The Prosthetics and Orthotics Program
A. Bennett Wilson. Jr. *
Early in 1945, at the request of the
Surgeon General of the Army, the National Research Council sponsored a
conference of surgeons, engineers, physicists, and prosthetists to consider the
feasibility of effecting improvements in artificial limbs . Conclusions that
emerged from the conference were that virtually no organized research of
significance had been conducted in the field of limb prosthetics, and that
application of technology already in existence should produce improved
devices.
Organization of Research Program
Subsequently, at the request of the
surgeon general, the NRC established the Committee on Prosthetic Devices (later
the Committee on Artificial Limbs) to organize a research program. (The
members of the Committee on Prosthetic Devices were: Paul E. Klopsteg, Ph.D.,
Chairman; Harold R. Conn, M.D.; Roy D. McClure, M.D.; Robert R. McMath, D.Sc;
Mieth Maeser; Paul B. Magnuson, M.D.; Edmond M. Wagner; and Philip D. Wilson,
M.D. Consultants: Robert S. Allen and Charles F. Kettering.) Subcontracts were
entered into with sixteen universities, industrial laboratories, and
foundations:
- Adel Precision Products Corp., Burbank, Calif.
- Armour Research Foundation, Chicago, Ill.
- C. C. Bradley and Sons, Inc., Syracuse, N.Y. (Catranis, Inc.)
- Goodyear Tire and Rubber Co., Akron, Ohio
- A. J. Hosmer Corp., Los Angeles, Calif.
- International Business Machines Corp., Endicott, N.Y.
- Mellon Institute of Industrial Research,
Pittsburgh, Pa.
- National Research and Manufacturing Co.,
San Diego, Calif.
- Northrop Aircraft, Inc., Hawthorne,
Calif.
- Northwestern University, Evanston,
Ill.
- Research Institute Foundation, Detroit,
Mich.
- Sierra Engineering Co., Sierra Madre,
Calif.
- United States Plywood Corp., New
Rochelle, N.Y.
- University of California, Berkeley and
San Francisco, and Los Angeles
- Vard, Inc., Pasadena, Calif.
Funds were initially supplied by the
Office of Scientific Research and Development. With the impending
disestablishment of OSRD shortly after World War II, the Office of the Surgeon
General of the Army for a short time assumed fiscal responsibility for the
program. Then, for fiscal year 1947, the Army and the Veterans Administration
shared the support. The Army, the Navy, and the Veterans Administration
cooperated by establishing laboratories within their own
organizations.
In some laboratories, development of
components and application of new materials was begun, but it soon became clear
to the committee that more knowledge of the patients' requirements was needed if
significant progress was to be made. This in turn required a more detailed
knowledge of the biomechanics of human extremities, and thus projects in this
area were started. Also, anthropometric data were obtained with the idea of
selecting rationally a series of standard sizes of components.
The activities of the various groups were
initially coordinated by the Committee on Artificial Limbs, and considerable
progress was made during the first two years. By the spring of 1947, the
committee felt that it had completed its task
of establishing an organized program and suggested that contracts between the
government and the research laboratories be made directly, and that the
committee be reconstituted as an advisory group to the sponsoring agency. At
that time, the majority of service-connected amputees had been discharged from
the armed forces, and their medical care had become the responsibility of the
Veterans Administration. Therefore, new contracts were effected between the VA
and those laboratories in which promising developments were identifiable (1947:
Catranis, Inc.; Northrop Aircraft, Inc.; University of California, Berkeley and
San Francisco, and Los Angeles; 1948: New York University.) At the request of
the VA, the NRC established the Advisory Committee on Artificial Limbs to
continue the coordination and the correlation of the program. The Army, the
Navy, and the VA continued to operate their own laboratories.
The general feeling at the beginning of
the program was that the solution to the problem of providing better prostheses
lay in developing new devices, and rapid advances were made by applying new
materials and fabrication methods. It was apparent, however, that fit,
suspension, and control were at least as important as components were in the
successful use of an artificial limb, and perhaps even more so. Letters of
inquiry were sent by the committee early in its history to all known limb
manufacturers, and one of the first subcontracts was made with the Research
Institute Foundation, a laboratory operated by the Orthopedic Appliance and Limb
Manufacturers Association.
In the spring of 1946, arrangements were
made with certain prosthetists to fit experimental suction-socket above-knee
limbs, with cooperation from local surgeons and assistance from the committee
staff. Studies to establish the principles of socket configuration, fitting, and
alignment were initiated as supplements to the existing projects. Both fitting
and harnessing of artificial arms were studied at other projects.
Public Law 729
In 1948, the Eightieth Congress,
recognizing the need for continuity in a program of this kind, passed Public Law
729, which authorized the expenditure of $1,000,000 annually for research in
limb prosthetics and sensory aids (amended by P.L. 85-56, Eighty-fifth Congress,
to remove the $1,000,000 limitation). The Veterans Administration was designated
as the appropriate agency for the administration of the funds, and the
Administrator of Veterans Affairs was authorized and encouraged to make the
results of the proposed program widely available, so that all disabled persons
might benefit.
Suction-Socket "Schools"
By October 1948, experience in a number
of experimental settings indicated that the suction socket provided significant
advantages over other methods of fitting and suspension for above-knee
amputations, and that the technique should be released for general use. Because
of the many factors which enter into the successful application of the suction
socket, however, the publication of a teaching manual was not considered
sufficient to ensure success. Therefore, with the assistance of the Orthopedic
Appliance and Limb Manufacturers Association (now the American Orthotic and
Prosthetic Association) and a distinguished group of surgeons, the NRC organized
a series of regional workshops to teach surgeons and prosthetists the proper
application of the suction socket. The University of California at Berkeley was
assigned the initial responsibility for this program. The regional workshops
were continued under VA auspices with cooperation of OALMA through 1952, by
which time it was felt that the suction-socket technique had become established.
During the entire program, approximately forty workshops were held.
Prosthetics Education Program
Through the findings of the UCLA case
study and other endeavors, a considerable body of knowledge in
upper-extremity prosthetics had been accumulated by 1952.
Hence, the development was undertaken of a medium through which knowledge about
the greatly improved devices and techniques that were available could be
disseminated throughout the nation. Since the new developments involved the use
of plastic laminates for all upper-extremity amputation levels, the time
required for thorough instruction in fabrication of prostheses ruled out the use
of regional teaching sessions. The Veterans Administration therefore financed
the organization and operation of the Prosthetics Education Program at the
University of California at Los Angeles. Following a pilot school in 1952 for
teams from the Chicago area, participation in the UCLA cources was ultimately
extended to surgeons, physicians, occupational and physical therapists, and
prosthetists from all over the United States. Prosthetists attended for six
weeks; they were joined by the therapists for the last two weeks, and by the
physicians and surgeons for the final week, during which these disciplines
worked together as a clinic team.
The upper-extremity courses proved to be
extremely popular and very successful. During the initial, intensive phase of
the program (1953-55), 12 courses were conducted. As a result of these efforts,
personnel constituting 75 specialized amputee clinics, and representing 30
states and the District of Columbia, were trained. Twenty-eight of these clinics
were held at Veterans Administration installations, while 47 were at other
public and private institutions. Concomitant with the upper-extremity education
program, the VA funded a nationwide field study, conducted by New York
University, to assess the value not only of specific devices but also of the
treatment program taught at the schools. This study gathered much useful
information and also served to reinforce the instructional material.
This combined education-research program
not only served to introduce new improved concepts in the management of
upper-extremity amputees, but also was a tremendous stimulus to the formation
of amputee clinics and clinic teams
throughout the nation. Today, more than 400 amputee clinics staffed with trained
personnel are in operation in the United States. This treatment concept has also
spread to other countries throughout the world.
The education program at UCLA proved to
be so successful that the VA sponsored the establishment of a similar education
program at New York University in 1956 to meet the needs of clinic personnel.
Subsequently, the Vocational Rehabilitation Administration funded an additional
prosthetics school at Northwestern University in 1959. As new devices and
techniques emerged from the research program, additional courses were developed
at all three schools, so that today every aspect of amputee management is
covered.
Present Program Organization
By 1953, the Advisory Committee on
Artificial Limbs recognized that child amputees had special problems, and began
to work with the Michigan Crippled Children Commission to determine what might
be done to solve some of these problems. The Children's Bureau supported the
establishment of several research centers, and in 1955 the committee created the
Subcommittee on Child Prosthetics Problems.
From the beginning, the committee had
felt that much of the experience gained in research in limb prosthetics was
applicable to the field of orthopedic bracing, but it recognized that problems
in orthotics were even more complex. Therefore, work was initially concentrated
on prosthetics. About 1960, the Committee on Prosthetics Research and
Development took steps to assist in the development of improved orthotic devices
and techniques. At the present time, an active program in orthotics,
supplementary and complementary to the prosthetics program, is under
way.
In 1966, at the request of the Veterans
Administration, CPRD formed the Subcommittee on Sensory Aids to advise
the VA concerning its research program in
that area. The subcommittee also serves the Social and Rehabilitation Service in
the same capacity.
Prior to 1954, most of the research,
development, and education activities in prosthetics and orthotics in the United
States were supported by the Veterans Administration. In 1954, Congress enacted
the Vocational Rehabilitation Act, which for the first time authorized the
Office of Vocational Rehabilitation (later the Vocational Rehabilitation
Administration and now the Social and Rehabilitation Service of the Department
of Health, Education, and Welfare) to support research and education in
rehabilitation. The prosthetics and orthotics research and education programs of
the VRA were initiated gradually, beginning in 1955-a significant milestone
being the assumption of the fiscal responsibility for the three prosthetics
schools.
Today the Veterans Administration, the
Social and Rehabilitation Service, the Maternal and Child Health Service, and,
to a limited extent, the National Institutes of Health, all support extramural
research in these fields. The VA, the Army, and the Navy also operate research
and development laboratories as part of their respective organizational
endeavors.
The VA, SRS, and MCHS support the
Committee on Prosthetics Research and Development, which is responsible for
correlating the various research projects and for advising the interested
governmental agencies on matters related to prosthetics and orthotics. The VA
and SRS also support the Committee on Prosthetic-Orthotic Education of the
Division of Medical Sciences, National Academy of Sciences—National Research
Council. CPOE's activities are directed toward the stimulation of educational
programs for medical and paramedical personnel.
Laboratories supported by the VA, SRS,
MCHS, the Army, and the Navy, and their areas of interest, are listed at the end
of this article.
Accomplishments
As a result of the research program,
virtually every aspect of the management of amputees has been changed and
improved. A similar program has now been initiated in orthotics, with the
findings of the prosthetics program already strongly influencing research and
clinical practice in orthotics.
Fundamental Studies
The fundamental studies supported
originally by the VA, supplemented later by support from SRS and NIH mainly at
the University of California at Berkeley and at Los Angeles, have widely
increased our knowledge about human locomotion, phantom pain, the functions of
the upper extremities, the properties of voluntary muscle, and energy
consumption. These studies not only have provided the basis for most of the new
designs that have emerged from the research program but also have proven to be a
stimulus to others to investigate the basic principles underlying the
neuromuscular system. It is anticipated that fundamental studies will continue
to contribute to the total research effort. Fig. 1
Fitting, Alignment, and Harnessing
Techniques
Prior to the research program, it was the
general surgical practice to amputate at certain specified levels, referred to
as "sites of election." Most lower-extremity amputations resulted either in
below-knee stumps that were six inches or shorter, or, in the case of above-knee
amputations, in stumps no longer than two-thirds the length of the original
thigh. Similar circumstances prevailed for upper-extremity amputations. The
primary reason for these surgical practices was the lack of satisfactory
techniques for fitting the longer stumps, especially those involving
disarticulation, despite the fact that, in most cases, the longer the stump, the
more functional it is. Improved techniques have now been developed for
fitting stumps at all levels, and surgeons have been encouraged to save all
length medically feasible. Fig. 2,Fig. 3
New approaches to alignment based on
biomechanics have been established for most amputation levels. New devices to
aid in achieving optimum alignment have been devised and made available
commercially. Descriptions of the new alignment principles, techniques, and
instruments have been widely published, and their application is stressed in the
Prosthetics Education Program. Fig. 4
As an outcome of biomechanical analyses,
new lower-extremity socket designs have been developed for all levels of
amputation. The new socket designs have revolutionized fitting practices not
only in the United States but also throughout the world. Fig. 5,Fig. 6
New harnessing techniques for
upper-extremity prostheses, also based on biomechanical analyses, have been
developed and made available for general use.
Not only have the new fitting, alignment,
and harnessing techniques provided the patient with increased function and
comfort, but they also are easier for the prosthetist to apply than the older
methods. Fig. 7
Among the more significant techniques
developed under the program are: the plastic Syme prosthesis, the
patellar-tendon-bearing below-knee prosthesis and its variations, the
quadrilateral total-contact above-knee socket (with or without suction
suspension), the Canadian-type hip-disarticulation and hemipelvectomy
prostheses, and various plastic-socket designs for upper-extremity
amputations.
Devices
A large number of mechanical components
have been developed to provide additional or improved functions.
While most of the designs have involved
individual components, each was planned in relation to the total prosthesis.
Hence, these new items can be used in various combinations to meet the needs of
each individual patient. Noteworthy examples among the components developed
through the research program are: the harness-operated elbow lock, the APRL
voluntary-closing hand and hook, the Northrop 2-load hook, voluntary-opening
hand sizes 1-5, the SACH foot, the Henschke-Mauch "Hydraulik" knee units, the
Hosmer-DuPaCo "Hermes" unit, and the UCB pneumatic knee unit. Fig. 8,Fig. 9,Fig. 10,Fig. 11Fig. 12
Clinic-Team Concept
As a planned objective of the VA research
program, the clinic-team concept was introduced and encouraged as the preferred
method of amputee management. The results achieved have fully established the
validity of this concept in providing superior service to the amputee and in
promoting more successful use of prostheses. Today, utilization of the amputee
clinic team is standard practice in the VA, and many state agencies have
followed the lead of the VA by insisting that their patients be treated by a
clinic team. Moreover, as a result of the VA experience, the Children's Bureau
has encouraged the establishment of more than twenty specialized clinics
throughout the United States to serve child amputees. Fig. 13
Specifications and Checkout
Procedures
In the course of the research program,
specifications for manufactured components have been developed. The Veterans
Administration Prosthetics Center in New York City regularly checks components
against the specifications in order to insure that quality is being maintained. This
procedure not only insures the provision of safe, durable devices to veterans,
but also helps to keep the quality of the devices used by others at a high
level.
Procedures designed to assure that the
total prosthesis is adequately constructed, fitted, and aligned have been
developed for the use of clinic teams. These "checkout" procedures are modified
as new devices and techniques become available,
and have been of great assistance in raising the quality of amputee
management.
Reduction in Rehabilitation
Time
As a result of the introduction of
immediate postoperative fitting proceduresand early fitting
procedures, a substantial reduction in the time between amputation and return to
home and job has been effected. The use of a rigid dressing immediately after
amputation also helps to reduce edema and pain.
At one time it was the rule in many
hospitals, once the decision was made to remove part of a limb because of
peripheral vascular disease, to amputate through the thigh because of the better
blood supply in that region. Various studies have shown, however, that the knee
joints in peripheral vascular cases can, with judicious care, be saved. As a
result of these studies, rehabilitation time for many geriatric cases has been
reduced even further. Indeed, the probability of rehabilitation itself can be
markedly increased.
Reduction in Costs
The Veterans Administration has shown
that, because of improved devices and procedures for fitting and aligning
prostheses, artificial limbs were lasting
twice as long in 1968 as they were in 1948. Although the average cost of
artificial limbs increased 116.5% during that period, the increased "life"
reduced the cost per year per eligible amputee veteran to about the same as it
was in 1948.
In addition to an effective reduction in
the cost of the devices, repair, maintenance, and clinic visits were also
reduced substantially. There has been no discernible increase in the number of
prosthetists in the United States over the past 20 years, yet the number of
patients being served has increased considerably during that period, owing to
the increase in the general population and to an increase in the number of
amputations because of peripheral vascular disease in a population surviving to
greater ages.
Dissemination of Information
Prosthetics Education
Program
The Prosthetics Education Programs
originally established by the VA for training its clinic teams have proven to be
extremely successful. The short-term courses have made possible the rapid and
effective introduction to clinic teams of the new devices and techniques
developed by the research program.
Since the Prosthetics Education Program
was organized in 1953, over 15,000 students have attended the courses offered by
the three participating schools-New York University, Northwestern University,
and the University of California at Los Angeles.
Degree and Associate in Arts
Programs
Historically, the provision of
educational opportunities in a given discipline has tended to create a demand
for further education. This phenomenon has also been true of prosthetists and
ortho-tists, and has led to the establishment of longer-term courses at several
institutions. Fig. 14
New York University undertook the most
ambitious venture by establishing, in 1964, a four-year curriculum in
prosthetics and orthotics leading to the Bachelor of Science degree. Two-year
courses leading to the degree of Associate in Arts in prosthetics were begun at
Chicago City Junior College (1965) and Cerritos College (1964).
These expanding educational endeavors,
plus numerous additional offerings such as the certificate course at UCLA and
the technicians course at Delgado College, have raised the standard of
prosthetics- orthotics practice at all levels, and have exerted a steady upward
pressure on the requirements for certification.
Publications
From the beginning of the research
program, it has been the policy of the sponsoring agencies to make new
information available as it is developed to those concerned with the welfare of
the amputee. This program, which has involved both periodic and special reports, was financed initially by the Veterans Administration. SRS and the
MCHS have since added their support.
Artificial Limbs, a semiannual
journal, was created in 1953 to provide a vehicle for dissemination of timely
information, primarily to clinic-team personnel. Publication and distribution of
the journal is the responsibility of the Committee on
Prosthetics Research and Development, and it is mailed gratis to more than 4300
physicians, surgeons, therapists, pros-thetists, and research
personnel.
In 1961, the Subcommittee on Child
Prosthetics Problems of the Committee on Prosthetics Research and Development
inaugurated the publication of the Inter-Clinic Information Bulletin, a
monthly bulletin which serves as a vehicle for the exchange of information
between child amputee clinics. The material for each issue is provided on a
regularly scheduled basis by the 29 clinics affiliated with the SCPP's
cooperative research program. More than 2500 copies of the ICIB are distributed
gratis each month to interested individuals and institutions in the United
States and abroad.
In 1964, the Prosthetic and Sensory Aids
Service of the VA began publication of its own semiannual journal, the
Bulletin of Prosthetics Research, which is designed primarily to meet the
needs of PSAS and covers a wide range of topics. It is available from the
Superintendent of Documents of the U.S. Government Printing Office. Typically,
some 2300 copies of each issue are sold, in addition to an official distribution
of 3500 copies.
In 1954, Human Limbs and Their
Substitutes, published by McGraw-Hill Book Company, was prepared
principally from manuscripts developed by research personnel supported by the
VA, and with the collaboration of the Office of the Surgeon General of the Army.
This book was essentially a report on the results of
the research program up to that time, and contains much basic information. Four
thousand copies were printed, and the book had been out of print after 1960
until it was reprinted by the Hafner Publishing Company in 1968.
Reports of special conferences organized
by the Committee on Prosthetics Research and Development have been prepared in
order to provide information useful to others as well as to those attending the
meeting.
References:
- Burgess, Ernest M., Robert L. Romano, and Joseph H. Zettl, The management of lower-extremity amputations, TR 10-6, Prosthetic and Sensory Aids Service, Veterans Administration, August 1969.
- Committee on Artificial Limbs, National Research Council, Terminal research reports on artificial limbs covering the period from 1 April 1945 through 30 June 1947 (to the Office of the Surgeon General of the Army and the U.S. Veterans Administration).
- Committee on Prosthetics Research and Development, Selected bibliography on limb prosthetics, Artif. Limbs, 12:2:42-48, Autumn 1968.
- Klopsteg, Paul E., Philip D. Wilson, et al., Human limbs and their substitutes, McGraw-Hill, New York, 1954. (Reprint edition, Hafner, 1968)
- Talley, William H., Prosthetics research-a cost reduction program, an editorial, Bull. Pros. Res. 10-10, Fall 1968.
- University of California (Berkeley), Prosthetic Devices Research Project, Fundamental studies of human locomotion and other information relating to design of artificial limbs, Report to the Committee on Artificial Limbs, National Research Council, 1947, two volumes.
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