3>Clinical Review of Some Specific Cervical Orthoses</h3> <p>To follow is a review of the major types of cervical orthoses. They are categorized on the basis of <i>effectiveness of control</i>. Thus, we have divided cervical orthotics into minimum, intermediate, and most effective control (<b>Table III</b>).</p> <p><b>Minimum Control</b>: The basic Thomas collar and numerous variations of it are examples of minimum control orthoses. These collars vary in height, contour and rigidity. They may be worn either forwards or backwards to increase or decrease the amount of flexion/extension possible. Generally, they are to be worn so that the chin rest, which is a convexity in the collar that points downwards, is anterior. However, some patients find it more comfortable to reverse this position, and certainly in cases where one is more interested in restricting extension than flexion, a reversal of this position will block extension more effectively. In other words, if a high portion of the collar is worn posteriorly there is relatively less extension. Although these collars probably do little or nothing in the way of immobilizing the spine, they do provide warmth as well as psychological comfort and support. They can be helpful to the patient in the treatment of a broad variety of conditions including some whiplash injuries, minor sprains and strains, cervical spondylosis, and some stable postoperative surgical constructs.</p> <p><b>Intermediate Control</b>: There are a number of orthotics that are appropriately classified in this group. The Philadelphia collar is a beefed-up version of a Thomas collar. It is more rigid, has an anterior and a posterior plastic reinforcement, a rigid chin support, and a significantly developed extension block posteriorly to support and restrict the occiput.</p> <p>In order to achieve a greater level of immobilization, some extension of the orthosis down into the shoulder and/or thorax is required. This lengthening of the orthosis provides a more effective anchoring, purchase, and immobilization. There are several braces that fit into this category, most notably the four-poster brace, the Duke brace, the Guilford brace, and the SOMI brace. The SOMI is the most effective immobilizer in this group. These orthoses are probably more effective in the standing and sitting positions. In the supine, prone, or side lying positions, relaxation and rotation of the shoulders and thorax minimize the effectiveness of these orthoses.</p> <p>We should also note that if we wish to prevent anterior displacement of C1 or C2 in a rheumatoid patient we cannot rely upon a soft cervical collar, a Philadelphia collar, a four-poster brace, or even a SOMI brace (Altoff and Goldie 1980).</p> <p><b>Most Effective Control</b>: If there is a clinical problem involving significant loss of clinical stability, the cervical orthosis hould provide the maximum amount of immobilization, unloading of the spine, and protection. Major control is needed in all of the parameters of motion. Depending on the particular clinical situation, it may be more important to control some particular motion or combination of motions.</p> <p>One option in this situation is a significantly more rigid version of the Thomas collar. The Minerva cast incorporates the concepts of extending the brace down towards the thorax and immobilizing the chin and occiput. This cast extends from the forehead down to the pelvis. The goddess Minerva was born by popping from the head of Jupiter, fully armored. From this Roman myth the cast has taken its name. This device, although not used very much currently, can be useful, especially in the protection of irresponsible patients. It should be kept in mind, however, that even with a well-applied Minerva cast, a few degrees of cervical spine motion are possible. Most of the motion occurs at the occiput-C1 region. The cast has to be open enough to allow an adequate range of motion for the mouth so that the patient can talk and chew. This same range of motion allows for motion at the occiput-C1-C2 joint complex. Thus, when your patients are in a Minerva cast but can talk and chew, you must be aware that they can move C1-C2.</p> <p>In difficult clinical situations, where there is extensive disease or surgery, or an injury has rendered the cervical spine unstable, use of a halo apparatus should be considered. This device is fixed to the skull with pins and is attached either to an individually molded plaster jacket or to a prefabricated jacket which comes in several sizes. Experimental studies generally agree that this device is the most effective immobilizer of the cervical spine. One should be aware that use of this device carries the risk of several complications. These include: penetration of the skull by fixation pins, brain abscesses, abducens, glossopharangeal and facial nerve palsy, and the development of cervical spondylosis. Facial complications can be recognized during the first few days after application by requesting patients to smile, roll their eyes, and stick out their tongue. If the patient is unable to do any of these three activities, careful neurological evaluation is indicated.</p> <h3>Resume</h3> <p>A rational approach to the use of cervical orthotics may be taken by posing several questions. What is the clinical condition of the spine? What are the therapeutic goals to be achieved by the brace? Is the goal to protect the spine, or to rest it? In what way should the mechanics of the spine be changed to achieve that goal? What kinds of forces are necessary in order to achieve these therapeutic aims?</p> <p>In the cervical spine, the standby orthosis for minimal immobilization is the Thomas collar. If one needs a high level of control, then an intermediate zone orthosis, such as the Philadelphia collar or any variety of collars that involve thoracic attachments, can be employed. The SOMI brace is the most effective in this intermediate group. If the therapeutic goal is to obtain maximum control and immobilization of the cervical spine, a halo apparatus with an individually molded plaster jacket is required. One should be aware that this apparatus carries the liability of exposure to complications. These complications can be minimized by diligent care techniques and follow-up evaluation.</p> <p><b>References:</b></p> <ol> <li>Altoff, B. and Goldie, I.F.: Cervical collars in rheumatoid atlauto-axial subluxation. A radiographic comparison. <i>Annals of the Rheumatic Diseases</i> 39: 485, 1980.</li> <li>Edward, J.W.: <i>Orthopaedic Appliances Atlas.</i> Vol. I, Ann Arbor, Michigan, American Academy of Orthopaedic Surgeons, 1952.</li> <li>Hartman, J.T., Palumbo, F., and Hill, B.J.: Cineradiography of the braced normal cervical spine. <i>Clinical Orthopaedics</i> 109: 97, 1975.</li> <li>Johnson, R.M. et al.: Cervical orthoses. A study comparing their effectiveness in restricting the cervical motion in normal subjects. <i>Journal of Bone and Joint Surgery </i>59A: 332, 1977.</li> <li>O'Brien, J.P.: The halo-pelvic apparatus. A clinical, bio-engineering and anatomical study. <i>Acta Orthopaedica Scandinavica</i> 163 (supplement), 1975.</li> <li>Victor, D.I., Bresnan, M.J., and Keller, R.B.: Brain abscess complicating the use of halo traction. <i>Journal of Bone and Joint Surgery</i> 55A: 635, 1973.</li> <li>White, A.A. and Panjabi, M.M.: <i>Clinical Biomechanics of the Spine</i>, Philadelphia, J.B. Lippin-cott, 1978.</li> </ol> <em><b>*Augustus A. White, III, M.D. </b> The Department of Orthopaedic Surgery Beth Israel Hospital and Harvard Medical School, and the Charles A. Dana Research Institute, Beth Israel Hospital, Boston, Massachusetts</em><br /><br /><br /> <div style="width: 400px;"></div> Page Number(s) 5 - 7 Year 1983 Volume 7 Issue 3 Figure 2 TABLE II http://www.oandplibrary.org/cpo/images/1983_03_005/1983_03_005-2.jpg Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Figure 3 TABLE III http://www.oandplibrary.org/cpo/images/1983_03_005/1983_03_005-3.jpg Figure 1 TABLE I http://www.oandplibrary.org/cpo/images/1983_03_005/1983_03_005-1.jpg Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Some Comments on Cervical Orthoses Creator An entity primarily responsible for making the resource Augustus A. White, III, M.D. * https://staging.drfop.org/files/original/13d59df7eaa0bb5ef10ecff3a8fa4fd9.pdf 0247ed6219932127b8f05567d483ea5a Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Clinical Prosthetics & Orthotics Description An account of the resource The American Academy of Orthotists and Prosthetists published this periodical from 1977 through 1988, when it was replaced with the Journal of Prosthetics & Orthotics (JPO). Earlier issues went under the heading Newsletter: Prosthetics & Orthotics Clinic. The name was changed to Clinical Prosthetics & Orthotics (CPO) in Spring of 1982 (Vol. 6 No. 2). Creator An entity primarily responsible for making the resource The American Academy of Orthotists and Prosthetists Language A language of the resource English DRFOP - Legacy Full Text PDF PDF Including Full Text and Original Layout https://www.oandplibrary.org/cpo/pdf/1983_03_003.pdf Text Any textual data included in the document <h2>Analysis of the Results From the Questionnaire on Metal vs. Plastic Orthoses</h2> <p>By May 1st, fifty-four (54) responses had been received, considerably more than usual. Fifty-two (52) respondees were certified personnel, one was a physician, and one was an unspecified "other." Interestingly enough, the individual listing himself as other was by far the most negative in his comments.</p> <p>The results were as follow:</p> <ol> <li> <p>Percentage of plastic vs. metal orthoses prescribed:</p> <ul> <li> <p>100% plastic—17%</p> </li> <li> <p>75% plastic, 25% metal—61% of the time</p> </li> <li> <p>25% plastic, 75% metal—13%</p> </li> <li> <p>100% metal—2%</p> </li> </ul> </li> <li> <p>Percentage of staff trained in plastic:</p> <ul> <li> <p>100%—74% of respondees</p> </li> <li> <p>75%—9%</p> </li> <li> <p>50%—9%</p> </li> <li> <p>25 %—7%</p> </li> </ul> </li> <li> <p>Most significant advantages:</p> <ul> <li> <p>lightweight—43%</p> </li> <li> <p>cosmesis—28%</p> </li> <li> <p>versatility—26%</p> </li> <li> <p>correction increased—17%</p> </li> <li> <p>other—11%</p> </li> <li> <p>total contact—9%</p> </li> </ul> <p>Many individuals checked more than one.</p> </li> <li> <p>Most significant disadvantage, most commonly indicated factors (actual numbers):</p> <ol> <li> <p>Inability to adjust dorsiflexion/plantarflexion—20</p> </li> <li> <p>Fluctuating edema—7</p> </li> <li> <p>Fitting a proper shoe and heel height—5</p> </li> </ol> </li> <li> <p>Durability of plastic and hybrid orthoses vs. metal orthoses:</p> <ul> <li> <p>more durable, less maintenance—40% equal—30%</p> </li> <li> <p>less durable, more maintenance—22%</p> </li> </ul> </li> <li> <p>Do you agree with Mr. Shurr's arguments for the use of traditional metal upright orthoses?</p> <ul> <li> <p>yes—69%</p> </li> <li> <p>no—30%</p> </li> </ul> </li> <li> <p>Do you share Mr. Shurr's skepticism regarding prefabricated plastic AFO's?</p> <ul> <li> <p>Yes—83%</p> </li> <li> <p>No—13%</p> </li> </ul> </li> </ol> <p>This seems to be one issue about which considerable unanimity exists within the profession. Questions one and two seem to indicate that plastic plays a major role in the practice of many orthotists and that most of them are versed in its usage. The response to question 5 indicates that most practitioners are not experiencing significant problems with durability, probably as good an indication of good fabricating technique as any. In looking at questions 3, 4, 6 and 7, it appears that most respondents understand the role of plastic in orthotics and its advantages and disadvantages.</p> <p>In light of this unanimity of opinion it is interesting that the question of plastic vs. metal should excite enough interest to spark so large a response, particularly as plastic orthoses have now been in use for over ten years. It may be that orthotists still confront the need to defend plastic orthoses and justify their use. Contrarily it may be that enough individuals have enough experience with plastic that they feel comfortable responding to the issue.</p> <p><b>Additional responses:</b> The following samples are chosen somewhat at random as examples of differing opinions:</p> <p><i>Comments on question 4</i>:</p> <ol> <li> <p>It is my firm belief that the fixation of any joint will have the result of severe atrophy and eventual fusing of the joint. The long term results of the use of the (non-jointed) plastic AFO are not known. Putting it simply:</p> <p>What's the use of working toward recovery of use of an extremity (and that return gradually takes place) when the 'treatment' by an orthotic device has created other problems that the degree of recovery is not able to overcome?</p> </li> <li> <p>I feel there has been an overemphasis on plastic AFO/prefab AFO used by R.P.T.'s which have a limited application, and may be used with some success on geriatric patients in convalescent areas. They do make damned good night splints and that's about all. If used on hilly terrain or streets the patient usually ends up on his butt or smashes his face.</p> </li> <li> <p>How anyone could argue the cause for plastic AFO's is unreal. Any amount of comparisons with the traditional AFO reveals less durability and limited function. Seven out of 10 patients have disabilities necessitating metal over plastic, numerous modifications [to plastic] are a <i>must</i>, and medial lateral support is nil. In my experience, I have found that very mild cases necessitate the use of a plastic AFO when drop-foot (only) is the reason for bracing. Instability in the M-L plane is often accompanied by drop-foot, thus ruling out the plastic AFO.</p> </li> <li> <p>I feel that the plastic AFO is definitely a more desirable type of orthosis for all the reasons mentioned in question #3. However, not every patient is a candidate for a plastic AFO, especially if the patient has edema or needs adjustability at the ankle.</p> </li> <li> <p>Most students coming out of schools at this time only know how to make plastic AFO's and are not proficient or comfortable in making conventional orthoses. These "students" who usually possess degrees never spend sufficient time working in the lab to become bench technicians and most, when handed a pair of bending irons, are in jeopardy of hurting themselves.</p> </li> <li> <p>I agree with Mr. Shurr, but only from the standpoint of a therapist. Adjustment of plastic AFO's requires more than just a general knowledge of thermoplastics. During patient rehabilitation, minor changes in the degree of dorsi or plantar flexions that the orthosis is set in can make a drastic change in patient function. In clinical settings, this should always be done by the orthotist. However, physicial therapists working with patients wearing AFO's may not have accessibility to an orthotist whenever they want to "experiment" with different ankle settings. I can therefore understand Mr. Shurr's interim preference. This is, however, no comparison between the superiority of plastic systems over metal. Orthotists should be involved with any change made to their patients orthotic system.</p> </li> </ol> <p><i>In response to question 6</i>:</p> <p>Therapist adjustment syndrome (TAS) is not a valid RX criterion.</p> <p><i>General Comments</i>:</p> <p>Far more important than durability is the ability to provide superior fit alignment and function. Improperly fitting plastic orthoses, by their very nature, are far more obvious and as a result more nearly considered unacceptable than the traditional Brace—which by its very nature masks improper fit and alignment and of course results in improper braces being worn. In 1980, we introduced a policy of providing all necessary repairs and adjustments without additional cost for the life of any plastic orthosis. This policy specifically excludes traditional metal/leather braces.</p> Page Number(s) 3 - 4 Year 1983 Volume 7 Issue 3 Review Status Status of review after import from old O&P Library into Omeka platform. Content Review Complete Dublin Core The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/. Title A name given to the resource Analysis of the Results From the Questionnaire on Metal vs. Plastic Orthoses