Professional Documents
Culture Documents
Pain relief
Mechanical unloading
Scoliosis management
Spinal immobilization after surgery
Spinal immobilization after traumatic injury
Compression fracture management
Kinesthetic reminder to avoid certain movements
Discomfort
Local pain
Osteopenia
Skin breakdown
Nerve compression
Ingrown facial hair for men
Muscle atrophy with prolonged use
Decreased pulmonary capacity
Increased energy expenditure with ambulation
Difficulty donning and doffing orthosis
Difficulty with transfers
Psychological and physical dependency
Increased segmental motion at ends of the orthosis
Unsightly appearance
Poor patient compliance
Decreased pain
Increased strength
Improved function
Increased proprioception
Improved posture
Correction of spinal curve deformity
Protection against spinal instability
Minimized complications
Healing of ligaments and bones
Maintenance of orthosis:
Orthosis should be simple and durable as possible.
Patient should be taught for:
Cleaning the leather.
Oiling the joints.
Wash the orthosis if possible.
Physicians must understand the biomechanics of the spine and each individual
orthosis. The cervical spine is the most mobile spinal segment with flexion
greater than extension. The occiput and C1 have significant flexion and
extension with limited side bending and rotation. The C1-C2 complex accounts
for 50% of rotation in the cervical spine. The C5-C6 region has the greatest
amount of flexion and extension. The C2-C4 region has the most side bending
and rotation.
When compared to the cervical and lumbar spine, the thoracic spine is the least
mobile. The thoracic spine has greater flexion than extension. Lateral bending
increases in a caudal direction, and axial rotation decreases in a caudal direction.
The lumbar spine has minimal axial rotation. The greatest movement in the
lumbar spine is flexion and extension. Immobilization of the spine increases
erector spinae muscle activity since normal rotation that occurs with ambulation
is limited by the orthosis.
Pressure
equilibrium
Types of orthosis
Types of
orthosis
Upper limb
orthosis
Spinal
orthosis
Lower limb
orthosis
Foot orthosis
Knee orthosis
Hip orthosis
Cervical orthosis
Thoracic orthosis
Sacral orthosis
Sacroiliac orthosis
Hand orthosis
Wrist orthosis
Elbow orthosis
Shoulder orthosis
AFO
KAFO
HKAFO
RGO
Ankle-foot orthosis
Knee-ankle foot orthosis
Hip-Knee-ankle foot orthosis
Reciprocal Gait orthosis
CTO
CTLSO
Cervical-Thoracic orthosis
Cervical-Thoracolumbosacral orthosis
Thoracolumbosacral orthosis
TLSO
LSO
Lumbosacral orthosis
WHO
EWHO
SEO
SEWHO
Wrist-Hand orthosis
Elbow-Wrist-Hand orthosis
Shoulder-Elbow orthosis
Shoulder-Elbow-Wrist-Hand orthosis
Cervical Orthotics
Several drawbacks to cervical orthotic (CO) use have been noted. The soft tissue
structures around the neck (eg, blood vessels, esophagus, trachea) limit
application of aggressive external force. The high level of mobility at all segments
of the cervical spine makes it difficult to restrict motion. Cervical orthoses offer no
control for the head or thorax; therefore, motion restriction is minimal. Cervical
orthoses serve as a kinesthetic reminder to limit neck movement.
Observe appropriate precautions associated with orthotic use. Keep in mind that
continued long-term use has been associated with decreased muscle function
and dependency.
The soft collar is a common orthotic device made of lightweight material,
polyurethane foam rubber, with a stockinette cover. It has Velcro closure strap for
easy donning and doffing. Patients find the collar comfortable to wear, but it is
soiled easily with long-term use.
Soft collar
Indications for use of the soft collar include the following benefits for the
patient:
Warmth
Psychological comfort
Support to the head during acute neck pain
Relief with minor muscle spasm associated with spondylolysis
Relief in cervical strains
The soft collar provides some limitations of motion for the patient,
including the following:
The hard cervical collars are similar in shape to a soft collar but are made of
Plastizote, a rigid polyethylene material shaped like a ring with padding. Height
can be adjusted in certain designs to fit patients better. Velcro straps are used for
easy donning and doffing. The hard collar is more durable than a soft collar with
long-term use.
Malibu collar
Indications for use of a Miami J collar are the same as the Philadelphia
collar.
The Malibu collar is similar to the Philadelphia collar as it is a semi-rigid orthosis
designed in a 2-piece system with an anterior opening for a tracheostomy. The
Malibu collar comes in only one size, but it is adjustable in multiple planes to
ensure proper fit. Anterior chin support height is also adjustable. Straps around
the chin, occiput, and lower cervical area provide for tightening. Padding around
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the chin can be trimmed to ensure proper fit. Thoracic extension can be added to
increase support and treat C6-T2 injuries.
Indications for use of a Malibu collar are similar to those for the Miami J and
Philadelphia collars.
The Aspen Collar has a 2-piece system made of polyethylene with soft foam
liner with an anterior opening for a tracheostomy. The Aspen collar is a semi-rigid
HCO with Velcro straps for easy donning and doffing.
Motion restrictions mirror those of the Miami J collar and include the
following:
Indications for use of the Aspen collar include the same as the HCOs discussed
above. The Jobst Vertebrace is made of high-density polyethylene with soft
polyethylene foam liner. The Jobst Vertebrace is a semi-rigid HCO designed for
use in emergent transport situations, and it is similar to the Yale or Philadelphia
collar in restricting motion. The Jobst Vertebrace provides full contact along its
costal ends to the sternum and cradles the mandible for stability.
Motion restrictions for the Jobst Vertebrace are similar to those of the Yale
and Philadelphia collars, including the following:
The Jobst Vertebrace is made of high-density polyethylene with soft polyethylene
foam liner. The Jobst Vertebrace is a semi-rigid HCO designed for use in
emergent transport situations, and it is similar to the Yale or Philadelphia collar in
restricting motion. The Jobst Vertebrace provides full contact along its costal
ends to the sternum and cradles the mandible for stability. Motion restrictions
for the Jobst Vertebrace are similar to those of the Yale and Philadelphia
collars, including the following:
11
Indications for use of the Jobst Vertebrace are similar to those for the Miami J
and Philadelphia collars
12
The Yale orthosis is a modified Philadelphia collar with thoracic extension made
of fiberglass extending anteriorly and posteriorly with mid-thoracic straps on the
sides connecting the 2 thoracic extensions. The thoracic component helps to
treat C6-T2 injuries. The occipital piece extends higher up on the skull posteriorly.
Increased contact surface area improves stability of the brace. Patients find the
Yale orthosis comfortable to wear. The Yale orthosis is easy to fabricate and
costs approximately
Various indications for use of the Yale orthosis include the following:
The four-poster brace is a rigid orthosis with anterior and posterior chest pads
connected by a leather strap. Molded occipital and mandibular support pieces
connect to the chest pads and have adjustable struts. Straps connect the
occipital and mandibular support pieces. The mandibular plate can interfere with
eating. This brace uses shoulder straps, but it has no underarm support. Open
design allows heat loss from the neck. The brace is as effective as the
cervicothoracic brace in controlling flexion in the mid-cervical area and is better
than the Philadelphia collar. The four-poster design limits lateral bending and
rotation better than the two-poster brace.
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The Guilford brace is a rigid CTO with a two-poster design with anterior chest
plate and shoulder straps that connect to the posterior plate. Chin plate and
occipital piece connect to the anterior and posterior struts. Underarm straps circle
the lower chest wall for stability. The brace has poor control of flexion, extension,
rotation, and lateral bending at C1-C2. Motion restrictions afforded by the
Guilford brace include limitation of flexion and extension from C3-T2.
Indications for use of the Guilford brace include the following:
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Halo device
The halo device is the most common device for treatment of unstable cervical
and upper thoracic fractures and dislocations as low as T3. The halo provides
maximum motion restriction of all cervical orthotics. The halo ring is made of
graphite or metal with pin fixation on the frontal and parietal-occipital areas of the
skull. Development of lightweight composite material led to design of radiolucent
rings compatible with magnetic resonance imaging (MRI). The halo ring attaches
to the vest anteriorly and posteriorly via 4 posters.
Halo device.
The halo vest has shoulder and underarm straps for tightening and usually is
made of rigid polyethylene and extends down to the umbilicus. Restriction in
cervical motion depends on the fit of the halo vest since improper fit can allow
31% of normal spine motion. The halo vest is the weak link in terms of motion
control. Compressive and distractive force can occur with variable fit of the vest.
Multidirectional shear forces can cause increased pinhole size with craterlike
enlargement. Pin loosening occurs twice as frequently with a heavier halo vest.
Generally, upper cervical spine injuries are treated best with a full-length vest to
the iliac crest.
Indications for use of a halo device are for immobilization in the following
cases:
Dens type I, II, and III fractures of C2 (Note: Dens type III fractures of C2
are treated more successfully with surgery.)
C1 fractures with rupture of the transverse ligament
Atlantoaxial instability from rheumatoid arthritis with ligamentous
disruption and erosion of the dens
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C2 neural arch fracture and disc disruption between C2 and C3. (Note:
Some patients may need surgery for stabilization.)
Bony single column cervical fractures
Following cervical arthrodesis
Following cervical tumor resection in an unstable spine
Following debridement and drainage of infection in an unstable spine
Following spinal cord injury (SCI)
The relative contraindications for use of the halo device include the
following:
The application process for the halo device consists of several steps. Optimal
placement for the anterior pins is the anterolateral aspect of the skull 1 cm above
the orbital rim on the lateral part of orbit since this prevents penetration into the
orbit. Avoid placing pins in the temporalis muscle and through the
zygomaticotemporal nerve, which supplies sensation to the temporal area. Pins
inserted into the temporalis muscle affect mandibular motion and cause pain.
Placement away from the medial one third on the orbital rim preserves the
supraorbital and supratrochlear nerves and decreases risk of entering the frontal
sinus.
Insertion of posterior pins on the posterolateral aspect of the skull is less crucial.
Skin incisions are not necessary prior to pin placement. The halo ring should be
1 cm above the top of the ear. Place all pins perpendicular to the skull, and allow
1-2 cm clearance with the halo ring along the skull perimeter.
In adults, pin insertion requires a torque wrench set at 8 inches per pound since
this lowers incidence of pin infection and loosening. In children, set the torque
wrench between 2-5 inches per pound since the skull is too weak to sustain
heavier forces. Use multiple pin sites in children because of the weaker skull.
Determine the halo vest size by measuring chest circumference at the xiphoid
process. Elevate the patient at 30-40 for vest placement. Secure the posterior
portion to the halo first, then to the anterior part of the vest. Tighten the bolts on
the vest to a torque setting of 28 feet per pound. Tools for the vest sometimes are
taped to the anterior part of the vest in case of emergency.
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At 24-48 hours after placement, recheck all pins for loosening. Clean the pin sites
with saline or soap and water on a sterile swab. Take x-rays immediately after
halo placement and after any adjustment to check spinal alignment. Shaking of
the cervical spine because of forced movement against the orthosis or changes
in pin tightening can cause some segmental motion. Symptoms of dysphagia
may result from placement of the neck in too much extension. Repositioning of
the halo, if possible, can eliminate dysphagia.
Motion restrictions provided by the halo include the following:
In use of the halo device, keep in mind the following important considerations:
The halo fixation device is used for 3 months to allow adequate time for
bone healing.
Use of an HCO after removal of the halo provides some support for the
head, as the neck muscles are weak and stiff.
Approximately 40-45% of patients with facet joint dislocations achieve
stability with the halo vest, whereas 70% of patients without facet joint
dislocations achieve stability.
Nearly 75% of patients without facet joint dislocation achieve good
anatomic results.
Surgical stabilization in cases of facet joint dislocation improves outcome.
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Patients with facet joint dislocation have higher likelihood of spinal cord
injury.
Thorough neurologic examination before and after reduction of facet joint
dislocation is important.
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Thoracolumber orthotics
Thoracolumbar orthotics (TLOs) are used mainly to treat fractures from T10-L2
since their mobility is not restricted by the ribs, unlike fractures from T2-T9.
Immobilization from T10-L2 helps prevent further collapse.
The cruciform anterior spinal hyperextension (CASH) brace features anterior
sternal and pubic pads to produce force opposed by the posterior pad and strap
around the thoracolumbar region. Sternal and pelvic pads attach to the anterior
metal cross-shaped bar, which can be bent to reduce excess pressure on the
chest and pelvis. The brace is easy to don and doff, but it is difficult to adjust.
Compared to the Jewett brace, it provides greater breast and axillary pressure
relief. Two round upper chest pads can be used instead of the sternal pad to
decrease discomfort around the breast area. Average cost of a CASH brace is
approximately $460.
Indications for the CASH brace include the following:
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thoracic region. The posterior pad keeps the spine in an extended position, and it
has a lightweight design that is more comfortable than the CASH brace. Pelvic
and sternal pads can be adjusted from the lateral axillary bar where they attach.
The pads can cause discomfort from pressure applied to small surface area. No
abdominal support is provided with this device. When the patient is seated, the
sternal pad should be half an inch inferior to the sternal notch, and the pubic pad
should be half an inch superior to the pubic symphysis. The Jewett brace is not a
custom-molded brace.
Jewett hyperextension brace
One important consideration in use of the Jewett brace is that it is more effective
than the CASH brace. The Korsain brace is a modification of the Jewett brace
with added abdominal support for increased rigidity. The cost of the Korsain
brace is similar to that of the Jewett brace.
Indications for the Korsain brace include the following:
20
Motion restrictions and contraindications of the Korsain brace are similar to the
Jewett brace.
The Knight-Taylor brace features a corset type front with lateral and posterior
uprights and shoulder straps to help reduce lateral bending, flexion, and
extension. Shoulder straps may cause discomfort in some patients. The brace
can be prefabricated and made with polyvinyl chloride or aluminum. The
posterior portion of the brace has added cross supports below the inferior angle
of the scapula and a pelvic band fitted at the sacrococcygeal junction. The
anterior corset is made of canvas and provides intracavitary pressure. The
anterior corset is laced to the lateral uprights. The brace is indicated to provide
flexion immobilization to treat thoracic and lumbar vertebral body fractures.
Cruciform anterior spinal hyperextension brace with round anterior chest
pads.
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heat, so an undershirt helps to absorb perspiration and protect the skin. Frequent
checks to ensure proper fit help prevent pressure ulcers.
Limits sidebending
Limits flexion and extension
Limits rotation to some extent
Lumbosacral orthotics
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The chairback brace is a rigid short lumbosacral orthotic (LSO) with 2 posterior
uprights with thoracic and pelvic bands. The abdominal apron has straps in front
for adjustment to increase intracavitary pressure. The thoracic band is located 1
inch below the inferior angle of scapula. The thoracic band extends laterally to
the mid-axillary line, and the pelvic band extends laterally to the mid-trochanteric
line. Place the pelvic band as low as possible without interfering with sitting
comfort. Position the posterior uprights over the paraspinal muscles. Uprights
can be made from metal or plastic. The brace uses a 3-point pressure system
and can be custom molded to improve the fit for each individual patient.
Chairback brace from side view
The chairback Ortho-Mold brace is similar to the chairback brace, but it has a
rigid plastic back piece custom molded to the patient. The plastic back can be
inserted into the canvas and elastic corset. The chairback Ortho-Mold brace
costs approximately $500-600.
Indications for use of the chairback Ortho-Mold brace and its motion restrictions
are the same as the chairback brace noted above..
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The Williams brace is a short LSO with an anterior elastic apron to allow for
forward flexion. Lateral uprights attach to the thoracic band, and oblique bars are
used to connect the pelvic band to the lateral uprights. The abdominal apron is
laced to the lateral uprights. The brace limits extension and lateral trunk
movement but allows forward flexion. The brace is indicated to provide motion
restriction during extension to treat spondylolysis and spondylolisthesis. The
device is contraindicated in spinal compression fractures.
Limits extension
Limits side bending at terminal ends only
The MacAusland brace is an LSO that limits only flexion and extension. This
brace has 2 posterior uprights but no lateral uprights. The 3 anteriorly directed
straps connect with the abdominal apron to provide increased support.
Indications for use of the MacAusland brace are similar to the chairback brace.
Motion restrictions include limitation of flexion and extension in the L1 to L4 level.
The Standard LSO corset has metal bars within the cloth material posteriorly that
can be removed and adjusted to fit the patient. The anterior abdominal apron has
pull-up laces from the back to tighten. The abdominal apron can come with
Velcro closure for easy donning and doffing. The Standard LSO corset has a
lightweight design and is comfortable to wear. The corset increases intracavitary
pressure. Anteriorly, the brace covers the area between the xiphoid process and
pubic symphysis. Posteriorly, the brace covers the area between the lower
scapula and gluteal fold.
Indications for the Standard LSO corset include the following:
Treatment of LBP
Immobilization after lumbar laminectomy
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be trimmed easily to make adjustments for patient comfort and may be used in
the shower if needed.
Indications for use of the rigid LSO brace include the following:
Motion restrictions provided by the rigid LSO brace include the following:
Rigid LSO with hip spica uses a thigh piece on the symptomatic side and extends
to 5 cm above the patella. The hip is held in 20 of flexion to allow sitting and
walking. Some patients require a cane for ambulation after application.
Indications for the rigid LSO with hip spica use include the following:
Motion restrictions of the rigid LSO with hip spica include the following:
New brace designs for LSO have strapping systems designed to pull the brace
inward and up to improve hydrostatic affect to relieve pressure on the lumbar
spine. The better fit helps limit migration. Some low-profile designs take pressure
off the hip and rib area, which, in turn, improves patient compliance. Low-profile
braces allow easier fitting under clothes. These braces can treat areas from L3S1.
Some spinal braces come with an interchangeable back with an open center or
flat back design for postoperative patients. The same brace can be interchanged
with a back that has an indentation to fit the lordotic curvature of the lumbar spine
for pain management purposes. Braces with interchangeable parts allow a LSO
to be converted into a TLSO with a large back support and an attachment for a
sternal extension to prevent unwanted flexion. The sternal extension has straps
that attach to the LSO.
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Stage 0 = 0% excursion
Stage I = 25% excursion
Stage II = 50% excursion
Stage III = 75% excursion
Stage IV = 100% excursion and correlates with end of spinal growth
Stage V = fusion to ilium, indicating cessation of vertical height growth
The clinician must take into account several bits of clinical information about use
of braces in scoliosis including the following:
Patients aged younger than 13 years with curves of 30-39 require surgery
25% of the time, whereas only 14% of patients older than 14 years with
curves 30-39 require surgery.
The most common time to lose control of idiopathic curves is at puberty.
Boys tend to show less curve progression than girls, and tend to have
later onset of curve progression between 15-18 years.
Younger patients show greater initial in-brace correction. Curve correction
with bracing greater than 50% is expected to have final net correction,
whereas curve correction less than 50% is expected to have limited
progression.
Generally, curves between T8-L2 have the best correction. Young patients
with large curves usually fail treatment with a brace.
Patients successfully completing treatment for idiopathic scoliosis using a
TLSO with initial curves measuring 20-45 can anticipate their scoliosis to
remain stable until adulthood. The correction of the curvature can be lost
over time, to its initial magnitude. Therefore, obtaining a spinal radiograph
in the third or fourth decade of life to check progression is reasonable.
Patients with Risser score of I-II and curves greater than 20-30 that
progress by 5 over 1 year need application of brace.
27
Curves between 30-40 need bracing, but not curves less than 20.
Curves of 20-30, with no year-over-year progression, require observation
every 4-6 months. The Milwaukee brace is used for curves with apex
above T7.
Jaw deformity
Pain
Skin breakdown
Unsightly appearance
Difficulty with mobility
Difficulty with transfers
Increased energy expenditure with ambulation
Keep in mind clinical information regarding use of the Milwaukee brace, including
the following:
28
When comparing the Milwaukee and Boston braces, note that curve
progression beyond 45 occurred in 31% of patients with the Boston brace
and in 62% with the Milwaukee brace.
X-rays to evaluate scoliosis in the Milwaukee brace are performed with the
patient in a standing position.
Successful outcomes with brace treatment show an in-brace curve
reduction greater than 50%.
The Milwaukee brace and a custom-made TLSO can be used to treat
Scheuermann kyphosis in children with pain, or pain with kyphosis greater
than 60.
Side effects associated with use of the Boston brace include the following:
Local discomfort
Hip flexion contracture
Trunk weakness
Increased abdominal pressure
Skin breakdown
Accentuation of hypokyphosis above brace in the thoracic spine
29
Curve above T7
Improper fit
Poor patient compliance
31
lumbosacral junction and behind the lumbar vertebral bodies to intersect the
spine at the thoracolumbar junction, then (4) continues in front of the thoracic
vertebral bodies and through the cervicothoracic junction, and, lastly, (5) travels
behind the cervical vertebral bodies to the occipitocervical junction. When the
center of gravity does not fall through the area of support, it is unstable at that
moment.
Gait cycle is defined as the activity that occurs between the initial contact of one
extremity and the subsequent initial contact of the same extremity. During a
single gait cycle, each extremity passes through one stance phase and one
swing phase. Stance phase occupies over 60% of the gait cycle during walking at
average velocity. Stance phase includes initial contact, loading response,
midstance, terminal stance, and preswing. Swing phase includes initial swing,
mid swing, and terminal swing.
The average total displacement of the center of gravity in both the vertical and
lateral directions is less than 2 inches in normal gait. The increase in
displacement of the center of gravity increases the amount of energy for walking.
The purpose of using an orthosis is to enhance normal movement and to
decrease abnormal posture and tone. Lower extremity orthoses can be used to
correct abnormal gait patterns and to increase the efficiency of walking.
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MATERIALS
An orthosis can be constructed from metal, plastic, leather, synthetic fabrics, or
any combination. Plastic materials, such as thermosetting and thermoplastics,
are the materials most commonly used in the orthotic industry.
Plastics
o Thermosetting materials can be molded into permanent shape after
heating. They do not return to their original consistency even after
being reheated. Thermoplastic materials soften when heated and
harden when cooled.
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35
36
Sole
o
o
o
o
Heel
o
o
o
o
o
o
Leather with rubber on the plantar surface commonly is used for the
heel.
A spring heel is one-eighth inch high.
An Oxford heel is three quarters to one inch high.
A military heel is one and one quarter inches high.
A Cuban heel is one and a half inches high.
The heel counter is the posterior portion of the upper part between
the quarters. This structure is used to reinforce the quarters and
support the calcaneus. The heel counter can increase the posterior
stability of the shoe.
Upper
o
37
o
o
o
o
o
Shoe modifications
A properly fitted shoe should have adequate room for the foot to expand while
the patient is bearing weight. The shoe should be at least 1 cm longer than the
longest toe, and the widest part also should correspond to the widest part of the
foot. Shoes can be modified to reduce pressure on sensitive areas by
redistributing weight toward pain-free areas.
External shoe modifications
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Heel modifications
o A cushioned heel: A wedge of compressible rubber is inserted into
the heel to absorb impact at heel strike. This cushion often is used
with a rigid ankle to reduce the knee flexion moment by allowing for
more rapid ankle plantar flexion.
o A heel flare: A medial flare is used to resist inversion, and a lateral
flare is used to resist eversion. Both flares are used to provide heel
stability.
o A heel wedge: A medial wedge is used to promote inversion, and a
lateral wedge is used to promote eversion. The heel counter should
be strong enough to prevent the hindfoot from sliding down the
incline created by the wedge.
o Extended heel: The Thomas heel projects anteriorly on the medial
side to provide support to the medial longitudinal arch. The reverse
Thomas heel projects anteriorly on the lateral side to provide
stability to the lateral longitudinal arch.
o Heel elevation: A shoe lift is used to compensate for fixed equinus
deformity or for any leg-length discrepancy of more than one
quarter of an inch.
Sole modifications
o
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Heel modifications
o Heel cushion relief: This soft pad with excavation is placed under
the painful point of the heel.
o Heel wedges: A medial heel wedge can rotate the hindfoot into
inversion. A lateral heel wedge can evert the hindfoot to avoid
pressure on the cuboid.
Sole modifications
o Metatarsal pad: This domed pad is designed to reduce the stress
from metatarsal heads by transferring the load to metatarsal shafts
in metatarsalgia.
o Inner sole excavation: A soft pad filled with compressible material is
placed under one or more metatarsal heads.
o Scaphoid pad: This type of pad extends from one half inch posterior
to the first metatarsal head to the anterior tubercle of the calcaneus.
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The apex of the scaphoid pad is between the talonavicular joint and
the navicular tuberosity. The scaphoid pad is used for medial arch
support.
Toe crest: A crescent-shaped pad is placed behind the second
through fourth phalanges. The toe crest fills the void under the
proximal phalanges and reduces the stress.
Foot orthosis
The foot orthosis extends from the posterior border of the foot to a point
just posterior to the metatarsal heads. This device is used to
accommodate the abnormal foot to help restore more normalized lower
limb biomechanics.
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ANKLE-FOOT ORTHOTICS
An AFO is commonly prescribed for weakness or paralysis of ankle dorsiflexion,
plantar flexion, inversion, and eversion. AFOs are used to prevent or correct
deformities and reduce weight bearing. The position of the ankle indirectly affects
the stability of the knee with ankle plantar flexion providing a knee extension
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force and ankle dorsiflexion providing a knee flexion force. An AFO has been
shown to reduce the energy cost of ambulation in a wide variety of conditions,
such as spastic diplegia due to cerebral palsy, lower motor neuron weakness of
poliomyelitis, and spastic hemiplegia in cerebral infarction.
Thermoplastic molded ankle-foot orthosis (posterior leaf spring, minimal
resistance, moderate resistance, maximal resistance/solid ankle-foot
orthosis).
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5. AFO with flange: This AFO has an extension (flange) that projects
from the calf shell medially for maximum valgus control and laterally
for maximum varus control.
6. Hinged AFO: The adjustable ankle hinges can be set to the desired
range of ankle dorsiflexion or plantar flexion.
7. Tone-reducing AFO (TRAFO): The broad footplate is used to
provide support around most of the foot, extending distally under
the toes and up over the foot medially and laterally to maintain the
subtalar joint in normal alignment. The TRAFO is indicated for
patients with spastic hemiplegia.
Metal and metal-plastic AFOs
This type of AFO consists of a shoe or foot attachment, ankle joint, 2 metal
uprights (medial and lateral), with a calf band (application of force) connected
proximally. The stirrup anchors the uprights to the shoes between the sole and
the heel. The caliper is a round tube placed in the heel of the shoe, which
connects to the uprights and also allows for easy detachability of the uprights. A
molded shoe insert is another alternative to fit the stirrup into the shoe, which
also allows maximum control of the foot and aligns the anatomic and mechanical
ankles.
Ankle joints: The mechanical ankle joints can control or assist ankle
dorsiflexion or plantar flexion by means of stops (pins) or assists (springs).
The mechanical ankle joint also controls mediolateral stability. Knee
extension moment is promoted by ankle plantar flexion, and knee flexion
moment is promoted by ankle dorsiflexion.
1. Free motion ankle joint: The stirrup has a completely circular top,
which allows free ankle motion and provides only mediolateral
stability.
2. Plantar flexion ankle joint stop: This ankle joint stop is produced by
a pin inserted in the posterior channel of the ankle joint or by
flattening the posterior lip of the stirrup's circular stop. The plantar
flexion stop has a posterior angulation at the top of the stirrup that
restricts plantar flexion but allows unlimited dorsiflexion and
promotes knee flexion moment. This design is used in patients with
weakness of dorsiflexion during swing phase and flexible pes
equinus.
3. Dorsiflexion ankle joint stop: The stirrup has a pin inserted in the
anterior channel of the ankle joint or by flattening the anterior lip of
the stirrup's circular stop. The dorsiflexion stop has an anterior
angulation at the top of the stirrup that restricts dorsiflexion but
allows unlimited plantar flexion and promotes a knee extension
moment in the meantime. This design is used in patients with
weakness of plantar flexion during late stance.
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4. Limited motion ankle joint stop: This ankle joint stop has anterior
and posterior angulations at the top of the stirrup with restricted
dorsiflexion and plantar flexion ankle motion. The limited motion
ankle joint stop has a pin in the anterior and the posterior channel,
and it is used in ankle weakness affecting all muscle groups.
5. Dorsiflexion assist spring joint: This joint has a coil spring in the
posterior channel and helps to aid dorsiflexion during swing phase.
6. Varus or valgus correction straps (T-straps): A T-strap attached
medially and circling the ankle until buckling on the outside of the
lateral upright is used for valgus correction. A T-strap attached
laterally and buckling around the medial upright is used for varus
correction.
knee stability and control flexible genu valgum or varum. KAFO also is used to
limit the weight bearing of the thigh, leg, and foot with quadrilateral or ischial
containment brim. A KAFO is more difficult to don and doff than an AFO, so it is
not recommended for patients who have moderate-to-severe cognitive
dysfunction.
Knee joints: The mechanical knee joint can be polycentric or single axis.
Polycentric is used for significant knee motion, and a single axis is more
common and is used for knee stabilization. Single axis knee joints include
the following:
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1. Free motion knee joint: This joint has unrestricted knee flexion and
extension with a stop to prevent hyperextension. The free motion
knee joint is used for patients with recurvatum but good strength of
the quadriceps to control knee motion.
2. Offset knee joint: The hinge is located posterior to the knee joint
and ground reaction force; thus, it extends the knee and provides
great stability during early stance phase of the gait cycle. This joint
flexes the knee freely during swing phase and is contraindicated
with knee or hip flexion contracture and ankle plantar flexion stop.
3. Drop ring lock knee joint: The drop ring lock is the most commonly
used knee lock to control knee flexion. The rings drop to unlock
over the knee joint while the knee is in extension by gravity or
manual assistance. This type of joint is stable, but gait is stiff
without knee motion. A ball bearing on a spring can be added just
above the drop lock to keep it from slipping up as the patient
ambulates. Patients over 120 pounds usually feel more secure with
both medial and lateral drop locks.
4. Pawl lock with bail release knee joint: The semicircular bail attaches
to the knee joint posteriorly, and it can unlock both joints easily by
pulling up the bail or backing up to sit down in a chair. A major
drawback is the accidental unlocking while the patient is pulling his
or her pants up or bumping into a chair.
5. Adjustable knee lock joint (dial lock): The serrated adjustable knee
joint allows knee locking at different degrees of flexion. This type of
knee joint is used in patients with knee flexion contractures that are
improving gradually with stretching.
6. Ischial weight bearing: Most individuals in a KAFO sit partially on
the upper thigh band unless the cuff is brought up above the
ischium.
Knee cap and strap: The knee cap can be placed in front of the knee in
the orthosis to prevent flexion of the knee. A medial strap is used for genu
valgum and a lateral strap is used for genu varum. These buckles wrap
around the upright in the same way as ankle straps.
Knee orthoses
A knee orthosis (KO) only provides support or control of the knee but not of the
foot and ankle. The knee joint is centered over the medial femoral condyle. If the
patient does not have adequate gastrocnemius delineation so that there is a shelf
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for the distal end of the orthosis to rest on, the brace may slide down the leg with
wear. In that case, the brace needs to extend to the sole of the foot.
HIP-KNEE-ANKLE-FOOT ORTHOTICS
An HKAFO consists of a hip joint and pelvic band in addition to a KAFO. The
orthotic hip joint is positioned with the patient sitting upright at 90, while the
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orthotic knee joint is centered over the medial femoral condyle. Pelvic bands
complicate dressing after toileting unless the orthosis is worn under all
clothing. Pelvic bands increase the energy demands for ambulation.
Pelvic bands
1. Bilateral pelvic band: This band is used more commonly with its
posterior metal ends located anterior to the lateral midline of the
pelvis and is interconnected by a flexible belt.
2. Unilateral pelvic band: This band rarely is used because most
conditions requiring a HKAFO have bilateral involvement.
3. Pelvic girdle: The pelvic girdle is made of molded thermoplastic
materials, providing a maximum degree of control in patients with
bilateral involvement.
4. Silesian belt: This belt has no metal or rigid band and offers mild
resistance to abduction and rotation of the hip. The Silesian belt
attaches to the lateral upright and encircles the pelvis.
Hip joints and locks: The hip joint can prevent abduction and adduction as
well as hip rotation.
1. Single axis hip joint with lock: This joint is the most common hip
joint with flexion and extension. The single axis hip joint with lock
may include an adjustable stop to control hyperextension.
2. Two-position lock hip joint: This hip joint can be locked at full
extension and 90 of flexion and is used for hip spasticity control in
a patient who has difficulty maintaining a seated position.
3. Double axis hip joint: This hip joint has a flexion-extension axis and
abduction-adduction axis to control these motions.
TRUNK-HIP-KNEE-ANKLE-FOOT ORTHOTICS
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: Rocker shoe.
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Limb Prostheses
General Background:
External prosthetic appliances are devices used to replace the function of a
missing body part and are often referred to as prosthetic devices, or prostheses.
Lower limb prostheses are used to replace the function of a lower extremity. In
the elderly population, amputation (loss) of the lower extremity most often results
from complications of disease processes, such as diabetes, peripheral vascular
disease, thromboembolism and vasculitis. The second most common cause of
lower limb amputation is trauma to the limb, which is frequently seen in a
younger population. Amputation may also result from treatment for a malignancy
or various other medical conditions.
Several prosthetic devices are available to replace the function of lower limbs.
For amputees with above-knee limb loss, devices have traditionally consisted of
single-axis knees and/or hydraulic or pneumatic fluid-controlled therapy devices.
These devices provide optimum gait control at usual speed but require additional
compensation when walking slower or faster and also require increased
concentration and effort of the amputee. Although a device of this type does
produce a limp, the greatest stability is offered with the use of a manual locked
knee which locks the prosthesis straight for walking. The manual locked-knee
device has a release lever or cable that can be pulled to unlock the joint and
allows bending. Prosthetic devices consisting of an ankle and/or foot device are
also utilized for below-the-knee amputees.
Definition:
A limb prosthesis is an artificial replacement for any or all parts of the lower
extremity or upper extremity.
An artificial limb is a type of prosthesis that replaces a missing extremity, such
as arms and legs.
Purpose:
A prosthesis is used to provide an individual who has an amputated limb with the
opportunity to perform functional tasks, particularly ambulation (walking), which
may not be possible without the limb.
Amputation surgery most often is performed due to complications of peripheral
vascular disease or neuropathy; trauma is the second leading cause of
amputation. Industrial, vehicular, and war related accidents are the leading cause
of amputations, disease is the leading cause of amputations. [1] Cancer, infection
and circulatory disease are the leading diseases that may lead to amputation.
Amputations performed because of tumor or congenital limb deficiency are less
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common. A congenital defect can create the need for an artificial limb when a
person is born with a missing or damaged limb.
The type of prosthesis (artificial limb) used is determined largely by the extent of
an amputation or loss and location of the missing extremity.
Recovery Stages:
The American Academy of Orthotists and Prosthetists (AAOP) formed the Clinical
Standards of Practice (CSOP) on Post-operative Management of the Lower
Extremity (2004). The committee defined stages of care extending from the
preoperative period to the late stage postoperative rehabilitation. Typically, the
postoperative recovery period (including activity recovery, reintegration,
prosthetic management and training) lasts from 1218 months. However, healing
of a residual limb is a continuous process and prosthetic readiness is an
individualized transition point. The following stages of care were defined:
Preoperative stage: This stage begins with the decision to amputate.
Acute hospital postoperative stage: This stage includes the time in the
hospital after amputation surgery, generally 514 days.
Immediate postacute hospital stage: This stage begins with the hospital
discharge and may extend up to eight weeks after surgery. Endpoints of
this stage are characterized by wound healing and readiness for a
prosthetic fitting.
Intermediate recovery stage: This stage begins with wound healing and
extends 46 months from the healing date and involves the use of a
preparatory prosthesis or first prosthesis. Often, the most rapid limb
volume changes occur during this period as a result of ambulation and
prosthetic use. This stage typically ends with stabilization of residual limb
size, as defined by consistency of prosthetic fit for several months.
Transition to stable stage: A period of relative limb stabilization after the
immediate recovery stage. This stage was historically marked as a
transition from the preparatory prosthesis to the definitive prosthesis,
although more recently it has been characterized by a change from a
rapidly changing limb to a slower maturation of the limb. While limb
volume changes are not as drastic in this stage, the limb may continue to
change for 1218 months after initial healing. Modular systems are
frequently encouraged during this stage.
Postoperative rehabilitation should begin as soon as possible. Fitting for the
prosthesis may begin once the suture line has completely healed, and swelling is
minimized, although in some rare cases (e.g., young patients with traumatic
amputations), a temporary prosthesis may be fitted in surgery. Immediate
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postoperative prosthetic limb fitting has not gained wide acceptance due to
unacceptable rates of wound complications (Pinzur, 2003).
Residual limb shrinkage and swelling are often controlled in the postoperative
recovery phase with the use of various types of dressings. Ace wraps prevent
swelling and encourage shrinkage and may be used prior to complete healing of
the limb. A rigid dressing, such as a cast, may be used when temporary
prosthetic devices are recommended. Other methods to assist in shrinkage and
reduction of swelling include the use of compression stockings and stump
shrinkers (elastic stockings). The initial shrinkage and shaping of the limb takes
approximately six weeks to three months, depending on response and condition
(Sherman and Jones, 1995). Care of the residual limb is a lifelong process, and
changes in residual stump size may be the result of weight gain, weight loss or
swelling.
Prosthetic devices for children are often staged based on the childs
developmental readiness. The prosthesis must accommodate growth and other
physiological changes. According to AAOP (Cummings and Kapp, 1992),
methods that allow for growth and that may increase the lifespan of the
prosthesis include the following:
modification of socket liners
flexible sockets
removable sockets (slip or triple wall sockets)
adding or decreasing sock thickness
distal pads
the use of modular systems
growth oriented suspension systems and modifications
Furthermore, although the prosthetic treatment plan is highly individualized,
children require frequent follow-up for growth and typically require new devices
every 1218 months on average, although the actual lifespan of the device
depends on the childs rate of skeletal growth.
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transparent diagnostic test sockets and special fitting techniques to accurately fit
the prosthesis so problems can be eliminated before it is copied for the
permanent prosthesis. The average use of these devices may last for 36
months in some cases or until the residual limb has reached its final shape and
size. Stabilization of the residual limb is difficult to define; however, AAOP CSOP
(2004) suggests that a permanent prosthesis be recommended when a patient
has used a prosthetic device full time for a period of six months and when the
limb volume has stabilized to a point where the socket fit remains relatively
consistent for 23 weeks. Once fitted, the permanent prosthesis, also referred to
as a definitive prosthesis, is classified as a device that meets accepted clinical
standards for comfort, fit, function, appearance and durability. In some
circumstances, a patient may be fitted only for a permanent device, and fitting
should be delayed until the residual limb is fully mature (usually 34 months) or
until stabilization occurs in the patients weight and stump circumference
(Bodeau, 2002).
When an initial below-knee prosthesis (Health Care Financing Administration
[HCFA] Common Procedural Coding System [HCPCS] code L5500) or a
preparatory below-knee prosthesis (HCPCS codes L5510L5530, L5540) is
provided, prosthetic substitutions and/or additions of procedures and
components may be medically necessary in accordance with the functional level
assessment, except for HCPCS codes L5629, L5638, L5639, L5646, L5647,
L5704, L5785, L5962 and L5980; the latter are not considered medically
necessary. When a below-knee preparatory, prefabricated prosthesis (HCPCS
code L5535) is provided, prosthetic substitutions and/or additions of procedures
may be medically necessary in accordance with the functional level assessment,
except for HCPCS codes L5620, L5629, L5645, L5646, L5670, L5676, L5704
and L5962; the latter codes are not considered medically necessary.
When an above-knee initial prosthesis (HCPCS code L5505) or an above-knee
preparatory (HCPCS codes L5560L5580, L5590L5600) prosthesis is provided,
prosthetic substitution and/or additions of procedures and components may be
medically necessary in accordance with the functional level assessment, except
for HCPCS codes L5610, L5631, L5640, L5642, L5644, L5648, L5705, L5706,
L5964, L5980, L5710L5780 and L5790L5795; the latter codes are not
considered medically necessary. When an above-knee preparatory, prefabricated
prosthesis (HCPCS code L5585) is provided, prosthetic substitution and/or
additions of procedures and components may be medically necessary in
accordance with the functional level assessment, except for HCPCS codes
L5624, L5631, L5648, L5651, L5652, L5705, L5706, L5964 and L5966; the latter
codes are not considered medically necessary.
Functional Classifications
Prior to being fitted with a prosthetic device, the patient must demonstrate
specific functional levels. A functional level is defined as a measurement of the
capacity and potential of the patient to accomplish his/her expected post-
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rehabilitation daily function. The Centers for Medicare and Medicaid Services
(CMS) have defined the following functional levels:
Level 0: Does not have the ability or potential to ambulate or transfer safely with
or without assistance and prosthesis does not enhance his/her quality of life or
mobility.
Level 1: Has the ability or potential to use prosthesis for transfers or ambulating
on level surfaces at fixed cadence; typical of the limited and unlimited household
ambulator.
Level 2: Has the ability or potential for ambulating with the ability to traverse
environmental barriers such as curbs, stairs or uneven surfaces; typical of the
limited community ambulator.
Level 3: Has the ability or potential for ambulating with variable cadence; typical
of the community ambulator who has the ability to traverse most environmental
barriers and may have
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Description
There are several levels of lower limb amputation, including partial foot, ankle
disarticulation, transtibial (below the knee), knee disarticulation, transfemoral
(above the knee), and hip disarticulation. The most common are transtibial (midcalf) and transfemoral (mid-thigh). The basic components of these lower limb
prostheses are the foot-ankle assembly, shank, socket, and suspension syste
The basic components of a lower extremity prosthesis include:
the socket, a sock or gel liner, a suspension system, a knee joint (articulating
joint), the shank (a pylon), and a foot (terminal device)
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(Fig. 1).
Foot-ankle assembly
The foot-ankle assembly is designed to provide a base of support during
standing and walking, in addition to providing shock absorption and push-off
during walking on even and uneven terrain. Four general categories of foot-ankle
assemblies are non-articulated, articulated, elastic keel, and dynamic-response.
One of the most widely prescribed foot is the solid-ankle-cushion-heel (SACH)
foot, due to its simplicity, low cost, and durability. It may be inappropriate,
however, for active community ambulators and sports participants. Articulated
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assemblies allow motion at the level of the human ankle; this motion may occur
in one or more planes, depending on whether it is a single-axis or multi-axis foot.
These assemblies offer more mobility at the cost of less stability and increased
weight. The elastic keel foot is designed to mimic the human foot without the use
of mechanical joints; the dynamic-response foot is designed to meet the
demands of running and jumping in athletic us
Shank
The shank corresponds to the anatomical lower leg, and is used to connect the
socket to the ankle-foot assembly. In an endoskeletal shank, a central pylon,
which is a narrow vertical support, rests inside a foam cosmetic cover.
Endoskeletal systems allow for adjustment and realignment of prosthetic
components. In an exoskeletal shank, the strength of the shank is provided by a
hard outer shell that is either hollow or filled with lightweight material. Exoskeletal
systems are more durable than endoskeletal systems; however, they may be
heavier and have a fixed alignment, making adjustments difficult.
Suspension
Suspension devices should keep the prosthesis firmly in place during use and
allow comfortable sitting. Several types of suspension exist, both for the
transtibial and transfemoral amputation. Common transtibial suspensions include
sleeve, supracondylar, cuff, belt and strap, thigh-lacer, and suction styles.
Sleeves are made of neoprene, urethane, or latex and are used over the shank,
socket and thigh. Supracondylar and cuff suspensions are used to capture the
femoral condyles and hold the prosthesis on the residual limb. The belt and strap
method uses a waist belt with an anterior elastic strap to suspend the prosthesis,
while the thigh-lacer method uses a snug-fitting corset around the thigh. The
suction method consists of a silicone sleeve with a short pin at the end. The
sleeve fits over the residual limb and the pin locks into the socket. With a
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transfemoral prosthesis, suction and several types of belt suspension also are
available.
Transfemoral amputations also provide the additional challenge of incorporating
a prosthetic knee unit. The knee unit must be able to bend and straighten
smoothly during ambulation, in addition to providing stability during weightbearing
on that limb. Knees are available as single-axis, polycentric, weight-activated,
manual-locking, hydraulic, and pneumatic units. Technology using
microprocessors in knee units is becoming a reality, although costs can be
prohibitive.
The socket
The socket enables the prosthesis to connect and fit to the stump (residual limb).
This is the most important prosthetic component. A good fit is critical. A socket
that is uncomfortable is a common reason why a prosthesis is rejected.
Contoured sockets fit closer to the remaining bones, muscles, and soft tissues
providing better support, and provide relief where it's needed for comfort. 8
Examples of contoured sockets include the Hanger ComfortFlex Socket
System, Quadrilateral Socket, CAT/CAM Socket, ML socket, Acrylic socket, Total
Contact Socket, Pump It Up system, the Otto Bock Air Cushion Socket system
and more. Liners are sometimes used inside the socket to obtain a better fit and
for comfort. A gel liner helps in pressure distribution, comfort, and skin
smoothing.
Operation
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gait assessment and should watch for compensations and gait deviations that
may indicate a problem with the prosthesis.
Training
The main goal of prosthetic training usually is smooth, energy-efficient gait. This
includes the ability of the individual to accept weight on either leg, balance on
one foot, advance each leg forward and adjust to different types of terrain or
environmental conditions. Principles of motor learning often are used in training,
progressing from simple to complex tasks. Individuals begin with learning to keep
their bodies stable in a closed environment with no manipulation or variability. An
example may be practicing standing balance on one or both legs. Mobility,
environmental changes, and task variability are added slowly to further challenge
the individual as tasks are mastered. In the end, an example of a more complex
task practiced may be the ability walk in a crowded hallway while carrying an
object in one hand. In addition to ambulation training, the patient also should be
taught how to transfer to and from surfaces, assume a variety of positions such
as kneeling or squatting, and manage falls. Depending upon the individual's
previous and present level of function, use of a traditional cane, quad cane, or
crutches may be indicated. Patient motivation, comorbidity, level of amputation
and level of function are all factors in determining the outcome of rehabilitation.
Current Technology/Manufacturing
In recent years there have been significant advancements in artificial limbs. New
plastics and other materials, such as carbon fiber, have allowed artificial limbs to
be stronger and lighter, limiting the amount of extra energy necessary to operate
the limb. This is especially important for transfemoral amputees. Additional
materials have allowed artificial limbs to look much more realistic, which is
important to transradial and transhumeral amputees because they are more likely
to have the artificial limb exposed.[4]
In addition to new materials, the use of electronics has become very common in
artificial limbs. Myoelectric limbs, which control the limbs by converting muscle
movements to electrical signals, have become much more common than cable
operated limbs. Myoelectric limbs allow the amputees to more directly control the
artificial limb. Computers are also used extensively in the manufacturing of limbs.
Computer Aided Design and Computer Aided Manufacturing are often used to
assist in the design and manufacture of artificial limbs. [4]
Most modern artificial limbs are attached to the stump of the amputee by belts
and cuffs or by suction. The stump usually fits into a socket on the prosthetic.
The socket is custom made to create a better fit between the leg and the artificial
limb, which helps reduce wear on the stump. The custom socket is created by
taking a plaster cast of the stump and then making a mold from the plaster cast.
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Newer methods include laser guided measuring which can be input directly to a
computer allowing for a more sophisticated design.
One of the biggest problems with the stump and socket attachment is that there
is a large amount of rubbing between the stump and socket. This can be painful
and can cause breakdown of tissue.
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Types of Prosthesis
Prosthetic Shoes:
Prosthetic shoes (HCPCS code L3250) may be medically necessary if they are
an integral part of the prosthesis for a patient with a partial foot amputation.
These types of devices are used when all or most of the forefoot is missing and
are considered terminal prosthetic devices. The function of a prosthetic shoe is
different from that of an orthopedic shoe and supportive foot device, which are
used by individuals whose feet, although impaired, are essentially intact. Claims
for prosthetic shoes for other conditions are considered not medically necessary.
Foot Prostheses:
The basic lower-extremity foot prosthesis consists of the solid-ankle/cushionedheel (SACH) foot. Other prosthetic feet may be considered medically necessary,
based upon functional classification, ability and individual need. The SACH
simulates plantar flexion at heel strike by compressing an elastic heel wedge and
provides forefoot dorsiflexion by way of a flexible toe section. The device has no
moving parts and is frequently indicated for amputees defined as functional level
1, but may be used in level 2 or level 3 amputees. It may also be selected as a
preparatory prosthesis. A single-axis foot provides fore-aft movement about an
ankle axis limited and cushioned by plantar flexion and dorsiflexion bumpers. It is
often used in amputees of functional level 3 and is frequently preferred for abovethe-knee amputees because of the increase in knee stability during early stance
phase. Multiaxial devices provide inversion-eversion and some degree of
transverse rotation in addition to dorsiflexion and plantar flexion. These types of
devices are particularly suited for ambulating on uneven terrain and for bilateral
amputees. A flexible keel provides dynamic assist at toe-off, helping to propel the
leg into swing phase. The flexible keel is often used with a dynamic response
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that allows the amputee to ambulate at variable cadence. The device deforms
during weight-bearing, storing energy and then releasing it during late stance
phase, allowing forward movement. The flexible keel is also known as a SAFE
(solid-ankle-flexible-endoskeletal) foot. Foot covers are included in the codes for
the prosthetic foot component.
Medical necessity for a prosthetic foot is based on the following functional levels:
An external-keel SACH foot (HCPCS code L5970) or single-axis ankle/foot
(HCPCS code L5974) may be medically necessary for a patient whose
functional level is 1 or above.
A flexible-keel foot (HCPCS code L5972) or multiaxial ankle/foot (HCPCS
code L5978) may be medically necessary for a patient whose functional
level is 2 or above.
A flex foot system (HCPCS code L5980), energy-storing foot (HCPCS code
L5976), multiaxial ankle/foot with dynamic response (HCPCS code
L5979), a flex-walk system or equal (HCPCS code L5981), or shank
system with vertical loading pylon (HCPCS L5987) may be medically
necessary for a patient whose functional level is 3 or above.
Knee Prostheses:
The basic lower-extremity prosthesis includes a single-axis, constant friction
knee. This device is a basic knee that acts as a door-and-hinge device, is freeswinging and does not allow stance control. It allows one-speed ambulation and
is often used in children. Other prosthetic knees may be medically necessary
based upon functional classification, ability and individual need. A hydraulic unit
that includes piston cylinders and contains either air (i.e., pneumatic) or fluid (i.e.,
hydraulic) may be added to the knee device to allow swing control as the
amputee speeds up or slows down. Swing control may allow the amputee to walk
at variable speeds. It is often used in more active amputees. The polycentric
knee, a device with multiple rotational axes, is sometimes referred to as the four
bar knee. It has four points of rotation connected by a linkage bar. The device is
asserted to be very stable in early stance and easy to flex in swing phase.
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Ankle Prostheses:
Axial rotation units (HCPCS codes L5982L5986) may be medically necessary
for patients whose functional level is 2 or above.
Sockets:
The socket is the part of the prosthesis that fits around the residual limb and fits
around the liner or socket insert. Test sockets are used prior to permanent
sockets to determine correct fitting. Test sockets (e.g.,
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Transtibial Prosthesis:
A transtibial prosthesis is an artificial limb that replaces a leg missing below the
knee. Transtibial amputees are usually able to regain normal movement more
readily than someone with a transfemoral amputation, due in large part to
retaining the knee, which allows for easier movement.
Transfemoral Prosthesis
A transfemoral prosthesis is an artificial limb that replaces a leg missing above
the knee. Transfemoral amputees can have a very difficult time regaining normal
movement. In general, a transfemoral amputee must use approximately 80%
more energy to walk than a person with two whole legs. [5] This is due to the
complexities in movement associated with the knee.
Transradial Prosthesis
A transradial prosthesis is an artificial limb that replaces an arm missing below
the elbow. Two main types of prosthetics are available. Cable operated limbs
work by attaching a harness and cable around the opposite shoulder of the
damaged arm. The other form of prosthetics available are myoelectric arms.
These work by sensing, via electrodes, when the muscles in the upper arm
moves, causing an artificial hand to open or close.
Transhumeral Prosthesis
A transhumeral prosthesis is an artificial limb that replaces an arm missing above
the elbow. Transhumeral amputees experience some of the same problems as
transfemoral amputees, due to the similar complexities associated with the
movement of the elbow. This makes mimicking the correct motion with an
artificial limb very difficult.
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Sach Foot
Single Axis (Low Impact Level)
A hinged ankle joint is incorporated into the prosthetic foot. Rubber bumpers
.within the ankle structure absorb ankle motion induced by body weight
Dycor Foot
Multi Axis (Moderate Impact Level)
Rubber bumpers in the ankle mechanism permit a rocking motion of the foot from
heel to toe as well as from side to side. This can be useful for walking on uneven
terrain. Generally these feet do not have much stored energy return and they
.have a softer feeling underfoot than the SACH feet
Endolite Foot
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Genesis II Foot
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Luxon Foot
Talux Foot
Luxon DP Foot
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Ceterus Foot
Pathfinder Foot
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.Custom Prosthetic Services Ltd. to inquire about various prosthetic knee options
Single Axis Constant Friction Knees (Impact Level Low)
This is a basic knee where the friction is set for each patients walking speed.
The knee will feel stiff if the person is walking slower than the setting and not stiff
.enough if walking faster
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Cosmetic Covers
Custom Prosthetic Services Ltd. can provide very realistic looking cosmetic covers over below knee
.and above knee prostheses using custom colored latex and silicone skins. Inquire for more details
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Amputation level
Contour of the residual limb
Expected function of the prosthesis
Cognitive function of the patient
Vocation of the patient (eg, desk job vs manual labor)
Avocational interests of the patient (ie, hobbies)
Cosmetic importance of the prosthesis
Financial resources of the patient
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Residual limb - The preferred term for the remaining portion of the
amputated limb
Relief - A concavity within the socket that is designed for areas that
are sensitive to high pressure (bony prominences)
Buildup - A convexity that is designed for areas that are tolerant to
high pressure (such as a bulge)
Terminal device - The most distal part of a prosthesis that
substitutes for the hand; it may be a prosthetic hand, a hook, or
another device.
Myodesis - Direct suturing of residual muscle or tendon to
bone/periosteum
Myoplasty - Suturing of agonist-antagonist muscles pairs to each
other
Prehensile - Grasp
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Body-powered prostheses
Body-powered prostheses (cables) usually are of moderate cost and weight.
They are the most durable prostheses and have higher sensory feedback.
However, a body-powered prosthesis is more often less cosmetically pleasing
than a myoelectrically controlled type is, and it requires more gross limb
movement.
Externally powered prostheses
Prostheses powered by electric motors may provide more proximal function and
greater grip strength, along with improved cosmesis, but they can be heavy and
expensive. Patient-controlled batteries and motors are used to operate these
prostheses. Currently available designs generally have less sensory feedback
and require more maintenance than do body-powered prostheses. Externally
powered prostheses require a control system. The two types of commonly
available control systems are myoelectric and switch control.
A myoelectrically controlled prosthesis uses muscle contractions as a signal to
activate the prosthesis. It functions by detecting electrical activity from select
residual limb muscles, with surface electrodes used to control electric motors.
Different types of myoelectric control systems exist.
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Pros
Cons
Cosmetic
Most lightweight
Best cosmesis
Less harnessing
Body powered
Moderate cost
Moderately
lightweight
Most durable
Highest sensory
feedback
Variety of
prehensors
available for
various activities
Moderate or no
harnessing
Least body
movement needed
Battery
to operate
powered(myoelectric and/or
Moderate cosmesis
switch controlled)
More functionproximal areas
Stronger grasp in
some cases
Hybrid (cable to elbow or
TD* and battery powered)
If excursion to elbow and
battery-powered TD
If excursion to TD and
battery-powered elbow
Heaviest
Most expensive
Most maintenance
Limited sensory feedback
Extended therapy time for
training
All-cable excursion
to elbow or TD
All-cable excursion
to elbow
Battery-powered TD weights
Increased TD pinch forearm (harder to lift but
good for elbow disarticulation
All-cable excursion or long THA)
to TD
Low effort to
Lower pinch for TD and least
position TD
cosmetic
Low-maintenance
TD
*TD=terminal device
THA=transhumeral amputation
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Socket
Suspension
Control-cable system
Terminal device
Components for any interposing joints as needed according to the
level of amputation
Socket
The socket of an upper extremity prosthesis typically has a dual-wall design
fabricated from lightweight plastic or graphite composite materials. In this design,
a rigid inner socket is fabricated to fit the patient's residual limb and the second,
outer wall is added, designed to be the same length and contour as the opposite,
sound limb. Comfort and function are directly tied to the fit of the inner socket. An
alternative approach parallels the rigid frame, flexible liner approach sometimes
used in lower extremity socket fabrication. The inner socket is fabricated from
flexible plastic materials to provide appropriate contact and fit. Surrounding the
flexible liner, a rigid frame is utilized for structural support and for attaching the
necessary cables and joints as
needed. The windows in the outer socket allow movement, permit relief over
bony prominences, and enhance comfort.
Suspension
The suspension system must hold the prosthesis securely to the residual limb, as
well as accommodate and distribute the forces associated with the weight of the
prosthesis and any superimposed lifting loads. Suspension systems can be
classified as follows:
Harnessed-based systems
Self-suspending sockets
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Suction sockets
Harnessed-based systems and their variants are the most commonly used
systems. For the figure-8 strap, a harness loops around the axilla on the sound
side. This anchors the harness and provides the counterforce for suspension and
control-cable forces. On the prosthetic side, the anterior (superior) strap carries
the major suspending forces to the prosthesis by attaching directly to the socket
in a transhumeral prosthesis or indirectly to a transradial socket through an
intermediate Y-strap and triceps cuff. The posterior (inferior) strap on the
prosthetic side attaches to the control cable. For heavier lifting or as an
alternative to the figure-8 harness, a shoulder saddle with a chest-strap
suspension can be used with a transradial prosthesis. A chest strap alone is
sometimes used to suspend a transhumeral prosthesis. The figure-9 harness is
an alternative for a patient with a long transradial amputation or a wrist
disarticulation, in order to provide the control harness provides minimal
suspension and requires a self-suspending socket, it is more comfortable than a
figure-8 harness. Self-suspending and suction sockets are capable of providing
adequate prosthetic suspension without the use of a harness. However, either
design can also be used with a harness suspension to provide for a more secure
suspension of the prosthesis.
Self-suspending sockets are largely limited to wrist or elbow disarticulations and
to transradial amputations. This socket design is most commonly utilized with an
externally powered, myoelectrically controlled transradial prosthesis. An example
of this type is the Munster socket. Proper fit of this socket precludes full elbow
extension.
Suction suspension is similar to lower extremity options. These sockets use an
external, elastic suspension sleeve; a one-way air valve; or roll-on gel
suspension liner with a pin-locking mechanism. Upper limb suction sockets
(unlike nonsuction sockets) require a total contact socket design and ideally a
residual limb with no skin invagination, scarring, and stable volume to avoid skin
problems, such as a choke syndrome. Suction socket designs are most
commonly used for the patient with a transhumeral amputation.
cable's necessary attachment point and counterforce. Although the figure-9
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Harness
Selfsuspending
Suction
Indications
Figure-8
Transradial
Transhumeral
Light to
normal
activities
Advantages
Disadvantages
Simple,
durable,
adjustable
Axillary pressure
produces
discomfort
Greater lifting
ability, more
comfortable
than figure-8
harness
Reduced control
compared with
figure-8 harness,
difficult to adjust
in women
because straps
cross breasts
Shoulder
saddle and
chest strap
Transradial
Transhumeral
Heavy lifting
Muenster
Northwestern
Supracondyla
r
Wrist
disarticulation
Elbow
disarticulation
Short
transradial
Myoelectric
transradial
Ease of use
Limited lifting
capacity
compared with
harness
systems,
compromised
cosmesis,
reduced elbow
flexion
Suction
socket with
air valve
Transhumeral
with good soft
tissue cover
Secure
suspension,
elimination of
suspension
straps
Requires stable
residual volume,
harder to put
on than other
suspension
systems
Gel sleeve
with locking
pin
Transradial
Transhumeral
Compromised
limbs with
scarring or
impaired skin
integrity
Accommodate
limb volume
change with
socks,
reduced skin
shear
Greater cleaning
and hygiene
requirements,
can be
uncomfortable in
hot climates
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Control-cable mechanisms
Body-powered prosthetic limbs use cables to link movements of 1 part of the
body to the prosthesis in order to control a prosthetic function. This usually is a
movement of the humerus, shoulder, or chest, which is transferred via a Bowden
cable (a single cable passing through a single housing) to activate the terminal
device of the prosthesis. A control cable used to activate a single prosthetic
component or function is called a single-control cable, or Bowden cable system.
A dualcontrol-cable system uses the same cable to control 2 prosthetic
functions (such as flexion of the elbow and, when the elbow is locked, activation
of the terminal device). This latter control cable setup is accomplished with a
single cable passing through two separate cable Body movements that are
captured for prosthetic control
Nudge control Less cosmetic-appearing action; however, nudgecontrol devices and similhousings known as a fair lead cable system.are
types of systems are sometimes invaluable, offering cable-control options for
more complex cases where many control functions are needed.
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TERMINAL DEVICE
The major function of the hand that a prosthesis tries to replicate is grip
(prehension). The 5 different types of grips are as follows:
Precision grip (i.e., pincher grip) - The pad of the thumb and index
finger are in opposition to pick up or pinch a small object (e.g., a
small bead, pencil, grain of rice).
Tripod grip (i.e., palmar grip, 3-jaw chuck pinch) - The pad of the
thumb is against the pads of the index and middle finger.
Lateral grip (i.e., key pinch) - The pad of the thumb is in opposition
to the lateral aspect of the index finger to manipulate a small object
(such as turning a key in a lock).
Hook power grip - The distal interphalangeal joint and proximal
interphalangeal joint are flexed with the thumb extended (as
when carrying a briefcase by the handle).
Spherical grip - Tips of the fingers and thumb are flexed (when, for
example, screwing in a light bulb or opening a doorknob).
Terminal devices generally are broken down into 2 categories: passive and
active.
Passive terminal devices
Passive terminal devices fall into two classes, those designed primarily for
function and those to provide cosmesis. Examples of the functional passive
terminal devices include the child mitt frequently used on an infant's first
prosthesis to facilitate crawling or the ball handling terminal devices used by
older children and adults for ball sports. The main advantage of most passive
terminal devices is their cosmetic appearance. With newer advances in materials
and design, some passive hands are virtually indistinguishable from the native
hand. However, most of these cosmetic passive terminal devices usually are less
functional and more expensive than active terminal devices.
Active terminal devices
Active terminal devices usually are more functional than cosmetic; however, in
the near future, active devices that are equally cosmetic and functional may be
available. Active devices can be broken down into 2 main categories: hook (and
similarly specialized function) terminal devices and prosthetic hands. There are
designs of both of these terminal device groups available to operate with cable or
externally powered prostheses.
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A prosthetic hand usually is bulkier and heavier than a hook, but it is more
cosmetically pleasing. A prosthetic hand can be powered by a cable
or utilize external power. With a myoelectrically controlled device, it is possible for
the patient to initiate palmar tip grasp by contracting residual forearm flexors and
to release by contracting residual extensors.
Most hook-style terminal devices provide the equivalent of active lateral pinch
grip, while active hands provide a 3-point chuck action. Many different options
are available for terminal devices that address occupations, hobbies, and sports.
Many specialized terminal-device designs are available or are custom fabricated
by prosthetists to meet the unique functional requirements of individual
amputees. Most of the commercially available specialized terminal devices are
designed for various recreational and hobby activities. There are terminal
devices available for specific activities, such as golfing, bowling, swimming,
tennis, weight lifting, fishing, skiing, shooting pool, rock climbing, baseball,
hunting (bow and rifle), photography, and the playing of musical instruments
(guitars and drums).
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Wrist units
The wrist unit provides orientation of the terminal device in space. It can be
positioned manually, by cable operation, or with external power (whether
myoelectrically or by switch). Once positioned, the wrist unit is held in place by a
friction lock or a mechanical lock. Several different unit designs are available,
including a quick-disconnect unit, a locking unit, and a flexion unit. Frictioncontrol wrist units are easy to position but can slip easily when carrying heavier
loads.
Quick-disconnect wrist unit
This style is configured to allow easy swapping of terminal devices that
have specialized functions.
Locking wrist unit
Wrist units with a locking capacity prevent rotation during grasping and lifting.
Wrist flexion unit
A wrist flexion unit can provide an amputee (especially a bilateral upper extremity
amputee) with improved function for midline activities, such as shaving,
manipulating buttons, or performing perineal care. A flexion wrist unit usually is
employed on only one side, most often the longer of the two residual limbs, but
ultimately it should be placed on the side that the amputee prefers. Multifunction
wrist units have become available.
Elbow units
Elbow units are chosen based on the level of the amputation and the amount of
residual function. It is helpful to remember that supination and pronation of the
forearm decrease as the site of amputation becomes more proximal.
Flexible elbow hinge
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Flexible elbow hinges are utilized for medium and long transradial amputations
and wrist disarticulations. When the patient has sufficient voluntary pronation and
supination, as well as elbow flexion and extension, flexible elbow hinges help
translate any residual active pronation and supination to the terminal device. A
triceps pad or cuff helps distribute suspension forces and is needed to anchor the
control cable.
Rigid elbow hinge
With short transradial amputations, a patient has no residual, active forearm
pronation and supination but does have adequate native elbow flexion. Rigid
elbow hinges provide additional stability. Hinges are available in single-axis or
polycentric versions. Rigid hinges are important in amputees with short
transradial limbs. In patients with very short transradial, residual limbs or limited
active elbow flexion, the use of step-up elbow hinges can improve prosthetic
function by increasing functional, active elbow motion. This system uses special
elbow joints together with a split-socket design permitting the prosthetic forearm
and attached terminal device to move 2 of motion for every 1 of actual residual
limb and elbow motion. Since movement of the limb and the prosthesis are not
directly connected, the proprioceptive feedback is compromised.
Internal elbow
The standard elbow component for a transhumeral prosthesis is an internal
locking elbow joint. This allows for 135 of flexion and can be locked into a
number of preset flexed positions. The standard internal elbow joint incorporates
a turntable that allows passive internal or external humeral rotation. Elbow
spring-lift assists are available and are used to counterbalance the weight of the
forearm, making elbow flexion easier.
The standard elbow unit requires a length of 8-10 cm to be adequately installed
in a transhumeral prosthesis. If the level of amputation is less than 8-10 cm
proximal to the distal end of the humerus, then an internal locking elbow unit
cannot provide symmetric elbow centers (prosthesis and sound upper
extremity). Even if an asymmetric elbow position (compared with the sound side)
is acceptable, functional problems will result with the prosthesis from this
alignment. Unless the forearm section of the prosthesis is lengthened to
accommodate the lengthened arm section, the amputee will not be able to reach
the midline or mouth, with the prosthesis compromising function. However,
lengthening the forearm to accommodate the added arm length will result in
difficulties when the patient tries to perform bimanual activities, and it usually will
not be cosmetically acceptable to the patient. For long transhumeral amputations
or elbow disarticulations, locking external elbowjointsmay be used, but they are
not cosmetic or as durable as internal elbow joints.
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Bevel the bone end. This can help to minimize soft-tissue trauma
from sharp or irregular bone edges.
When severing a nerve, place gentle traction on it, sharply transect
it, and allow the nerve to retract into proximal soft tissue. A severed
nerve forms a neuroma (scar tissue) at the distal end. When the
neuroma forms in soft tissue, there is less likelihood of postsurgical
pain.
Perform a myoplasty (in which agonist-antagonist muscle pairs are
sutured to each other) or a myodesis (in which residual muscle is
stitched to bone) to secure the muscles of the residual limb. These
procedures stabilize the bone and soft tissues in the residual limb,
minimizing bone movement within the soft-tissue envelop of the
residual limb and therefore enhancing prosthetic
function. Maintaining muscle tension also facilitates the potential for
future myoelectric control, if desired.
During skin closure, position the wound edges to avoid bony
prominences at the distal end of the residual limb. This prevents
future pressure on the incision from the underlying bone when the
patient wears the prosthesis.
Ensure proper length so that specific prosthetic components may
be used that result in cosmesis and functional goals.
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Acute postsurgery
The major physical issues in this phase are adequate wound healing, pain
management, instruction in the performance of ADLs, mobility, ROM, and
strength. During this phase, a program to prepare the residual limb for the
prosthesis should be initiated. A skin desensitization program consists of the
following:
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14. Tan JC. Prostheses. In: Practical Manual of Physical Medicine and
Rehabilitation. St Louis, Mo: Mosby; 1998:229-59.
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