Page 6 p h y s i o t h e r a p y DECEM BER, 1971 A Physiotherapist's View of the Modular System of Prosthesis D O N N A B JO R E , D ip . P .T . (M anitoba), Senior T herapist, A m putee Service, M a n itoba Rehabilitation H ospital, M a y , 1968, to January, 1971. H E A T H E R M cL A R E N , D ip . P. & O .T ., B .P.T. (M anitoba), C ertificate in Treatm ent o f L ow er E x tre m ity Am putees, N ew Y ork University. Senior therapist in charge o f am putee p r o ­ gram m e, Toronto E a st General H ospital, O ctober, 1966, to August, 1968. E nrolled in M .A . (Physiological P sychology) program m e, U niversity o f M anitoba. A dvances in m edicine since W orld War T w o have resulted in an increase in th e number o f persons w ho m ust undergo am putation o f the low er extremities as a preventive measure. Progress in prosthetic research has increased th e number o f am putees w ho can be considered candidates for artificial limbs. In this paper it is our aim to indicate the advantages to b o th the therapist and patient that a m odular system o f prosthetics provides in overcom ing som e o f the problem s encountered. EAR LY P R O S T H E T IC F IT T IN G T he m ain advantages o f the m odular system are apparent in the early stages o f rehabilitation. Since the early 1960s m any centres have begun to use the technique o f im m ediate post-surgical fitting developed initially in France, and publicised by D r. M arian W eiss in Poland, and D r. Ernest Burgess in the U n ited States.2 T his technique has proved useful for a w ide variety o f patients. Where this technique is not in use a n am putee patient m ay have a tw o to three m onth period o f treatment prior to receiving a prosthesis. U sually prosthetic appliances are n o t introduced until the sutures have been rem oved and the stum p conditioned to receive a prosthesis. A programme o f general strengthening exercises, balance training, religious stum p bandaging, and am bulation with crutches or a walker is part o f the normal post-operative regim en.6 - W ith the m odular system , prosthetic fitting and gait training can begin on ce the stitches have been removed. In the initial phase o f gait training the above-knee (A /K ) am putee is fitted with a prefabricated plastic laminate socket which is available in four sizes. A split dow n the lateral side and velcro straps a llow adjustm ent to be m ade as the stump shrinks. The below -knee (B /K ) am putee is also fitted with a prefabricated plastic lam inate socket, available in 11 left and 11 right graduated sizes. A s the stum p shrinks th e patient is fitted w ith a smaller prefabricated socket. One or m ore w oollen stump socks are w orn with the socket. D ista l tissue support is obtained by filling the bottom o f the socket with polyethylene tubing. T he sock et can then be quickly attached to the rem aining com ponent parts (see preceding article by Mr. J. F oort). A result o f early application o f a lim b is that com plications as contractures and circulatory embarrassment due to pro­ longed bed rest are reduced. The early wearing o f a pros­ thesis toughens th e stum p, m aintains or im proves m uscle tone, strength and fun ction. Stump shrinkage and shaping progress at a faster rate as total stum p contact is provided. Early prosthetic training consists o f: (1) Transference o f body weight from heel to to e and from side to side. (2) Correct placem ent o f the artificial fo o t to assure an even step length. (3) Control o f the artificial knee join t and transference o f weight to the prosthesis using stum p extension and anterior pelvic thrust. T his applies only to the A /K amputee. A lignm ent changes are usually m ade for tw o reasons: (1) T o relieve pressure areas o n the end o f the stump. (2) T o im prove the heel-toe gait pattern. T he fo o t position is adjusted using the upper wedge disc alignm ent unit. A ll such alterations m odify the position o f the fo o t with respect to the knee joint centre, in either the anterior-posterior or medial-lateral directions. The foot angle is adjusted using the low er W edge-D isc-A lignm ent U n it. Alignment Adjustments (1) F o o t P osition (U pper W edge-D isc-A lignm ent U n it) M axim um Thickness F oot P osition A nterior Retarded Posterior A dvanced M edial Outset Lateral Inset (2) F o o t A n gle (Low er W edge-D isc-A lignm ent U n it) M axim um Thickness F oot Angle A nterior Plantarflexed Posterior D orsifiexed M edial Everted Lateral Inverted F or any o f these alterations the prosthesis is rem oved and realigned. Subsequently the patient’s gait is re-assessed and further changes are m ade if necessary. O nce the patient has mastered the use o f the prosthesis in the parallel bars he is progressed to elb ow crutches or a walker, and then to canes, etc. It is im portant that the patient is placed on the Jobst Peripheral C om pression U n it prior to applying the prosthesis to m inim ize daily fluctuations in stum p circumference. The prosthesis should be worn as long as it can be com fortably tolerated, gradually increasing the tim e period to a full day. W hen the m odular prosthesis has been fitted and aligned so that th e patient is com fortable and his gait is acceptable, he is provided with a rem ovable covering which gives the lim b a normal cosm etic appearance, yet allow s alignm ent changes to be m ade easily. D esp ite th e fact that m axim um stum p shrinkage has not occurred the patient is ready for discharge. H e returns m onthly to the am putee clinic for re­ assessm ent and m ay return at any tim e sh ould problem s arise. A t each visit his gait is checked as is the con d ition o f the stum p. A lignm ent changes can be carried ou t im m edi­ ately. This is particularly advantageous to the geriatric patient in w h om stump shrinkage tends to occur at a slower rate. T he patient is functionally independent at h o m e while w aiting for his definitive limb. T H E D E F IN IT IV E L IM B T he procedure for prescribing the final or definitive limb for a patient varies betw een centres. T his is usually delayed until it is certain that the stum p has achieved m axim um shrinkage, and that only m inor adjustm ents m ay then be required once the lim b has been m ade. T o avoid costly m ajor changes this decision m ay be delayed for m onths. W hen changes m ust be m ade the patient norm ally will leave his lim b with the prosthetist for a period o f a few hours to a week. T his can create hardships for the patient and, if these delays occur frequently, he m ay becom e dis­ satisfied and reluctant to co-operate further. U sin g the m odular system the only new part for the defini­ tive lim b required is th e custom fit socket .and receptacle which is then used with the existing com ponents o f the pre­ fabricated lim b. M inor alignm ent changes are necessary at this tim e to com pensate for the new receptacle. These changes are m ade by the prosthetist and the patient then possesses a com fortable, cosm etically acceptable, permanent R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) DECEM BER, 1971 P H Y S I O T H E R A P Y Page 7 limb. Furtherm ore, if alignm ent or socket changes becom e necessary these can be m ade at m inim um expense and with minimum loss o f time. P R E -P R O ST H E T IC E V A L U A T IO N O F T H E BO R D E R L IN E A M P U T E E One o f the m ost difficult duties o f a physiotherapist work­ ing on an am putee team is that o f assessing those patients who, for on e reason or another, it is felt, may not becom e successful prosthetic users. T hese are com m only older patients with advanced peripheral vascular obstructive disease where the remaining lim b is in jeopardy, and other medical problem s. D esp ite m any attem pts, by both physi­ cians and therapists, to develop a set o f criteria to use in assessing these patients the therapist is still left to rely m ainly on her ow n judgem ent. M any patients w ho have been refused a prosthesis o n the ground that they were incapable o f walking sufficient distances using crutches, or that they were unable to master the use o f crutches at all, could quite possibly have used a prosthesis su ccessfu lly.1'3'1'7 The inability to m anage with crutches is not sufficient basis against which to judge their prosthetic ability. It is know n that the energy expenditure during crutch walking exceeds that necessary to successfully walk on a prosthesis.6 The addition o f another support point can certainly im prove their standing balance. F rom a m edical standpoint, the use o f a limb helps to m inim ize the am ount o f strain to which the remaining leg is subjected and lightens the load on the cardio­ vascular system. P sychologically, the benefits o f having a prosthesis are obvious. In the older patient it can m ean the difference betw een independence and being a “plu s-one” person at a tim e w hen he is struggling to m aintain his independence. The m odular system allow s the am putee team to evaluate these patients individually w ithout putting the patient or social agency to great expense. U se o f a prefabricated socket attached to the other com ponents allow s the patient to be given a tw o to three week trial period o f prosthetic training. Should it prove that the patient is incapable o f managing a prosthesis the team has obtained a decision based on m ore than subjective judgem ent. This decision is easier for the patient to accept as he has been given adequate opportunity to dem onstrate his ability. TH E A D V A N T A G E S O F T H E M O D U L A R P R O ST H E T IC S Y S T E M T O T H E T H E R A P IS T A lthough the m ain advantages are to be seen as they relate to the patient, there are a lso im portant advantages for the therapist. The therapist is provided with an objective m eans o f assessing a potential prosthetic user without undue expense. Therapists trained in the use o f this system are capable o f making the alignm ent changes in the department. In centres where the m odular system is not in use the therapist must rely on the prosthetist to m ake alignm ent changes. U nless there is a prosthetist in the centre arrangements m ust be made for the prosthetist to attend the centre, or the patient to visit his shop. T his m ay result in loss o f treatment time for the patient and, w hen the therapist is required to accom pany the patient, loss o f the therapist’s tim e in addi­ tion. In a centre with an active am putee pop ulation, this can seriously cut into the tim e available for productive treat­ ment and will thus unavoidably prolong the average rehabilitation period. Equipment Provided there is a P rosthetic D epartm ent in the hospital to store the various sizes o f prefabricated sockets, tubing and S A C H feet, etc., very little space and equipm ent is needed in the Physiotherapy D epartm en t in order to m ake alignment changes. The equipm ent required is as follow s: various lengths o f alum inium tubing, screwdriver, alien wrench, aligning screws, polyethylene tubing and an open end wrench. Therapist Training T he training necessary for therapists w orking with the m odular system consists o f a sou n d know ledge o f the b io ­ m echanics o f norm al gait, the variations in biom echanics im posed by a prosthesis, familiarity with the W edge-D isc- A lignm ent U n its, and the principles u p on which they operate. In this area, a s in any specialized area o f physiotherapy, training and practical experience will permit a therapist to carry ou t an efficient and successful treatment programme. SU M M A R Y The m odular system o f prosthetics as outlined by M r. J. F oort has been discussed from a physiotherapist’s poin t o f view. T he m ain advantages o f this system a s opposed to a conventional system are noted with respect to b oth the therapist and the patient. The effectiveness o f early pros­ thetic fitting in the geriatric am pu tee is em phasised. This system provides the treatment team with an objective m eans o f quickly assessing the patient’s ability to becom e a successful prosthetic user. Therapists trained in the use o f m odular system can perform required alignm ent changes with ease, in the department. B IB L IO G R A P H Y 1. Anderson, A . D ., C um m ings, V ., L evine, S. L ., and K raus, A . T he U se o f Lower Extremity P rosthetic Lim bs by Elderly Patients. Archives o f P h ysical M edicine and Rehabilitation, 1967, V ol. 48, N o . 10, 533-538. 2. Burgess, E. Im m ediate Postsurgical P rosthetics in the M anagem ent o f Low er Extrem ity A m putees. Veterans Adm inistration, W ashington, D .C ., 1967. 3. C om m ittee o n Prosthetic-O rthotic Education. The Geriatric A m putee. N ation al A cadem y o f Sciences, W ashington, D .C ., 1971. 4. D a v is, W. C ., Blanchard, R . S., and Jackson, F . C. R ehabilitation o f the Geriatric A m putee: A P lea for M oderation. A rchives o f P h ysical M edicine and R e ­ habilitation, 1967, V ol. 48, N o . 1, 3 1-36. 5. K lop steg, P. E ., and W ilson, P. D . (eds.). H um an Lim bs and their Substitutes. M cG raw -H ill B o o k Co. In c., N ew Y ork, N .Y ., 1954. 6. Koerner, I. T h e G ait o f the A m putee. Journal o f the Canadian P hysioth erapy Association, 1967, V ol. 19, N o . 5, 321-329. 7. K oh n , K . H ., and G ordon, E . E. F unctional R ating Scales for Low er Extremity A m putees. A rchives o f P h ysical M edicine a n d Rehabilitation, 1965, V ol. 46, N o . 6, 427-432. EXPANDING HORIZONS OF PHYSICAL THERAPY Y O U A R E IN V IT E D T O A T T E N D T H E S E V E N T H I N T E R N A T IO N A L C O N G R E S S O F T H E W O R L D C O N F E D ­ E R A T IO N F O R P H Y S IC A L T H E R A P Y , T O B E H E L D I N M O N T R E A L , C A N A D A , J U N E 16-23, 1974. W O R L D C O N F E D E R A T IO N F O R P H Y S IC A L TH E R A P Y P .O . B ox # 6374, Station “ A ” , Toronto 116, Ontario, Canada. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )