Essentials of

Prosthetics and Orthotics

with MCQs and Disability
Assessment Guidelines

For: {MS Orthopaedics, MD Physical Medicine & Rehabilitation, MBBS,

BPT, BOT, BPOE Students}

AK Agarwal
MS (Ortho) FICS FIMSA MNAMS
Professor and Ex Head of Department
Department of Physical Medicine and Rehabilitation
King Georges Medical University, Lucknow
Uttar Pradesh, India

Foreword
RK Srivastava

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Essentials of Prosthetics and Orthotics

First Edition: 2013

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 Contributors

Dr HC Goyal Dr Sanjay Keskar

Addl Director General of Health Services, Govt of India Associate Professor,
New Delhi NIOH Bon Hoogly, BT Road, Kolkata,
Consultant and Head (Ex) West Bengal, India
Department of Rehabilitation
Safdarjung Hospital Dr VS Gogia
New Delhi, India Senior Consultant and Head
Department of Rehabilitation Medicine
Dr Shishir Rastogi St Stephens Hospital, Tis Hazari
Professor Delhi, India
Department of Orthopedic Surgery
All India Institute of Medical Sciences Prof NK Mathur
New Delhi, India Head (Ex)
Department of Physical Medicine and Rehabilitation
SMS Medical College, Jaipur, Rajasthan, India
Dr Rajendra Sharma
Consultant and Head
Department of Rehabilitation
Prof MK Mathur
Ex HOD
Safdarjung Hospital
Department of Rehabilitation
New Delhi, India
SMS Medical College, Jaipur, Rajasthan, India
Dr Poonam Kishore
Prof JV Singh
Professor, Ophthalmology
Professor and Head
KG Medical University
Department of Community Medicine
Lucknow, Uttar Pradesh, India
Dean, Faculty of Medicine
KG Medical University, Lucknow, Uttar Pradesh, India
Dr SK Jain
Maj General (Ex) AMC Prof VP Sharma
Formally Commandant Artificial Limb Centre Head
Poona, Maharashtra, India Department of Physical Medicine and Rehabilitation
KG Medical University
Dr RK Srivastava Lucknow, Uttar Pradesh, India
Director General
Central Health Services, Govt of India, New Delhi, India Prof U Singh
Consultant and Head (Ex) Head
Department of Rehabilitation Department of Physical Medicine and Rehabilitation
Safdarjung Hospital, New Delhi, India All India Institute of Medical Sciences
New Delhi, India
Dr Ratnesh Kumar
Director Prof SK Guha
National Institute of Orthopaedically Handicapped Professor in Biomedical Engineering
Govt of India, Bon Hoogly, BT Road, Indian Institute of Technology
Kolkata, West Bengal, India New Delhi, India
 Foreword

I am very pleased to introduce Dr AK Agarwal, who is editor of Essentials of Prosthetics and

Orthotics with MCQs and Disability Assessment Guidelines. This book is having contributions from
very senior specialists and Professors of Physical Medicine and Rehabilitation from many presti-
gious medical institutes, university and colleges across India. Many new chapters and revisions have
been added to make this book a very comprehensive one to fulfil the present day needs.
Dr Agarwal has a long journey as faculty in the speciality of Physical Medicine and Rehabilitation
in KG Medical College, now known as KG Medical University, Lucknow from 1976 till today. He
has authored six books, a large number of research papers and chapter in textbook of Orthopaedic
Surgery. In 2011, he has published a book on Leprosy for Medical and Allied Health Workers in
Hindi. Dr Agarwal has received many awards from State Government, Government of India, Inter-
national Fellowship and from many Nongovernmental Organisations for his excellent services to
uplift disabled. Dr Agarwal has visited Australia, 1977, USA 1991, Bangladesh 2004, Nepal 2006 and
2012.
India has achieved a milestone in prevention of Polio in the current year, i.e. Polio free in last 12
months, the longest ever. But now we all have to maintain this milestone in the future as well.
Another current problem of Japanese Encephalitis is also to be taken seriously by proper measures
of prevention, early detection, adequate management of its sequelae specially in paddy growing
regions.
I sincerely hope that this new book will help Physicians, Surgeons and Allied Health Workers
concerned in comprehensive rehabilitation of physically disabled specially locomotor handicapped.

RK Srivastava
Director General (Ex)
Central Health Services
Government of India
Nirman Bhawan
New Delhi
 Preface

Fifteen years ago, first book on the title of Prosthetics and Orthotics was published by me for
Postgraduate Students of Orthopaedic Surgery, Neurology, Paediatrics, Neurosurgery with only nine
chapters. We have covered basic chapters like Prosthetics and Orthotics for upper and lower limbs
and trunk, etc. At that point of time I was involved in teaching and training, research and development
and service delivery in Department of Physical Medicine and Rehabilitation, KG Medical College,
Lucknow, I felt at that time there was no such book published by any of us, who were responsible for
academic activities in the speciality of Physical Medicine and Rehabilitation. Postgraduate of Physical
Medicine and Rehabilitation (PMR) and Orthopaedic Surgery were very happy to go through such a
small book which was very useful in their day-to-day clinical practice, Late Prof MK Goel had
always encouraged us for such book while he was Professor and Head of Orthopaedic Surgery, KG
Medical College, Lucknow.
Later, Dr Ratnesh Kumar, Director, National Institute of Orthopaedically Handicapped, Kolkata
(Under Ministry of Social Justice and Empowerment, Government of India) has requested for Hindi
translation of Prosthetics and Orthotics for students in Hindi speaking states like Uttar Pradesh,
Bihar, Madhya Pradesh, Punjab, Haryana, Chattisgarh, etc. Since few courses in the speciality of
Prosthetics and Orthotics like diploma/certificate courses were started in these states where there
was a good demand for such kind book, i.e. written in Hindi. In view of above, I have done translation
of my first book in Hindi and added few new chapters as per their syllabus. Uttar Pradesh Hindi
Sansthan, Lucknow has published Hindi version of my first book in Prosthetics and Orthotics in 2008.
In a short span of time this book became popular and order for bulk purchase came from Bihar, MP,
UP, etc.
I was having constant pressure from postgraduates, undergraduates of medical, paramedical and
technical streams to publish the present book incorporating newer chapters like CAD-CAM in
prosthetics and orthotics, aids for leprosy, foot ulcer in diabetes, low vision aids, HDPE limbs, locomotion,
etc. Fortunately, few of my good and worthy friends have given their excellent contribution in the
present book. The present book is third in the series starting from 1997 to 2012.
As an editor, I wish to thank all my colleagues who have contributed new important chapters in
this book and this present book is published under their constant cooperation and guidance.
We have added a new useful chapter of multiple choice questions (MCQs) to test the instant
knowledge of readers. My colleague, Dr Ratnesh Kumar , Director, National Institute of orthopedically
viii ESSENTIALS OF PROSTHETICS AND ORTHOTICS

Handicapped, Kolkata, has very kindly agreed to contribute a chapter on Disability assessment as
per guidelines of Government of India. He is very keen to provide the sensitization to all Chief
Medical Officers, Orthopaedic Surgeons in whole of the country. This chapter will serve to the needs
of all the Orthopaedic Surgeons specially who are also members of Disability Board in each district.

AK Agarwal
 Acknowledgments

I would like to express my emotions to Dear God, whose eternal blessings, divine presence, and
masterly guidance helps us to fulfil all my goals.
I wish to express my gratitude and appreciation to the contributors of different chapters who
have collaborated and guided in the preparation of this book, specially Dr RK Srivastava, Prof U
Singh, Dr SK Jain, Dr Rajendra Sharma, Prof NK Mathur, Dr Shishir Rastogi, and Dr HC Goyal.
No words can describe the immense contribution of my family members, specially my mother,
my wife and my three children, without whose support this book could not have seen the light of the
day.
We further wish to put on record, our sincere thanks to the management and staff of M/s Jaypee
Brothers Medical Publishers (P) Ltd, New Delhi, India for their skillful handling of the manuscript,
extremely efficient collaboration, excellent support in attending to minute details in editing and lastly
their greetings in every communication. The present book will serve the need and requirements of
undergraduate and postgraduates of medical and nonmedical students.
 Introduction

India has a large population of Persons with Disability (PWD) who are in need of education,
employment and Rehabilitation services. NSSO Survey indicates, India is having 18.49 millions
PWD forming about 1.8% of the total population (Disabled Persons in India, Refer No 485, 58th
Round, July-Dec. 2002, published in Dec. 2003).
The prevalence of locomotor disability is highest among all types of disabilities followed by
hearing disability and blindness. Prevalence and incidences of disability has been changing, over the
years, with the causes of disability. Over the years, the concept of Rehabilitation has undergone a
sea change in its approach. Today, the care and management of PWD does not mean only educating
and training the PWD but also empowering PWD to be integrated with normal mainstream in their
own community.
Modern advancement and global research in the field of Rehabilitation sciences, has given a
new impetus to life in overall management of PWD. The introduction of stem cell in cases of spinal
cord injury has given a new ray of hope similarly with CAD-CAM technology, a better quality of
Prosthesis/Orthosis is now possible in shortest time. This is a new revolution in fabrication, fitting
and trial of aids/appliances.
My earlier publication, Prosthetics and Orthotics in 1997 has been revised and many more
chapters like low cost aids for Low Vision, Leprosy cure cases, visually handicapped, footwear
modifications for anesthetic foot, concept of various mobility aids, HDPE Limbs, disability assessment
guidelines and MCQ have been added for the benefit of undergraduates and postgraduates of
Orthopedic Surgery, Neurology, Neurosurgery, Plastic Surgery and Physical Medicine and
Rehabilitation. This book is equally useful to students of Physiotherapy, Occupational therapy,
Prosthetic and Orthotics who wish to keep abreast and update in common locomotor diseases/
disabilities and also interested in their comprehensive Rehabilitation.
Uttar Pradesh Hindi Sansthan, Lucknow has published my Hindi translation of previous book,
Prosthetics and Orthotics in 2008 which was given prestigious Award by AICTE, New Delhi, India
being second best among the Hindi books on technical subjects received by them at all India level.
The award includes cash prize of 21,000/- along with a citation from Chairman, AICTE, New
Delhi, India in 2009.

AK Agarwal
 Contents

1. Prevalence of Disability in India: An Update................................................................... 1

2. Splints: Common Types and Technique of Fabrication .................................................. 11
3. Poliomyelitis: Etiology, Clinical Course, Prevention and Rehabilitation .................. 15
4. Prescription Criteria for Lower Limb Orthosis .......................................................... 22
5. Amputation and Stump: Etiology, Site and Types ........................................................ 31
6. Lower Limb Prosthesis ................................................................................................. 35
7. Upper Limb Orthosis .................................................................................................... 51
8. Upper Limb Prosthesis ................................................................................................. 57
9. Fabrication of Below Knee HDPE Prosthesis... ......................................................... 66
10. Normal and Amputee Locomotion................................................................................ 78
11. Role of CAD-CAM Technology in Prosthetics and Orthotics ................................... 86
12. Jaipur Foot and Limb .................................................................................................... 91
13. Spinal Orthosis: General Concept, Fabrication, Types and Indications ................... 98
14. Mobility Aids for Ambulation... ................................................................................... 107
15. Role of Rehabilitation Aids and Appliances in CP .................................................... 113
16. Rehabilitation Aids for Visually Handicapped ............................................................ 122
17. Devices for Low Vision................................................................................................ 128
18. Rehabilitation Aids for Paraplegics ............................................................................ 132
19. Shoe and Shoe Modifications ...................................................................................... 136
20. Hand Splints .................................................................................................... ............. 149
21. Leprosy: Aids and Appliances .................................................................................... 156
22. Footwear in Diabetes Mellitus ................................................................................... 165
23. Skeletal System .................................................................................................... ........ 169
24. Orthotic Management of Post Polio Syndrome ......................................................... 173
25. Materials in Rehabilitation Aids: Present and the Future ....................................... 179
26. Disability: Assesment Guidelines as per Notification ............................................... 185
27. Multiple Choice Questions and Answers .................................................................. 209
C H A P T E R 1
Prevalence of
Disability in India:
An Update
AK Agarwal, JV Singh
2 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
INTRODUCTION
In India, Persons with disabilities (PWD) have
been receiving attention during last five decades
since independence. Prevalence and incidence of
disability has been changing over the years with
changing causes of disability. Approach to
rehabilitation has also seen a change in view of
changing disability scenario. Rehabilitation is a
difficult and challenging task which requires
overall combined efforts of government, commu-
nity, voluntary organizations, and individuals.
Earlier, rehabilitation of the persons with dis-
ability meant taking care of them and placing in
special institution where their needs in terms of
food and shelter were cared for. Over the years,
the concept of rehabilitation has undergone a sea
change in its approach; the care and management
of PWD; today means not only educating and
training the PWD, but also empowering PWD to
be included with normal mainstream in their own
community (Grover, 2005).
In the recent past, there has been however a
growing realization all over the world especially
among developing countries about the need to
evolve suitable policies and programs for the
welfare of the disabled. But the paucity of data
on the size of population of the handicapped
belonging to different categories, needed for
understanding the magnitude of the welfare
services for their rehabilitation, is a major impedi-
ment for evolving a realistic approach to their
problems.
In order to evolve a successful program for
their comprehensive rehabilitation including social
integration, detailed information relating to
prevalence, types of disability, incidence of their
age, sex, etiology, etc. is very essential. Present
article, based on the findings of the Government
of India publication, Disabled Persons In
India Report No. 485, NSS 58th Round July-
Dec 2002 (published in Dec-2003) will be of
immense help to policy makers/ planners and
administrators, rehabilitation professionals and
medical, paramedical persons who are actively
involved in strengthening of disability prevention
and rehabilitation services for the disabled persons.
The objective of this article is to present the
prevalence of disabilities in India in different
geographical and cultural regions, pattern of age
of onset, etiology and to describe the social status
of the PWD in the country.
METHODOLOGY
The National Sample Survey Organization
(NSSO) had conducted thrice the detailed survey
of PWD to provide information on their magnitude
and other relevant features of PWD. The first
survey was conducted during July-Dec 1981
(NSS 36th Round) followed by second survey
during July-Dec 1991 (NSS 47th Round) The third
and recent survey of PWD was held during July-
Dec 2002 (NSS 58th Round) wherein for the first
time the information on mental retardation and
mental illness was also included.
In this NSSO survey, 45571 households from
4637 villages and 24731 households from 3354
urban blocks were surveyed from the whole
country. The 49300 PWD were observed in rural
area whereas in urban area 26679 PWD were
enumerated. NSSO categorized, mentally disabled
in two groups, i.e. mental retardation (MR) and
mentally ill (MI). Categorization was done through
three probing questions and based on the
information so obtained the persons were grouped
into MR and MI. The visually disabled persons
were categorized in two groups, i.e. Blindness
and Low Vision. Inability to hear properly was
considered as Hearing Disability (HD) and
Inability to speak properly was considered Speech
Disability (SD). Locomotor Disability (LD)
included (a) paralysis of limb or body, (b) deformity
of limb (c) loss of limb (d) dysfunction of the joints
of the limbs (e) deformity of body other than in
the limb.
 PREVALENCE OF DISABILITY IN INDIA: AN UPDATE 3

OBSERVATIONS Assam followed by Jharkhand and Rajasthan.

(IMPORTANT FINDINGS)
The NSSO survey revealed that for every 100,000
people in India, there were 1755 PWD who were
either mentally or physically disabled (Table 1.1).
Among rural and urban residents, the prevalence
of disability was 1.85% and 1.50% respectively.
Further between the two sexes, prevalence of
disability is marginally higher in males (2.12% and
1.67%) while among female is (1.5% and
1.31 %) in both rural and urban areas respectively.
Prevalence of locomotor disability is highest
followed by hearing disability and visual disability.
About 48% could not speak at all and 19% could
speak only single words. The speech of about
33% was not understandable. The distribution by
sex follows a similar pattern except that the
proportion of disabled female was higher in
category of blindness. The results show more than
one type of disabilities was present in
10.63% PWD.
PREVALENCE OF DISABILITIES IN
MAJOR STATES
Across the country, the prevalence rate per
100,000 was highest in Orissa followed by Kerala
and Punjab. The lowest rate was observed in
The prevalence rate of speech disability was
maximum in Kerala (335), followed by Himachal
Pradesh (281), Andhra Pradesh (259) and Tamil
Nadu (353)
Locomotor disability was highest in rural areas
of Punjab (1484) and in urban areas of Kerala.
The lowest prevalence rate for LD was observed
in both rural and urban areas of Assam (406 and
471) respectively.
RURAL AND URBAN DISTRIBUTION
The aggregated estimates of the disability in rural
and urban India are given in (Table 1.2)
separately for each sex and type of disability.
These estimates are obtained by using survey
proportions on the projected populations.
According to study estimates, the number of
PWD in our country was 18.49 million during
July to Dec. 2002 and they formed about 1.8%
of the total estimated population. The survey
estimated prevalence of locomotor disability is
highest in our country, i.e. 1046 in the rural and
901 in the urban per 100,000 persons. The second
highest is hearing disability, i.e. for every 100,000
persons living in rural areas 310 were having
hearing disability whereas number is 236 in
Urban Sector. This is followed by speech disability

Table 1.1: Number of disabled persons (for 1,00,000 persons) by sex and sector (All-India)

Type of disability Rural Urban Rural + Urban

M F P M F P M F P
Mental retardation 113 69 92 118 81 100 115 72 94
Mental illness 128 91 110 105 71 89 122 86 105
Blindness 191 230 210 116 166 140 171 214 192
Low vision 76 95 86 46 62 54 68 87 77
Hearing disability 319 301 310 234 238 236 296 285 291
Speech disability 242 176 210 221 151 187 237 169 204
Locomotor disability 1274 804 1046 1058 730 901 1217 785 1008
Any disability 2118 1556 1846 1670 1311 1499 2000 1493 1755

M = Male, F = Female, P = Persons

4 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

Table 1.2: Estimated* number (in 00) of PWD by type of disability and sector
Type of disability Rural Urban
Male Female Persons Male Female Persons

Any disability 83102 57748 140850 25811 18249 44060

Mental disability
Mental retardation 4434 2561 6995 1824 1128 2951
Mental illness 5022 3377 8399 1623 988 2611

Physical disability
Visual disability
Blindness 7494 8536 16030 1793 2311 4104
Low vision 2982 3563 6545 711 877 1588
Hearing disability 12516 11171 23687 3617 3313 6930
Speech disability 9495 6532 16027 3416 2102 5518
Locomotor disability 49987 29839 79826 16352 10162 26514

Estd (00) Total Persons 3923611 3711319 7634930 1545555 1391996 2937551

* Estimates are obtained by using survey proportions on the projected population

** At least of mental, visual hearing, speech and locomotor disability

(210 rural and 187 urban) and visual disability,
i.e. Blind (210 rural) and 171 (urban) (Fig. 1.1).
ETIOLOGY AND AGE OF ONSET OF
DISABILITIES
Mental Disability (MR and MI)
Causes of MR
In majority of MR cases, cause was illness during
childhood (42%) followed by Head Trauma in
childhood (10%) and pregnancy and birth related
problem (3%). Only 2% reported, hereditary as
caused of MR. The remaining 23% of the
respondents were not aware of probable cause
of MR.
Causes of Mental Illness
About 9% cases of MI reported, illness during
childhood as cause of their disability. Large
number (36%) was not aware of the cause. 46%
respondents reported, pregnancy and birth related
illness, childhood illness, head injury and
hereditary) as a cause of their disability which
were not included in the list of causes.
Age at Onset of MR/MI
Unlike other disabilities, MR was reported since
birth or at very early age. About 87% of
mentally disabled had the problem since their
birth and about 8% had the onset at age of
04 years. Among females about 90% had the
MR since their birth. The other important point
observed among MR is that the manifestation
of disability is completed within the teenage.
The problem of MI is more of an old age and
the possibility of onset of MI increases as one
gradually become old.
 PREVALENCE OF DISABILITY IN INDIA: AN UPDATE 5

Fig. 1.1: Percentage distribution of disabled persons by types of disability

Table 1.3: Number of persons with hearing disability (100,000 Persons) by

degree of disability for each sex and sector (All India)

Hearing disabled persons per 1,00,000 persons

Degree of disability Rural Urban Rural + Urban
M F P M F P M F P

Profound 102 90 96 81 82 81 96 88 92
Severe 123 124 123 85 85 85 113 114 113
Moderate 93 86 90 68 70 69 86 82 84
All 318 300 309 234 238 236 296 285 291
M = Male, F = Female, P = Persons

Visual Disability (VD) Hearing Disability (HD)

Causes of VD
About 24% reported, old age as the cause for
their blindness followed by cataract (21%) and
other eye diseases caused by blindness in about
17%. The 57% PWD with low vision reported
this problem due to old age or cataract
followed by other eye diseases (12%). Probable
cause of low vision was not known to 10% PWD.
At all India level about 32% had profound and
39% had severe hearing disability (Table 1.3).
Probable Cause of HD
Old age was reported as a probable cause of
HD by 25% and 30% for rural and urban PWD
respectively followed by other illnesses and ear
discharge.

Age at the Onset of VD Age at Onset of HD

About 68 to 72% acquired VD at the age of 60 NSSO estimated that about 7% of PWD with
years and above. 1 to 2% cases of visually HD were born with it. Onset of HD at age of 60
disabled by birth. years and above in the rural and urban area was
reported in 56% and 62% PWD respectively.
6 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

Speech Disability (SD) Probable Cause of LD

Causes of SD At all India level, Polio was the major cause of
LD in 30% and 27% of PWD with LD in rural
Among the reported causes, paralysis and other
and urban area respectively, followed by injury
illnesses were the major ones, i.e. 46 and 49%
other than burns accounting for 26% and 27%
reported paralysis or other illness as the cause of
cases of LD. Contrary to visual and hearing
speech disability in the rural and urban sectors
disability, percentage of PWD with acquired LD
respectively. MR/MI accounts for 9% SD and
due to old age was as low as 3% or 4% at all
8% due to voice disorders. Only 1% reported
India level. Leprosy (cured and not cured)
old age as the cause of SD in contrast to visual
reported as the cause of LD by 3% of PWD.
and learning disabilities.
Pattern of Age at Onset of LD
Age at Onset of SD
Age was observed in the case of VD and HD
At all India level, about 35% and 43% in rural
for LD also as high as 49% and 57% were found
and urban areas respectively reported that they
to have acquired the disability at the age of 60
were affected by SD at the age of 60 or more.
and above in rural and urban sectors respectively.
About 38% (Rural) and 31 % (Urban) PWDs had
The said percentage in the preceding age group
congenital speech defects.
(4549 years) was 27% to 29%. It was also
observed that people in rural areas have relatively
Locomotor Disability (LD)
higher incidence of LD in the lower age groups
The deformity of limbs is the maximum among than those in the urban area.
different type of LD both in rural (458) and urban
(442) followed by dysfunction of joints of limbs TYPE OF AIDS/APPLIANCES USED BY
in rural (222) and urban (250) and paralysis of PWD
limbs in rural (144) and urban (146). The loss of
The majority of PWD with LD were using
limb constitutes only about 7 to 8%. NSSO
crutches both in rural (33%) and urban area
Survey also revealed that 4% of LD reported to
(34%). Interestingly a good proportion of PWD
have either multiple LD or 2 or more other
with LD (27%) were using aids/appliances which
disabilities in both rural and urban sectors
were not among the listed aids/appliances. The
(Table 1.4).

Table 1.4: Distribution of PWD with LD (Per 1000) by type of disability

Type of LD Rural Urban Rural + Urban
M F P M F P M F P

Paralysis 143 146 144 142 154 146 142 148 145
Deformity of limb 463 448 458 448 433 442 460 444 454
Loss of limb 92 51 77 95 46 76 93 50 77
Dysfunction of joint 203 253 222 233 277 250 210 259 228
Deformity of body 98 99 98 81 89 84 94 97 95
All 1000 1000 1000 1000 1000 1000 1000 1000 1000
M = Male, F = Female, P = Persons
 PREVALENCE OF DISABILITY IN INDIA: AN UPDATE
use of caliper was seen in only 9% rural PWD
and 15% urban PWD. About 24% of visually
disabled persons were using glasses while 51%
of PWDs with low vision were using glasses.
SOCIAL STATUS
Literacy Status
In NSSO survey, literates were defined, those
who could read and write a simple message with
understanding. Those who were unable to do
were considered as illiterates.
About 55% of the PWD were illiterate; only
9% had completed higher secondary education.
As expected literacy was highest among the
MR(87%) followed by visually disabled (74%
to 77%). The proportion of illiterate was 59%
and 40% among rural and urban disabled
respectively. The current enrolment ratio per
1000 PWD of age 518 years in ordinary school
was higher in rural (475) than in urban (444).
About 11% PWD of age 518 years were enrolled
in the special schools in urban area as compared
to less than 1% in rural area.
The highest literacy among disabled was
observed in Delhi followed by Kerala. Lowest
literacy was seen in Arunanchal Pradesh followed
by Sikkim, Jharkhand, and Bihar and Orissa.
Marital Status
NSSO survey indicated that about 3% PWD were
living alone and 5% with their spouse. Out of
1000 males PWD, residing in rural areas, 471
were never married, 448 were married currently
while in urban area the corresponding numbers
were 484 and 450 respectively. Nearly 31%
female PWD were widowed, divorced, or
separated as compare to male PWD (8%). About
47% PWD were never married. The majority of
MR persons were unmarried but situation was
little better for people with hearing disability.
7
Employment Status
Among all PWDs, 26% PWD were employed.
NSSO survey found that about 37% PWD
(age 5+) as a whole were working before the
onset of disability. Fifteen to thirty five out of 1000
PWD were able to complete some vocational
courses. Employment was lowest among MR
persons, where only 6% were employed.
DISCUSSION
NSSO-2002 reveals shocking figures, a total of
18.53 million disabled, constituting about 1.8%
of the total population. The disability rate
(number of disabled per 100,000 populations) for
whole country works out to 1755. Frustrating
enough, more than 10% of the disabled
population is suffering from multiple disabilities.
Census 2001 also reported high disability rate of
2130 for the country. Rehabilitation Council of
India estimated that there would be 8.94 million
locomotor disabled, 3.24 million hearing disabled,
1.96 million speech disabled, 9 million mental
disabled, and 4.01 million visual disabled and 3
million CP in the age group 514 years in India
(estimated total 30.15 million). According to
Krishnaswamy the total disabled population in
India amounted to 14.27 million based on NSS
prevalence rates of disabilities and 1981 census
report of India; whereas NSS reported nearly 12
million total disabled number vide 36th Report
1981. J. Narayan also observed that reports on
disabilities in India reveal different statistics.
In comparison to previous two NSS Rounds,
prevalence and incidence rate seems to have
declined during two decades in each sector and
sex (1981, 1991 and 2002). Incidence of LD per
100,000 persons obtained from 1981 and 1991
showed an increase, it remained steady during
1991 to 2002 in the rural but showed a very
marginal dip in urban sector. The prevalence of
VD has decreased marginally between 1981 and
8 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
1991 and substantially between 1991 and 2002.
It may be due to improved health conditions and
availability of better quality of services for
cataract surgery in the country under National
Blindness Control Programme. Large numbers
of people are using glasses as a preservative
measure to improve their ability to see properly
that they could not have done so without glasses.
However rural urban differential is of great
concern. The prevalence of disability is more in
rural areas, and difference in the proportions of
the disabled by sex is marginally higher in males.
Similarly census 2001 also revealed more number
of disabled in rural areas but also shows that there
is no appreciable difference in the proportions of
the disabled by sex in rural and urban areas. One
of the reasons for higher number of disabled in
rural areas might be attributed to lack of medical
services/facilities in these areas but factors like
ignorance, customs and superstitions, illiteracy as
well as use of indigenous medicines also play a
significant role in development of disability. So
with the increase in provision of medical facilities
and personnel, efforts are needed to made people
aware about cause of disability and proper
preventive/precautionary measures to be taken.
Use of appliances/aids is minimal in the survey
population especially in the rural areas similar to
this. Tripathi Anand et al also found in rural
Lucknow that only 4.08% PWD were using any
appliance or aids. The biased distribution of health
infrastructure/ rehabilitative services in favor of
urban area is a visible truth in our country. With
the dearth of both private and government health
facilities in the rural areas, a great responsibility
has to be shared by the NGOs especially in the
field of rehabilitative services. Services provision
by community based mode will be the best answer
in rural areas.
Survey found that except mental retardation,
age of onset for all other disabilities was 60 years
and above. Old age was also cited as one of the
most probable cause of visual, hearing and speech
disability. It is important to focus here that with
increase in life expectancy among older persons
in the country there will be ever increasing
proportions of persons over age 65, with the
largest proportionate increase involving those
over age 80, among whom functional disability
is more prevalent. Under these circumstances
there will be need of early medical or surgical
interventions and comprehensive accessible
rehabilitation services or continuing supportive
care to limit disability and to improve quality of
life of aged persons, in the coming years. Most
of other reasons cited as causes of disabilities,
e.g. pregnancy or birth related, illness, childhood
illnesses, ear discharge, injury other than burns.
etc, in the survey are preventable through primary
or secondary prevention. So it is necessary to put
conscious efforts to provide effective and
affordable primary health care throughout the
country and to sensitize community about the
need for proper medical attention for expectant
mothers from the early months of pregnancy till
delivery. Special focus is needed for remote rural,
tribal, and urban slums areas of the country.
When the respondents were explored further
for their literacy, education, and marital status,
NSSO observed that 47% of the PWDs were
never married and only 5% were living with their
spouses. To ensure that disabled person should
lead a full, accepted and participated life in a
community, it is important that everyone in the
community should realize that they also need
normal, healthy sexual relationship; stability and
security that the institution of marriage offers.
Except for a few inherited disabilities, most of
the disabled persons are capable of getting
married and having children. Disabled marriages
should be encouraged. But the ability of a married
disabled person to bring-up a family depends more
on economics. Thus, an effort to help young
 PREVALENCE OF DISABILITY IN INDIA: AN UPDATE
disabled persons learn the skills necessary to work
and earn a living or maintain a home is an
important part of the rehabilitation. This survey
found that only 45% PWDs were literate. Very
few PWD were able to complete any vocational
courses and only 26% were employed. Jayanti
Narayan (2005) estimated that there are over
3500 special schools for PWD. It is estimated
that there are only 900 schools for HD, 900
schools for VD, 1000 schools for MR, and 700
schools for LD in the whole country. What is even
more disturbing is that inspite of high prevalence
of disability in rural areas and their low
socioeconomic status which is further making the
situation worst, whatever scant services available
are highly skewed in favor of a few large urban
cities. Most NGOs efforts are also restricted to
urban areas. However it is encouraging that,
despite non availability of special schools and
even less than 1% current enrollment ratio in
special schools from rural areas, current enroll-
ment ratio in ordinary school is higher in rural
areas. This revealed that there is wide scope and
urgent need to reach the rural disabled through
educational and training programs so that people
with disabilities develop competences to live
independently. There is need of special schools
and vocational schools at least one in each
district.
To conclude this, continuous and sustained
efforts are needed to educate and uplift the
economic status of the disabled so that they can
live self-independent life. With medical services/
facilities, extensive efforts are also needed to
educate families of PWDs, community for
complete and full social acceptance of the
disabled and to ensure rights of disabled. The
family and the community can also play a
significant role in prevention and early detection
of the disability if given the right information,
motivation, and proper material assistance.
Voluntary organizations engaged in area of
9
disability can also do a lot; they should be
encouraged with suitable financial and technical
support to expand education and training
programs for disabled especially in rural areas.
For this continuous networking activities are
required within the different service sectors and
with the NGOs. More research and infrastructure
is needed in field of rehabilitation and special
education.
ABSTRACT
Background
In recent years, there is a growing realization
among developing countries about the need to
evolve suitable policies and programs for the
welfare of the disabled. But the paucity of data
on the size of population of the handicapped
belonging to different categories, needed for
understanding the magnitude of the welfare
services for their rehabilitation, is a major
impediment for evolving a realistic approach to
their problems.
Objectives
The objective is to present the prevalence of
different disabilities with a focus on rural and
urban differential in distribution, their age of
onset, etiology, and social status of disabled in
the country.
Methods: NSSO survey methodology.
Mental retardation and mental illness was included
first time in NSSO survey.
Results
NSSO survey indicates, India is having 18.49
million PWD forming about 1.8% of the total
population. For every 100,000 people there are
1755 PWD either mentally or physically disabled.
About 10.63% PWD were having more than one
type of disabilities. In rural and urban area about
10 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
8.4% and 6.1% of total estimated households
respectively reported to have at least one PWD.
The prevalence of locomotor disability is highest
among all types of disabilities. About 55% PWD
were illiterate and only 26% PWD were
employed. Survey showed that 5% live with their
spouse and 47% were never married.
CONCLUSIONS
India has a large population of disabled who are
in need of education, employment, and rehabi-
litative services. Special focus is needed for rural
areas.
KEY WORDS
Person with Disability (PWD), Locomotor
Disability (LD), Hearing Disability (HD), Speech
Disability (SD), Visual Disability (VD) Mental
Disability (MD), Mental Retardation (MR),
Mental Illness (MI).
FURTHER READING
1. Grover U. The effect of Training Siblings on the
academic achievement of their siblings with MR. J of
Rehab Council of India, 2005; 2:4861.
2. Disabled Persons in India NSSO 58th Round (July-
Dec-02) published by National Sample Survey
Organization, Government of India, (MSPI), New
Delhi, Dec-03.
3. Census of India, Office of the Registrar General and
Census Commissioner, India, 2001.
4. Padmanabha PP. Census of India, 1981, series 1,
India, Part VII-B. The physically disabled. A
Government of India Publication, 1983.
5. Krishnaswamy S. The demography of the Disabled
and the Handicapped in India. Indian J. of Social
Work. 1987; 48(1): 8394.
6. Jayanti Narayan. Educational Status of Children with
Disabilities. NIMH News letter. 2005; 18(283): 38.
7. National Sample Survey Organization Report on the
survey of disabled persons, 36th Report (1981) No.
305, Government of India, Deptt of Statistics, New
Delhi 1983.
8. National Sample Survey Organization Report on the
survey of disabled persons, 47th Report (1991),
Government of India, Deptt of Statistics, New Delhi
1983.
9. Agarwal AK, Sharma VP, Mishra US. Prevalence of
Physical Disability in India with special Reference to
Amputation. Indian J, of Disability and Rehabili-
tation. 1988; 2(2) : 110.
10. Tripathi Anand, et al. Pattern of Disability in rural
Area. Thesis for MD (Social and Preventive
Medicine). King George Medical College, Lucknow.
(Dr J V Singh and Dr A K Agarwal, 2000Chief and
Co-guide).
C H A P T E R 2
Splints: Common Types
and Technique of
Fabrication
AK Agarwal
12 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

Splints are used in clinical practice for providing

support to weak part of the extremities. It helps
in providing support to the joints, long bones and
small bones of the hand and feet. It is commonly
used in fracture and dislocation in traumatic
cases. However splints are also used in various
other conditions like acute poliomyelitis, acute
septic arthritis, neuropathic joints, etc. Fig. 2.1: Support for knee and foot

MATERIAL
Splints are prepared with the following material.
1. Cardboard: Splints can be easily prepared
with locally available Cardboard in the home.
2. Waste Paper/Magazine: Simply old
newspapers or magazines can be used for
splints making (Fig. 2.1).
Fig. 2.2A: Below knee splint
3. Wooden/Bamboo Splints: Wooden splints
provide more stability and support to the limb.
4. Aluminum: Splints made-up of aluminum are
available in the big centers and are prepared
in Rehabilitation centers. It is more durable
and can be properly cleaned. It is rather
expensive as compare to other material.
5. Plastic: The plastic splints are lighter, can be
cleaned and useful in children. It requires
technical skill, electric oven and proper
fitting, Hence it is expensive as compare to
other types of splints.

Fabrication of Splints for Lower Limb Fig. 2.2B: Well-padded below knee splint

For children, cardboard/thick sheets of paper

can be used in preparation as shown in
Figure 2.1 for leg and foot.

METHOD OF WOODEN SPLINTS

FABRICATION
Below Knee Splint
Two pieces of flat wood having thickness of 3 to
4 mm are taken as shown in Figure 2.2A, 2.2B Fig. 2.2C: Below knee splint with leg and foot
 SPLINTS: COMMON TYPES AND TECHNIQUE OF FABRICATION
and 2.2C and both are joined at 90 degree with
the help of nails. Some soft padding on the inner
surface of the flat surface is also done. It is always
necessary to put some foam or felt at the place
where heel will come to avoid pressure sores/
blisters. Children using below knee wooden
splints should not try to walk.
This below knee splints is useful for cases of
foot drop, traumatic lesion of ankle and foot and
in severe cases of infection in the ankle and foot.
It gives supports to upper third of leg, ankle and
foot.
Above Knee Splint
It is just extension of the below knee splint and
covers knee and lower third of thigh, It is also
known as posterior leg splints Figure 2.3.
In place of wooden splints, bamboo can also
be used after making two half of it. However
proper padding is necessary while it is applied
to the extremity.
Fig. 2.3: Above knee splint
Long Listen Splint
It is used for traumatic lesions of thigh, hip, spine.
It comprise of simple long, flat wooden piece
which can be tied at pelvis, hip, knee and ankle
(Fig. 2.4) on lateral side of extremity.
Fig. 2.4: Long listen splint
13
A B
Figs 2.5A and B: Cuff and collar sling
Upper Limb Splint
It is commonly used in cases of paralytic lesions
of upper limb like acute Polio, Brachial Plexus
injury etc.
Cuff and collar sling is frequently used to
provide rest to upper limb (Figs 2.5A and 2.5B).
Simple Splint
It is just like wooden scale of 12 used to immo-
bilize wrist and hand as shown in Figure 2.6.
Fig. 2.6: Simple splint
Lateral Elbow Splint
In this type two flat wooden pieces like scales
are joined at 90 degree on one end with the help
of nails and applied on lateral side of upper arm
and forearm with the help of bandages. It gives
support to elbow, forearm, wrist and hand. In case
of injury to upper arm, then high lateral elbow splint
is applied to support humerus bone (Fig. 2.7).
In place of cuff and collar splint, triangular
support of thick cloth can also be used which can
be prepared locally. Nowadays ready-made
14 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
Fig. 2.7: Lateral elbow splint
forearm supports are also available for the use
which is quite popular.
Apart from these simple splints made from
wooden/cardboard or thick cardsheet, simple
wire splints are also available in different sizes
ready from shelf for orthopedic cases. Plaster of
Paris (POP) slab is also used in place of wooden
splints. However in emergency situation, even
simple walking sticks/umbrella (long) can also
be used in place of wooden splint. If nothing from
above available, then simply tie/join both the
FURTHER READING
lower limbs together for safe transportation to
emergency room, similarly upper limb can be tied
to the chest with bandage for transportation.
PRECAUTIONS
Proper padding should always be done while
using splints at bony prominences like elbow,
wrist.
While using Long Liston splints, head of fibula
should be protected with the use of extra
cotton/foam, Otherwise pressure can produce
lateral popliteal nerve palsy leading to foot
drop.
The proximal and distal ends of splint should
have extra cotton/foam to prevent extra
pressure on the soft tissues.
We must properly examine each case before
applying the splint so as to note down any
neurovascular impairment.
After applying splints on upper and lower limb,
we must ensure active movements of fingers
and toes respectively.
Elevation must be advised after application
of the splints.
We must ensure normal neurovascular
functions after splintage.
1. Agarwal AK., Prosthetic and orthotics (Hindi)
Published by U.P. Hindi Sansthan, Lucknow, First
Ed. 2008.
2. Agarwal AK., Polio Margdarshika, Hindi Translation
of WHO Guidelines for Preventation of deformities in
Polio, 1994.
3. Sunder S., Textbook of Rehabilitaion, 2nd Ed., 2003
published by Jaypee Brothers Medical Publishers (P)
Ltd., New Delhi.
C H A P T E R 3
Poliomyelitis; Etiology,
Clinical Course,
Prevention & Rehabilitation
AK Agarwal
16 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
Poliomyelitis was recognized as a clinical entity
in first half of nineteenth century and out breaks
were reported in UK and USA in 1854 and 1843
respectively. Polio was a major cause of
locomotor disability nearly 10 years before. But
now due to launch of Pulse Polio immunization
programme, the prevalence of new cases of polio
has come down remarkably.
ETIOLOGY
Polio is caused by Polio virus which is of 3 types
in Type I, II, III (Leon, Lancing and Brunhilde)
respectively. Polio virus gains entry in man
through esophageal route. It occurs mainly in
warmer months and was more commonly seen
in first 3 years of life. Polio virus affects anterior
horn cells of spinal cord leading to lower motor
neuron type of weakness (flaccidity of limb) in
limbs.
IDENTIFICATION
Polio is a disease of early childhood usually there
is history of fever followed by weakness in limbs.
The involved muscles are painful and tender.
Child may also have other symptoms of fever as
well headache, pain in back, uneasiness and
irritation.
CLINICAL COURSE
The clinical course in Polio child is from acute
stage to recovery stage then to stage of residual
Paralysis.
1. Acute stage: Acute Poliomyelitis.
2. Recovery stage: PIP (Post Infantile Para-
lysis)
3. Residual stage: PPRP (Post Polio Residual
paralysis)
MANAGEMENT
Acute Stage
It lasts from 0 to 6 weeks and during acute phase,
the treatment should include:
Bedrest, hot packs to involved limb/limbs.
Gentle passive movements of the joints in the
limb.
Proper splintage (wooden/cardboard, PVC/
Aluminum) to be applied on the affected limb.
(Details of Splints making is given in another
chapter)
Medical treatment for fever and its related
symptoms.
Note: Massage of any kind should not be
given till pain, spasm and tenderness of the
muscles disappear and child is comfortable.
Recovery Stage
It lasts from 6 weeks to 1824 months, during
this stage proper physiotherapy in the form of
heat therapy, gentle message, exercises (first
passive exercises then active assisted exercise
followed by active exercise) Fig. 3.1 showing
exercises of Lower limb and Fig. 3.2 showing
exercises for upper limb and splintage (to prevent
future deformity) is being advised. The tendency
of deformity in the limb should be identified and
suitably prevented with splints. The above
therapy should be given 3 to 4 times daily. The
maximum recovery takes place in first 3 months
and 6 months.
Residual Stage
After 18 to 24 months, the chances of recovery
is not there, hence a detailed evaluation of each
case is done as given below for providing
mobility aids.
LOWER LIMBS
After proper assessment of motor power around
hip, knee and ankle, suitable lower limb orthosis/
caliper is being advised. When hip, knee and
ankle have no power then HKAFO (Hip Knee
Ankle and Foot Orthosis) is prescribed. When
hip has power but knee and ankle have no power
POLIOMYELITIS: ETIOLOGY, CLINICAL COURSE, PREVENTION AND REHABILITATION 17

A B

C D

E F

Figs 3.1 A to F: Showing exercises of hip joint and knee joint

18 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

G
A

H C

Figs 3.1 G to H: Showing exercises Figs 3.2 A to C: Showing exercises of

of ankle joint shoulder joint and elbow joint
POLIOMYELITIS: ETIOLOGY, CLINICAL COURSE, PREVENTION AND REHABILITATION 19

E F

Figs 3.2 D to F: Showing exercises of shoulder joint and elbow joint

G H

Figs 3.2 G and H: Showing exercises of wrist joint

20 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
then KAFO (Knee Ankle Foot Orthosis) is given.
Similarly if hip and knee has sufficient power (3 or
above) then AFO (Ankle Foot Orthosis) is
prescribed. When trunk muscle has no sufficient
power, then lumbar brace is attached to pelvic
belt of HKAFO (Details of Orthosis is given in
separate chapter).
The cases where HKAFO bilateral is being
advised, then some walking aids like crutches/
walker/walking stick is being given for gait
training.
In neglected cases of PPRP (Post Polio Resi-
dual Paralysis), surgical correction is necessary
without which long leg calipers cannot be fitted.
The common procedures for Polio corrective
surgery are given below.
1. Soft tissue surgical release at hip (Souters),
Knee (Younts) and ankle (TA lengthening).
2. Tendon transfer like TP transfer for Foot
Drop.
3. Short tenotomy procedures at hip, knee and
ankle.
4. Stabilization procedure like triple arthrodesis
of foot.
5. Nowadays polio corrective surgery camps are
being organized in Life Line Train
(NGO),with the help of Government of India,
State Governments and corporate houses at
many remote and tribal areas of our country.
A new technique of instant Postoperative
fitting of calipers has been developed by
National Institute of Orthopedically Handi-
capped (NIOH), Kolkata where instant fitting
by prefabricated lower limb orthosis are being
fitted post surgery in the camps. It also helps
in proper patients compliance, easy gait
training and it is cost effective as well.
For Upper Limb
Abduction splint is being used where upper
limb is paralyzed.
Cock-up splint in used when, wrist extensors
are weak.
In some cases trapezius is being transferred
to weak deltoid muscle surgically followed
by splintage and then physiotherapy.
PREVENTION
Primary Prevention
Here we try to prevent occurrence of impairment
due to polio virus by providing suitable vaccination
to all children below 5 years against Poliomyelitis.
There are 2 types of vaccination for prevention
of Polio.
1. Salk developed injectable vaccine in 1954.
2 Sabin developed oral Polio vaccine in 1957,
commonly known as Polio drops.
Both the vaccines are equally effective and
well tolerated; however oral vaccine is preferred
in developing countries and given to all children
under 5 years. In our country Pulse Polio method
of vaccine has been very successful, effective
and markedly brought down the incidence of
Poliomyelitis. The majority of the countries
globally have achieved the eradication of Polio,
however in some of countries in Southeast Asia
have yet to reach the stage of Polio Free Nation.
Secondary Prevention
The secondary prevention is possible by early
detection and proper treatment. It means that
early identification is necessary to prevent future
problem of weakness of the limbs. It requires
proper sensitization of medical, paramedical, non
medical manpower, family members and village
level workers for proper community awareness
and immediate intervention. However basic aim
is to prevent impairment to become disability.
Tertiary Prevention
In this type of third level of prevention we try to
prevent transformation of disability into
 POLIOMYELITIS: ETIOLOGY, CLINICAL COURSE, PREVENTION AND REHABILITATION
handicapped stage in the child. Therefore
comprehensive rehabilitation program is provided
which include medical and economic component.
Medical Rehabilitation
It includes medical/surgical treatment of
deformities which has occurred due to improper
management of Polio followed by ambulatory
aids like, orthosis, walking aids, wheelchair, tricycle
so that child can go to nearby school
independently and get proper education. The
proper ambulation is the primary aim, the
economic rehabilitation includes, vocational
counseling, training, placement and self
employment to Polio effected children in later
stage.
The ultimate aims of Rehabilitation of Polio
child is independent living with dignity and self
esteem.
21
FURTHER READING
1. Agarwal AK: Poliomyelitis. Disability and
Rehabilitation, 2009; 346.
2. Agarwal AK: Polio Margdarshica, Book in Hindi
published in 1997.
3. Khare R, Agarwal AK, et al: Polio Rehabilitation
Surgery camps. Indian Journal of Physical Medicine
and Rehabilitation (IJPMR) 2007;18(1):21-23.
4. Keskar S, Kumar R, Agarwal AK, et al. Immediate
fitment of pre-fabricated orthosis in Polio corrective
surgery Camps. Indian Journal of Physical Medicine
and Rehabilitation, 2009; 20(2):52-4.
5. Huekstep RL, Poliomyethis, A Guide for Developing
Countries. ELBS Ed. 1982 published by Churchill
Liningstone, Edinburgh.
C H A P T E R 4
Prescription Criteria for
Lower Limb Orthosis

AK Agarwal
 PRESCRIPTION CRITERIA FOR LOWER LIMB ORTHOSIS
An orthosis is a mechanical device to support
the weak part of the body. The basic need of the
patient with biomechanical lower limb deficits
is those of ambulation, comfort, significant
improvement of function, cosmesis and ease of
application, all these basic needs should be in
balance for the patient to be adequately served
by the orthoses.
A brace may help by reducing pain, by
supporting body weight and by aiding in
ambulation. It may be supportive, preventive,
corrective or protective device to improve the
function. Supportive bracing is meant for
stabilization of the part or a joint with paralyzed
musculature. Preventive bracing for the
deformity prevention is the most common
application in childhood disabilities. Corrective
bracing is used for congenital deformity of feet,
tibial torsion, CDH and Scoliosis, etc. Protective
bracing is needed for anesthetic foot. Patients
without motivation, i.e. if he has no inner will to
improve his functions, he will not use the Orthosis
even though it may be prescribed and fabricated
for him. Further patients with medical problems
with no sufficient strength to utilize the orthosis
properly or with severe degree of motor weakness
may find the use of an orthosis too problematic
for practical use.
Before prescribing the brace, a detailed
clinical evaluation is essential, especially the
following points should be carefully noted.
1. Proper clinical history of the case.
2 Complete neurological assessment including
motor and sensory examination of the
extremity and spine.
3. Assessment of deformity around hip, knee and
ankle.
4. Limb length discrepancy.
PROPER CLINICAL HISTORY
The detailed clinical history of each case is to be
taken. A case having high grade fever with signs
23
of meningeal irritation, headache, nausea vomiting
along with spastic weakness of limb gives
suspicion of encephalitis. A case who gives history
of fever followed by flaccid weakness of limb/
limbs then suspicion of Polio is there.
COMPLETE NEUROLOGICAL
ASSESSMENT
Proper motor and sensory assessment of affected
limb is noted. Proper grading of muscle power
of all the groups of muscle around the joints is
recorded. It is necessary to record the sensory
status of the limb.
Assessment of the Deformity
The deformity around hip, knee, and ankle is
noted. If deformity is more than 10 to 20 degrees
at hip or knee then ideally long leg caliper can
not be given. The deformity should be corrected
either by physiotherapy or surgically.
Limb length discrepancy should be measured
either by tape or by wooden blocks.
TERMINOLOGY IN ORTHOSIS
The term orthosis is encouraged rather than the
use of terms as brace, splints and calipers. The
HKAFO (Hip Knee Ankle Foot Orthosis) for
long leg caliper with hip joint and pelvic belt,
KAFO (Knee Ankle Foot Orthosis) and AFO
(Ankle Foot Orthosis) for short leg bracing are
being widely used in prescription of the Orthosis.
This should be followed by specifications for hip,
knee and ankle joints. The orthosis for lower
limbs are either ambulatory or non ambulatory.
The ambulatory may be weight bearing or weight
relieving.
Ambulatory
1. Weight bearing orthosis
HKAFO
24 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
KAFO
AFO
2. Weight relieving orthosis
Above knee type
Below knee type
Non Ambulatory
It is used for static purpose like night boot for
corrected CTEV, CDH frame for congenital
dysplasia of hip, Mermaid splint for genu valga/
vara (Figs 4.1 A and B).
MATERIAL USED IN ORTHOSIS
Various different materials are being used in
fabrication of orthosis like wood, metal, steel,
aluminium and its alloy, plastic for PTB brace,
etc. Leather apart from padding, it may be used
in PTB brace, recently carbon fiber has been used
in fabrication of orthosis.
Criteria of the Prescription for Orthosis
As already stated, surgeon or specialist in
Physical Medicine and Rehabilitation has to
decide the nature of the disease and how best an
orthosis can be used in an individual case.
Evaluation: Foot and Ankle
It is generally advisable to examine the lower
limb in orderly sequence. The flexible deformities
around ankle and foot may be taken care of in
the orthosis. Various types of Ankle joints are
available depending upon muscular imbalance.
Motor weakness Check at ankle
Strong Weak
PF DF Posterior
DF PF Anterior
For valgus and varus imbalance, dictum is to
use iron on strong side and T strap on weak
side in orthosis. For associated cavus deformity,
metatarsal pad is being used below first MP joint.
When Hallux Valgus is also present then trian-
gular insert is being used between first web. For
completely flail ankle, i.e. when there is no motor
power in dorsiflexor (DF) and plantarflexor (PF)
then fixed ankle joint is to be provided and for
partial imbalance in DF and PF, limited ankle
joint motion is to be given.
Knee Joint
In children up to 56 years knee joint is not given
in the orthosis, the associated problems like genu
recurrvatum can be corrected by giving high calf
and low thigh bands and for genu valgum/varum,
strap in the knee cap could be provided accord-
ingly. For weak extensors of knee, Swedish Knee
Cage is helpful provided power around hip and
ankle is satisfactory.
Hip Joint
Commonly hip joint is provided along with lock
for proper stability in ambulation. When the case
either has severe external rotation deformity
while walking or with insufficient power around
hip joint, then hip joint with lock along with
pelvic belt (HKAFO) is being advised. In cases,
where muscles around hip has satisfactory power,
but knee and ankle have weak musculature then
only KAFO with cuff top orthosis is being given.
Similarly if lower limb has no external rotation
tendency and muscles around hip has some
power, then KAFO with ischial weight bearing
orthosis can be sufficient for the ambulation.
Prescription criteria of orthosis depend upon
motor power around hip, knee and ankle as given
below.
Example Hip Knee Ankle Orthosis
01 0 0 0 HKAFO
02 3 0 0 KAFO
03 3 3 0 AFO
04 3 0 3 Knee Cage
(Swedish)
 PRESCRIPTION CRITERIA FOR LOWER LIMB ORTHOSIS
A These are the orthosis, commonly used when
B so the whole of the affected extremity is in
Figs 4.1A and B: Mermaid splint
HKAFO
It is being given when there is no power around
hip, knee and ankle. This limb is also known as
flail limb. (Figs 4.2A to C, 4.3A and B)
KAFO
It is being given when power around hip is
sufficient and there is no power around knee and
ankle. (Figs 4.4A to C, 4.5A and B).
AFO
It is being given when power around hip and knee
is satisfactory and there is no power around ankle.
(Figs 4.6A and B)
Anesthetic Foot
The inside lining of footwear should be soft,
stitching is preferred than the nails, upper should
25
be of soft calf leather and generally we provide a
little bigger size in relation to foot.
Weight Relieving Orthosis
Two types of weight relieving orthosis are
prescribed as given below.
Above Knee Type
patient cannot be confined to bed after initial
treatment is complete. Hence by this orthosis, he
can be made ambulatory without weight trans-
mission on the effected parts. Example: In case
of Perthes disease, when healing process has
started in the femoral head after rest and special
type of POP immobilization (Broom stick POP)
then AK weight reliving caliper is advised which
has patteen type attachment on the affected side,
suspension; while patient is ambulating it means
that there should be atleast 1 and inch distance
from ground to shoe. (Figs 4.7A and B). Usually
shoe raise is given in normal ortho boot which
helps in weight relieving on the affected side.
Further modification has been described like
Toranto brace where containment of femoral head
within the acetabulum is obtained by abduction
(40 %45%) and moderate internal rotation (20%)
of the lower limb.
Some times in cases of mild to moderate genu
valgum, a three point orthosis is being prescribed
which can be used in place of plaster of Paris.
Below Knee Type
In case of difficult non union of Tibia, where
neither patient nor surgeon (not all) are willing
for further surgical intervention, a special
orthosis, i.e. PTB orthosis can be prescribed. It
can also be used when partial weight bearing
through fractures (in process of healing) is being
advised. (Fig. 4.8)
26 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

A
Fig. 4.2A : HKAFO front view
Front view HKAFO bilateral

B
Back view
Fig. 4.2B : HKAFO side view Figs 4.3A and B: HKAFO bilateral

Fig. 4.2C : HKAFO back view Fig. 4.4A : KAFO side view
 PRESCRIPTION CRITERIA FOR LOWER LIMB ORTHOSIS 27

Fig. 4.4B : KAFO back view Fig. 4.6A: AFO front view

Fig. 4.4C : KAFO front view Fig. 4.6B: AFO side view

A B A B

Figs 4.5A and B: KAFO with cuff top Figs 4.7A and B: AK weight relieving orthosis
28 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
Fig. 4.8: Parts of PTB orthosis
We have used the PTB orthosis in cases of crush
injury of foot where partial weight bearing is
required, also in cases of Hensens disease and
in other cases of anesthetic foot lesions where
sole is not only anesthetic but very delicate and
having old healed planter ulcers which are very
prone to recurrence.
PARTS OF HKAFO
The standard HKAFO consists of following parts.
1. Ankle Stirrup: This is most distal part of the
caliper which is attached to base of heel of
orthopedic boot with the help of rivets
(Fig. 4.9).
2. Joints: Each HKAFO has 3 joints.
A. Ankle Joint: Ankle joint is attached to
ankle stirrup.
B. Knee Joint: Usually lock is given in the
knee joint so that person can sit easily on
chair by unlocking. Knee joint is not given
in children below 5 years so as to keep
orthosis light.
C. Hip Joint: Hip joint is attached proximally
with the pelvic belt and distally with the
single outer upright.
3. Upright: 2 uprights made-up of aluminium or
mild steel are used for giving erect posture to
the child. All the 3 joints are attached in the
uprights.
4. Band: Every HKAFO has 4 bands which are
given posteriorly.
A. Pelvic band
B. Ischial Band
C. Thigh Band
D. Calf Band
5. Knee Cap: It provides 3 points pressure on
anterior part of orthosis which is attached to
the middle of caliper by 4 leather straps).
Note: Some time lumber frame is also
attached to the HKAFO when there is a
weakness of paravertebral musculature.
Spine
This is important to have proper assessment of
the spine before lower extremity orthosis is
being prescribed. According to status of para-
vertebral musculature, various types of spinal
orthosis can be incorporated in lower limb
orthosis.
 PRESCRIPTION CRITERIA FOR LOWER LIMB ORTHOSIS
Fig. 4.9: Parts of HKAFO
Upper Limbs
While prescribing for lower limb orthosis we
should examine the strength and power of the
upper limbs. Since in a case of bilateral weakness
of the lower limbs, where HKAFO bilateral has
been advised, the patient has to use some of the
walking aids additionally like axillary/elbow
crutches, walking sticks or walkers depending
upon individual case.
NON-AMBULATORY ORTHOSIS IN
LOWER LIMB
In case of CTEV, where deformities have been
corrected either by repeated plasters or surgically,
then special type of Night boot is being prescribed
so that recurrence of the deformity can be
prevented, followed by day shoes when child has
reached the stage of standing and walking. In day
shoes for corrected CTEV, lateral border of the
insole is raised by 1/6-1/8 along with medial
straight and stiff border.
We come across very commonly the cases of
pes planus in our day-to-day practice. The role
of modification in the shoes has a place if it is
being used in association with proper foot
29
exercises program. Thomas Crooked Elongated
Heel (TCE) with medial heel wedge of 1/4 with
or without valgoid insole should be prescribed
depending upon individual need. We prefer valgoid
insole in adults and when short muscles of foot
has motor weakness like in spina bifida, etc. Since
correction is passive by its use, hence active
correction in pes planus should be envisaged by
active play therapy and home care program in
children along with shoe modifications.
In cases of genuvalgum/varum in children,
Mermaid splint is being prescribed. But we have
very limited experience of its effectiveness.
MODERN ADVANCEMENT IN LOWER
LIMB ORTHOSIS
Recently for better cosmosis plastic has been tried
for KAFO and AKO at various places. (Figs 4.10
A to C and 4.11 A to C) The method of fabrication
is not very difficult and if cost is not a
consideration, it can be very well used. For simple
foot drop problem, Spiral plastic orthosis is being
widely prescribed since it is cosmetically very well
acceptable. Further carbon fiber has been used
in few places which add to the strength and
durability.
In addition to above, electronic devices are
also being tried where electrodes are attached to
weak muscles having computer programming as
per analysis of gait and patient can ambulate
without orthosis. The technique is known as
Functional Electrical Stimulation (FES).
Further needs and requirement of the
orthosis: As awareness is increasing a large
number of cases are coming for such lower limb
orthosis, which can provide nearly all the
activities of daily life including squatting, cross
leg sitting and climbing the stairs. That time is not
far away when these functions can also be
incorporated in the conventional orthosis.
Although this is a challenging task for those who
have a concern for disabled.
30 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

A B C
Front view Side view Back view

Figs. 4.10 A to C : Plastic AFO

A B B
Front view Side view Proximal front view

Figs. 4.11 A to C: Plastic KAFO

FURTHER READING 5. Meyer Paul R, JR. Lower Limb Orthotics, Clin.

1. Singh U, Wason SS. Multiaxial Orthosis Hip Joint for
squatting and Cross Legged Sitting with Hip-Knee
Ankle Foot Orthosis Prosth and Orthotics
International 1988;12:36-41.
2. Atlas of Orthotics, Biomechanical Principles and
application. American Academy of Orthopaedic
Surgeons. The C.V Mosby Company, 1975.
3. Bobachko, W.P McLaurin, CA and Motloch WM: The
Toronto Orthosis for Leg Perthes Disease. Artificial
Limbs 1968;12-36-41 (A).
4. Petrie JG, Bitene I. The abduction weight bearing
treatment in Legg-Perthes Disease. J Bone and Joint
Surgery 1971;53B:54-62.
Orthoped. Related Res. 1975; 102:58-71
6. Sarmiento, A. Fracture bracing. Clin Orthop
1974;102:502.
7. Wickstrom J, Willian RA. Shoe correction and Ortho-
paedic Foot supports. Clin. Related Res:
1970;70:30-42.
8. Ross WF. Foot wear and Prevention of ulcers in
Leprosy, Leprosy Rev 1962;33:202-6.
9. Agarwal AK, Sharma VP, et al. Simple shoes to go
with calibres. Aids for Living, AHR&T Action Group,
London, 1984.
10. Agarwal AK, Rastogi S, et al. Low cost orthoses:
A Follow up study. Indian J of Phy Med and Rehab,
1986; 1:25-8
C H A P T E R 5
Amputation and
Stump: Etiology, Site
and Types
AK Agarwal
32 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

The loss of limb or part of the limb due to any leprosy and diabetes, amputation has to be
cause is known as amputation and the remaining performed as a part of life saving modality.
part is known as stump. Amputation can be either
since birth or due to any disease or accident that Malignancy
is after birth. Some times a child is born without
any part of the limb then it is called as Amelia. In certain cases of malignancy in upper or lower
limbs, amputation is the first line of treatment
ACQUIRED CAUSES OF and hence number of such cases is also
AMPUTATIONS increasing.
In general, amputation is performed in two
The common acquired causes are given below. situations. As emergency amputation or planned
1. Trauma (Train and Road Traffic Accidents) amputation. In the emergency situation, there
2. Vascular (Peripheral vascular disease) is no choice of surgeons, hence amputation is
3. Infections (Chronic) performed immediately and usually wound is kept
4. Malignancy open till infection subsides, followed by revised
or planned amputation as per need of prosthesis.
Trauma
The majority of amputations are due to trauma LEVEL OF AMPUTATIONS:
which takes place due to Rail-Road traffic LOWER LIMB (FIG. 5.1)
accidents, agriculture based mechanization, war, 1. Around hip region:
playground, natural disaster like flood, tsunami,
Hemipelvectomy
earthquake and also due to personal enemity. As
the number of vehicles is increasing everyday, Disarticulation of hip
accidents are also increasing in same proportion. Above knee amputation
Further due to fast unplanned mechanizations in 2. Around knee region
the agriculture sector, a large number of cases of Disarticulation of knee
upper limb amputation are added. The wars are Below knee
also contributing to the number of cases of 3. Around ankle region
amputation. Symes/disarticulation of Ankle
4. Around foot
Vascular Boyds
Vascularity of the limb decreases in certain Pirgoff
diseases like, Diabetes mellitus, Atherosclerosis, Chopart
then distal part of the limb becomes black leading Transmetatarsal
to amputation. Due to life styles changes, the Disarticulation of toes
incidence of diabetes is increasing which means Upper Limb:
more number of amputations. Similarly, smoking 1. Around shoulder
also gives rise to Burgers disease leading to Forequater amputation
amputation of lower limb. Disarticulation of shoulder
Above elbow
Infection 2. Around elbow
The cases having chronic infection of small bones Disarticulation of elbow
of feet if not treated properly as in cases of Below elbow
 AMPUTATION AND STUMP: ETIOLOGY, SITE AND TYPES 33

3. Around wrist CHARACTERISTIC OF GOOD STUMP

Disarticulation of wrist (FIGS 5.2A AND B)
4. Around hand
Transmetacarpal 1. Length of the stump should be adequate as
Disarticulation of MP, IP joint per need.
2. Good muscle power in the stump.
3. Full ROM in proximal joint.
4. Operation scar should be healthy, nontender
and not adhered to underlying tissues.
5. Good muscle coverage of the stump.
6. Normal sensation in the stump.
7. Absence of Neuroma on the end of the stump.

Fig. 5.1: Levels of lower limb amputation

STANDARD SIZE OF VARIOUS

STUMPS
S.No. Level of Size B
amputation
Figs 5.2A and B: Good below knee stump
01 BK stump 5 to 6 from joint line
whereby length of BK CHARACTERISTIC OF BAD STUMP
Stump is calculated as 1
per feet of body height 1. Small and inadequate size
02 AK Stump 12 from tip of greater 2. Flabby musculature around stump
trochanter to down below 3. Bony stump
03 BE Stump 6 to 8 from tip of 4. Restricted ROM in proximal joint
olecranon process
5. Painful Scar
04 AE stump 6 to 8 from tip of acromion
6. Presence of Neuroma.
process
34 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
Pre Prosthetic Preparation of the Stump
Usually after 4 to 6 weeks of amputation, while
maturation process is going on in the stump, the
measurement of the stump is taken. This
maturation period is more in old age and in case
of diabetes mellitus. The following regime is
advised to each case during maturation period.
1. Cleaning of stump that is stump hygiene.
2. Stump exercises.
3. Stump strapping with elastrocrepe bandage.
4. Stump training.
5. Ambutation.
By following above steps, finally we get
suitable stump. The stump should be cleaned with
soap and water everyday and then properly dried,
followed by full range of movements on the
proximal joint of the stump. The stump should
always be kept in proper strapping. The strapping
helps in building of appropriate shape in the stump.
It also helps in reducing postoperative edema. The
case should be well motivated and encouraged
to stand and walk with mobility aids like walker
or crutches. This helps the case psychologically
to overcome his mental stress, anxiety and
depression.
FURTHER READING
1. MK Mathur. Artificial Limbs, published by Bhagwan
Mahaveer Viklang Sahayata Samiti, Jaipur.
2. Goel MK, Agarwal AK, Srivastava RK, Rastogi S. A
clinical study of amputations of the lower limbs. J of
Prosth and Orthotics International, 4, 162-64 1980.
3. Agarwal AK, Sharma VP, Verma S. A Retrospective
study of 1022 cases of lower limb amputations J of
Physio-Occup. Therapy and Rehab 11-16, 1983.
4. Agarwal AK, Sharma VP, Jain UK, Singh OP. A
clinical study of bad stumps, J of Bone and Joint
Diseases, Vol 13, 1, 1987.
5. Sharma VP, Agarwal AK, et al. A clinical study of
upper limbs amputees. Indian J of Phy Med and Rehab,
Vol 3, 1990.
C H A P T E R 6
Lower Limb
Prosthesis

AK Agarwal
36 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

DEFINITION Levels of Lower Limb Amputation

Any artificial substitute for lost part of the body A. Around Hip - Hemipelvectomy
is called prosthesis. Prosthetics can be defined - Hip disarticulation
as state of art which deals with prescription, - Above knee amputation
design, fabrication and fitment of artificial Limbs B. Around knee - Knee disarticulation
in a scientific manner. - Below knee amputation
Prosthesis can be for external or internal use. C. Around ankle - Syme amputation
The external prosthesis is used for upper and D. At foot - Pirgof
lower limbs, whereas internal prosthesis is used - Chopart (mid tarsal)
for replacement of heart valves and joints, etc. - Lisfranc
Amputations are performed due to certain (tarsometatarsal level)
medical and surgical considerations at various - Boyds amputation
levels in the lower limbs. The commonest site of - Disarticulation of toes.
amputation is below knee followed by above
knee, disarticulation of knee and ankle (syme). PRESCRIPTION CRITERIA
The following are standard levels of amputations
The ideal lower limb prosthesis in a individual
in the lower limb (Fig 6.1).
case should provide proper posture, balance,
stability and comfort in ambulation and also in
performing his activities of daily life including
vocation. It should be functionally and cosmeti-
cally acceptable to him.
The following parameters are to be taken into
consideration before making proper prescription
of lower limb prosthesis.
1. Level of amputation.
2. Stump condition.
1. Level of amputation: Depending upon site
of amputation in the lower limb a suitable
prosthesis can be prescribed.
2. Stump condition: Size of stumpThe
standard length of above knee stump
(Transfemoral) is measured from tip of greater
trochanter to distal end of the stump which is
nearly 12 14. Alternatively length can be
short of 5 6 to the normal thigh.
The standard length of below knee stump
(Transtibial) is measured from joint line to distal
end of stump. Ideally the length of a below knee
Fig. 6.1: Levels of lower limb amputation stump should be 1 per feet of his height, i.e. 6
long BK stump is ideal for person having the height
of six feet.
 LOWER LIMB PROSTHETICS
INFERENCE
In both above situations, AK prosthesis and PTB
prosthesis can be prescribed. However, when
stump is short, flabby, with bony prominences
or with limitation of joint movements than
conventional prosthesis that is AK prosthesis with
Hip joint with pelvic belt or BK prosthesis with
thigh corset are prescribed.
Types of Lower Limb Stumps
There are two types of stumps in the lower limb
extremity.
1. End bearing stump.
2. Side bearing or total contact.
The end bearing stump is best among lower
limb amputations since prosthesis for such stump
provides better stability, balance and comfort in
standing and walking. Example, knee disarti-
culation and Symes Amputation (Ankle level).
However prosthesis for this site is not very
much cosmetically accepted specially in females.
The rest of all the stumps in lower limb are
side bearing with additional advantage of cosmo-
sis.
PRE-PROSTHETIC PREPARATION
Usually (Amputee) patient is sent to Department
of Physical Medicine and Rehabilitation after
removal of stitches for measurement and fitting
of the prosthesis. But the process of stump
maturation (shrinkage) takes 6 to 8 weeks. The
stump maturation can be assessed by measuring
the circumference of the stump at different level
and then comparing with previous measurements.
Alternatively the stump can be lowered in a jug
of water and then measure the displaced water
and then compare the displaced water after 4 to
6 weeks. During this period the following
activities should be explained to the patient.
1 Stump hygiene.
2. Stump exercises.
37
3. Stump strapping.
4. Sensory training.
Apart from above program, general
conditioning exercises be started immediately
along with crutch walking as soon as possible.
Early ambulation is further necessary in old age,
vascular lesions and in cases of diabetes. Patient
is taught about proper maintenance of stump
cleanliness by washing the stump with soap and
water and then drying it by soft towel. He should
be explained stump exercises first active assisted
followed by active and then active resisted
exercises. The special emphasis should be given
for building-up of quadriceps in a below knee
stump. Quadriceps setting exercises can be
started from day one of surgery. The delay in such
exercises program will lead to wasting of the
muscles particularly in quadriceps. Exercises also
help in wound healing, promotes venous drainage
and reduces edema of stump, prevents joint
stiffness, joint contracture, promotes strength of
muscles of the stump.
Stump strapping should be explained to each
individual which helps in reducing edema and
flabbiness along with maintenance of shape.
Strapping should be opened thrice a day for
undertaking exercises of stump. Sensory training
of stump is necessary for sensory feedback of
the distal end of the stump. The propioceptors
can be further developed situated at the end of
the stump to help in ambulation like sole of the
foot.
Types of Prosthesis
Four types of prosthesis are presently available.
1. Plastic resin limb
2. Metal limb
3 HDPE limb
4 Custom built limb
1. Plastic Resin Limb: In this type, the limb is
made-up of wood and plastic resin, this limb
is most commonly prepared in all most all
38 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
developed and developing (some) countries
where such limb is used.
2. Metal limb: This was first made in Jaipur
hence also known as Jaipur limb, here
aluminum sheet is molded on Plaster mold
(Replica of the stump) and shape of stump is
given by trained artesian. In place of SACH
foot Jaipur foot is used where external shoe
is not needed. It is very popular and accepted
among farmers who have to work in
agriculture fields. It takes less time in fabri-
cations and easily affordable.
3. HDPE limb: In this type High Density
Polyethylene (HDPE) type of plastic is used
in place of wood/plastic resin followed by
attachment of Jaipur foot. It is easily prepared
in rural camps for large number of amputees.
HDPE limb is economical also and can be
used in rough field conditions.
4. Custom built limb: This type of limb is needed
for high end of the society since it is very
expensive as compare to other conventional
limbs. These endoskeleton limbs are also
preferred for play grounds that is for running,
jumping, playing on fields, etc. Nowadays
these limbs are also available in our country.
Various Prosthesis for below Knee
Amputations
The following types of BK prosthesis are
fabricated depending upon status of stump and
knee joint.
1. PTB prosthesis
2. PTB prosthesis with thigh corset
3. PTS (Patella tendon supra condylar)
prosthesis
4. TK (Through Knee) prosthesis
5. Bent knee prosthesis
6. PTB symes prosthesis
7. A K ischial weight bearing prosthesis for BK
Stump.
1. PTB prosthesis: It is commonly prescribed
for ideal below knee stump (Figs 5.2 A and B
and Figs. 6.2 A to C). This provides stable
and cosmetic gait with minimum energy
consumption and maximum output.
2. PTB prosthesis with thigh corset: When
stump is not ideal, stump has sensory
impairment commonly seen in diabetes and
leprosy and when quadriceps is not healthy
then thigh corset is attached to PTB
prosthesis. Therefore weight of the body is
taken on thigh through uprights of the knee
joint. It prevents stump breakdown and the
amputee is comfortable. (Figs 6.3 A and B).
3. PTS prosthesis: In PTS type of below knee
prosthesis, the extent of the socket is further
extended to the contour of femoral condyles.
Usually it does not require knee cap (Supra-
condylar cuff).
4. T K prosthesis: It is given to a case of through
knee amputation (Disarticulation of Knee)
where weight is taken on distal end of the
stump. (Figs. 6.4 A to C)
5. Bent knee prosthesis: It is given when stump
is small and PTB type prosthesis cannot be
given to the case. Here again weight is taken
to the area of bent knee, i.e. patella and
adjoining area.
6. PTB syme prosthesis: This type of prosthesis
is given in a case of disarticulation of ankle
where the posterior flap of the heel is not
proper and therefore ideal symes prosthesis
cannot be prescribed. In this case, weight is
not given at distal end of stump but weight
is given at PTB area of knee region.
7. A K ischeal weight bearing prosthesis for
BK stump: It is prescribed in cases of bad
BK stump with ankylosis of knee joint. Hence
a long above knee socket is prepared with
proper ischial seat which is apart of quadri-
lateral socket.
 LOWER LIMB PROSTHETICS 39

A B C
Back view Front view Side view
Figs. 6.2 A to C: PTB prosthesis

A B
Front view Side view
Figs. 6.3 A and B: PTB prosthesis with thigh corset

A B C
Back view Side view Front view
Figs. 6.4 A to C: Through knee prosthesis
40 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

BELOW KNEE PROSTHESIS distally: Then bench alignment is done.

Technique of Fabrication of PTB
Prosthesis
It involves 4 steps:
1. Measurement of the stump and socket
making.
2. Fabrication of temporary prosthesis.
3. Trial of temporary prosthesis.
4. Finishing/Finalization of temporary
Prosthesis.
1. Measurement of the stump: First POP mold
in prepared by using POP bandages and then
POP paste is filled in the mold, After drying
of POP paste then external POP is removed.
The POP replica of BK stump is finally
shaped manually.
Then plastic socket is prepared after
pouring a mixture of plastic resin (Plastic
resin + Hardner and Accelator) on the
outer surface of few layers of stockinet
and proper shape is given manually. After
drying up the resin, POP mold is removed
and now plastic socket is ready for trial
(Figs. 6.5 A and B).
2. Fabrication of temporary prosthesis: Now
already prepared plastic socket is put on shin
piece (wooden) and sach foot is attached
(Figs. 6.6 A to C)
3. Trial of temporary prosthesis: The temporary
prosthesis is given to the amputee to check
the height of the prosthesis and his comfort
level. The case must feel pressure on the PTB
area. Then the gait training is given to him
first in parallel bars and then with walking
stick and finally without any mobility aids.
Then patient learns the technique of walking
with prosthesis independently.
4. Finalization of the temporary prosthesis:
Now prosthesis is finally ready for lamination
and made permanent (Fig. 6.7).
COMPONENTS OF BELOW KNEE
PROSTHESIS
1. Suspension
2. Socket
3. Shank/shin piece
4. Ankle and foot assembly
SUSPENSION
Every below knee prosthesis needs suspension
for proper attachment to the proximal part of the
stump. Depending upon level of amputation and
status of below knee stump, three types of
suspensions are available.

A B
Figs 6.5A and B: (A) PTB socket, mould and plastic socket
(B) Symes socket and plastic socket
 LOWER LIMB PROSTHETICS 41

A B C
Temporary bilat prosthesis Temporary Temporary
bilat prosthesis bilat prosthesis
front view side view
Figs. 6.6 A to C: PTB prosthesis

Fig. 6.7: PTB prosthesis (Final)

Flexible Attachment
A. Supracondylar cuff: It is made-up of leather
or of special fabric which is attached to each
sides of proximal part of the Socket by metal
screw/stud, It is adjustable and requires little
manipulative skill to fasten (Fig. 6.8).
B. Sleeve: It is made up of rubber or rubberized
fabric tube extending from proximal part of
socket to distal part of thigh. It provides snug
suspension and smooth contour when user
sits. It is available in different size.
Fig. 6.8: PTB prosthesis
C. Suction: The suction valve inside socket held
the stump distally.
Brim contour: BK Prosthesis can be
suspended by its brim contour.
A. Supracondylar: Brim of the socket is
extended upwards medially and laterally.
42 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

It provides proper mediolateral stability and Medially: Medial condoyle of tibia.

maintains reasonable natural contour when
user sits. The patellar tendon bearing (PTB) concept is
B. Suprapateller: Brim of the socket is universally accepted nowadays. Earlier
extended upwards medially, laterally and conventional below knee prosthesis (wooden
inferiorly, Wedge is medial. It also provides socket) suspension with thigh corset was used
proper mediolateral stability and suitable for more than two centuries. In PTB prosthesis
for short below knee stump. first plaster mould of stump is prepared follower
Thigh corset: It consists of two metal bars by plastic resin lamination of the socket is being
attached to the side of the socket along with done.
knee joints and leather or flexible plastic corset.
Corset has anterior lacing or Velcro straps or
leather straps. It provides maximum
mediolateral stability and increased weight
bearing area (Fig. 6.9).

Disadvantages
1. Conspicuous look when wearer sits
2. It promotes thigh atrophy
3. Heavy
4. Expensive
5. Time consuming in wearing.

Socket
Two types of socket are used in BK Prosthesis,
depending upon the status of stump.
1. Hard socket is used for ideal below knee
stump. Fig. 6.9: BK conventional prosthesis
2. Hard socket with inner lining is used when
stump is having bony prominences with
minimum muscular covering and in anesthetic
stumps (sensory impairment). It should be
preferred in cases of diabetes and in old age.

Weight Bearing in PTB Socket

Weight is born on the following four surfaces of
the socket anteriorly by lower third of patella,
ligamentum patelle, Tibial tuberosity and shin of
tibia, posteriorly by popliteal fossa
A B C
(Figs. 6.10 A to C).
Lateral view Frontal view Posterior view
Laterally: Lateral condoyle of tibia and head of
fibula. Figs. 6.10 A to C: Weight bearing in PTB socket
 LOWER LIMB PROSTHETICS 43

Shank/Shin Piece: Two types of shin are
used for a below knee prosthesis.
1. Exoskeleton: It is made-up of wood
hollow inside along with plastic resin
lamination on external surface.
Advantage:
1. It provides maximum strength.
2. Less expensive.
Disadvantage: Unnatural appearance and
texture.
2. Endoskeleton (modular): It is made-up
of metal (aluminum) or of PVC tube. Foam
rubber covering provides natural appear-
ance and texture. The alignment adjust-
ment can be made. (Figs. 6.11 A and B)
Disadvantage: Rubber covering deter-
iorates.
Ankle Foot Assembly: Two types of foot
ankle assemblies are available.
1. Non articulated.
2. Articulated.
SAFE FOOT (Stationary Attachment
Flexible Endoskeleton)
It has following features:
Rigid polyurethane bolt block.
Keel is made-up of semirigid polyurethane
elastomer.
Resilient heel wedge.
Size: adult.
ROM: Planter flexion with minimum dorsi-
flexion and slight inversion - eversion.
Minimum energy release as plug recoil in late
stance phase.
Toe: hyperextension.
STEN (Stored Energy) FOOT
It has following features (Fig. 6.13)
Keel is of wood which is divided into three
sections and joined by rubber plugs.

NON ARTICULATED
When there is no separation between foot and
ankle.

SACH FOOT
(Solid Ankle Cushion Heel)
A B
It is most commonly used in our country.
Figs. 6.11: Endoskeleton (Modular) prosthesis
It is made-up of wooden keel surrounded
by rubber. This comprises of few layers of
rubber sheet of varying degree of hardness. Toe
break is also provided. The foot provides slight
inversion-eversion and plantar and dorsiflexion by
compression of heel (Fig. 6.12).
Advantages: Readily available in different sizes
and can be fitted in most of the shoes.
Disadvantages: The constant use leads to
Fig. 6.12: SACH foot
gradual loss of elasticity of the rubber. (Solid ankle cushion heel)
44 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

Resistant heel wedge. QUANTUM

Size: most
It consists of following features.
ROM: Planter flexion with minimum
dorsiflexion and slight inversion. Keel consists of sole springs, secondary spring
Minimum energy release as plug recoil in late and ankle base.
stance phase. Hollow resilient foot mold.
Toe-hyperextension. ROM Plantar and dorsiflexion possible with
slight inversion-eversion.
CARBON COPY II Toe-hyperextension.
Light weight.
The carbon copy II has following features.
Keel is made of two carbon fiber composite SEATTLE (FIG. 6.13)
plates.
Resistant heel wedge. It consists of following features:
Size: Adult Delrin semirigid angled keel.
ROM: Planter and dorsiflexion possible with Resilient heel wedge.
very little inversion and eversion. ROM Plantar and dorsiflexion possible with
Toe-hyperextension. slight inversion-eversion.
Moderate energy release as plates bent in Toe hyperextension.
early and midstance and recoil in late Moderate energy release.
Light weight. Available in different realistic surface contour.
Weight: moderately heavy.
Flex foot

C-Walk foot

Sten foot

Seattle foot
Fig. 6.13: Prosthetics foot
 LOWER LIMB PROSTHETICS
FLEX FOOT (FIG. 6.13)
It has following features:
Keel/shank of carbon fiber bolted to heel plate
and covered with cosmetic foam Rubber.
Size adult.
ROM : Plantar and dorsiflexion possible with
minimal inversion/eversion and toe Hyper-
extension.
Energy release : Maximum.
Weight light.
Cost very expensive.
SPRINGLITE
Its design is similar to flex foot.
No bolts.
It is less expensive.
JAIPUR FOOT
It was developed at SMS Medical College, Jaipur
by Prof PK Sethi and his team. It provides bare
foot walking. The foot and ankle assembly is
made of uncured rubber compound which is used
for retreading automobile tyres. The aluminum
die has been made in four sections (Fig. 6.14).
The following different materials are being
used.
1. Treaded rubber compound.
2. Rubber cushion compound.
Fig. 6.14: Jaipur foot
45
3. Cosmetic rubber cushion compound.
4. Vulcanizing rubber.
5. MCR rubber for heel, metatarsals and toes.
Blocks
Three different blocks are used.
1. Wooden malleolar block.
2. Metatarsal sponge rubber block.
3. Heel sponge rubber block.
Advantages
1. Cosmetically well accepted in rural popu-
lation.
2. It provides barefoot ambulation.
3. ROM: It provides enough dorsiflexion to
permit an amputee to squat.
Permits transverse rotation of the foot on
the leg to facilitate walking and to allow
cross legged sitting.
It provides sufficient range of inversion-
eversion to allow the foot to adapt itself
while walking on uneven surfaces.
4. Exterior is made of a waterproof durable
material.
5. Less expensive.
6. Material is locally available.
ANKLE FOOT/PROSTHESIS WITH
ARTICULATED BONY ENDOSKELETON
Dr Kabra and N Ramji from Jaipur have reported
ankle foot prosthesis incorporating the intact
articulated bony skeleton of a surgically amputated
limb as an endoskeleton. They have substituted
core and rubber blocks of the Jaipur foot with
entire small bones (tarsal, metatarsal and rubber
blocks of the Jaipur foot with entire small bones
(tarsal, Metatarsal and phalange) while retaining
the reinforced rubber shell of the Jaipur foot. They
have also tried formalin fixed cadaveric bones. It
is still in process of development and trial.
46 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

Articulated socket. Socket is total contact with snug

SINGLE AXIS
The wooden foot joined to ankle block by metal
both with transverse axis.
ROM: Plantar flexion is controlled by posterior
rubber bumper and dorsiflexion is controlled by
anterior firm rubber or felt stop.
It is a available in most sizes.
Bumpers are readily adjustable.
Weight-heavier than non articulated feet.
Disadvantage
Prolonged use loosens and becomes noisy.
MULTIPLE AXIS
The wooden foot piece joined to ankle block by
cable and rubber block.
ROM: Plantar and dorsiflexion possible with
moderate inversion-eversion.
Cost: It is more expensive than single axis.
Weight: It is heavier than single axis.
Disadvantage: Same as in single axis.
fitting with valve.
B. Silesian belt: It is most commonly used
for ideal above knee stump.
It encircles the pelvis and one end is
attached to anterior wall and another
end is attached to lateral wall of the
socket. It can also be used with suction
socket (Fig. 6.15).
C. Pelvic band: It is made of metal and belt
which encircles pelvis.
It is attached to socket on lateral wall
with single axis hip joint.
It is used for short above knee stump
and provides feelings of security
(Fig. 6.16).
D. Shoulder suspender: It should be given in
a selected case only. It has the same points
of attachment as in selesian belt and it
encircles the opposite shoulder across the
chest.
2. Socket:
1. Quadrilateral socket: It is commonly
used for AK prosthesis. It is usually made

ABOVE KNEE PROSTHESIS

Components
1. Suspension
2. Socket
3. Knee joint
4. Shank or shin piece
5 Ankle and foot assembly
1. Suspension: The attachment of above knee
prosthesis can be by the following methods.
A. Suction
B. Silesian belt
C. Pelvic belt with Hip Joint
D. Shoulder suspender.
A. Suction: In this method of suspension one Fig. 6.15: AK prosthesis
way valve permits air to exist from the
 LOWER LIMB PROSTHETICS 47

and controlled movement for ambulation

Fig. 6.16: AK prosthesis with hip
joint and pelvic band
(Fig. 6.19).
A. Conventional single axis knee is least
expensive and requires simple mainte-
nance. It is commonly used.
B. Polycentric knee joints are not com-
monly used.
C. Constant friction knee has the same
amount of friction during swing phase.
D. Constant friction with friction lock
should be used when stump is having
poor musculature and balance. It is
commonly used in elderly amputee
where stability is of primary concern.
Other modifications include hydraulic (more
resistive) and pneumatic (Less resistive) knee
which provide excellent cosmetic gait. These are
very expensive and do require proper and periodic

of plastic resin and earlier it was made of

wood. Weight is borne mainly on ischial
tuberosity and gluteal grip of muscles.
Fabrication of socket is same as for PTB
socket (Figs 6.17 A to C and 6.18).
2. Total contact Socket: In this type, the
stump is in complete contact with the
socket, however weight is mainly borne A B C
on ischial tuberosity. Socket is suspended (Temporary) (Temporary) (Temporary)
back view front view side view
by suction valve situated on medial wall
Figs. 6.17 A to C: AK prosthesis
of the socket. It provides better sensory
feedback and intern provides better control
and confidence in prosthetic use.
The recent development of CAD-CAM
(computer added design. and Computer
added manufacturing) has revolutionized
the whole concept of socket design and
fabrication. It has added new dimensions
to the existing state-of the-art in prosthetic
technology.
3. Knee joint assembly: The basic purpose
of the prosthetic knee is to provide stability Fig. 6.18: AK prosthesis (Final)
48 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

condyles of tibia, head of fibula and on popliteal

surface of the knee, as it is being done in
patellar tendon bearing prosthesis. The method
of fabrication, alignment and fitting, etc. is also
as of PTB prosthesis. The suspension of PTB
syme prosthesis is by a cuff, like in PTB
prosthesis.

NEW MODIFICATION IN THE

PROSTHESIS
Fig. 6.19: Knee joint assembly
1. Thigh rotation device for AK prosthesis:
The conventional AK prosthesis does not allow
day-to-day maintenance by highly trained and sitting cross legged which is our socio-cultural
skilled staff. need. Hence a simple device had been made
in Department of Physical Medicine and
SYME AMPUTATION Rehabilitation, CSM Medical University
Syme amputation is performed at distal level of Lucknow, for providing cross-legged sitting in
tibia and fibula, 0.6 cm proximal to periphery of AK Prosthesis: (Figs. 6.21 A to D).
ankle joint passing through dome of ankle. 2. Squatting device for PTB prosthesis:
Posterior heel pad is attached anteriorly which Another simple device has been attached to
provides good weight bearing surface. Even the the junction of shin and sach foot which allows
individual can walk bare footed in the night. squatting to below knee amputation cases. This
device was developed in Department of
Types of Syme Prosthesis Physical Medicine Rehabilitation, CSM
Medical University Lucknow. The squatting
1. Conventional symes prosthesis: It provides is essential activity of our day-to-day life and
full weight bearing on distal end of the stump. majority of rural people need them
Amputee can walk even without prosthesis (Figs. 6.22 A to E).
in case of emergency like going to toilet in
the night. However for females since
prosthesis has bulky look at distal end, it is
cosmetically not accepted. Conventional syme
prosthesis has a leather or plastic laminated
socket having medial opening to accommodate
distal end of the stump and socket is attached
to SACH foot (Fig. 6.20).
2. PTB syme prosthesis: When heelpad is not
sufficient or when full weight bearing is not
tolerable on the distal end of the stump or in
cases of sensory impairment at the end of
the stump then partial weight is taken on
the patellar tendon, lower third of patella, Fig. 6.20: Symes conventional prosthesis
 LOWER LIMB PROSTHETICS 49

A B C D
AK prosthesis with AK prosthesis with AK prosthesis with AK prosthesis
thigh rotation device thigh rotation device thigh rotation device showing thigh
front view Back view in sitting posture rotation

Fig. 6.21: AK prosthesis with thigh rotation device

A B C
PTB prosthesis with PTB prosthesis with PTB prosthesis with
squatting device squatting device squatting device
(front view) (side view) (front view)

D E
PTB prosthesis with PTB prosthesis
squatting device showing squatting
(Side view) posture

Figs. 6.22 A to E: PTB prosthesis with squatting device

50 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
For Better Outcome of Prosthesis
Dos
1. Always use individually made prosthesis
2. Use only after leaving bed
3. Stump should be cleaned daily with soap and water
4. Always clean inner surface of socket daily
5. Always check nut bolt of prosthesis
6. Use proper sized foot wear
7. Always clean stump sock
k
FURTHER READING
1. American Academy of Orthopaedic Surgeons: Atlas
of Prosthetics 2nd Ed. St. Louis C.V. Mosby 1992.
2. J Edelsteing, Lower Limb Prosthetics and Gait
Abnormalities, Proceedings of Review Course in
Physical Med. and Rehab, Vol I, 1993,
3. Hollinshead WH and Jenkins DB. Functional
Anatomy of the Limbs and Back. 5th Ed. 1981 WB
Saunders Co. : Philadelphia 1981.
4. Howard A Rusk Rehabilitation Medicine, 4th Ed.
C.V. Mosby Co; Saint Louis, 1977.
Do not
1. Do not use prosthesis when you are not in mood to use
2. Do not use prosthesis of other person
3. Do not wet prosthesis
4. Do not change socket yourself
5. Do not use continuously
6. Do not use prosthesis if skin has cut or infections
7. Do not go to place of fire and accident, etc.
8. Do not use prosthesis without doctors advice in
case of diabetes and heart disease, etc.
5. Sethi PK, Designing Aids for Physically
Handicapped in developing Countries, Indian Journal
of Physical Medicine and Rehab. 1990;3.
6. Kabra SG, Narayanan. Ankle Foot Prosthesis
incorporating the Articulated Bony skeleton of a
surgically amputated limb. Indian Journal of Physical
Medicine and Rehab, 1993; 6.
7. Agarwal AK, Sharma VP, et al. A Five years follow up
study of artificial limbs for the lower limb, Indian J of
Phy Med and Rehab, 1986; 1:35-8.
C H A P T E R 7
Upper Limb
Orthosis

Shishir Rastogi
52 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

Upper limb of Human beings requires controlled Rheumatoid arthritis, following joint replacement)
coordination of different muscles and joints with or permanent (as in brachial plexus or spinal cord
intact sensation. Here mobility and function are injury or stroke) Their names are based on
more important than stability. Various Orthotics eponyms, descriptive phases and recently based
is being advised keeping this in mind. They help on terminology developed by Committee on
to align, or resist or assist or simulate particular Prosthetic and Orthotic Education of National
function. Thus they may be of static, dynamic or Academy of Sciences.
functional types. The Static devices used for shoulder are the
Static orthoses immobilize a part, maintain Airplane splint (Fig. 7.1) (which holds the arm
correct alignment, protect an injured part or in 90 degree abduction and permits no gleno-
stabilize a part; Dynamic devices allow humeral joint motion) and the sling (which of
controlled motion of some joints, neutralizing course, is the most common orthosis for shoulder).
progressive deforming forces and substituting for The Elbow Static orthoses may be used to
weakened muscles. On the other hand, functional increase range of motion or prevent anticipated
orthoses are used to substitute for irreversible contractures. At the wrist, they are used as static
loss of function. cock-up splint/orthosis to prevent or correct
Orthoses for upper limbs should be comfort- deformities in rheumatoid arthritis.
able, cosmetically acceptable, fulfill a real need, The static Wrist-Hand Orthoses (WHO)
light weight, be relatively inexpensive and be supports the wrist while allowing freedom to use
easy to use. The most important determining the fingers and thumb. Various assistive devices
factor in patients acceptance of an upper limb are often attached to these orthoses (Fig. 7.2).
orthosis, is whether the orthosis permits the
patient to perform activities which would not be
possible without it and which patient wishes to
perform.
Initially, it was the field of craftsman and
armor makers, the preparation and fitting of
Prosthetics has not developed into an advanced
scientific area where new devices are being
produced like Myo electric and Electrophysio-
logical splints. They are being used in wide range
of conditions. Modular wrist, hand and finger
orthoses are under development.
They have two sets of componentsInterface
components (for forearm, hand, fingers) and
Connecting components (with dynamic or static
characteristics). Orthotics devices may be
temporary (used in management of fractures and
dislocation, peripheral neuropraxia, tendon
repairs and management of contractures), semi
permanent (used after tendon transfers as
assistive devices, acute and sub acute phases of Fig. 7.1: Airplane splint
 UPPER LIMB ORTHOSIS
Fig. 7.2: Wrist hand orthosis for ulnar nerve lesion
with a metacarpophalangeal extension stop
and C-Bar
Fig. 7.3: Flexor-Hinge wrist hand orthosis
(Wrist-Driven)
They can be bases for support of thumb, meta-
carpophalangeal and interphalangeal joints for
treatment of conditions like burns, joints replace-
ment, rheumatoid arthritis, peripheral nerve
injuries, nerve and tendon repairs. They may be
simple hand orthosis or flexor hinge hand orthosis
(which creates a three jaw chunk prehension)
(Fig. 7.3). Various static finger orthosis in the
form of rings or spiral are available
(Figs. 7.4 A and B).
53
The functional or dynamic orthoses use
springs, rubber bands, batteries, tanks of
compressed gas and electricity. The dynamic
shoulder devices are mobile arm supports
including ball bearing, overhead sling, suspension
and friction feeders (for ambulatory patients),
functional arm braces (for non ambulatory
patients) with specially molded plastic shoulder
caps. The dynamic elbow orthoses (Fig. 7.5) are
usually to substitute for elbow flexion using
springs, rubber bands, compressed gas or trough
a boviden cable. In case of profound weakness
of the upper extremity, a balanced forearm
orthosis (Fig. 7.6) can be used.
It consists of a trough for proximal forearm,
a pivot, linkage system adjusted and present so
that patient can produce motion at elbow and
shoulder by small motions of trunk.
The functional hand orthoses are based on
simple hand orthosis. Various assistive devices
like a swivel thumb, thumb interphalangeal joint
assist; first dorsal interosseous assist can be used.
The flexor hinge orthosis uses wrist movement
for flexion of metacarpophalangeal joint for active
prehension (Fig. 7.3) The metacarpophalangeal
joint dynamic hand and wrist hand orthoses are
probably the most widely used upper limb
orthoses. They may assist in flexion (like knuckle
A B
Figs. 7.4: Static finger orthoses (A) For
boutonniere deformity (B) For swan neck deformity
54 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
Fig. 7.5: Dynamic elbow orthosis with
single axis articulation
bender) or extension (Fig. 7.7 and 7.8) abduction
or adduction in flexor- hinge orthosis, when both
hand and forearm muscles are paralyzed, scapular
abduction or humeral flexion will operate the
orthosis.
The development of small electric motors has
made it possible to open and close a flexor- hinge
hand orthosis by electricity. Myoelectric control
may be used but is still under development.
Fig. 7.6: Balanced forearm orthosis
Various devices like mouth sticks (Fig. 7.9)
may be used for writing, painting, etc. Environ-
mental control devices are used for controlling a
variety of electric devices using different types
of switches. For example for television, etc.
Electrophysiological (EP) splints (actuated) by
mechanical movement of distant part, Myoelectic
(ME) splint (actuated by electric output of a
distant muscle) are being developed.
In prescribing orthosis, detailed assessment
of deficits and remaining function of the upper
limb, sensation and skin coverage, needs of the
patient, socioeconomic and psychological status
of the patient is done. Good knowledge of
orthoses available, principles on which they work
and possible modifications help in providing the
best possible orthosis for a particular patient. The
patient and family should be trained in the use of
the orthosis.
Orthotics and surgery are not used indepen-
dent of each other. Proper and complete assess-
ment of the patient, intelligent use of available
orthoses and timely surgery will provide best
possible functional outcome for the patient.
 UPPER LIMB ORTHOSIS 55

Fig. 7.7: An Opponens hand splint with wrist spring extension assist

Fig. 7.8: Functional hand orthosis with metacarpophalangeal extension assist

Fig. 7.9: Mouth stick for holding pencil, brush, etc.

56 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
A well prepared and applied orthosis can do
much to alleviate the problems of the patient
while the one improperly prescribed/manufac-
tured/applied can compound patients problems.
FURTHER READING
1. Bender LF. Upper Limb Orthotics: In Krusens Hand-
book of Physical Medicine and Rehabilitation, 3rd
Ed, (Eds Kottke F.J. Stillwell G.K Lehmann J.F.) W.B.
Saunders Company, Philadelphia. 1982. pp. 518-29.
2. Buch WH, Keagy RD. In Principles of Orthotics
treatment. St. Lousis EV Mosby, 1976.
3. Fess RE, Philips C. Hand splinting: Principles and
Methods Ed 2, St. Louis. 1986, Mosby-year Book
Inc.
4. Long C. Upper Limb Bracing: In Orthotics Etcetera,
(Ed Licht. S) Waverly Press. Baltimore, 1966.
5. Long C, Schutt AH. Upper Limb orthotics in Orthotics
Etcetera, 3rd Ed, (Ed. Reford J.B), Williams and
Wilkins, Baltimore 1986. pp. 198-277.
6. Nickel VL. Perry J, Garrett AL. Development of useful
function in severely paralyzed hand. J Bone Joint
Surg, 1963;45A:933-52m.
7. Peacock EE Jr: Dynamic splinting for the prevention
and correction of hand deformities: A simple and
inexpensive method, J Bone Joint Surg 1952; 34A:789.
8. Schell MD, Boweker JH Bunch WH. The Orthotics.
In Orthopedic Rehabilitation, First Ed. (Ed. Nickel
V.L) Churchill Livingstone Inc; New York, 1982. pp.
103-35.
9. Thomas FB. An improved splint for Radial (Musculo-
spiral) nerve paralysis J Bone Joint Surg 1951;
33B:272.
10. Weber ER, Davis J. Rehabilitation following hand
surgery. Orthop Clin North Am 1978;9:529.
C H A P T E R 8
Upper Limb
Prosthesis

SK Jain
58 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
Loss of a limb not only causes physical handi-
capped but also leads to severe degree of psycho-
logical, social and economic handicap. This
affects the individual, his family as well as the
society and the country as a whole to some extent.
This handicap is far too severe in case of upper
limb amputees.
WHAT IS REHABILITATION?
As we know Rehabilitation aims to achieve
the maximum possible functional capacity out
of the remaining. In the present context the
remaining is the stump and rehabilitation
indicates achieving maximum function out of this
stump.
The human hand is one of natures most
intricately designed mechanism, its loss present
a very difficult problem in individual both
functionally as well as psychologically. For these
reasons there had always been a great need to
develop hand substitutes which in utility and
appearance might bring to an amputee a new
measure of satisfaction and confidence. This has
been, to some extent, achieved by the develop-
ment of split hook which gave the ability to grasp
as the primary function. Though many types of
terminal devices had been developed through the
ages, only a few are in actual use.
BASIC UPPER LIMB PROSTHESIS
Basic upper limb prosthesis comprises of
Figure 8.1:
1. Socket
2. Suspension system
3. Arm section and elbow mechanism
(For AE amputee)
4. Forearm section
5. Wrist unit
6. Hand
7. Terminal devices, and
8. Power transmission system
Fig. 8.1: Basic upper limb prosthesis
SOCKET AND ARM SECTION
Socket is the part of prosthesis which remains in
contact with the stump. The arm section or
forearm section themselves can act as the socket.
In case of thin stumps a double walled socket
should be prepared. This helps amputee in having
rotation of the prosthesis to some extetent
(Figs. 8.2 A and B).
Suspension System
Function of the suspension system is to hold the
prosthesis in proper position during all possible
movements. When the hand is by the side, it
should be able to pull the prosthesis up against
its weight and at the time of abduction it should
be able to pull the prosthesis towards the other
shoulder (Figs 8.3A to D).
Basic suspension system is figure of 8 type
where the loop remains in the opposite axilla and
the two free ends are fixed to anterior and
posterior sides of the upper end of the socket.
The operating cord starts from the posterior
aspect of the opposite axillarys loop. This system
works well in single amputees (Figs 8.4A and B).
A new suspension system for double
amputees has been designed in Artificial Limb
Centre, Pune. A figure of 8 type of metallic ring
 UPPER LIMB PROSTHESIS 59

A B
Figs. 8.2 A and B: Socket and arm section

Figs. 8.3 A to D: Position of hook in relation to shoulder and

elbow with the help of suspension system
60 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

Fig. 8.4A

Fig. 8.4B

Figs 8.4A and B: Suspension system

is used on the back side. Upper ring helps in
stabilizing the prosthesis and the lower ring helps
in operating the terminal devices independent of
each other.
Elbow Mechanism
Elbow mechanism is actually a hinge joining the
arm and forearm section with facility of locking
the elbow in various degrees of flexion. In earlier
models the lock was to be operated with the other
hand while the flexion was performed by pulling
the operating cord attached to the suspension
harness (Figs 8.5A and B).
Automatic locking system was later devised to
be operated by downward and upward move-
ment of the shoulder, locking positions coming
alternately. Rotation at elbow is also available
which can be of constant friction or ball catch
type.
Forearm Section
It is the portion which joins the elbow mechanism
with the wrist unit. In earlier hands, there was no
wrist unit as such and it was only a nut and bolt
type of joint connecting the hand with the flat
forearm section.
 UPPER LIMB PROSTHESIS
Figs 8.5A and B: Elbow mechanism
Later on, when terminal devices were develo-
ped and when patients started using them, wrist
unit was added and the shape of the forearm
section was made rounded so that there was no
change in the shape of the wrist in any position
of hand.
Wrist Unit
Three systems are provided in the wrist unit:
(i) Quick gripping system, i.e. the hand or
terminal devices can be fixed (ii) Spring ball
type of catch to adjust the position of hand or
terminal devices, and (iii) Locking system so
that the hand could be locked in any of the
positions of supination or pronation. As a
modernization program, quick grip system and the
locking system were incorporated in one single
unit and were controlled with the help of only one
lever.
61
B
Hand
Hand is the most important unit of the prosthesis.
In initial stages, only rigid hands were made.
Many designs of fingers ranging from simple one
piece to those with inter-linked articulated fingers
were fabricated and used. The multisegmented
finger, in which each segment in itself is a lever
system, offers a great number of advantages. It
permits wider opening and also remains optimal
position while grasping any object. However,
lateral instability is a problem in such fingers.
Presently the most successful arrangement has
been to operate first and second fingers along
with some motion of thumb in a three jaw chuck
type of prehension pattern, while the ring and
little fingers are constructed from a flexible
material so that they conform to the shape of the
object held by the hand without exerting
appreciable force (Figs 8.6A and B).
62 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

A B

Figs 8.6A and B: Wrist and hand system

In the rehabilitation of the upper extremity Power Transmission System

amputee, not only it is necessary to restore lost
function, but it is also of importance to restore
lost appearance.
Cosmetic glove may be described as a plastic
glove resembling the human hand in shape and
simulating natural skin details and texture.
Cosmetic glove were developed in late forties.
In our country they have been in use for last many
decades.
TERMINAL DEVICES
The terminal device is usually regarded as the
most important component of the upper limb
prosthesis, since it provides replacement of the
most required function, prehension or ability to
grasp an object. As many as 6070 terminal
devices have been developed at various centers.
Only a few are provided to an amputee depending
upon his requirement according to his profession.
Voluntary opening hook is one of the most
preferred terminal devices. There has been
improvement in the designing of the hook as well.
Light or heavy split hooks are the choice of the
day (See Figs 8.6A and B).
Leather/nylon cords, or Bowdens cable are being
used in transmitting tension force generated by
the movement of shoulder or by movements of
other parts of the body to operate the terminal
devices and forearm components. (See Fig. 8.7).
Source of Energy
For practical purposes, the arm amputee has three
sources of energy that can be converted into linear
power for operation of an artificial arm and
terminal device without the aid of the other hand.
These are stump, shoulder shrug, and shoulder
elevation. Energy generated by these movements
and by using the force of gravity, it is possible to
provide the arm amputees with a good many
function, but by no means do the prosthetic
functions approach of the normal arm, neither in
number nor in degree or usefulness. Additional
source of power can be provided by cineplastic
muscle tunnels. This system was in fashion at
one time but not now.
Two types of external energy sources were
considered at one time (1) Pneumatic and (2)
Electrical, which were later on discarded as they
were not found suitable.
 UPPER LIMB PROSTHESIS
Fig. 8.7: Power transmission system
Fig. 8.8: Various types of articulated fingers
63
Pneumatic Prosthesis
The energy is provided by a small size, high
pressure cylinder placed in wrist unit. It has
following disadvantages:
i. Movements are noisy and produce hissing
sound.
ii. Frequent leakages are present.
iii. Refilling of cylinders is not easy.
iv. The patient has to concentrate visually to
control the hand movements.
v. It requires frequent maintenance.
Electric Prosthesis
In this prosthesis the electrical energy in utilized
to operate the opening and closing of fingers. A
chargeable battery is fitted in the forearm or arm
section. This battery operates an electric motor
fitted in the wrist unit. The switching system is
operated by the shoulder or stump movements.
This has been found suitable due to following
reasons.
64 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
i. The movements are robot like.
ii. Movements are noisy.
iii. Switching system operating the hand
becomes unnatural.
iv. The patient has to concentrate visually to
control the hand movements.
v. It requires frequent maintenance.
Electronic Prosthesis
This is some what similar to electric hand. The
switching system operating the hand is located
in the arm section and is operated by the move-
ments of the stump. One of the important
disadvantages of this prosthesis are its prohibitive
cost. Mainly due to this reason, this prosthesis
has not gained popularity in our country.
Articulated Fingers
In this prosthesis the fingers can also move at
interphalangeal joints. This has also not been
found suitable due to poor grip and frequent
maintenance, though the movements of the
fingers improve cosmesis (Fig. 8.8).
Myo-electric Prosthesis
It is also known as Bionic hand. When an amputee
thinks and makes an effort to open his fingers-
the fingers of the prosthetic hand really open-up.
A B
Figs. 8.9 A and B: Myo-electric prosthesis
Similarly when he desires to close his fingers by
thinking and making an effort to do so, he is really
able to close his fingers. Thus the prosthesis acts
as a natural extension of the stump working on
central nervous system.
Sensors are located in the socket at a place
which correspond with the maximum electrical
potential activity at myoneural junction (nerve end-
plate). These signals are picked up by the sensor
which activates an electrical motor fitted in the
hand or wrist unit thus obtain the desired
movements of the fingers. The electrical intensity
is proportional to the conscious effort of the
amputee to move the otherwise non functional
muscles at the stump. Most commonly prescribed
and used myo-electric prosthesis is the below
elbow prosthesis with facility of opening and
closing of fingers operated by a single motor
(Figs 8.9A and B).
Myo-electric Terminal Devices
The myo-electrically controlled terminal devices
are also available now for the use with myo-
electric (Fig. 8.10).
PRESCRIPTION PRINCIPLES
The basic aim of the prescription for an upper
limb amputee is to provide him the most suitable
artificial limb in all respects. This depends on
various factors, which are:
 UPPER LIMB PROSTHESIS
Fig. 8.10: Myo-electric terminal devices
i. Amputation: whether bilateral/unilateral
ii. Amputation: Dominant hand/non dominant
hand
iii. Level of amputation: AE/BE
iv. Profession of the patient
v. Economic status of the patient
vi. Age and sex of the patient
vii. Availability of the prosthesis
Amputation is an important factor. The
disability as well as requirement of prosthesis
increases many folds in a double amputee as
compared to a single amputee. A double amputee
would require functional hands since he would
totally depend upon them. A patient who has lost
the dominant limb can be substituted with a
cosmetic limb since the patient may not be using
the prosthesis specially if he is a office worker/
executive. However a manual worker will require
a functional hand even for the loss of non-
dominant hand. A below elbow amputee may
require a working hand since he can use it easily
with less effort.
Profession of a patient has definite influence
on the prescription or upper limb prosthesis
specially the terminal devices like split hook,
spade grip, tumbler holder where many types of
jobs can be performed by one appliance. They
65
are very handy to the amputees. However there
are few appliances which can perform only
specific jobs like grass cutter can be used for
cutting the grass, pen holder will hold the pen,
sanitary appliances is used for cleaning. Combi-
nation of general purpose appliances with spe-
cific job appliances depending on the profession
of the patient will be most suitable for most of
the patient. They can be changed in their next
visit when they come for replacement, by then
he would exactly know requirements.
Economic status is also an important factor.
A middle class or high middle class amputee
cannot afford a myo-electric prosthesis which
costs about one lakh rupees.
Age and sex of the patient also influence the
prescription. A prosthesis for a young child may
be like a toy while a suitable working prosthesis
may act as a bread winner of the whole family. A
cosmetic hand may be essential for a young girl
while the same may be useless for an elderly
patient.
FURTHER READING
1. Bender LF. Prosthesis and Arm Rehabilitation After
Arm Amputation. Springfield IL, Charles C, Thomas,
1974.
2. Kritter AE. Current concepts review: Myoelectric
prosthesis. J Bone J Surg 1985;67A(4):654-657.
3. Dalsey R, Gomez W, et al. Myoelectric prosthetic
replacement in the upper extremity amputee. Ortho
Rev 1989, 18(6)697-702.
4. American Association of Orthopaedic Surgeons: Atlas
of Limb Prosthetics, St. Louis: CV Mosby, 1981.
5. Leonard JA, Meier RH. Prosthetics. In: DeLisa JA
(Ed). Rehabilitation Medicine: Principles and Practice.
Philadelphia: JB Lippincott, 1988, pp 330-345.
6. Resier E, Pirrello T. Principles and practice in upper
extremity prostheses. Orthop Clin North Am, 1972,
3:399-417.
7. Radocy B (Summer 1987). Upper extremity
prosthetics: Considerations and designs for sports and
recreation. Clinical Prosthetics and Orthotics, 11(3),
131-153.
C H A P T E R 9
Fabrication of Below Knee
HDPE Prosthesis with
Polypropylene Total
Contact Socket
MK Mathur
 FABRICATION OF BELOW KNEE HDPE PROSTHESIS...
As dicussed in earlier chapter on lower limb
Prosthetics HDPE is being used in some centers,
specially when mass production is required. BK
HDPE limb fabricated in five steps.
STEP 1: Positive Mould by Wrap
Casting Method and use of Laser
Alignment Systems
Materials
1. Cotton stockinette 6 1.5 m.
2. Pre-formed POP (Plaster of Paris)
Bandages - 6.
3. Indelible Pencil (to mark modification
points).
4. POP paste: To make positive mould of
stump.
5. Inch-tape: To measure stump length.
6. Measuring caliper - to note A-P and M-L
diameters of stump at various sites.
7. Surgical blade/knife: To cut negative mould.
8. Sand paper: To smoothen the marks.
9. Condom: The advantage of condom over
cast sock/stockinette is that it is only
1/3rd as thick and a rubber band at one
end helps to keep it in position. A much
more exact replica can be obtained.
10. Alignment wall frame.
11. Laser alignment system.
Measurements
Various measurements of stump and sound limb
are noted:
a. Sound Limb
1. Length of sound limb from medial tibial
plateau to medial malleolus.
2. The patient is made to stand and a plumb line
is dropped from the tip of head of fibula. The
distance of anterior and posterior surface of
67
the leg at the level of medial malleolus is
measured and recorded.
3. The plumb line is again dropped from tibial
tubercle to the center point b/w medial and
lateral malleolus. The distance from the
plumb line to medial and lateral malleolus is
recorded.
b. Stump
1. The length of the stump-from medial tibial
plateau (MTP) to the distal end of the stump
with the help of measuring tape (Fig. 9.1).
2. A-P (Anteroposterior) diameter of the stump-
from just below the lower end of patella
anteriorly to popliteal area parallel to the
anterior area posteriorly. It is taken with the
help of measuring callipers keeping knee in
full extension (Fig. 9.2).
3. Mediolateral diameter is from the widest area
mediolaterally of the amputated knee joint,
again with the help of measuring callipers (Fig.
9.3). It is considered as first mediolateral
diameter. Then the same procedure is repeated
at the distance of 1. downwards from this
Fig. 9.1: Measurement of stump
Fig. 9.2: A-P diameter of stump
68 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

area till the distal end of the stump. The

procedure helps a great deal in making a
positive mould with accurate dimensions
(simulating the stump).

Method
Amputee is seated on a firm bench with his/her Fig. 9.5: Application of POP
bandage on the stump
thigh supported and back of knee approximately
100 mm in front of the anterior edge of the chair.
1. A moistened cast sock/condom is slipped over
the stump which is placed in an attitude of
slight flexion (approximately 510 degrees at
knee) (Figs 9.4, 9.5 and 9.6). A snug fit is
maintained by applying tension on the top of
the cast sock from a strap around the waist
clamped on each side of the cast sock. This
can also be done by using a rubber-band to
maintain cast sock in the desired place and
preventing it from slipping. These problems
(of slipping) are not encountered if a condom
is used which has at its one end a rubber band
that prevents it from slipping.
Fig. 9.6: Use of condom
2. Marking of certain prominences which will
be important in modification procedure, are
made with indelible pencil on the following
areas :
i. Outline of the patella.
ii. Mid patellar tendon - 2 horizontal lines,
one at lower end of patella and the other
at tibial tubercle. These indicate an
important weight bearing area in the
finished socket.
Fig. 9.3: Mediolateral diameter of stump iii. The tubercle of tibia.
iv. Head of fibula: It requires a relief area in
the socket to prevent skin abrasions and
pinching of the peroneal nerve between
the head of fibula and the socket.
v. Anterior crest of tibia.
vi. Distal end of fibula.
vii. Anterior distal end of tibia.
viii. Medial flare of tibia.
Fig. 9.4: Sock is slipped over the stump ix. Medial border of tibia.
 FABRICATION OF BELOW KNEE HDPE PROSTHESIS... 69

x. Any other sensitive area which may

indicate the presence of bone spurs,
adherent scar tissues, neuromas, or other
conditions.
The following areas are outlined on the
stump only if they require special treat-
Fig. 9.7: Wrapping of POP bandage
ment because of prominence, sensitivity
to pressure or other reasons.
xi. Anterior prominences of the lateral and
medial tibial condyles.
xii. The lateral border of tibia.
3. Two 6 POP bandages (either pre-formed or
prepared by simply smearing POP powder on Fig. 9.8: Wrapping of POP bandages
plain 6 bandage) are submerged in water
and when adequately soaked, they are taken
out and excessive water is squeezed prior to
use.
4. Begin the wrap by laying one or two layers of
these bandages lengthwise, starting in front
slightly above the patella and passing down and
around the end and up the back of the stump to Fig. 9.9: Wrapping of POP bandage
the posterior crease of the knee. Begin a series
of circumferential wraps starting at the upper in the cast, and continue to work the cast until
border of patella and spiralling down and up it begins to harden.
the stump, overlapping one half the width of 6. As the plaster begins to harden, the ends of
the plaster bandage with each layer, smooth the thumb and fingers are used to outline
each layer as it is applied. Apply bandage until patellar tendon and compressing the popliteal
the cast has maximum thickness of tissues. Thumbs are placed at a 3045 angle
approximately 1/8 (3mm) in the proximal (top) to the long-axis of the tibia, on either side of
third. Add additional layers over the distal end the patellar tendon and pressed inwards,
to build-up a thickness of approximately 6 layers midway between the lower edge of the patella
of bandage. Be sure to cover the femoral and the tubercles of the tibia (Fig. 9.11). Be
condyles. This requires that the wrap extend careful not to push upon the inferior edge of
approximately 3 above mid patellar tendon area the patella or on the anterior prominences of
(Figs 9.7, 9.8 and 9.9). the tibial condyles. (One can also use first web
5. Instruct the amputee to keep his/her stump space of the hand for the same). Firm pressure
muscles relaxed and to hold a fixed angle of is applied with the fingers. The depth of the
knee flexion. Smooth the plaster over the finger tip impression in the popliteal area
surface of the stump by moving the hands serves as a measure of tissue firmness and an
around the stump and working towards the indication of how much modification of the
knee (Fig. 9.10). Work the plaster around bony model is required. When the plaster has
prominences so that they are clearly defined hardened, release finger pressure but allow
70 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

3. Wire mesh
4. POP paste
5. Sand paper
6. Wire screen

Fig. 9.10: Finishing of POP model
Objects
a. To increase stump socket contact pressure
where the forces between stump and socket
must be developed and to decrease contact
pressure in sensitive areas. Where greater

Fig. 9.11: Pressure points on wet POP model

the wrap to remain on the stump for additional

12 minutes.
7. The wrap cast is filled with POP paste. An Fig. 9.12: POP model with steel rod
18" long iron pipe is inserted in the mould to
a depth of not more than 6. This will serve
as amanfrel for future bench vise operation
and also helps in removing the air bubbles
present in POP paste (Figs 9.12 and 9.13). So
a solid positive mould is obtained with no air/
gap left in it.
8. After the plaster has set (20-30 min), strip off
the wrap by cutting it lengthwise down the
posterior surface (Figs 9.14, 9.15 and 9.16).
The model is now ready for modification.
Fig. 9.13: POP model with steel rod
STEP II : Modification of the Mould
The second step involves modification of the
stump mould so that it will serve as a model for
the inside contours of the socket.

Material
1. Knife
2. Metal files Fig. 9.14: Stripping off the wrap
 FABRICATION OF BELOW KNEE HDPE PROSTHESIS...
Fig. 9.15: POP model (Front view)
Fig. 9.16: POP model (Side view)
pressures are required more plaster is
removed from the corresponding areas in the
model and to provide relief of pressure in the
final socket, the model is built-up with patches
of leather or POP paste shaped to fit the
sensitive areas.
b. To recheck whether all the measurements
taken of the stump (including length and
various A-P and M-L diameters) are exactly
same on the modified positive mould of the
stump.
Method
1. Modify the patellar tendon area by cutting
away the model midway between the lower
edge of the patella and the tubercle of the tibia
to a minimum depth of . The channel thus
formed (which will become a protuberance
in the socket) should have a height of
71
approximately 1 as seen from the side. The
modified area should extend on either side to
the center of the thumb prints and as seen
from the front should have a width of approxi-
mately 1..
2. Modification at the medial tibial flare by
shaving off at least 1/8 to 3/8 of plaster
at the deepest point, tapering out to the
edges.
3. On the lateral side of the stump model a
minimum of approximately 1/8 to 3/8 of
plaster should be removed starting 3/4 or
finger width below the distal border of the
head of fibula and continuing to within 1
from the end of the fibula.
4. Shave off a minimum of 1/8 of plaster all
along the anteromedial surface of the tibia,
extending from below the medial flare to
within 1 of the distal end of tibia.
5. Shave off 1/8 to 1/4 of the plaster from the
anterolateral surface of the stump model,
blending in with any modification of the
lateral surface, to within 1 of the distal end
of the fibula.
6. Modification of the popliteal area Shave
away plaster to the depth of finger prints from
the crease of the knee extending upwards
and 2 downwards. Precautions must be
taken not to touch hamstring area. Maximum
depth is to be shaven off in popliteal region
at the center point in the knee crease, then as
proceeding towards the peripheral area the
depth of shaven off area is reduced with
minimum depth at peripheral area.
7. Relief or build-ups with the help of POP paste
( thickness) or leather patches are applied
over pressure sensitive areas like:
a. Fibular head
b. Distal end of tibia
c. Distal end of fibula
d. Any other bony prominence or sensitive
area requiring pressure relief.
72 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

Finally the length of the stump model is

increased by (to accommodate shrinkage of
poly propylene socket) at the lower end (Figs 9.17
and 9.18).

STEP III : Fabrication of Soft Insert

Material
1. 6 mm thick EVA Rubber Sheet (which is a Fig. 9.18: Final stump model
thermoplastic)
2. Solution
3. Scissors - for trimming
4. Brush
5. Oven (preheated 180C)
6. Wooden stick
7. Measuring tape.

Method
The procedure for fabrication of soft insert is as
follows:
Fig. 9.19: Stump model in bench vise
a. Place the mandrel of the stump model in the
bench vise with the model held in a vertical
position (Fig. 9.19).
b. The length of the stump mould and its width
at the upper and lower end is measured and
marked on the EVA rubber sheet which is cut
accordingly and both the ends are glued
together using the solution. This is placed on
a stick and inserted into the pre-heated oven
for 35 min to make it more malleable Fig. 9.20: EVA rubber sheet
for stump model
(Fig. 9.20).
c. This is then taken out of the oven and sleeved
over the stump model and allowed to cool d. A further covering of nylon sock /stockinette
(Figs 9.21 and 9.22). is applied over it to obtain final negative mould.
e. Application of soft insert is needed in cases
where local or systemic disease causing
sensory deficit or hypoesthesia / hyperesthesia
in the stump. Most commonly encountered
diseases are - diabetes mellitus, leprosy,
peroneal nerve palsy, sciatic nerve injury,
etc.
Fig. 9.17: Final stump model
 FABRICATION OF BELOW KNEE HDPE PROSTHESIS... 73

2. 2 metal frames of 15 15 (square).

3. 4 metal clamps.
4. Soap stone powder.
5. Pre-heated oven with max. temp of
180 C to heat HDPE sheet.
6. Suction machine.
7. Metal or wooden platform with an iron
rod fixed on to the suction machine.
8. Asbestos gloves.
9. Scalpel with surgical blade attached to it
Fig. 9.21: EVA sheet is sleeved over mold to cut the excessive HDPE/PP sheet.
10. Metal file to trim off the HDPE / PP
socket.
11. Cutting machine.
12. De-burring knife for finishing off the PP
socket (A piece of glass may be used
instead).

Fig. 9.22: EVA rubber sheet model
UNIQUE CHARACTERISTICS OF EVA
EVA or Ethylene Vinyl acetate, one of the vinyl
compounds is a poly -vinyl chloride thermo-
plastic. Previously it was more popular in
fabrication of orthosis as the densities available
range from 30360 kg/m3 indicating the range
over which a particular compound can be
prepared so that a low density EVA can be used
for cushioning. EVA is a polyethylene co-
polymer. It is light weight, has shock absorbing
characteristics that is why in our center we use it
for fabrication of soft insert.
Method
a. A 15 15 piece of HDPE/PP sheet (10
mm thick) is cut from the larger sheet.
b. It is fixed between 2 metal frames of the same
dimension (15 15) with the help of metal
clamps.
c. It is placed on a stockinette (unfolded) and
soap stone powder is sprinkled between sheet
and stockinette so that the HDPE/PP sheet
does not stick to it.
d. Now this assembly is placed in the preheated
oven (at 180) for 20 min. At this temperature
HDPE/PP sheet is molten (melting point of
HDPE/PP thermoplastic is 160168 C)
(Fig. 9.23).

STEP IV: Development of HDPE/PP

Total Contact Socket by Vacuum
Moulding Technique
Material
1. 15 15 HDPE (10 mm thick). Fig. 9.23: Electric oven
74 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

e. At its melting point HDPE/PP sheet becomes

transparent. This property is of great help in
recognizing that the sheet is ready for further
use.
f. The mould with mandrel covered with soft
insert is placed over the metallic/wooden
platform which is a part of suction apparatus.
The mould should be kept in inverted
position, i.e. distal end of the mould facing
the ceiling (Fig. 9.24).
g. A nylon sock or stockinette is placed over the
stump model so that a smooth inside of the
socket can be attained later.
h. The oven is switched off as the sheet becomes Fig. 9.25: Sheet mould falls by itself
transparent.
i. Two people wearing asbestos gloves, take out
this heated sheet with each person holding
two ends. This sheet is held over the mould.
j. Great care is taken that the sheet falls by itself
on the mould rather than pulled down by
the people. Otherwise the socket obtained will
be of unequal thickness (Figs 9.25 and 9.26).
k. The suction apparatus needs to be handled
carefully. Instead of switching it on totally at
once it should be switched on and off in rapid
bursts. This method helps a great deal in
preventing any wrinkling in the heated sheet

Fig. 9.26: Sheet mould

and in getting perfect approximation of the

sheet over the mould (Fig. 9.27).
l. The sheet takes the shape of the stump model
by creating vacuum with the help of suction
apparatus (Figs 9.28 and 9.29). (Now the
excessive area of the socket which is to be
trimmed off is marked with the help of pencil.)
1. Anteriorly the wall of the socket extends
up to lower 1/3rd to 1/2 of the patella.
2. Mediolaterally the socket walls cover the
Fig. 9.24: HDPE mould is placed over medial and lateral femoral condyles
plateform of suction apparatus respectively.
 FABRICATION OF BELOW KNEE HDPE PROSTHESIS... 75

m. Now the stump mould (inside the PP socket)

is broken off with the help of hammer and
nail (Fig. 9.30 and 9.31).
n. The socket is shaped properly by trimming it
with the help of cutter, chisel, file and
de-burring knife (Figs 9.32 and 9.33).
o. After trimming off the socket patient is made
to wear the socket for trial. For the conven-
ience of donning the socket a 1 diameter hole
is made at the lower end of the socket so that
Fig. 9.27: Sheet over mould the patient can pull-up the socket with the help
of stockinette (pulling downwards).

Fig. 9.30: Removal of POP socket

Fig. 9.28: Sheet mould

Fig. 9.31: Removal of POP socket

Fig. 9.29: Sheet mould

3. Posterior wall is of such height at medial

and lateral ends so as to accommodate
medial and lateral hamstring tendons. As
the medial hamstring tendon is inserted at
a lower level on the tibia as compared to
the lateral hamstring tendon so the medial
side of the posterior wall is lower in height
as compared to the lateral side. Fig. 9.32: Trimed socket
76 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

3. The socket is held in vise in inverted position

and aligned with vertical line on the wall
of room at level of posterior reference line
of socket. The vertical line acts as a
reference line.
4. Now this socket is adjusted in such a way
that posterior reference line is titled 5
degree anteriorly in relation to vertical
plumb line on the wall .
5. An HDPE tube of the diameter of calf is
selected from stock of preformed tubes
available. The tube is then placed over
Fig. 9.33: Final socket socket in such a way that area
corrsponding lateral and medial malleoli
of tube are at same distance from vertical
STEP V : Fitting the Socket in Jaipur plumb line on the wall as they were from
Prosthesis plumb line of the sound limb.
Material 6. The whole assembly is now rotated in
lateral plane and vertical line on wall is
1. HDPE pipe (PVC pipe) now aligned with lateral reference line on
2. Heating oven the socket. The tube is adjusted by moving
3. Rivets it in such a way that the distance of the
4. POP paste anterior and posterior surface of tube at
5. Jaipur foot the medial malleolus level; from vertical
6. Threaded screws and bolts line on the wall is same as it was from
7. Cuff suspension plumb line in sound limb.
8. Plastic emulsion paint 7. Thus after obtaining correct position of
9. Cotton stockinette. the pre-formed HDPE tube on the socket
it is attached to socket and filled with POP
Method cream (Fig. 9.34)
1. A posterior reference line is drawn on the 8. When the cream sufficiently sets and dries,
external surface of socket after brim has the tube is gently removed and this
been trimmed by connecting center points lengthened mould is left to dry.
at the posterior socket brim and near the
distal end of the shell.
2. Another reference line is drawn on the
surface of the socket by finding mid point
of center of patellar tendon protuberance
to the posterior brim. A line is drawn from
this point on lateral side of the socket shell,
to a center point near the distal-lateral
edge. Fig. 9.34: Pre-formed HDPE tube on the socket
 FABRICATION OF BELOW KNEE HDPE PROSTHESIS... 77

9. After drying it is again smoothened with a

wire mesh and an attempt is made to make
it an exact replica of sound limb, which is
not at all difficult as dimensions are
exactly simillar (Figs 9.35 and 9.36).
10. Now a piece of HDPE pipe 7.5 cm longer
than sound limb is selected and covered
both inside and outside with a cotton Fig. 9.37: HDPE pipe
stockinette. A wooden rod is inserted in
the pipe and it is inserted in pipe and
placed in a preheated electric oven at 180
degreeC for 20 minutes. This makes the
pipe fairly malleable.
11. This heated pipe is now sleeved over
socket and worked with hands.This is well
moulded over socket and shank by
applying sufficient pressure over the Fig. 9.38: Process of moulding
scooped out areas in the infrapatellar area
in popliteal region, over shin area and over

Fig. 9.39: Final process of moulding

medial and lateral malleoli (Figs 9.37, 9.38
and 9.39).
12. After the pipe is sufficiently cold and hard
Fig. 9.35: Finishing of mould and taken the exact shape of the mould,
POP mould is hammered out and exce-
ssive pipe at lower end is cut-off.
13. The lower end of this prosthesis is heated
again and Jaipur foot of matching size of
sound limb is attached to it by shrink
fitting method with the foot in plantigrade
position. 4 threaded screws are fixed to
provide extra grip to the foot in the shank.
14. A cuff suspension is attached at the upper
end of the prosthesis for suspension.
15. The prosthesis is now ready for dynamic
Fig. 9.36: Finished mould alignment.
CHAPTER 10
Normal and Amputee
Locomotion

MK Mathur
 NORMAL AND AMPUTEE LOCOMOTION
Human locomotion, is a difficult subject to
understand; still it is essential that at least some
basic concepts of it are understood by all those
who are interested in fabricating limbs. Only then
they would be able to critically evaluate their
handiwork against an analytical framework with
a view to making an amputee, whole again.
The present day understanding of this subject
stems from the outstanding work done at the
University of California at Berkely during
World War II under the leadership of Prof VT.
Inman. This project was sponsored by the
advisory committee on Artificial Limbs, National
Research Council of USA and the team consisted
of Electrical and Mechanical engineers,
physicians, physiologists, orthotists and
prosthetists. One cannot avoid leaning heavily
on the enormous amount of basic quantitative
data made available by them.
BASIC SUBDIVISIONS OF GAIT CYCLE
It is convenient to confine the analysis of the gait
cycle to the movements of the body below the
umbilicus, though we must recognize that trunk
sways, arm swing and head motion play an
extremely important role in normal gait. Viewed
from the side, one can see that the limb repeats
its movements for each step, progressing through
a sequence of standing on the ground followed
Fig. 10.1: Analysis of single stride
79
by swinging through the air. By convention, the
start of a complete gait cycle is the instant at
which the swing-limb heel strikes the ground.
Following a progression of events, the cycle ends
when that particular heel-strike indicates both 0
and 100% of the gait cycle.
The gait cycle is thus seen to consist of two
phases. STANCE, which comprises 60% of the
entire cycle, is followed by SWING, the remaining
40% since the stance phase is longer, it follows
that there is an overlap of phases, when both lower
limbs are weight bearing. This is called period of
double support. As we walk faster, the period of
double support becomes shorter; while running,
the period of double support disappears and is
replaced actually by a period of double float, with
both lower limbs being simultaneously in the air.
In competitive long distance walks, the judges are
keenly watching for this double float to disqualify
a candidate. This amounts to cheating, a walk
being converted into a run.
These two phases of support and swing are
further subdivided into periods of events known
as critical incidents. These incidents are heel
strike, foot flat, heel off, knee bend, toe off; they
are well illustrated in Fig. 10.1. After the toe leaves
the ground, the limb gets into the swing phase.
This is subdivided into initial swing, mid-swing and
deceleration.
80 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
ENERGY CONSUMPTION IN WALKING
It is not enough that a person should be able to
stand and walk, he should be able to walk as
efficiently as possible so that energy consumption
levels are reduced to minimum.
To be able to understand this, it is necessary
to introduce the concept of the Center of Gravity
of the body. By reducing the complex human
shape to a single point, the subject is simplified
and we can then apply the simple laws of physics
to understand some of the peculiarities of human
gait.
The Center of Gravity (CG) of the upright
human body lies at level just anterior to the second
sacral vertebra within the pelvis; seen from the
front it lies just above the pubic symphysis: from
the side, just above the tip of the greater trochanter.
If the pathway of center of gravity moving in
space is followed a fairly accurate comprehension
of energy consumption can be realized. In normal
walking pattern the center of gravity undergoes
a rhythmic upward and downward motion as it
moves forward describing a sine wave rising and
falling a total of about 2 inches. The summit of
rise appears when appearing limb is in midstance,
and the lowest point occurs at the time of double
support when both the lower limbs are separated
apart.
In other words there would inevitably be an
alternate rise and fall of the center of gravity during
forward motion. Every time the body is required
to be raised against gravity, work is done and an
input of energy would be required. Obviously the
greater rise and fall of centre of gravity, the
greater would be the energy requirement.
In absence of a straight line progression, which
is going to consume minimum energy, the next
most efficient pathway along which the center of
gravity should move in the form of sine wave, i.e.
there should be an equal rise and fall with a smooth
and gradual transition from the crest to the trough
of this waveform.
It may be pertinent to point out another
interesting fact. Walking height of a person is
always lower than his standing height. If a person
is made to stand in a tunnel with a roof just
touching his head, he can continue to walk
fearlessly without the risk of bumping his head
against the roof. But the moment he stops, his
head would strike against the roof.
With the conviction that man, for all his
complexity, is a structure capable of undergoing
mechanical analysis, an attempt was made to
devise a mechanical model for more exact
engineering studies of gait. A simple pylon of
average limb length was fitted with a non-
articulate foot. Instead of the sine wave pattern
of human locomotion, the tracing of CG path was
a series of connected arcs with sharp reversal
points. They are described by the moving center
of gravity at the tip of the artificial greater
trochanter, given an average stride length, was
found to produce a 3 inch vertical displacement
from heel strike to mid stance. The 3 inch CG
shift of the model would produce a 50% greater
expenditure of the energy in elevating the body
weight with each step than normal, and to this
will be added additional energy expenditure due
to sharp up and down movement of center of
gravity as there would be a complete halt and
then a restart of the movement at the end of each
step.
How is this remarkable sine wave progression
of C.G. brought about? There exist six
mechanisms in human body which convert these
connected arcs of the movements of CG of
mechanical model into smooth undulating sine
wave, and these are so important and crucial that
Inaman and Saunden called them The Major
Determinants of Gait.
To understand this mechanism, look at
Figs. 10.2 A and B. It shows two triangles. In
 NORMAL AND AMPUTEE LOCOMOTION 81

Figs. 10.2A and B: First determinant of gait

triangle A the length of the sides is X inches, of

base is Y inches, and the height is H inches, If
somehow Z inches could be added to the length
of sides of triangle A, situation would become as
shown in triangle B, where the height of triangle
has become H inches, which is more than the
height (H inches) of the former triangle A.
FIRST DETERMINANT OF GAIT -
PELVIC ROTATION
In human locomotion at the start of double
support, the swing limb is at the heel strike and
the stance limb is at the heel off, thus forming a
triangle, the apex of which establishes the CG
height from the ground, which is at its lowest
point of undulating path. This situation is something
shown in Figure 10.2A, the pelvis at this rotates
4 forward with the swing limb and 4 backwards
with the stance limb, This actually increases the
length of the lower limbs, creating a situation like
Figure 10.2B, where Z inches have been added
to X inches, increasing the height of the triangle
consequently elevating the CG at the lowest point
of its excursion.
By horizontal pelvic rotation alone, the
theoretical 3 inches up and down excursion in a
series of arcs, the lower most point of arcs is
raised by 3/8 inches. The curve thus becomes
flatter (Fig. 10.3).
Fig. 10.3: Pevic rotation
SECOND DETERMINANT OF
GAIT - PELVIC TILT
It is generally assumed that when a person stands
on one leg, the pelvis on the unsupported side
rises. This is the basis of the classical
Trendelenburg Test.
This is not true, however, when we are walk-
ing. An elevation of the pelvis on the unsupported
side would raise the level of CG and this would
require extra energy expenditure. Actually a
person always walks with a mildly positive
Trendelenburg sign. The pelvis always tilts down
on the unsupported side. Thus when the lower
limb becomes vertical in the midstance phase,
the resulting rise in CG is reduced by a 5 drop of
the pelvis on the unsupported side. This is a
controlled drop and the gluteus medius carefully
allows this by undergoing a lengthening or eccen-
tric contraction. This controlled drop of the pelvis
is an energy saving device; an uncontrolled
drop, however, is energy consuming because such
82 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

an excessive drop leads to an unstable equilibri-

um and to save oneself from falling the excessive
suprapelvic trunk deviation becomes essential.
The lowering of CG at the crest of the summit
has been found to be about 3/6 inch, due to this
controlled pelvic tilt (Fig. 10.4).

THIRD DETERMINANT OF GAIT - KNEE Fig. 10.4: Pelvic tilt

FLEXION AT HEEL STRIKE
At the time of heel strike, the lower limb has to
reach out by nearly fully extending the knee. As
the foot is lowered to the ground, there
commences a flexion of the knee which reaches
a figure of 15 at foot flat, during midstance phase,
the knee is never fully extended. It is this which
prevents a walking person from reaching his full Fig. 10.5: Third determinant of gait
standing height. This initial knee flexion is actually
a diminution in rise of the CG summit by
the ground depends on the verticality of the
7/16 inch.
calcaneum. At heel strike the calcaneum is
This knee flexion after heel strike serves
relatively vertical but as the forefoot drops the
another very useful purpose. It dampens the
calcaneum becomes more horizontal. Thus the
impact of ground reaction much as a shock
ankle axis which is high initially gradually falls
absorber.
at foot flat, where it remains at a fixed level till,
If the individual contributions of the first three
after mid stance, the heel rises from the ground,
basic determinants, viz. pelvic rotation, pelvic
causing the center of rotation at the ankle to rise
tilt and knee flexion after heel strike are added
again (Fig. 10.6).
up, the 3 inch vertical excursion of the CG of the
mechanical model gets reduced by 1 inch, i.e. up
FIFTH DETERMINANT OF GAIT - KNEE
and down movement of CG is now only 2 inches.
MOTION
However, the pathway still remains a series of
arcs with abrupt reversal at the low point. instead As already mentioned the knee starts to flex
of the efficient, smooth, undulating sinewave path immediately after heel strike, simultaneously as
(Fig. 10.5). the ankle axis is also falling during foot flat. Then
These abrupt reversal arcs are smoothened out the knee reverses its action to one of extension
by the fourth and fifth determinants of gait, which while the ankle remains level. This concurrent
are best considered together as they are intimately knee and ankle action serves to smoothen out the
related. CG pathway which otherwise would have
included an abrupt reversal point.
FOURTH DETERMINANT OF GAIT- As the heel rises. the knee simultaneously
FOOT AND ANKLE MOTION flexes. These cancel out each other and the
The axis of movement at the ankle rises and falls pathway assumes a smooth, undulation character
along an interesting pathway. Its distance from (Fig. 10.7).
 NORMAL AND AMPUTEE LOCOMOTION
Fig. 10.6: Fourth determinant of gait
Fig. 10.7: Fifth determinant of gait
SIXTH DETERMINANT OF GAIT -
LATERAL PELVIC MOTION
The CG lies in the midline of the pelvis, just anterior
to second sacral vertebra, and is located about 4
inches from the hip joints; when the weight is
shifted over one foot, the CG has to be brought
over the point of support to establish equilibrium.
In other words a person has to shift his body from
side to side at each step. One can appreciate this
when two people are walking side by side. If they
walk out of step, they keep on bumping against
each other.
If the lower limbs were suspended down in a
vertical line from the hips, the width of our
walking base would be about 8 inches. This
would lead to a very marked lateral shift of our
CG from step to step.
Two important anatomical features, however,
narrow our base of support. One is the relative
adduction of the femoral shaft in varus in relation
to the hip joint, and the other is the tibio-femoral
angle which allows the tibial shafts to drop
vertically in valgus. This leads to the width of
83
the walking base which is only 4 inches or so.
This allows the shifting of the CG only 1 inch
laterally towards the stance foot, resulting in a
total CG displacement of 2 inches per gait cycle.
The total excursion of the CG occurs within a
square box of 2 inches. It would of course be
appreciated that the up and down movement
occurs twice during each gait cycle while lateral
movement occurs only once (i.e. from heel strike
to heel strike). This composite movement of CG
projected in a coronal plane describes an
almost perfect figure of eight. A three dimen-
sional picture of the pathway of CG is that of a
spiral.
AXIAL ROTATION OF
LIMB SEGMENTS
During walking not only the pelvis rotates, tilts
and sways, there is considerable rotation of
various limb segments about their long axis. The
thigh rotates on the pelvis, leg rotates on the thigh;
this rotation is transmitted to the foot. At the time
of heel strike the lower limb is in internal rotation;
it reaches its maximum of 4 at foot flat; this is
followed by an abrupt reversal and the lower limb
goes into external rotation reaching its maximum
of 5 at the toe off. In swing phase there starts a
progressive serial internal rotation, so that when
the same limb reaches for heel strike again it is
in internal rotation.
This fact of axial rotation is very important
in the design of prosthetic foot piece. Most con-
ventional foot pieces (e.g. SACH foot) have no
provision for allowing a rotation of the shank on
the foot piece. Therefore this rotation takes place
at the stump socket interface. If the stump is
scarred or tender, this causes a lot of discomfort.
Herein lies the superiority of the Jaipur foot. Its
design permits considerable transverse rotation
of the shank on the foot piece. This absorbs a lot
of ground reactions at the shank level and thus
protects the stump.
84 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

FOOT AND THE GAIT CYCLE
The behavior of the foot has to be altered
considerably during the different phases of gait
cycle. At heel strike, the foot has to be gently
lowered till it gets fully grounded and here it must
be supple and mobile to be able to adapt to the
contours of the ground. As it gets loaded, it has
to become increasingly rigid, so that when the
heel is lifted off the ground, foot is braced to
provide a rigid lever for an effective push off.
There is a locking and unlocking mechanism
provided at the level of the mid-tarsal joint and
this, in turn, is related to whether the subtalar
joint is inverted or everted. If the heel is everted,
the forefoot can be moved up and down very
considerably-The foot is unlocked. But if the heel
is inverted, this excursion becomes markedly
restricted.
The axis of talonavicular and calcaneo cuboid
joints are parallel to each other when the foot is
everted and so the foot is mobile. During
inversion, however, these axis are no longer
congruent and midtarsal joint gets locked.
Inversion and eversion, in turn, are related to
the rotation of legs; here the subtalar joint acts
as a metered hinge joint. External rotation of the
leg inverts the foot, while internal rotation
everts it.
When a person walks, he has to reckon with
two major forces: first, the pull of gravity and
second, the forces generated by the muscular
contractions. Analysis of both these forces makes
it possible to measure the magnitude and direction
of the external forces acting on the limb during
the different phases of gait (Kinetics).
AMPUTEE LOCOMOTION
The appearance of normal gait is the sum total
of various characteristic determinants of human
locomotion. The gait of an amputee will depend
upon the condition of the determinants he has
remaining, e.g. joints, skeletal links and muscles,
the extent to which the prosthetic replacements
mimic the original body parts, and the interface
between body and prosthesis.
In below knee amputees, the knee and hip are
intact; thus, provided there are no contractures,
they can be expected to walk as normal persons.
The patellar tendon bearing (PTB) prosthesis with
cuff suspension permits the amputee to flex his
knee from heel strike through a foot and extend it
from foot flat to midstance. The swing phase is
controlled by muscles which are intact but a little
abnormality may be observed as hyperflexion at
knee and hip to allow swing through.
However, after good alignment of a well fitting
prosthesis, the below knee amputee can be
regarded as having a minimum of disability. The
success of the prosthesis depends upon an intimate
fit of socket and prosthetic foot designed to
minimize the loss of ankle function.
To obtain an intimate fit of the socket, the
present HDPE design was developed, and it has
very successfully achieved it. The superiority in
the present design lies in its foot piece - the Jaipur
Foot.
An amputee using SACH foot has to vault
because of long keel; in the Mahaveer prosthesis,
the foot piece is fixed in plantigrade position thus
obliviating any need to vault.
Conventional prosthesis does not acco-
mmodate for the axial rotation of the limb
segments. The force generated by these rotations
must either be absorbed in the superficial layers
of the skin at the socket stump interface or at the
ground. Shearing forces within the socket may
seriously irritate stump tissue. Rotational forces
between the foot and the ground may create
instability by forcing the foot to rotate on the
ground. The Jaipur foot permits considerable
transverse rotation and all the movements in this
plane are completely absorbed by it. No forces
are created either at the socket stump interface
or at the ground.
 NORMAL AND AMPUTEE LOCOMOTION
In prosthetic feet, plantar flexion bumpers
which are too soft produce an apparent foot slap
and those that are too hard do not simulate plantar
flexion. Dorsiflexion bumpers which are too
soft tend to produce an apparent drop off.
Resilient bumpers or springs have a reasonably
characteristic load versus deflection curve and
therefore do not respond adequately to the
changing moment generated in walking.
The Jaipur foot is a complete unit and does not
have adjustable bumpers. It has an exce-
llent range of dorsiflexion (40) and is fixed
in plantigrade position, thus mimicking
normal action of the foot from heel strike to toe
off.
In the SACH foot, the ankle or center of
rotation in the sagittal plane has effectively been
85
relocated somewhere in the heel, the resiliency
of which determines both the range and rate of
ankle plantar flexion under force applied. The
SACH foot provides no dorsiflexion in the range
of motion about the ankle and tends to shift the
center of pressure under the foot rapidly to the
ball represented by the end of keel. Whereas
in Jaipur foot, the center of rotation is at the ankle
level only and as described has excellent range
of dorsiflexion, thus providing natural
characteristics to gait, and so much mimics a
normal foot that most of the time the onlooker is
at a loss to recognize the artificial limb.
FURTHER READING
1. MK Mathew. Jaipur Artificial Limbs, published by
Bhagwan Mahaveer Viklang Sahayata, Samiti, Jaipur,
1997.
CHAPTER 11
Role of CAD-CAM
Technology in Prosthetics
and Orthotics
U Singh
 ROLE OF CAD-CAM TECHNOLOGY IN PROSTHETICS AND ORTHOTICS
Innovations in technology have brought about
advances in the field of Prosthetics and Orthotics
and the use of computers in designing and
manufacturing was only natural. Computer aided
designing and computer aided manufacturing
(CAD-CAM) with special software and hardware
suited for measurements, designing and
machining are used by many prosthetic and
orthotic centers around the world.
A graphic user interface (GUI) and software
are used to design and edit the design of
prostheses/orthoses.
Common applications of CAD-CAM are:
Sockets of prosthesis
Lower limb and spinal orthoses
Shoe modifications/inserts for the insensate
feet.
The conventional practice of socket measure-
ment involves taking a plaster of Paris cast,
making a positive mould and then doing the
necessary modifications for pressure relief and
weight bearing, before the actual fabrication. The
use of CAD-CAM can completely avoid the use
of plaster of Paris casts and thus save consi-
derable amount of time and effort on the part of
the prosthetist. However, the technology does not
compensate for the knowledge and expertise of
the expert prosthetic engineer as the design needs
to be modified for pressure areas, adjustments
for deformities, changes in residual limb volume,
skin conditions, etc. before final fabrication, to
achieve better results.
The essential components of a CAD-CAM
system (Fig. 11.1) may be listed as:
1. Scanner with processor and transmitter
(Fig. 11.2).
2. Computer (PC) with processor having the
appropriate software.
3. Carver (Fig. 11.3).
The main steps of CAD-CAM in prosthetics
and orthotics:
1. Measurement taking (Fig. 11.4)
87
2. Design modification [CAD] (Fig.11.511.10).
3. Manufacturing/machining [CAM] (Fig. 11.3).
It is also known as CASD (computer aided
socket designing) as the above technique is
mainly used for making prosthetic sockets.
TAKING MEASUREMENTS
The part is measured using Opto-electric LASER
scanner, which allows capture of the image by
the camera, which is then transmitted to the PC
via a transmitter/digitizer so that a three
dimensional image is obtained. This is one of the
most commonly used techniques of measurement.
It is an easy and fast technique for measure-
ment taking. Despite the benefits, there are
inherent disadvantages too. Any unwarranted
movement of the part may cause errors. Besides,
the pressure sensitive and pressure bearing areas
may not be identified so well when compared to
the conventional cast taking. Though the modern
software specially suited for CASD may be able
to identify these areas using computer intelli-
gence but using the hand and the markings on
the stump socks before taking measurements in
the conventional technique still remains superior.
This is where the expertise of the prosthetist
comes into picture and only thorough knowledge
of the anatomy and the system can allow proper
design modifications. The optical LASER
digitizer allows quantitative characterization of
the parts spatial geometry and surface topo-
graphy, thus reducing the frequent variations and
errors in measurement.
Alternately, a digital camera may also be used
to take photographs of the part from different
perspectives. These photos are then fed to the
computer along with relevant measurements of
the body part to match the pre-fed designs. The
closest match is then used and modified as per
the need. Although not very accurate, it is still
used because of its simplicity, low expenses and
ease of taking measurements.
88 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

Fig. 11.1: Essential components Fig. 11.2: Scanner with processor

of a CAD-CAM system and transmitter

Fig. 11.3: Carver Fig. 11.4: Measurement taking

Fig. 11.5: Design Modification (CAD) Fig. 11.6: Design Modification (CAD)

Fig. 11.7: Design Modification (CAD) Fig. 11.8: Design Modification (CAD)
 ROLE OF CAD-CAM TECHNOLOGY IN PROSTHETICS AND ORTHOTICS
Fig. 11.9: Design Modification
A conventional plaster cast of the body part
may also be taken and measured using a revolving
probe suspended in the socket and data used for
3D designing.
COMPUTER AIDED DESIGNING AND
MODIFICATION
A number of suitable softwares are commercially
available of which Tracer CAD and Shapemaker
softwares are among the popular ones. The
computer aided designing and modification
essentially eliminates the very tedious process
of making the positive mould using conventional
plaster and modifying it.
The design modification part of CAD-CAM
technology is definitely superior to the conven-
tional techniques, allowing any number of rever-
sible modifications, adjustments in alignment,
etc. Data storage is another important advantage
as the design may be used for the same patient
again, if it is felt that the shape and size of the
stump would not have changed since the last
measurement. We can have a choice of socket
designs available on the computer in a center
which has a large turnover of patients and the
stock designs after minor modifications can also
be used for patients in a hurry or for patients
where camera pictures are used for making the
stump rather than the opto-electric scanning or
plaster cast reading by using a probe. The designs
can also be saved as digital data and transferred
to be kept by the laboratory, workshop, patient or
even email it to any other place for manipulation
89
Fig. 11.10: Design Modification
of the design or even having machining done for
making a real socket in future without having to
take the measurement again or modifying the
design or having to store the plaster mould which
occupy lots of space in the workshops besides
the danger of breakage, etc.
COMPUTER AIDED MACHINING/
MANUFACTURING
After modification of the three dimensional
design, data is sent to the carver to make modified
positive moulds. The carver has a cutting tool
which can be of different sizes and cutting
capacities according to the fineness and the type
of material used. A block of polyurethane is used
as the mould and the carver shapes the block as
per the design fed to it. This might take a few
minutes.
EXPECTATIONS, ADVANTAGES AND
LIMITATIONS OF CAD-CAM
The biggest advantage of CAD-CAM is that the
measurement needs to be taken only once and
can be modified any number of times. The
measurement can be easily stored on the
computer or any other storage device. One major
advantage is provision of services in remote areas
where technology is not available. Scanning/
measurement can be taken at the local area, data
transferred to a central laboratory or institution
where technology and expert manpower is
available, the prostheses/orthoses can be made
90 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
there and transported to the remote area. It can
also be an excellent tool for research and
development in the particular field especially when
combined with other technologies like
instrumented gait and motion analysis, interface
force studies, etc. The technology was also used
as a tool for distance education in Canada.
It is to be understood that the CAD-CAM
technique replaces the manual activities of plaster
of Paris cast taking, making a plaster mould and
then modifications of the plaster mould. Rest of
the process of making the appliance is done as
per the conventional techniques. Most devices
are still laminated or formed over computer carved
models. Advanced fabrication techniques using
computer aided manufacturing is still mostly in
research phase.
It is not entirely true that CAD-CAM can
lessen the time taken to make and fit the
appliances, it only reduces the time of
measurement and modification. Besides, it is quite
expensive and does require the necessary
equipment and adequate space besides trained
professionals. It is not essential.
FURTHER READING
1. Boone DA, Burgess EM. Automated fabrication of
mobility aids: Clinical demonstration of the UCL
computer aided socket design system. Journal of
Prosthetics and Orthotics 1998;1(3):187-90.
2. Borchers RB, Boone DA, Joseph AW, et al. Numerical
comparison of 3-D shapes: Potential for application
to the insensate foot. Journal of Prosthetics and
Orthotics. 1995;7(1):19-34.
3. Brncick M. Computer automated design and computer
automated manufacture. Physical Medicine and
Rehabilitation Clinics of North America. 2000; 11(3):
70113.
4. Hastings JA, Vannah WM, Stand JA, Harning DM,
et al. Frequency content of prosthetic and orthotic
shapes: A requirement for CAD/CAM digitizer
performance. Journal of Prosthetics and Orthotics.
1998;10(1):2-6.
5. Houston VL, Mason CP, Beattie AC, et al. The VA-
Cyberware lower limb prosthetics-orthotics optical
laser digitizer. Journal of Rehabilitation Research and
Developoment. 1995;32(11): 5573.
6. Lemaire ED. Distance education technology for
prosthetic CAD/CAM instruction. Journal of
Prosthetics and Orthotics. 1993;5(3):82-7.
7. Michael JW. Reflections on CAD/CAM in prosthetics
and orthotics. Journal of Prosthetics and Orthotics.
1989;1(3):116-21.
8. Oberg K, Kofman J, Karisson A, et al. The CAPOD
system A Scandinavian CAD/CAM system for
prosthetic sockets. Journal of Prosthetics and
Orthotics. 1989;1(3):139-48.
9. Raschke S, Bannon MA, Saunders CG, et al. CAD-
CAM applications for spinal orthotics preliminary
investigation. Journal of Prosthetics and Orthotics.
1990;2(2):115-18.
10. Saunders CG, Bannon M, Sabiston R, et al. The
CANFIT system: Shape management technology for
prosthetic and orthotic applications. Journal of
Prosthetics and Orthotics. 1989;1(3):122-30.
11. Smith DG, Burgess EM. The use of CAD/CAM
technology in prosthetics and orthotics-current clinical
models and a view to the future. Journal of
Rehabilitation Research and Developoment.
2001;38(3):3273.
12. Staats TB, Kriechbaum MP. Computer aided design
and computer aided manufacturing of foot orthoses.
Journal of Prosthetics and Orthotics. 1989;1(3): 182-6.
13. Steele AL. A survey of clinical CAD/CAM use. Journal
of Prosthetics and Orthotics. 1994;6(2):42-7.
14. Vannah WM, Harning DM, Hastings JA, Stand JA,
et al. Surface curvature-based modification as a practical
CAD/CAM rectification for transtibial limbs. Journal
of Prosthetics and Orthotics. 2000;12(2):55-9.
15. Walsh NE, Lancaster JL, Faulkner VW, et al. A
computerized system to manufacture prostheses for
amputees in developing countries. Journal of
Prosthetics and Orthotics. 1989;1(3):165-81.
CHAPTER 12
Jaipur Foot and
Limb

NK Mathur
92 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

India is a multicultural and agriculture based All the above material was kept in the die
country. As per our socio-religious culture and which was heated at high temperature and
traditions we remain bare footed in our home, pressure. This initial Jaipur foot model was having
religious places, social functions and in agri- required flexibility but was very prone to frequent
culture field. breakage. This model was not having required
Conventionally SACH (Solid ankle cushion supination and pronation.
heel) foot is provided in the artificial limbs and In second phase of development of Jaipur foot
therefore a footwear is required. SACH foot has the following changes were made.
wooden keel which is centrally located, different 1. Wooden block in the forefoot area was
layers of sponge rubber are in heel and proximally replaced by sponge rubber.
there is a wooden piece with bolt inside. Whole 2. Hard rubber which was used for toes was
foot is covered with rubber. Sach foot provides replaced by sponge rubber (Soft) Fig. 12.3.
heel to toe gait. Footwear is necessary for the This second version of Jaipur foot showed
sach foot (Fig. 12.1). flexibility in terms of pronation and supination.
In our day-to-day activities and during social For the external appearance, skin colored rubber
rituals, we have to sit in squatting posture which was used to give a look of natural foot. This final
is not possible with the use of sach foot. Hence model of rubber foot is known by the name of
footwear has to be removed. Further in rural areas Jaipur foot. Jaipur foot is very popular along with
people have to walk on narrow lanes and then
user of sach foot was very uncomfortable. In view
of above difficulties which were faced by rural
amputees, it was thought to have a change in
conventional sach foot. Further in view of our
vast population who live in the villages, where
there are plenty of local artisans, an artificial foot
and limb should be such which can be fabricated
by these artisans locally by using locally available
material and can take care of a large number of
rural amputees with minimum affordable cost.
Jaipur foot was developed due to these Fig. 12.1: SACH foot
changes which were needed in the sach foot, to
enhance the mobility in the sach foot. The
wooden keel was modified wherein 2 wooden
blocks were used in place of wooden keel. The
first wooden block was used with a second
wooden block was placed at the site of tarsal and
metatarsal bones of the foot. In between 2 wooden
blocks, a piece of sponge rubber was kept to work
as talus and calcaneum. This acted as a joint
between wooden blocks. This also provided
movement in all directions. The small pieces of
hard rubber were used to prepare toes. (Fig. 12.2) Fig. 12.2: Jaipur foot (First version)
 JAIPUR FOOT AND LIMB 93

Fig. 12.3: Present Jaipur foot

Jaipur limb (metallic) among rural population. This

works well even on rural uneven roads, muddy
farming fields, allows squatting and helps in sitting
on ground. The user does not need a shoe to use.
Since it looks as natural foot, the user can easily
perform social and religious activities without
removing artificial limb. Due to these qualities of
Jaipur foot, many amputees prefer Jaipur foot.

MEASUREMENT TECHNIQUE OF
JAIPUR LIMB
Every below knee stump should be evaluated
properly before measurement is taken (Fig. 12.4).
We must examine ROM of knee joint, muscle Fig. 12.4: Below knee stump
strength, skin lesion and site of pain in the stump.
The length of stump is measured from inside of
joint line to distal end of the stump (Fig. 12.5).
Circular width is measured at the central of
patella and down below at 1-1 distance
(Figs 12.6 and 12.7). Anteroposterior at lower pole
of patella to popliteal fossa is also measured along
with measurement of widest part of knee.
The length of normal leg is measured from
mid point of patella tendon to tip of medial
malleolus or inside joint line to ankle joint is
measured. (Fig. 12.8) The circumference of calf
is measured at every 3 and is noted (Fig. 12.9)
Then a piece of aluminium sheet is taken
having length of joint line to ankle (normal side) Fig. 12.5: Measurement of stump (Length)
94 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

Now the proximal part of aluminium (folded)

shell is given the shape of knee joint. Further a
depression is created at infront part of the shell
for weight bearing on patellar tendon. The size
of pressure area is 1 and 1/2 width, half inch
depth and 1 height. The proximal part of the
shell should also cover condyles (Figs 12.14
to 12.17). Posteriorly, more space is created for
hamstring muscles. The aluminium shell is also
given the shape of leg.
Finally a proper size wooden piece is put at
the distal end of shell and then a hole (10 mm) is
made in the center of wooden piece through which
a screw is tightened with proper sized Jaipur foot.
Fig. 12.6: Measurement of stump
at suprapatellar region

Fig. 12.8: Measurement of

sound leg (Length)

Fig. 12.7: Measurement of stump

at infrapatellar region

with width as per circumference of knee. Then a

line is drawn in the central of the sheet followed
by horizontal lines of the size of circumference
of the leg which was earlier noted at every 3
(Fig. 12.10). Then sheet is cut according to the
lines drawn on the sheet and then sheet is folded
slowly by using hammer on sunbill and finally
both edges of the sheet is joined with the help of
welding (Figs 12.11 to 12.13). Fig. 12.9: Measurement of sound leg
at calf region
 JAIPUR FOOT AND LIMB 95

Fig. 12.13: Shaping of sheet

Fig. 12.10: Marking on aluminium sheet

Fig. 12.14: Shaping of sheet

around knee

Fig. 12.11: Folding of the sheet

Fig. 12.12: Joining of sheet by welding Fig. 12.15: Use of hammer in shaping of sheet
96 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

Fig. 12.16: Use of scissor in shaping

Fig. 12.18: Leather suspension infixed

Fig. 12.17: Edges of sheet are everted

The leather suspension is fixed at proximal end

of the artificial limb. (Fig. 12.18). Now Jaipur limb
with Jaipur foot is ready for walking (Fig. 12.19).

Material
Jaipur foot of assorted size
Measurement tape
Marker pen for marking
Notebook for writing measurement
Aluminium sheet 18 gauze Fig. 12.19: Final fitting of Jaipur foot
Scissor for cutting the sheet. and Jaipur limb
 JAIPUR FOOT AND LIMB 97

DIFFERENCE BETWEEN SACH FOOT AND JAIPUR FOOT

Sach foot Jaipur foot

1. Provides less flexibility and without any joint 1. It has movement at various joints
2. It is essential to wear a shoe 2. No additional shoe is required
3. It has a wooden keel 3. It has no wooden keel
4. Shape is like shoe 4. Shape is like natural foot
5. Made-up of wood and rubber 5. Made-up of wood and sponge rubber
6. It cannot be used in muddy and uneven ground 6. It can be used in muddy and uneven ground
7. It requires modern technology to manufacture 7. It can be made by rural artisans
8. Squatting or cross legged sitting not possible 8. It allows squatting and cross legged sitting

FURTHER READING
1. Kabra SG, Narayan. Jaipur Ankle Foot Prosthesis
Rawat Publication, Jaipur, 1991.
2. Mathur MK. Fabrication technique of Jaipur below
knee aluminum prosthesis, Jaipur artificial limbs,
Published by Bhagwan Mahavir Viklang Sahayata
Samiti, Jaipur.
3. Sethi PK. A rubber foot for amputees in developing
countries. J of Bone and Joint Surgery 1972;54B: 177.
4. Sethi PK, Udawat MP, Kasliwal SC, et al. Vulcanized
Rubber foot for lower limb amputees. Prosthetic and
Orthotic International 1982;125-36.
CHAPTER 13
Spinal Orthosis:
General Concept,
Fabrication, Types and
Indications
AK Agarwal
 SPINAL ORTHOSIS: GENERAL CONCEPT, FABRICATION, TYPES AND INDICATIONS
Spinal brace/orthosis is a mechanical device
used for support of spinal column: It is useful in
relief of painful spine. Low back pain syndrome
affects nearly 80% of all persons during their life
time. Research studies have shown that 70%
cases recovered within one month, 26% within
3 month and only 4% remain affected for longer
than 6 months (Rene Cailliet, 1981). However
precise knowledge of functional anatomy is
essential in understanding of any form of
musculoskeletal pain.
INDICATION OF SPINAL ORTHOSIS
1. To reduce pain/spasm in the spinal column.
2. To restrict movements in the spine.
3. To correct deformity in spine.
4. To provide support to weak spine.
CHARACTERISTICS OF GOOD SPINAL
ORTHOSIS
1. The orthosis should be simple, comfortable,
durable and can be used by a common person.
2. It should by cosmetically acceptable to
patient.
3. It should be easy to prepare and repair.
4. It should be affordable.
MATERIAL USED IN FABRICATION
1. Drill Cloth
2. Leather
3. Plastic
4. Foam
5. Aluminium Stripes/Sheet
6. Velcro strap and elastic.
TYPES OF SPINAL ORTHOSIS
According to spinal regions, the different spinal
orthosis is being advised:
99
1. Cervical Region
Cervical collar
Soft
Hard
Adjustable
Correctable
SOMI Brace (Sterno Occipito
Mandibular Immobilizer)
2. Dorso-Lumbar Region:
Taylors Brace
ASH Brace
Milwaukee Brace
Underarm Plastic Spinal Orthosis
3. Lumbo sacral region: Lumbosacral corset/
Frame
1. Cervical Region:
Simple cervical collar: The measurement
is taken in the following manner
The front height is taken from tip of
chin to upper notch of sternum and
circumference of neck is taken. It is made
by plastic sheet with foam padding where
Velcro in attached to both the ends. It is
indicated in acute cervicospondylitis,
cervical radiculopathy, vertigo and trau-
matic lesions of cervical spine: It is also
used as a part of first aid to cervical spine
for transportation (Fig. 13.1).
2. Adjustable cervical collar: The height
can be adjusted by making 2 circular
pieces and attached in central with the help
of Velcro.
3. Corrective cervical collar: It is given for
torticollis cases along with proper cervical
spine exercise.
4. SOMI Brace: It is known as sterno
occipito mandibular immobilizer and
available in different sizes and accordingly
fitted around cervical spine. It prevents
cervical movements and it is suitable in
traumatic lesions of cervical spine.
100 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

A B

C D E
Figs 13.1A to E: (A) Cervical collar, (B) Cervical collar (Regular), (C) Cervical collar (Soft),
(D) Cervical collar height adjustable, (E) Cervical collar with chin support

Parts of SOMI Brace Measurement

1. Steel rods: Two on front and two on back.
The front rod provides support to chin and
sternum and back rods supports occiput area
of the skull and back (interscapular region).
2 Supports-2- one for chin and other for occiput
area.
3 Fastners-2-one each on right and left side of
neck.
2. Dorso Lumbar Region
2A Taylors Brace
Seventeen vertebrae make dorsolumbar spine.
The maximum movement is at the junction of
dorso lumbar spine:
1. Circumference of pelvic region.
2. Circumference of lower chest.
3. Height from upper border of sacrum to lower
cervical region (junction of cervico dorsal
spine).
Parts
It consists of two long flat steel strip uprights on
the back and pelvic belt is attached to distal tips of
strips. Two axillary long straps are also attached
to upper border of upright. It is available as high
and low types of brace. Some times lumbo sacral
corset is also attached with this brace. It is
commonly indicated for traumatic, tubercular lesion
and also in spinal tumors (Figs. 13.2 A and B).
 SPINAL ORTHOSIS: GENERAL CONCEPT, FABRICATION, TYPES AND INDICATIONS
A B
Figs 13.2A and B: Taylors Brace
2B ASH Brace
Nowadays anterior hyperextension spinal brace
is used in place of Taylor brace since it restricts
movement, provides better stability and prevents
further kyphosis of dorsolumbar spine, hence it is
also indicated in generalized kyphosis of the spine,
apart from other indications of Taylors brace.
The ASH brace is light, elegant, comfortable,
simple, easy to make adjustable in height and in
circumference of the chest and can be fitted on
the spot. It corrects the deformity of dorso-lumbar
spine and keeps the spine in desired position by
three point pressure technique that is two pressure
points are in front and one on the back (middle of
spine).
Indications
1. Compression fracture
2. Adolescent kyphosis
3. Senile osteoporosis
4. Tuberculosis of spine
5. Secondaries of the spine
Measurements
Two measurements for ASH brace are taken.
Circumference of chest and height between
notch of sternum to the upper border of pubic
symphysis.
101
Fabrication
It consists of two long aluminium strips joined at
90 degree on center part of vertical strips. The
horizontal strip has two triangular pieces (well
padded) attached to the edges. The long velcro-
strapes are attached to triangular pieces which
are tied on the back of the trunk. The ASH brace
is fitted on the front of the trunk area (Figs. 13.3A
to C).
2C Milwaukee Brace
The Milwaukee brace was designed to obtain
correction for the nonoperative treatment of
scoliosis by Dr Walter P Blount and Dr Albert
C Schmitt and exhibited the Milwaukee brace at
the meeting of the American Academy of
Orthopedic Surgeon in 1946. Since that time,
numerous changes have been made in the design
of the brace, and is being extensively used as the
ambulatory, nonoperative treatment of spinal
curvatures. The modern Milwaukee brace is
nicely contoured and cosmetically acceptable
(Figs. 13.4 A to C). Improvement can be obtained
in a patient with growth potential and with a mild
to moderate lateral curvature of 20 o to 40o.
Cooperation of patient and parents, properly
constructed brace and closely supervised
treatment are very essential for good results. The
treatment program typically followed, includes
102 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

A B C
Figs. 13.3A to C: (A) ASH brace (Front view), (B) ASH brace (Back view), (C) ASH brace

A B C
Figs 13.4A to C: (A) Milwaukee brace (Back view) (B) Milwaukee brace (Front view)
(C) Milwaukee brace (Side view)

full-time wearing of the brace until the end of the
adolescent growth spurt, then a gradual decrease
in the time it is worn and finally, during the last
year after completion of skeletal maturation, the
brace is worn only at night. A few patients with
mild curves wear the brace less than full time at
the start of treatment. With these and all other
brace patient, the time allowed out of the brace
each day must be carefully controlled on the basis
of the stability of curve correction during the
specified period time out of the brace.The patient
should wear Orthosis for about 23 hours a day.
He may take it out while doing dancing, swimming
and other athletic activities. A coordinated physical
therapy program is essential to develop trunk
muscles for encouraging active correction.
Stability is evaluated by comparing measure-
ments made on a standing roentgenogram of the
patient (spine) in the brace with those determined
from a standing roentgenogram made after the
specified period out of the brace. Loss of correc-
tion during this period indicates instability which
must be treated by increased daily wearing time.
Wearing of the brace until complete maturation
of the spine occurred, is nearly always necessary
to maintain correction. Skeletal development
should be assessed on the basis of wrist bone age,
the appearance and capping of the iliac apophysis,
the development of the vertebral ring epiphysis,
and growth in height.
 SPINAL ORTHOSIS: GENERAL CONCEPT, FABRICATION, TYPES AND INDICATIONS
Measurements, Parts and
Method of Fabrication
The child is kept in lying position on Rissers table
and traction is applied through head halter (cervical
region) and pelvic region in opposite direction and
deformity is corrected to maximum tolerable stage
of the child.
POP Bandages are applied on the whole trunk
and POP jacket is prepared.
Than the child is taken off from traction and
put on trolley and POP jacket is removed.
Negative POP mould is prepared.
Thick leather in mounted on the pelvic region
of POP mould and pelvic girdle part of the
brace is prepared.
Parts of Milwaukee Brace
Pelvic girdle
Neck ring with occiput pad.
Three adjustable uprights-two on back and
one front.
Pad for giving pressure on rib hump.
Pelvic girdle is open on back and two uprights
are attached to pelvic girdle posteriorly and
one upright is attached anteriorly. Proximally
all the uprights are attached to neck ring.
Some disadvantages have been observed after
prolong use of milwaukee brace like pressure sore
due to excessive pressure on iliac crest due to
pelvic girdle. The dental problems due to improper
fitting of the neck ring in the growing children
have been noted along with mental stress due to
inferiority complex in children.
2D Underarm Plastic
Spinal Orthosis: (UPSO)
Though Milwaukee Brace even today remain an
effective method of conservative treatment of
scoliosis in mild mobile curve in skeletally
immature patients but it has the disadvantage of
being uncomfortable and unacceptable by the
103
majority of patients and needs time in fabrication,
yet in cervico dorsal scoliosis it is the best type of
spinal orthosis. In an effort to overcome the above
mentioned disadvantage with milwaukee brace,
a number of underarm plastic spinal orthosis are
now available like Lexan Jacket from Pasadena,
PVC orthosis, orthoplast Jacket and Boston brace,
Bunnel, Mac Ewen, Hall, Park, Watts and Yates
5, 6, 8, 9, 12, 13, 14, have described different types
of under arm spinal orthosis. These orthosis
provide a rigid support and is efficient in treating
lumbar and thoraco lumbar curves and also helps
in correcting thoracic curves with apex at about
T7. It stops the progression of the scoliotic curves
in growing children. It extends anteriorly from
sternum to pubic symphysis, laterally from axilla
to the trochanter and posteriorly from the upper
thoracic region to the gluteal folds (Figs. 13.6 A
and B). The under arm orthosis has the
disadvantage that it is not suitable for cervico
thoracic curves and prolonged use may alter the
thoracic cage and even may reduce pulmonary
functions in a child whose pulmonary functions
are already low (Figs. 13.5A to C).
Measurement and Method of
Fabrication UPSO
First the plaster mould is prepared as done in
milwaukee brace and then a plastic sheet of
appropriate strength is put in electric oven. After
sheet is well warm then it is molded over the
positive POP mold. After cooling, the plastic sheet
mold is removed and trimming of the edges is
being done followed by padding on the edges.
The straps are attached to the anterior part of
UPSO along with buckles. Aneriorly UPSO in
open and tightened as per need.
Some disadvantage of longterm use UPSO
are also there like, it should not to be advised to
such children who have respiratory problems, and
it can retard the growth of breast in adolescent
girls.
104 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
A B
Figs 13.5A to C: (A) Underarm plastic spinal orthosis (Back view), (B) Under arm plastic spinal
orthosis (Side view), (C) Under arm plastic spinal orthosis (Front view)
A B
Figs. 13.6 A and B: LTTSO (Back view and
Front view)
LOW TEMPERATURE
THERMOPLASTIC SPINAL ORTHOSIS
Recently low temperature thermoplastic spinal
orthosis is being used. This is a colored perforated
sheet in different thickness of 2 to 5 mm. This
becomes transparent, soft and elastic at 60 degree
centigrade when kept in a tray containing hot
water. Then it is easily molded directly on the
spine in maximum correction, which hardens on
cooling thus maintaining the corrected position.
If any modifications are needed after wards then
it may be done after reheating it. It has the
property of elasticity and can be stretched to a
great extent as desired for molding. It has the
advantage of memory therefore it returns to its
C
original shape when reheated (Figs. 13.6 A
and B). This has the another advantage that
alteration can be made in the growing child. It
has also self adhesive properties, so Velcro sticks
to it when heated. The main advantage is directly
molded over the spine and so negative or positive
moulds are not needed. Another advantage is that
it can be used for immobilizing the spine after
surgery with internal instrumentation and bony
fusion thus replacing Rissers Plaster Jacket.
3 Lumbo Sacral Region
3A Lumbo Sacral Corset: It is very commonly
prescribed for acute pain of lower back. It is
available is different sizes in the market. The
measurement is very simple wherein circum-
ference of waist is taken along with vertical
height from back that is from dorsolumbar junction
to upper border of sacrum. It is also prescribed
as Lumbosacral belt/corset or as a Lumbar frame
(Figs. 13.7 A and B).
Lumbar corset is made-up of drill cloth and
aluminium sheet is put for back support. Elastic
is also attached on the sides of corset and 3 to 4
velcro staps are attached to the front side of the
opening.
In the lumbar frame, there are two frames of
aluminium, upper one for waist region and lower
one is for pelvic region. Both frames are joined
with 4 aluminium uprights, that is two posterior
 SPINAL ORTHOSIS: GENERAL CONCEPT, FABRICATION, TYPES AND INDICATIONS 105

uprights molded to lumbar lordosis and two
uprights are on two sides of waist properly molded
to the trunk contour. Anteriorly frame has few
straps are attached for the proper grip (Figs. 13.8
A to C).
It is usually indicated in acute lumbago with
or without radiculopathy in the lower limbs,
traumatic lesion of lower lumbar spine, degener-
atives lesions of lumbar spine, tuberculosis in
lower lumbar spine, and spondylolisthesis and
neoplastic lesions of lumbosacral spine. The
lumbar corset produces raised intraabdominal
pressure which in turn decreases intradiscal
pressure thus acute pain is relieved.
Corset helps in decreasing spasm of muscles,
off loading the lumbar spine by increasing the
intra-abdominal pressure, by improving the posture
and by reducing lumbar spine movement.
WHAT BRACE TO BE USED?
In scoliosis with single lumbar, thoracolumbar and
thoracic curve with an apex below T7 under-arm
orthosis is advised. For curves with apex above
T7, Milwaukee brace is recommended.
WHOM TO BRACE?
Lateral curves under 20 must be kept under
observation. In curve over 20 especially over
30 Orthosis should be prescribed. Curves over
50 in adolescents usually do not respond much
to orthosis.

A B
Figs 13.7A and B: Lumbo-sacral corset (Outer view), Lumbo-sacral corset (Inside view)

A B C
Figs 13.8A to C: (A) Lumbar frame (Front view),
(B) Lumbar frame (Side view), (C) Lumbar frame (Back view)
106 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
DOES ORTHOSIS CAUSE
PERMANENT CORRECTION
No long-term results of underarm orthosis are
available since they have not been used for a long
period. Some retention of the curve about 30
degree was noted when the brace was disconti-
nued. It was thought that milwaukee brace gave
permanent improvement but recent study from
milwaukee indicates that most of the permanent
correction is lost.
In future we have to find spinal orthosis for
scoliosis which may give permanent improvement
in scoliosis and cosmetically acceptable to the
patient. Low temperature thermoplastic orthosis
is light, has good appearance and helps in the
correction of the curves and is directly molded
on the spine. This is a great step forward in
orthosis for spinal scoliosis provided they live up
to their promise.
FURTHER READING
1. Agarwal AK, Sharma VP, et al. Evaluation of Underarm
plastic spinal orthosis in mangement of scoliosis,
Indian Journal of Physical Medicine and Rehab Vol 3,
April 1990.
2. Blount WP, Schmid AC, Keever ED, et al. The
Milwaukee Brace in the Operative Treatment of
scoliosis. J Bone Joint Sur 1958;40 AL:51125.
3. Blount WP. Scoliosis and Milwaukee Brace, Joint Dis
1958;19:152.
4. Blount WP, Moe JH. The Milwaukee Brace, Baltimore,
Williams and Wilkins Company, 1973.
5. Bunnel WP, Mac Ewen GD. Use of the orthoplast
Jacket in the Non-operative Treatment of Scoliosis,
Presented at the Tenth Annual Meeting of the
Scoliosis Research Society, Leuisville, KY
September 11, 1975.
6. Bunnel WP. Mac Ewen GP, Kumar S. Plaster Jackets
in Non-operative treatment of Scoliosis. J Bone Joint
Surg 1980;62A:31-88.
7. Goel MK, Agarwal AK, Goel R. Spinal Orthosis for
Scoliosis A preliminary study Indian Journal of
Physical Medicine and Rehabilitation. Vol 5 April 1992.
8. Hall J, Miller W. Prefabrication of Milwaukee brace
J Bone Joint Sur 56A,1974.
9. Hall J, Miller W, Shumann W, Stanish, WA. Refined
concept in the orthotic management of Scoliosis,
Orthotics Prosthetics 1975;29:9-16.
10. Park K Houthkin, S Grossman J, Levine DB.
A Modified Brace (Prenyl) for Scoliosis, Cin Orthop
1977;126:67-73.
11. Rusk H. Principle of Orthotics and Prosthetics,
1977;313.
12. Watts HG. Manual for Boston Brace System
Workshop, Ed Boston March 1979.
13. Watts HG. Hall JE, Stanish W. The Boston Brace
System for the Treatment of Low Thoracic and Lumbar
Scoliosis by the use of a Girdle without superstructure,
Clin Orthop 1977;126:87-92.
14. Yates G. Molded Plastic in bracing. Clin Orthop
1974;102:46-57.
15. Rene Cailliet. Low Back Pain Syndrome, Ed 3, FA
Davis Co. Philadelphia, 1981.
CHAPTER 14
Mobility Aids for
Ambulation Stick and
Crutches, etc.
AK Agarwal
108 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

Any person who is having difficulty in walking, PROPER MEASUREMENT, SELECTION

requires proper mobility or ambulatory aids AND FITTING OF MOBILITY AIDS
which are provided to them after proper
assessment and then measurement is taken. Types

This process is in four stages. Crutches, stick and walker

1. Proper assessment of his muscle power, joint
and pain. Material
2. Pre-fitment of ambulatory device exercises Wood, bet, steel, alloy, aluminium, rubber,
for development of his muscle power and leather/foam
range of movements in joints.
3. Proper measurement, selection and fitting of Crutches
mobility aids.
4. To develop proper pattern of his gait. It is of 3 types:
1. Axillary crutches (Fig. 14.1)
PROPER ASSESSMENT OF MUSCLE 2. Elbow crutches (Fig. 14.2)
3. Adult ortho crutches.
POWER, ROM OF JOINT AND PAIN
The following five sets of muscle are required
for ambulation with mobility aids.
A. Flexors of upper arm
B. Extensors of forearm
C. Flexors of fingers/thumb
D. Extensors of wrist
E. Depressor and internal rotators of shoulder.
The above five sets of muscles act on
shoulder, elbow, wrist and hand hence should be
properly evaluated and according to site of pain,
pressure is minimized.
Fig. 14.1: Axillary crutches
EXERCISES PROGRAM
This depends on the following points in whom
aids are prescribed
Range of movements
Strength of muscles
Status of weak muscles
Status of pain during weight bearing.
The development of effective strength in the
muscle depends upon ROM of the joints. When
ROM is within normal limit then proper exercises
of muscle shall provide maximum strength.

Fig. 14.2: Elbow crutches

 MOBILITY AIDS FOR AMBULATION STICK AND CRUTCHES, ETC. 109

Usually light wood is used in preparation of
crutches. Rural people usually make their own
crutches for their ambulation.
PARTS OF THE AXILLARY CRUTCH
Uprights Two straight wooden piece
Axillary Pad
Hand Grip
Rubber Tip
Nowadays aluminium pipe is also used in place
of wooden uprights which can be made adjustable
as per height of the person.
Continuous use of axillary type crutch can
produce radial nerve palsy or some times.
Brachial plexus injury can also occur. To avoid
above palsy, it is advisable to keep axillary pad
at least 2 below axilla, and adjacent to chest
(Fig. 14.1).
Elbow Crutch
It comprises of a straight upright which is folded
at 15-20 angle for forearm. The proximal part
has a grip for forearm and middle part is having
grip for hand and distal part is covered with
rubber tip; which helps in proper grip on the floor.
Elbow crutch is usually made-up of aluminium
pipe which forms upright. This crutch is
adjustable at main pipe and at forearm piece as
per height of the individual user. Both forearm
and elbow grips have molded rubber piece
(Fig. 14.2).
crutch is measured proximally from anterior fold
of axilla and distal point is taken from sole and
2 is added in the length. Alternately the distal
point is taken 6 away from the sole. The hand
grip is provided in the proximal half of the crutch
so that elbow is having 30 degree flexion and
wrist in extension. In lying position the
measurement is taken from tip of greater
trochanter to the sole of the foot while patient is
on bed. As per Bauer DM et al, selecting a crutch
height equal to 77% of patients height and
according to Beckwith JH ideal height can also
be calculated by subtracting 40 cm from a
patients height.
Walking Stick
The walking stick reduces the body weight on
the lower limbs which in turn helps in relief of
pain in the joint and also supports weak muscles.
It also provides balance, confidence and stability
more in old age (Fig. 14.3).
It is advisable to use walking stick on opposite
hand in relation to problem. It means if
discomfort is in right knee or in hip then stick to
be used in left hand.
Use
The individual, using walking stick is given
training to walk in three point gait. It is further

Adult Ortho Crutch

It is a combination of axillary and elbow crutch
thereby the weight of body is taken 2 below
axilla (chest wall) and also on hand grip. This
model has only one upright which is having
adjustable mechanism.

Measurement
In standing position: The length of axillary Fig. 14.3: Different walking stick
110 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
advised to climb stairs up with good (normal) foot
first and while climbing down then bad foot
(painful) should be put first.
Material
Usually wood, bet and aluminium are being used
in fabrication of these mobility aids. The distal
part of walking aid should always have a good
quality rubber tip. Apart from using this single
rubber tip, nowadays two more distal attachments
are available, i.e. tripod (3 legged attachment)
and quadripad, i.e. 4 legged attachment. Both
these attachments provide better self confidence,
balance and stability to the user. It is very useful
to the senior citizen and who are suffering from
neurological disorder (Figs 14.4 and 14.5).
Fig. 14.4: Tripod stick
Fig. 14.5: Quadri pad stick
Walker
It is more beneficial to use walker as compare to
other mobility aids since it provides broader
base for walking and center of gravity remain
inside the base. It is a common practice to initiate
training of walking in parallel bars followed by
walker and then with crutches and finally to train
the person on walking stick.
There are 3 types of walker
1. Standard walker
2. Reciprocal walker
3. Rolator walker
Standard Walker
It is made-up of the aluminium pipes joined in
square shape. The 2 hand grips are provided for
proper propulsion and 4 rubber tips are fixed on
digital ends of the aluminium pipes so as to avoid
slip on the ground. All the four aluminium pipes
are some times made adjustable also (Fig. 14.6).
Reciprocal Walker
The construction of reciprocal walker is more or
less similar to standard walker except one joint
is provided one after another for ease in pro-
pulsion to the individual. This type of walker is
useful for those cases who are not able to lift the
walker themselves or they need more stability in
ambulation.
Fig. 14.6: Simple walker and walker with wheel
 MOBILITY AIDS FOR AMBULATION STICK AND CRUTCHES, ETC.
Rolator
It is also made like standard walker however two
small casters are added at the base of front
aluminium pipes and two strong rubber tips are
attached to the end of back pipes of walker. This
is useful to those individuals who are unable to
lift the walker themselves and feel more stable
after a little push to the walker. They can
ambulate with confidence. However it is
necessary to give training to elder persons for
proper use of Rolator.
TO DEVELOP PROPER PATTERN OF
AMBULATION TO THE NEED OF
INDIVIDUAL CASE
There are seven types of crutch gait as per
requirement of the each case.
Four point alternate gait
Two point alternate gait
Three point crutch gait
Tripod alternate gait
Swing crutch gait is of two types
Swing to crutch gait
Swing through crutch gait
FOUR POINT ALTERNATE GAIT
This is the most simple pattern of gait with the
use of crutch where on every step there is some
support on the ground. The crutch and feet are
put on the ground in this sequence, i.e. first
(1) right crutch then (2) left foot, Then (3) left
crutch and finally right foot.
TWO POINT ALTERNATE GAIT
In this gait there is only 2 support points are
present on the ground therefore more balance is
required in the individual. The sequence of this
type of crutch gait is as (1) right crutch and left
111
foot together followed by (2) left crutch and right
foot together.
THREE POINT CRUTCH GAIT
This gait is used when one limb is very weak and
the weight cannot be put on the limb then the
sequence of the gait is as follows (1) Both the
crutches and one weak limb together followed
by (2) normal limb.
TRIPOD CRUTCH GAIT
It is of Two Types
Tripod one after Another Gait
The person is trained in the following way:
1. Right crutch
2. Left crutch
3. Whole body is taken together.
When the person is trained in the type of gait
then he is trained for the next step i.e.
Tripod Together
This is practiced in the following way, i.e.
1. Both the crutches together
2. Drag the whole body.
SWING CRUTCH GAIT
This is of 2 types:
Swing- to Gait
The person is trained in the following way:
1. Both crutches together
2. Lift the body up to crutches
Swing- through Gait
The sequences of this gait is given below:
1. Both crutches together
2. Lift the body ahead of the crutches.
112 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

FURTHER READING 3. Bauer DM, Finch DC, et al. A comparative analysis of

several crutch length estimation techniques . Phys
1. Safi R Faruqui, Todd Jaeblon. Ambulatory Assistive Ther 71. 1991.
devices in Orthopaedics: Uses and Modifications. 4. Dean E, Ross J. Relationships among cane fitting,
Journal of American Academy of Orthop. Surgeons, function and falls. Phys Ther 73, 1993.
Vol 18, No 1, 2010.
2. Beckwith JH Analysis of methods of teaching axillary
crutch measurement. Phys Ther 45, 1965.
CHAPTER 15
Role of Rehabilitation
Aids and Appliances in
Cerebral Palsy
HC Goyal
114 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
Cerebral Palsy(CP) is defined as disorder of
movement and posture occurring due to injury or
damage to the developing brain at or around birth.
It is a non progressive disorder, which affects
body movements and posture. The brain damage
occurs during prenatal, natal and postnatal period.
In this the whole brain is not damaged but only
part of brain is affected which concerned with
movement control. Once the damage occurred
then it cannot be repaired, however the
movements and posture, related problems can be
improved.
EARLY DETECTION OF CP
Cerebral Palsy child is often, low weight and
inactive during birth and more commonly it is
caused by birth asphyxia leading to delayed
milstone, i.e. neck holding, sitting and crawling,
standing and walking, etc. Neck holding may be
poor or child may have spastic tightness of body
and attention, reactivity and speech often develop
slowly.
More than half of CP children are mentally
retarded thats why they often seem to be inactive
and lazy. It needs attention with little care and
training so that the mentally retarded child can
be made independent. These children may have
convulsions, hearing and visual impairments.
TYPES OF CP
1. Spastic: Muscles are profoundly tight and
stiff which affects movement of body.
Important Spastic Positions:
a. Neck flexed to a side, knee flexed with
flexed arms.
b. Scissoring gait.
2. Athetosis: Uncontrolled movements or
involuntary tightness: Such children are not
able to control the movements. These are
involuntary movements. Few children do not
able control the movements of body parts
leading to involuntary movements. It is a type
of tremor like situation or sudden increase in
activity which provides movement in muscles
of limbs and face. These type of children are
often mentally normal.
3. Ataxic: Such type of children have difficulty
in sitting and standing and they walk with
wide base to balance themself.
Affected Body Parts
a. Hemiplegia: One side elbow is flexed, stiff
and same side leg is abducted.
b. Diplegia: The upper half of body is normal
or least affected but lower limbs are spastic
and stiff.
c. Quadriplegia: All the four limbs are affected
leading to inability to walk.
Causes of CP
a. Prenatal (Before birth)
i. Infection Measles and Herpes Zoster
ii. Toxiaemia and Diabetes during pregnancy
b. Natal (During birth)
i. Birth injury
ii. Premature delivery
c. Postnatal (After Birth)
i. Meningitis
ii. Head injury
iii. Cerebral thrombosis and hemorrhage.
Important Suggestions to Parents
a. Place a pillow between thighs in lying portion
if legs are crossed or make legs apart.
(Fig. 15.1)
b. If body is hyperextended (Fig. 15.2)
i. Make him lie on swing
ii. Make him lie prone on drum
iii. Make him sit on a swing made of tyre.
c. Place a broad object between legs to keep
them apart.
d. Carry the child in such a way that his arms
can be strengthened and his hips and knees
flexed.
 ROLE OF REHABILITATION AIDS AND APPLIANCES IN CEREBRAL PALSY 115

Fig. 15.1: Use of pillow to keep limbs abducted

Fig. 15.2: Child on swing, on drum

Suitable Aids and Appliances to iii. Wheelchair (Fig. 15.8)

Make Him Mobile iv. Splint or brace: These are made-up of
metal or plastic in order to support weak
A. Aids and Appliances for sitting muscles.
To make the balance better, assistive aids
v. Calipers are useful to support weak lower
should be lower enough so that child can
sit erect, e.g. Tyre made chair, corner seat limbs in standing.
or special CP chair in case of lower trunk vi. Special Boot: Special shoes are also given
weakness, it is useful to have wheelchair for specific problem of the toe and for
(Fig. 15.3). uneven surface.
Special cushions (Fig. 15.4).
Children whose hips are inclined backward
or abnormal lower back, i.e. lordotic spine
they should be provided with the lower back
support to keep the body erect by support
from either side.
Scoliosis increases due to inclination of
body to either side.
Child can sit erect with the help of Hip
guide and Body guide (Fig. 15.5).
B. Aids and Appliances related to mobility:
i. Special type of equipment for prevention
of Knock knee (Fig. 15.6).
ii. A wooden roller for uneven surface Fig. 15.3: Aids like tyres,
(Fig. 15.7). corner seat, CP chair
116 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

Fig. 15.4: Various cushions for sitting on chair

Fig. 15.5: Hip guide for CP child

Fig. 15.6: Use of toys to prevent knock knee

 ROLE OF REHABILITATION AIDS AND APPLIANCES IN CEREBRAL PALSY 117

Fig. 15.7: Wooden roller for uneven surface

Fig. 15.8: Wheelchair

C. Aids for activities of daily life

(Figs 15.9 to 15.16):
Important Tips for Betterment of
Physically Disabled Children
Desk of wheelchair should be higher enough
so that child can read without any incon-
venience.
Special type of arrangements should be made
for writing in case of weakness of shoulder,
arm and elbow, i.e. by providing writing
material according to easy grip of the hand.
Child may be allowed more time to complete
examination.
Tips for Supporting Environment of
School
A sympathetic and supporting attitude should
be there towards students.
An equal opportunity should be given to a
CP child for participation in school activities,
e.g. group PT, prayer and labor works.
Children should be encouraged appropriately
to participate in each activity.
Normal children must be guided to cooperate
with these children as their duty and also they
should not do harm to aids and appliances,
118 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

Fig. 15.9: Use of special spoon

and non-slippery mate

Fig. 15.10: Aids for eating in CP child

Fig. 15.11: Aids for writing in CP child

ROLE OF REHABILITATION AIDS AND APPLIANCES IN CEREBRAL PALSY 119

Fig. 15.12: Various adaptations for pencil holding

Fig. 15.13: Adaptation device for typing and reading

120 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

Fig. 15.14: Use of device to hold pen/spoon

Fig. 15.15: ADL devices

Fig. 15.16: Device to hold spoon

 ROLE OF REHABILITATION AIDS AND APPLIANCES IN CEREBRAL PALSY
i.e. crutches, calipers, artificial limbs and
hearing aids which are being used by CP
children.
Sports activities, drawing, painting compe-
titions must be organized and children should
be encouraged to participate.
Modifications in prosthesis, crutches, etc.
must be done time to time since child grows
speedily in earlier stages.
Special arrangements should be made in
school for convenience of children such as
ramp, suitable classroom, library, sports
ground and toilet, etc.
We can integrate these disabled children in
the society by providing above facilities and we
can make them important part of society.
FURTHER READING
1. Nwaobi OM. Seating orientation and upper extremity
functions in children with CP, Phys Ther 67, 1987.
121
2. Medhant MA, Redford JB. Experience of a seating
clinic, Int. Orthop., 9, 1985.
3. Holm VA, Harthun-Smith L, Tada WL. Infant walkers
and CP, Am J Dis Child 1984;137.
4. Bertoti D Effects of therapeutic horseback riding on
posture in children with CP. Phys Ther 1988;68.
5. Massagli TL. Spasticity and its management in children
Phy Med Rehab Clin N Am, 1991;2.
6. Wiley ME, Damiano DL. Lower extremity strength
profile in spastic CP. Dev Med Child Neurol. 1998;40.
7. Mackinnon JR. Therapeutic horse back riding: A
review of the literature. Phy Occup, Ther Paediatr
1995;15.
8. Breogren E, Hadders-Alga M, Forssberg H. Postural
control in children with spastic diplegia: Muscle
activity during perturbations in sitting. Dev Med Child
Neurol 1996;38.
9. Carlson WE, Vaughan CL, Damiano DL, et al. Orthotic
management of gait in spastic diplegia. Am J of PMR,
1997;76.
10. Rang M, Douglas G. Bennet GC, et al. Seating for
children with CP. Journal of Paediatr Orthop. 1981;1.
CHAPTER 16
Rehabilitation
Aids for Visually
Handicapped
Ratnesh Kumar
 REHABILITATION AIDS FOR VISUALLY HANDICAPPED 123

For proper rehabilitation of visually handicapped/

Low vision persons, the following types of assistive
aids/appliances are required.
1. Assistive devices for writing
2. Assistive device for communication
3. Assistive aids for ambulation
4. Low vision aids/devices Fig. 16.3: WD06-Interpoint Braille Slate
5. Assistive aids for recreational purposes
WD07Pocket frame (Big): It comprises
1. Assistive devices for writing: 9 types of of aluminum sheet with 7 lines and each
different assistive devices are available for line has got 23 cells. Fig. 16.4.
writing
WD04Braille slate (Small): This device
is used for beginners of Braille writing. It
comprises of laminated top where seven
lines are made and each line has 28 cells. Fig. 16.4: WD07-Pocket frame (Big)
One Style is given to make holes. Fig. 16.1.
WD08Pocket frame (Small): It consists
of a aluminum sheet with 5 lines and each
line has 18 cells. Fig. 16.5.

Fig. 16.5: WD08-Pocket frame (Small)

Fig. 16.1: WD04-Braille slate (Small)
WD 09Plastic styles. Different types of
WD05Braille slate (Big): It is similar to styles are used in braille writing. Fig 16.6
WD04 except there are nine lines and each to 16.9.
line has 36 cells and one stylus is also given
with each slate for making the holes.
Fig. 16.2.

Fig. 16.6: WD 09

WD 10Bullhead styles.

Fig. 16.2: WD05-Braille slate (Big)

WD06Interpoint Braille slate: In this

type there is a plastic top having 27 lines
and each line has 30 cells. This slate is
used for writing in Braille in A-4 size paper.
Fig. 16.3. Fig. 16.7: WD 10
124 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

WD 11Safety styles. CD15 (Abacus): It is made up of plastic

having 13 columns. Fig. 16.12.

Fig. 16.8: WD 11 Fig. 16.12: CD15 - Abacus

WD 12Concave styles. CD16 Geometry kit: The designs of
different types geometrys tools are raised
on aluminum sheet for identification.
Fig. 16.13.

Fig. 16.9: WD 12

2. Communication devices: It comprises of 8

types of aids
CD13 Tailor frame (Small): It has a
Fig. 16.13: CD16 - Geometry kit
aluminium top with 18 lines and each line
has 25 cells. It is given in a box. Fig 16.10. CD17: Measurement tape as used by
tailor. Fig. 16.14.

Fig. 16.14: CD17 - Measuring tactile tape

CD18: Aluminium braille scale of 12

Fig. 16.10: CD13 - Tailor frame (Small) size. Fig. 16.15.

CD14 Pocket frame (Large): It has a

aluminium top with 25 lines and each line
has 25 cells. In this type of frame, Fig. 16.15: CD18 - Aluminum braille scale
mathematics and algebra type is also CD19: Aluminium braille scale of 6 size.
available. Fig. 16.11. Fig. 16.16.

Fig. 16.16: CD19 - Aluminium braille scale

Fig. 16.11: CD14 - Pocket frame (Large)
 REHABILITATION AIDS FOR VISUALLY HANDICAPPED 125

CD20: Plastic braille scale of 12 and

6 size. Fig. 16.17.

Fig. 16.17: CD20 - Plastic braille scale

3. Assistive devices for ambulation: Ambu-

lation devices are of 2 types
MD21 Folding cane: The folding cane
has 5 pieces which can be folded for better
handling. The total length in 106 cm (White
in color). Fig. 16.18.
Fig. 16.20: LD23 - Spectacles
LD24 Illuminated hand held magnifier:
This device is available in 16D, 20D, 24D
and 28D power. Fig. 16.21.

Fig. 16.18: MD21 - Folding cane

Fig. 16.21: LD24 - Illuminated handheld magnifier

MD-22 Long cane: The total length is
127 cm. Fig. 16.19.
LD 25 stand magnifier: This is third type
of magnification device which is attached
on the stand and available in 16D, 20D,
24D and 28D power. Fig. 16.22.

Fig. 16.19: MD22 - Long cane

4. Low vision devices: It is of 3 types.

LD 23 Spectacles: For the persons with
low vision spectacles in 16D, 20D, 24D
and 28D power are available. Fig. 16.20. Fig. 16.22: LD25 - Stand magnifier
126 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

5. Assisted devices for recreation: The RD-29Pegges with peg board

different devices are available for recreation
of visually handicapped and low vision
persons. Fig. 16.23 to 16.34.
RD-26Centre peg board

Fig. 16.26: RD29 Pegges with peg board

DR-30Needle threaded

Fig. 16.23: RD26 - Centre peg b oard

RD-27Chess board

Fig. 16.27: DR30 Needle threaded

RD-31Playing cards in Braille

Fig. 16.24: RD27 Chess board

RD-28Draught Board
Fig. 16.28: RD31 Playing cards in Braille

RD-32Puzzle

Fig. 16.25: RD-28 Draught Board Fig. 16.29: RD-32 Puzzle

 REHABILITATION AIDS FOR VISUALLY HANDICAPPED 127

RD33-Signature guide on aluminium RD-36Cross puzzle

sheet

Fig. 16.33: RD-36 Cross puzzle

RD-37Paper role for short hand

Fig. 16.30: RD-33 Signature machine
guide on aluminum sheet

RD-34Tactile board

Fig. 16.34: RD-37 Paper role for

short hand machine
Fig. 16.31: RD-34 Tactile board
Note: All the above devices are easily avail-
RD-35Plastic ball which provides sound able from National Institute of Visually
Handicapped, Government of India, 116
Rajpur Road, Dehradun-248002, Uttaranchal.
Telephones : 0135-2744491,
2744979, 2744387
Fax : 0135-2747147
E-mail : nivh@sancharnet.in
Fig. 16.32: RD-35 Audible ball
CHAPTER 17
Devices for
Low Vision

Poonam Kishore
 DEVICES FOR LOW VISION 129

Low vision develops due to various diseases of 2. The books having big size alphabets and big
the eyes and is being managed with medical screen television.
treatment, spectacles or by surgery. However 3. By keeping reading material very close to
there are certain disorders of eyes which cannot eyes.
be treated with all types of conventional manage- 4. By seeing electric lamps where amount of
ment and vision disturbance becomes permanent. light can be manipulated to your choice
In some cases individual becomes completely (increase or decrease) by using such table
blind and some cases develop low vision. These lamp which can be adjusted as per need of
low vision individual can be helped by various the individual
low vision devices so as to make them self
dependent. LOW VISION AIDS: TWO TYPES
As per WHO reports, any person who is
Optical aids
having visual acuity of less then 6/18 but better
Non Optical aids
than 3/60 or visual field loss to less than 20 in
the better eye with best possible correction who
Optical Aids
cannot be improved by spectacles, drugs or
surgery is labelled as a case of low vision. Spectacle Magnifier: This type of spectacle
Presently 4.5 million people are blind and is commonly used in reading and writing.
nearly 45 million are low vision individuals. Hand Magnifier: This aid is taken in the hand
In Vision 2020 The Right to Sight to read, the price (Normally MRP is printed
programme, the low vision persons have been very small words) and to identify the coins,
given priority. With the use of different types of etc. (Fig. 17.1).
low vision aids, the life of such individual Stand Magnifier: This aid can be put on page
becomes comfortable and his self esteem and of the book to read only while hands are not
confidence level further enhances. used for holding the device (Fig. 17.2).
The following are the common causes of low Telescope: This device is used for seeing
vision: distant objects like number of the shop or to
1. Macular degeneration (due to ageing) see black board in the classroom (Fig. 17.3).
2. Retinopathy (Diabetic)
3. Optic Atrophy
4. Congenital (Since birth) defects of retina
5. Internal inflammatory lesions of eyes
6. Retinitis pigmentosa.
In the above disorders if vision is not improv-
ing by conventional methods then testing is done
by low vision equipments. The principle of the
low vision aid is that the low vision aids magnify
the blurred image to clear and bigger image. This
is known as magnification which can be done in
the following ways.
1. Magnifier spectacles, telescopes, micro-
scopes, etc. Fig. 17.1: Hand magnifier
130 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
Fig. 17.2: Stand magnifier
Fig. 17.3: Telescope
Contact Lenses: Some people can see better
with the contact lenses in comparison to spec-
tacles.
Non Optical Equipments and Methods
The following are the few examples of non
optical equipment.
By proper control of illumination
By proper distance of working
Adjustable table top
Writing Pads
By using thick felt pens for writing bigger
words
By using the book where bigger size words
are printed
By use of computer where size of photo can
be enlarged
By use of closed circuit television
Note: The testing of Low vision should be done
very accurately by the experienced professionals.
(Fig. 17.4)
The Low Vision Imaging System (LVIS)
LVAs are unfortunately, highly task specific, and
the patient may need several different aids to deal
with a variety of identified requirement. Recently,
however, alternative devices have been intro-
duced which offer a number of advantages over
conventional LVA in low vision rehabilitation.
Recent advances in optoelectronics and video
technology have permitted the development
of new low vision rehabilitation device for
example, the low vision imaging system (LVIS)
formerly known as the low vision enhancement
system, which in contrast with other devices,
have been designed to be used for a variety of
tasks. The LVIS, developed at Johns Hopkins
University, is a mains/battery powered video
HMD, equipped with autofocus camera, variable
magnification optics, and contrast enhancement
electronics (image processing capability)
(Fig. 17.5). This technology offers considerable
improvements to a patients visual function and
ability to perform activities of daily living when
Fig. 17.4: Testing of low vision
 DEVICES FOR LOW VISION
Fig. 17.5: The low vision imaging system
compared with the use of conventional aids.The
advantages includes:
1. The design is head mounted so it leaves the
hands free.
2. The device might be used for a range of tasks
because of flexibility of varible magnification
over a wide range of viewing distances.
3. There is a possibility for a wide field of view
with binocular vision.
WHAT THE FUTURE HOLDS
Progress is being made towards development of
electronic and optoelectronic retinal implant
technology, sometimes referred to as retinal
prosthesis, artificial retina, or even bionic eye.In
long run, there could be the possibility of a brain
implant. Now all of these approaches require
surgery and the associated implantable medical
devices still counts as highly experimental and
need to prove their value for instance ambulatory
visionthe ability to move around using only visual
information.
131
We must educate the individual properly
regarding usefulness of the Low vision aids since
it is sometimes very difficult to use them. Presently
the Government of India is making all efforts to
identify the cases of Low vision and to provide
these aids free under ADIP scheme to the persons
whose income is less than 6500/- per month.
Government of India has established National
Institute of Visually Handicapped at Dehradun
where these Low vision aids are readily available
to them. Nowadays these Low vision aids are
also manufactured in private sector since there is
good demand of these aids in general public.
FURTHER READING
1. Low vision aids, Central Scientific Instruments
Organization, Government of India, Sect. 30,
Chandigarh-160020.
2. Khan SA, Shamma BR, et al. Perceived barriers to
the provision of Low Vision services among Ophthal-
mologist in India, Indian J of Ophthalmology 2005;
53:69-75.
3. Thioforg B. A global initiative for the elimination of
avoidable blindness. American Journal of Ophthal-
mology 1998;124:90-3.
4. Dandona R, Dandona L, Srinivas M, et al. Planning
Low Vision Services in India. A population based
prospective. Ophthalmology, 2002:109, 1871-8.
5. David A. Duke Edders Practice of Refraction, 9th Ed.
Churchill Livingston 1978;188-92.
6. Agarwal LP. Agarwals Principles of Optics and
Refraction, 5th ed, CBS, 1998;247-63.
7. Pararajasegaram R. Low Vision Care: The need to
maximize visual potential. Community Eye Health
2004;17:9-20.
8. Robert Harper, Louise Culham, Christine Dickinson.
Head mounted video magnification devices for low
vision rehabilitation: A comparison with existing
technology Br J Ophthalmol 1999;83:495-500
doi:10.1136/bjo.83.4.495.
9. Bionic Vision, Doheny Eye Institute (Keck School of
Medicine, University of Southern California USA,
Mark Humayun, Eugene de Juan, James Weiland).
CHAPTER 18
Rehabilitation Aids for
Paraplegics

VP Sharma
 REHABILITATION AIDS FOR PARAPLEGICS 133

DEFINITION Stage of Reflex Activity

Complete or incomplete paralysis of both lower During this stage muscles below the level of lesion
limbs as a result of trauma or disease of thoracic become activated and reflexes can be elicitated.
or lumbar region of spinal cord.
Stage of Failure of Reflex Activity
Causes
In this stage muscles become hyperactive
A. Since birth - Meningomyelocele (Spastic), reflexes are exaggerated and ankle
B. After birth - clonus may be elicited.
1. Traumatic
Road traffic/train accidents Examination
Industrial accidents
1. History of present medical illness along with
Suicidal attempt
significant past medical history.
Gunshot/Sharp weapon injury
2. Occupation
Fall from height, in well
3. Significant family history.
Collapse of wall
4. Mode of injury
Sports injuries
5. Associated injuries to other areas
War injury
6. Motor function
2. Infection
7. Sensory function
Tuberculosis
8. Presence/Absence of reflexes
GB Syndrome
9. Diagnosis of level.
Transverse myelitis
3. Cancer Specific Assessment
Primary
1. Passive/Active range of motion of all
Secondary
involved joints.
4. Vascular lesions
2. Assessment of contracture if any.
5. Miscellaneous
3. Assessment of motor power
Multiple sclerosis
4. Grade/Type of spasticity
Hereditary spastic Paraplegia
5. Presence of edema
STAGING OF PARAPLEGIA 6. Respiratory status
7. Bladder and bowel status
Stage of Spinal Shock 8. Sensory loss
Immediately after the injury the patient enters into 9. Complications and secondary disability
the stage of spinal shock which persists from 24 10. ADL evaluation.
hours to 6 weeks. During the stage of shock there
Rehabilitation Management
is no reflex activity below the level of lesion. The
paralysed muscles are hypotonic, bladder and Stage 1: In immediate response to spinal cord
bowels are atonic and complete cessation of injury there is loss of function distal to the level
sympathetic activity. The return of bulbo- of injury and it persists for few days to few weeks.
cavernous reflex indicates cessation of spinal Aim of treatment is prevention of secondary
shock. complications.
134 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

Stage 2: Depending upon assessment the out of 1. Spinal Orthosis

bed activities are started for 2-3 hrs per day. For proper support of the injured spine the following
Stage 3: Patient is trained in developing specific spinal orthosis are used.
skill for independence like transfer from bed to a. Cervical spine - Cervical collar - soft, hard
wheel chair activities and ADL training. and adjustable type
Stage 4: Discharge planning from hospital to - Forepost cervical orthosis
home. - SOMI Brace (Sterno occiput
Mandibular Immobilizer)
Stage 5: OPD follow-up services, community - Halo Traction
integration. Patients may return to school or place b. Dorsolumbar - ASH Brace (Anterior
of work. spine spinal hyper extension)
- Taylors brace
Positioning c. Lumbar spine - Lumbo sacral frame
- Lumbo sacral Corset.
In dorsolumbar fracture, pillows are used to keep [See Chapter 13 for details]
the spine in extension and avoid pressure over
fracture areas. All the joints of lower limb are 2. Orthosis for Upper and Lower Limb
mobilized 2/3 times per day to avoid contractures. a. Upper limb Hand - Cock up splint-static
This process is continued for six weeks till reflex or dynamic type
activity returns. - Opponens splint
Shoulder - Abduction splint
PRECAUTIONS DURING EXERCISES
- Cuff and collar sling
During range of movement (ROM) exercises, b. Lower limb:
excessive force should be avoided. No rigorous - The following orthosis are used in SCI as
massage should be done to avoid myositis per requirement of individual need
ossificans. During exercises stress should be - HKAFO
avoided to injured spine. - KAFO
- AFO
Exercises The details are given in chapter on lower
limb Orthosis, hand splints and upper limb
Main aim of exercises is to strengthen the weak
orthosis.
muscles. Certain exercises are done on mat to
train the patients in ADL activities and they are
DIFFERENCE IN ORTHOSIS FOR POLIO
known as mat exercises.
AND SPINAL CORD INJURY
Rehabilitation Aids Parts of Polio Spinal Cord Injury
Orthosis
For paraplegics following aids and orthosis are
used. 1. Bands Normal width All bands are broad
2. Padding Ordinary Soft padding
1. Spinal orthosis.
3. Ischial seat Present Absent
2. Assistive devices for upper and lower limbs. 4. Ortho boot Normal One size bigger boot,
3. Walking aids like crutches, wheel chair and front open, soft lining, no
tricycle, etc. nails are used but
4. Functional electrical stimulation. stitching is done
 REHABILITATION AIDS FOR PARAPLEGICS
3. Walking aids: Mobility aids should have
following features.
i. Tip should be broad base.
ii. Strong and should provide stability
iii. Lightweight
iv. Adjustable
Different walking aids:
Handle cane
Adjustable walking stick
Adjustable axillary crutches
Elbow crutch
Walker
Hemi walker
Wheel chair/Tricycle
Details are given in Chapter 14: Mobility
aids for ambulationstick and crutches, etc.
For sitting positions - Tricycle/motorized
wheelchair
There are three positions to maintain in sitting
posture.
1. Without support of hands: When there is
enough strength in trunk muscles than a person
can maintain sitting balance without hand for
a long time.
2. With hand support: When trunk muscles are
not strong then person takes the help of one
or both hands to maintain balance.
3. Semi sitting position: When vertebral
column is more damaged along with significant
weakness of trunk muscles person will prefer
semi sitting position.
Cushion for Seating
For comfortable sitting on wheel chair, cushion is
used to avoid excess pressure on bony promi-
nences. Following types of foam cushions are
available.
1. Soft foam cushions: It is used for children
and elderly persons.
2. High density foam cushion: Used for cases
of spinal cord injury.
3. Hand made cushion: It is light, durable and
used for even distribution of weight.
135
As it is universally known that merely
providing a cushion does not ensure prevention
of ischial sores, hence the cases of SCI are
trained to practice push up at a regular interval
while sitting on bed/wheelchair (R Sharma, et
al 1999-2000).
4. Functional Electrical Stimulation (FES):
This is a new technique wherein, electrical
stimulation is given to weak group of muscles
in relation to gait cycle under proper computer
programming. For example in a case of weak
dorsiflexors (foot drop), the person will walk
in high stepping gait. These electrodes are
attached to dorsiflexors and stimulation is given
for short period of heel strike (during stance
phase) which helps in avoiding footdrop and
the gait is improved.
FURTHER READING
1. Guttman L. Spinal cord injuries: Comprehensive
Management and Research: Oxford, Blackwell
Scientific Publication, 1973.
2. R Sharma, HC Goyal, D Kumar. Development of
paraplegic kit Safdarjung experience. Indian Journal
of Physical Medicine and Rehabilitation, Vol 10, 11,
Apr 1999-2000.
3. Braddom, Randall L. Physical Medicine and
Rehabilitation. Philadelphia: WB Saunders, 1996;
334-6, 1194-6.
4. DeLisa JA, Gans BA. Rehabilitation Medicine:
Principles and Practice, 5th ed. Philadelphia:
Lippincott-Raven, 2011;665-716,2051-118.
5. Kottke FJ, Lehmann JF (Eds). Krusens Handbook of
PM and R, 4th ed. Philadelphia: WB Saunders; 1990,
967-75.
6. Reford JB (Ed). Orthotics: Clinical Practice and
Rehabilitation Technology. New York; Churchill
Livingstone, 1995.
7. Cerny D, Waters R, Hislop H, Perry J. Walking and
wheelchair energetics in persons with paraplegia. Phys
Ther 1980;60(9):1133-9.
8. Seymour R. Prosthetics and Orthotics, Lower Limb
and Spinal. Philadelphia: Lippincott, Williams and
Wilkins; 2002.
9. Agarwal AK, Sharma VP, et al. A follow up study of
usefulness of wheelchair. Indian J of Phy Med and
Rehab, Vol 3, 1990.
CHAPTER 19
Shoe and its
Modifications

Rajendra Sharma, RK Srivastava

 SHOE AND ITS MODIFICATIONS
Since time immemorial, shoes have formed an
integral part of ones attire. Fashion, taste and
trends, commercial advertisements and changing
life style perpetuated by our social, economic,
psychological and aesthetic values have guided
in designing of shoes.
PARTS OF NORMAL SHOES
Principal parts of shoe are upper, insole, outsole
and heel (Fig. 19.1).
Shoe Upper
Portion of shoe above the sole is called upper
while the anterior half of upper is called vamp,
the posterior part is called quarter. The tongue is
a piece of leather or manmade material
continuous or attached with vamp. At the base
of tongue is the throat. Eyelets are holes or metal
rings for lace may be a part of vamp depending
on the style.
Sole
It comprises essentially of two parts, out - sole
which touches the floor should be made of
leather/synthetic material of proper thickness,
Fig. 19.1: Parts of shoe
137
durability, flexibility. The insole, being
separated from the outsole by a layer of compre-
ssible material, lies directly in contact with the
foot. The widest part of sole called ball remains
exactly beneath the metatarsal heads. Shank is
the part of the sole, which lies between ball and
anterior border of heel. Reinforcement of this area
is accomplished be means of rigid strip of
corrugated metal with a view to resist the strain
imposed on the shank during ambulation.
Heel
Any solid part projecting from the posterior part
of shoe is called heel. Proximal half is made up
of firm leather in contrast to the distal half which
touches the ground. Height of heel is measured
from the floor up to the outsole.
TYPES OF SHOES
Various classifications based on varying criteria
are in use:
A. Quarter Height: Quarter contributes to the
functional characteristic of shoe greatly.
i. Low quarter height shoes are called Oxford
or Derby shoe in which quarter extends to a level
138 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

just below malleoli. It is more cosmetic in looks

and does not restrict ankle or subtalar joint
movement (Figs. 19.2A and B).
ii. High quarter shoe or boot: It covers
malleoli and reduces piston action, and
also resist back and forth sliding of the A B
Figs 19.2A and B: (A) Oxford shoe;
foot (Fig. 19.3). (B) Derby shoe
B. Throat Style: Design of throat portion of the
shoe influences the ease of donning the shoe,
based on throat style common basic types of shoe
are:
i. Blucher: It is a front laced shoe with
tongue serving as a part of the forepart
and its quarter remaining open. Most of
the orthopedic shoes have basic
construction of vamp of blucher pattern
for its adaptability (Fig. 19.4). Fig. 19.3: High quarter boot
ii. Balmoral: Front laced shoe in which two
quarters meet each other and the vamp is
stitched over quarter at the front of throat
(Fig. 19.5)
iii. Lace to Toe: Commonly used with ankle
orthosis in cases of oedematous foot,
ankle, flaccid foot and anesthetic foot. It
is a high top shoe with openings extending
up to toe level with or without soft inner
lining (Fig. 19.6).

C. Shoe Closure
Fig. 19.4: Blucher shoe
i. Adjustable closure: Usually cotton lacing
inserted into minimum of three but
preferable five pair of eyelets which
permit alteration of snugness of the vamp
to accommodate oedema. Other adjustable
closure is buckle and strap or velcro straps.
ii. Non Adjustable closure: Like zip fastener
require minimum dexterity.

D. Type of Construction
i. Goodyear welt construction is a superior
shoe making process in which a chain
stitch in seam unites outseam upper, insole Fig. 19.5: Balmoral shoe
 SHOE AND ITS MODIFICATIONS
Fig. 19.6: Lace to toes
and the welt together and lock stitch
outseam bind the welt to outsole to
complete the shoe unit. Welt is a marginal
ring of sole leather all around the border
of insole used for joining upper and outer
sole. Standard orthopedic shoe involves
goodyear welt construction method
because outsole can be easily separated
from insole and the upper in any desired
area for insertion of various shoe wedges
by simply cutting and reinserting the locks
stitch without damaging basic construction
of the shoe.
ii. Cement construction: Outsole and shoe
upper are bonded together using rubber
cement.
iii. Injection mold construction: The sole and
heel are simultaneously molded and
attached to the prefabricated upper or
entire shoe is molded as a single unit.
E. Last Characteristics
The last is wooden model of foot and undoubt-
edly most important element of the shoe mak-
ing. It determines size, shape, fit, balance, feel,
wear, flexibility, style and construction of the
shoe.
i. Regular last: It duplicates shape of healthy
foot. Most orthopedic shoes are built over
a regular last with added features like long
counter, stronger shank and Thomas heel
with medial wedge (Fig. 19.7).
139
ii. Straight last: Shoes constructed over this
last have medial border of shoe almost in
a straight line from heel to tip of hallux. In
fact, it is a truly neutral last without inflare
or outflare (Fig. 19.8).
iii. Inflare and outflare last: The adult inflare
last is designed to accommodate fixed
varus deformity by virtue of greater area
on medial portion, juvenile type of same
last produces a shoe which pushes forefoot
with valgus deformity medially by
adducting it. Outflare last is designed for
exactly opposite purpose. Custom lasts are
specifically constructed for particular foot
accommodating every deformed and
tender area of foot (Figs 19.9A and B).
MATERIAL USED IN FOOTWEAR
1. Natural - Leather, felt, wood, metal,
fabric, cord, rubber.
Advantage - Biologically friendly to the skin.
- Can be moulded to the shape of
the foot.
Disadvantage - Costly
- Ecological disturbances due to
constant demand.
2. Synthetic - PVC, rexin, nylon, cotton, poly-
ester, etc.
Advantage - Low cost
- Water resistant
- Easy maintenance
- Easy to clean
Disadvantage - Poor in absorbing foot perspi-
ration
- Humidity
- Bacterial growth and macera-
tion of skin
EVALUATION OF FITTING
Adequate room for the foot to expand and toes
to move upon and weight bearing should be
1/2 around.
Size should be ideally 13-15 mm longer than
the foot.
140 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
Fig. 19.7: Regular last
Fig. 19.8: Straight last
A B
Figs 19.9A and B: (A) Outflare last; (B) Inflare last
Toes must have enough room on their dorsum
for free movement.
Quarter should neither be excessively loose
nor be tightly fitted.
Quarter should not rub over the malleoli or
tendoachilles.
Heel should be low and broad to provide
maximal support.
PURPOSE OF SHOE MODIFICATIONS
Supportive function for the weak and insen-
sitive feet.
Correct the mobile deformities as well as
maintain the corrected deformities.
Relief of pain.
Provision of broader weight bearing surface.
Corrects limb length discrepancies.
Foundation for the lower limb orthosis.
GENERAL METHOD AND PRINCIPLES
OF ACCOMPLISHING THE PURPOSES
Accommodate the fixed deformities and
correct the flexible deformities.
In children the magnitude of corrective forces
required for the deformities should be within
the tolerance of soft tissues.
Shoes should be ideally light in weight, proper
in size, heel height and above all should be
made up of suitable material for effective and
useful shoe modifications.
COMMON MODIFICATION IN SHOE
Shoe Upper
Various parts of shoe upper can be made more
spacious by stretching with a shoe makers knife
or different shoe stress by splitting or making
cruciate cuts through shoe leather or by cutting
out impinging portion of shoe upper. These modi-
fication are quite helpful in various painful foot
disorders like ingrown nail, subungal exostosis,
arthogryposis, hammer toes, overlapping toes,
 SHOE AND ITS MODIFICATIONS 141

macrodactyly, hallux valgus (Bunion) or hallux

rigidus, cavus foot and accessory navicular bone,
etc.

INNER SOLE MODIFICATION

i. Excavation of innersole in the heel area
followed by fitting of this excavation with
foam rubber can provide relief from a
painful calcaneal spur and planter fascitis
(Fig. 19.10).
ii. Excavation of innersole in forefoot
region with subsequent filling of foam
Fig. 19.10: Excavated heel cushion
rubber can be used to treat painful planter
callosities, ulcers, warts, etc.
iii Heel pad glued to heel portion of
innersole can be used to provide a maxi-
mum heel lift of 6 mm. Any lift greater
than this should be applied to bottom of
the heel (Figs 19.11 and 19.12).
iv. Metatarsal pads: A metatarsal pad
consists of an oval piece of felt, sponge
rubber or some similar material thicker at
one end than other and enclosed within
an envelope of leather. It can be glued to
innersole immediately proximal to the
metatarsal heads to transfer weight
bearing stresses from metatarsal heads to
Fig. 19.11: U-shaped cushion
shafts (Fig. 19.13).
v. Removable metatarsal pads have an
elastic strap passing around forefoot
which restricts its movement.
vi. Metatarsal insoles: Besides working in
the same fashion as metatarsal pads it has
the unique advantage of preventing the
migration of insole within the shoe. A
variety call rose in sole is essentially a pad
which covers the three quarter or full
length or insole and completely fills the
longitudinal as well as the transverse archs
of foot.
vii. Navicular pad: A navicular pad
incorporated in a insole supports medial Fig. 19.12: Calcaneous pad
142 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

It also decreases stress on heel, ankle and

subtalar joints (Fig. 19.17).
v. Offset heel: It is broader than flare heel
thereby not only increases base of support
but also provides support for ipsilateral
heel counter.
vi Solid Ankle Cushion Heel (SACH) or
Plantar flexion heel: Commonly used in
conjunction with a rocker bar to produce
more natural gait from heel strike to push
off. Heel strike compresses elastic
Fig. 19.13: Metatarsal insole pad posterior heel cushion which helps planter
flexion of the foot to bring sole into early

longitudinal arch and is useful in cases with

element of pes planus deformity of foot
(Fig. 19.14).

MODIFICATION OF THE HEEL

i. Thomas heel or Thomas crooked
elongated (TCE) heel is 1/2 forward
extension of the medial aspect of the heel
breast which helps to invert the heel and
also supports medial longitudinal arch
(Fig. 19.15).
ii. Reverse Thomas heel: It is 1/2
forward projection of lateral part of heel
breast which assists in everting the heel Fig. 19.14: Navicular pad
and also supports lateral longitudinal arch
(Fig. 19.16).
iii. Stone heel: A stone heel is 1/2 forward
extention of medial or lateral aspect of the
straight and obliquely oriented heel be
instead of curved heel breast of a Thomas
heel.
iv. Flare heel: In flare heel bottom of the heel
in contact with the ground is wider than
top part of the heel which is in contact
with posterior part of sole. Flare is usually
equal to widest part of shoe counter. A
flare heel increases the shoe base and
supports and keeps heel from turning over. Fig. 19.15: Thomas heel
 SHOE AND ITS MODIFICATIONS 143

should be accompanied by proper sole lift,

ideally fairly step rocker sole to minimize
weight of shoe and for ease in ambulation.

MODIFICATION OF OUTER SOLE

i. Medial or lateral sole wedge: A 1/8 to
1/4 inch wedge inserted into the antero-
medial portion of the shoe between outsole
can invert the forefoot thereby shifting
weight to the lateral border of the sole.
Fig. 19.16: Reverse Thomas heel with Similarly wedge inserted between outsole
lateral side wedge and anterolateral aspect of sole everts the
foot and shifts weight to medial border of
the sole.
ii. Heel to toe spring steel shank: It is
placed between insole and outsole to
provide rigidity for the whole outsole.
iii. Shank filler: Reinforcement of shank
placed between heel breast and contact

Fig. 19.17: Flare heel

contact with grounds and also at time of

heel strike provides shock absorption from
ground reaction forces (Fig. 19.18). Fig. 19.18: Cushion heel
vii. Medial heel wedge: 1/8 inch to 1/4 inch
wedge inserted between medial aspect of
heel and outsole inverts the heel and en-
courages in toeing of the foot (Fig. 19.19).
viii. Lateral heel wedge: Similarly 1/8 inch
to 1/4 inch inserted between lateral aspect
of the heel base and outsole, everts the
heel and encourages out toeing of foot.
ix. Heel lift: By itself, heel lift can only be
utilized to equalize small amount of leg
length discrepancy of 3/4 and to reduce
stress on tendoachilles. To compensate
greater leg length discrepancy heel lift Fig. 19.19: Heel wedge
144 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

part of outsole stabilizes shank area and

provides a total contact weight bearing
area. It also supports corresponding
longitudinal arch and is useful in treatment
of valgus/varus deformity (Fig. 19.20).
iv. Metatarsal bar: Typical MT bar
approximately 3/4 wide and 3/16 high is Fig. 19.20: Shank filler
made of rubber, leather or similar material
and is usually fixed transversely across
bottom of outsole with apex immediately
proximal to the metatarsal heads to provide
pressure relief for symptomatic MT heads
and adjacent structure. Various causes of
metatarsalgia such as sesamoiditis, hallux
rigidus, callosities, Mortons neuralgia,
fracture of metatarsal, and hammer toes,
etc. can be treated effectively with
metatarsal bars (Fig. 19.21).
v. Sole lift: It is used mainly to treat leg length
discrepancy. Thickness of the sole
depends on amount of shortening in
affected leg. Use of cork and rubber
composition sole or multiple holes drilled Fig. 19.21: Metatarsal bar
into solid rubber sole provide weight
reduction of the built up shoe (Figs 19.22A
and B). Rocker sole with a high toe spring
made by tapering the part of the sole
proximal and distal to the ball significantly
reduces weight of the shoe and also
facilitates ease of walking (Fig. 19.23).

COMMON CONDITIONS AND THEIR A

MANAGEMENT
I. Ankle and Subtalar Joint
a. Painful Conditions
Principle - Restriction of the mobility at ankle
and subtalar joint.
Modifications - Rocker sole, increasing in
quarter height, cushioned heel to absorb the
B
heel strike.
b. Instability: Support to the unstable joints can Figs 19.22A and B: (A) External heel elevation;
be provided by providing wide heel base (heel (B) Internal heel elevation
 SHOE AND ITS MODIFICATIONS 145

Modification:
- Flexible Equinus - Mild. Metatarsal pad or
bar (Figs 19.25A and B)
- Moderate: Add toe pick
up.
- Fixed Equinus - Less than 1/2 heel
raise - Internal heel
elevation
- More than 1/2 heel
Fig. 19.23: Rocker sole raise - internal and
external heel elevation;
Contralateral heel to be
flare) in foot wear. Boot with ankle stiffener raised (Figs 19.22A
and orthosis with valgus or varus T strap also and B)
provide stability. c. Pes Cavus
c. Arthodesis: Restriction of mobility at ankle Principle:
joint and provision for shortening of affected - Redistribution of weight over entire foot.
limb as a result of ankle joint arthodesis - Restoration of anterior and posterior
requires, long rocker bar to facilitate toe off balance on foot.
so as to provide smooth gait pattern. In
Modifications:
addition, accommodation of shortening and
Flexible Cavus - Metatarsal pad or bar if
residual equinus deformity may require
needed, lateral heel wedge
suitable modification in the shoe in form of
alone or with sole wedge
equinus outsole raise.
also.
II. Mid and Hind Foot Fixed Cavus - Filler in cavus as high
medical longitudinal arch
a. Pes Planovalgus (Flat Foot): It may be support.
either mobile or fixed deformity. d. Talipes Equino-Varus
Principle: Correct eversion, support medial Principle: In flexible deformity, to bring the
longitudual arch for relieving the ligamentous foot into normal alignment
strain.
Modification:
- Broad heel with long medial counter.
- TCE heel with elongation on medial
aspect upto the navicular tubersosity.
- Medial heel wedge.
- Medial longitudual arch support (Figs
19.24A and B).
b. Pes Equinus
Principle:
Resist the tendency for plantar flexion.
Reduce the loads on metatarsal heads. Figs 19.24A and B: Longitudinal arch support
146 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

Modifications: Depending upon severity of

deformity high shoes without heel with high
long lateral counter or straight and stiff
medical border with lateral heel and sole
wedge (Fig. 19.26) or Reverse orthopedic
shoes.
In corrected equinovarus deformities
Medial sole and heel wedge
In fixed deformity: Eliminate the gap between
sole and foot and maintain foot in normal
position.
Fig. 19.26: CTEV shoes
e . Plantar calcaneal bursitis and spur
Principal:
Relieve pressure from painful areas.
Modifications:
- Medial arch support with heel cushion
(Fig 19.27).
- Scaphoid heel
- Horse shoe shaped excavated heel Fig. 19.27: Heel cushion with arch support
(Fig. 19.11).

III. Fore Foot Conditions Principal: Adequate shoe length and width
to allow the forefoot to spread. Reduce the
a. Metatarsalgia due to depressed transverse
heel height to lower the stress on metatarsal
arch
heads.
Modifications:
- Anterior three quarter insole with arch
support and MT pads
- Insole excavation with rubber sponge
filling under MT heads
- Metatarsal bar/rocker bar with SACH heel
b. Claw, Hammer, Mallet Toes
Principal:
- Support depressed transverse arch
- Relieve pressure from sensitive area
- Reduce tarsal deformity and improve the
push off
A Modifications:
B
- High toe box
- Long, wide, soft, unornamented vamp
Figs 19.25A and B: MT Bar - Rigid sole base
 SHOE AND ITS MODIFICATIONS
c. Hallux Valgus and Bunion
Principle: Accommodate the deformed toes
and prevent aggravation of valgus deformity
Modifications: Long vamp, low heel
- Medial longitudinal arch support
- Triangular small wedge between Ist web
d. Hallux Rigidus:
Principle: Prevent motion and pressure over
painful toe
Modifications:
MT bar, medial arch support, rocker sole and
rigid sole
IV. Foot and Limb Length Discrepancy
a. Short Foot
Small difference in sizes can be managed
with extra inner sole and in-padded
tongue.
In case of greater differences the distal
portion of vamp can be filled with micro-
cellular or sponge rubber.
LIMB LENGTH DISCREPANCY
i. In leg length discrepancy, the shortening
for compensation can be measured with
temporary wooden blocks placed under
heel ball and toes to align pelvis and
recording height at heel/ball and toe.
Internal heel elevation more then 6 mm
require custom fabricated shoe. Internal
elevation of 5 cm can be carried in the
boot by providing cork insole. Difference
of more then 5 cm can be corrected by
external elevation. These elevation are
called platform and can be made of
microcellular rubber, cork, light wood or
polyurethane foam. For better cosmetic
appearance raise at toe is kept less then
that of heel. Slope of heel should not be
gradual as it leads to overcrowding of toes.
At heel the raise should be horizontal and
147
then slope should start. Combination of
external and internal elevation can be done
whenever greater limb length disparity is
present.
ii. If shortening is more than 6 inches, patten
ended caliper with foot resting on a
metallic plate with extension provided in
form of wooden shin and SACH Foot may
be prescribed. Extension prosthesis with
foot placed in equinus with prosthetic foot
in the shoe is useful alternative.
CUSTOM MADE MOULDED SHOES
Indications and Foot
Casting Technique
The moulded shoe is fabricated directly over
plaster replica of human feet without using a shoe
last. It is an expensive shoe. The indications for
prescribing moulded shoes are as follows.
i. Severe foot deformities, extreme talipes
equinovarus, equinovalgus, calcaneo
varus, calcaneovalgus, etc.
ii. Marked leg length discrepancy or marked
foot size discrepancies.
iii. Congenital absence of various part of foot
or foot amputation at various levels.
iv. Insensitive foot - Neuropathic foot
produced by diabetes mellitus, chronic
alcoholism, pernicious anemia, tabes
dorsalis, syringomyelia and leprosy, etc.
v. Foot with poor circulation, e.g. peripheral
vascular disease.
vi. Weak and severely arthritic foot.
Technique
The foot cast for molded shoe is taken in a semi
weight bearing position with knee flexed to 90
degree with foot in neutral position. Thin layer
of Vaseline is applied to whole foot and ankle to
facilitate easy removal of plaster. A presoaked
fast setting below knee/plaster slap is applied and
carefully molded around each metatarsal head,
148 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
longitudinal and transverse arch of foot, medial
and lateral border of foot, counter of heel and
two malleoli. Another below knee dorsal plaster
slab is applied with careful molding around entire
dorsal surface. These slabs are removed after
hardening and tapes together for negative cast.
Shoe maker pours liquid plaster in hollow negative
cast to produce positive cast which will be exact
replica of the patient foot and is then used in place
of last for shoe construction.
EVALUATION OF MODIFIED SHOE
In the initial check up preceding delivery of modi-
fied shoe, it should be checked for fitting and
correction provided in it. Placement of metatarsal
bar, metatarsal pads, proper location of arch
support and heel or sole wedge and leg length
discrepancy compensation should be checked for
its correctness.
Periodic follow up is essential to check for
accuracy of diagnosis and subsequent change in
deformity, any pressure sore and finally to assess
need for the further corrective shoes or surgery.
After use for prolonged period, correction may
be needed in order to maintain intended function
as compression of flexible supports or bending
of rigid supports may not be able to provide
desired effect.
FURTHER READING
1. Jain S.K., Foot and Foot orthoses, 2003.
2. Agarwal A.K., Prosthetic and Orthotics, published
by U.P. Hindi Sansthan, Lucknow, First Edition. 2008.
3. Stewart John D.M. and Hallet Jeffrey P., Traction
and Orthopaedic Appliances., edition 1st 1994,
published by BI Churchil Livingstone, New Delhi.
CHAPTER 20

Hand Splints

Sanjay Keskar
150 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

INTRODUCTION Pressure = Force/Area of application of Force

It is necessary to understand the basic anatomy b. It controls parallel force system by increasing
of the hand and arm for the Orthotist who are mechanical advantage.
studying upper limb orthosis. The Orthotist must
have a reasonably clear understanding of the
characteristics of each bone, muscle and joint in
that complex part of the body which is weakened
or paralyzed to regain function. The relationship
between splints and the biomechanics or
dynamics of musculoskeletal system of the hand
and arm is also essential to get a scientific
approach on the upper extremity.
The basic purpose of use of upper limb Fig. 20.1: Mechanical principles of hand splint
orthosis is to assist/substitute weakened/total loss
of motor power. They also protect the part from
pain/fracture and correct the existing deformity.
c. It uses optimum rotational force when
TERMINOLOGY mobilizing a joint by dynamic traction.
d. It considers the torque effect on a joint and
Splint
control reaction effect at secondary joints.
It is an Orthopaedic device to hold a broken bone e. It eliminates friction and avoids high shear
for immobilization or support of any part of the stress.
body.
Design Principles
Brace
It varies from individual patient to patient, their
The device used to support/correct/prevent the problems and prescribed duration. Patient
spinal problems and segments in extremities. acceptance and cosmetic is also a design factor.

Orthosis CLASSIFICATION
It is scientific device to control, correct or com- Based on Mechanical Principles:
pensate for deformity. Static
Today these terms are often used synony- Dynamic
mously and in practice the common term is Based on Joint Involvement
orthosis. Articular : Involves joint
Non-articular: No involvements of Joints
PRINCIPLES
Based on Material Used
Mechanical Principles Molded
a. It reduces pressure by increasing area of force Conventional
applications as shown in Fig. 20.1.
 HAND SPLINTS 151

Based on Control System Based on Anatomical Parts and its function

Body Power Harness control Finger and Thumb Orthosis
Battery power Myo-electric control Wrist and Hand Orthosis
Mechanical power Spring Control Elbow and Forearm Orthosis
Air Cylinder power Pneumatic Control Shoulder and Arm Orthosis

Finger and Thumb Orthosis

Orthosis Name Indication Function

Gutter Splint, Fig. 20.2 To support the injured finger PIP/DIP extension immobilizer

Garter Splint, Fig. 20.3 To strap the finger in Phalanges # PIP/DIP extension immobilizer

Swan Neck, Fig. 20.4 Swan Neck Deformity (Hyper- To prevent hyperextension of PIP
Splint extension of PIP and Flexion of DIP) joint by three point pressure
Murphy Ring Hyper-extension of PIP due to permit flexion of all joints
Splint trauma/tendon rupture

Capener Splint, Fig. 20.5 Boutonniere Deformity (Flexion of To extend the PIP joints and to
PIP and hyperextension of DIP) keep the DIP Joints in neutral
Post traumatic flexion deformity of PIP

Mallet Finger, Fig. 20.6 Rupture of terminal Extensor tendon To immobilize DIP in extension

Frog Splint, Fig. 20.7 # Distal Phalanx To immobilize/protect

Base Ball Splint

Miniature, Fig. 20.8 Stiffness in Extension of PIP joints Dynamically flex the PIP joints
Knuckle Bender

Reverse, Fig. 20.9 Stiffness in Flexion of PIP joints Dynamically extend the PIP joints
Miniature
Knuckle Bender

Short - To Prevent adduction and web To oppose the thumb to the index
Opponens space contraction (Post Traumatic/ and middle finger
Splint Post Operative) without involvement To Prevent collapse of palmar arch
Fig. 20.14 of Wrist
- After Opponensplasty Operation

Thumb Spica, Fig. 20.12 - Post Traumatic Painful thumb To immobilize the thumb, for relief of
- Gamekeeper thumb pain and to maintain proper position
- Degenerative thumb of thumb

Knuckle Bender Claw Hand, Post traumatic stiffness of To Flex the MCP Joints
Fig. 20.10 MCP joint

Reverse - Post traumatic Flexion To extend the MCP Joints

Knuckle Bender - Contracture of MCP
Fig. 20.11 - Dupuytrens contracture
152 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

Fig. 20.2: Gutter splint Fig. 20.7: Base ball

Fig. 20.8: Mini-Knuckle bender

Fig. 20.3: Garter splint

Fig. 20.9: Rev- Mini-Knuckle bender

Fig. 20.4: Swan neck splint

Fig. 20.10: Knuckle bender

Fig. 20.5: Capener splint

Fig. 20.6: Mallet finger Fig. 20.11: Rev-Knuckle bender

 HAND SPLINTS 153

Fig. 20.13: Volar wrist hand resting

Fig. 20.12: Thumb spica

Fig. 20.14: Cock up (short) Fig. 20.15: Cock up (Full)

Fig. 20.16: Dynamic cock up

Wrist and Hand Orthosis

Cock up Splint Wrist arthralgia, De quervains, Disease To stabilize the wrist joint in neutral
Fig. 2014 and Colles #, tenosynovitis, carpal position
20.15 tunnel syndrome, wrist drop
Dynamic Cock up Post op. m/t of ex. Tendon repair - To assist prox./distal
Splint Post traumatic radial nerve palsy IP extension
Fig. 20.16 Tendon tr. For radial nerve (post op.) - To keep the wrist in extension
Volar Wrist Post wrist and hand surgery, RA - To maintain functional position of
Hand Resting (to prevent ulnar deviation of wrist and hand and wrist (glass holding position)
Orthosis finger), RN palsy (positional splint) - To prevent ulnar/radial deviation of
Fig. 20.13 wrist
154 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

Elbow and Fore Arm Orthosis

Elbow Cage (Static) # of forearm, epicondylectomy, To keep the elbow 90 degree in
Fig. 20.17 Nerve repairs, trauma or other flexion and immobilization
orthopaedic condition where
90 degree of flexion is required
Elbow Cage Effective in limiting flexion and Where limited range of motion is
(adjustable) extension following elbow desired
Fig. 20.18 arthroplasty and other post-surgical
or post injury
Elbow cage with turn Flexor contracture and To keep the elbow in maximum
buckle Extensor contracture stretch position
a . Extensor
b. Flexor, Fig. 20.19
Fore arm guard # of forearm, Colles #, To prevent pronation / supination, to
immobilize, to keep wrist in resting
position

Fig. 20.17: Elbow cage (Static) Fig. 20.18: Elbow cage (Adjustable)

Fig. 20.19: Elbow cage (Turnbuckle)

 HAND SPLINTS 155

Shoulder and Arm Orthosis

Aeroplane Orthosis # Neck Humerus, To keep shoulder in abduction, elbow in
Fig. 20.20 Erbs Palsy, Paralytic Shoulder, flexion
Post traumatic axillary
Scar Release,
Tendon Repair, Burn injury, etc.
Shoulder/Arm Sling Shoulder dislocation, Injury to the To immobilize shoulder
Fig. 20.21 shoulder capsule or supportive
muscle

Fig. 20.20: Aeroplane orthosis Fig. 20.21: Shoulder/Arm sling

EXTERNAL POWER ORTHOSIS FURTHER READING

For the paralytic segments in upper extremity,
external power source is required and depending
on control systems it is of three type.
Body Powered : Harness Controlled
Battery Powered : Myo-electric
Controlled
Mechanical : Spring Controlled
CONCLUSION
There are innumerable varieties of orthosis
depending on design/material/method of
fabrication/ functional application, etc for upper
extremity but the orthosis described above are
basic and commonly used which can be modified
as per requirements.
1. Atlas of Orthoses and Assistive Devices, Bartam
Goldberg and John D Hsu, 3rd Edition published by
Mosby, St Louis, Missouri, 1997.
2. Emesion S. The Rheumatoid Hand; Postoperative
Splint Options, J Hand Ther 1993; 6(3):214.
3. Evans R, Hunter J, Burkhalter W. Conservative
Management of the Trigger Finger: A New Approach.
J Hand Ther 1988; 1(2):5968.
4. Fees EE, Philips CA. Hand Splinting principles and
methods. St Louis, CV Mosby, 1987.
5. Swanson Alfred B, Pierce Tray D, Leonard Judy,
Swanson Gold. Orthoses for the Arthritic Hand and
Wrist. Atlas of Orthoses and Assistive Devices, 3rd
Edition. CV Mosby, 1993.
6. Boozer J. Splinting the Arthritic Hand. J Hand Ther
Jan 1993;46(1).
CHAPTER 21

Leprosy: Aids and

Appliances
AK Agarwal
 LEPROSY: AIDS AND APPLIANCES 157

Leprosy is caused by Mycobacterium leprae

which is acid-fast bacilli. Leprosy is one of the
oldest disease known to mankind. National
Leprosy Eradication Programme (NLEP) has
been successful in reducing incidence of
leprosy and brought down the prevalence of
leprosy to 1 per 10000. Since leprosy causes
disfigurement and deformities leading to strong
social stigma, it has been included in the Persons
with Disability Act. 1995 (PWDAct) separately
in the list of 7 types of disability as leprosy cured
person.
Fig. 21.2: Few patches (PB)

EARLY DETECTION
Leprosy can be diagnosed at an early stage by 2. Thickening in peripheral nerve/es with sensory/
the following features. motor changes.
1. Hypopigmented patch with anesthesia 3. Demonstration of Mycobacterium leprae
(Figs 21.1 to 21.3). bacilli in split skin smear (SSS).

Incubation
3 to 5 years

Mode of Spread
Through nasal/respiratory routes, usually these
bacilli are in the environment and affects the
person who is having least resistance.

Vaccine
Presently vaccine against leprosy is not available
Fig. 21.1: Small patch since bacteria cannot be cultured in conventional
media.
Types of Leprosy
Presently leprosy is classified into two groups:
Paucibacilliary Multibacilliary

1. Skin 1 to 5 Anesthetic patch More than 5 patches

2. Nerves One nerve or not More than one nerve
3. Skin smear examination Negative for M Lepra bacilli Positive for M Lepra bacilli
4. Duration of treatment 6 months MDT 12 months MDT
158 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

loss of toes, chronic infections and amputation of

foot, etc. The lateral popliteal nerve lesion leads to
foot drop (Fig. 21.9) and posterior tibial nerve lesion
leads to clawing of toes (Fig. 21.8) and foot
ulceration. (Figs. 21.10, and 21.11)

Fig. 21.3: Multiple patches (MB)

LESIONS IN LEPROSY
Leprosy affects commonly hands, feet, eyes and
bridge of nose.

Hand
It affects peripheral nerves like ulnar, median,
radial nerves leading to various hand deformities
like (Fig. 21.4). Fig. 21.4: Commonly affected nerves in leprosy
Ulnar nerve lesion leads to ulnar claw hand
deformity (Fig. 21.5).
Median nerve lesion leads to ape thumb and
Median claw hand deformity (Fig. 21.6).
Both ulnar and Median nerve lesion lead to
claw hand deformity (complete) with ape thumb.
In claw hand MP joints show hyperextension, PIP
and DIP joints show flexion deformity along with
sensory loss in whole hand. In only ulnar claw
hand, sensory loss is limited to little finger and Fig. 21.5: Ulnar claw
half of the ring finger. In only median claw hand,
the sensory loss is limited to thumb, index, middle
and radial half of ring finger. Radial nerve lesion
leads to wrist drop due to weakness of ECRL
ECRB and ECU (Fig. 21.7).

Feet
Leprosy affects Lateral popliteal and post tibial
nerves leading to foot drop, non healing ulcers in
Fig. 21.6: Clawing of all five fingers
plantar surface, disintegration of short bones (tarsal),
 LEPROSY: AIDS AND APPLIANCES 159

Treatment
MDT (Multi drug therapy) is standard treatment
for leprosy all over the world which is freely
available at every primary health centre, District
hospital and at many NGO run clinic. MDT
comes in blister pack and one month dose is given
to each identified case free of cost.

Fig. 21.7: Wrist drop

Fig. 21.8: Claw toes

Fig. 21.10: Cracks

Fig. 21.9: Foot drop Fig. 21.11: Plantar ulcer

Eyes
Lagophthalmos (incomplete closure of upper eye
lid) makes eyes red, watering and keratitis
develop due to frequent and continuous exposure
of cornea leading to blindness. Hence it should
be treated immediately (Fig. 21.12).

Nose
The damage to bridge of nose in leprosy leads to
depression of bridge of nose which is not only
cosmetic deformity but also adds to social stigma. Fig. 21.12: Lagophthalmos
160 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

MDT Regimen (Adult)

Types of Leprosy Drugs used Dosage Frequency Duration of MDT

MB Leprosy Rifampicin 600 mg Once monthly 12 months
Dapsone 100 mg Daily
Clofazimine 300 mg Once monthly
Clofazimine 50 mg Daily
PB Leprosy Rifampicin 600 mg Once monthly 6 months
Dapsone 100 mg Daily

MDT Regimen (Child - 10-14 years of age)

Types of Leprosy Drugs used Dosage Frequency Duration of MDT

MB Leprosy Rifampicin 450 mg Once monthly 12 months
Dapsone 50 mg Daily
Clofazimine 150 mg Once monthly
Clofazimine 50 mg Every other day
PB Leprosy Rifampicin 450 mg Once monthly 6 months
Dapsone 50 mg Daily

MDT Regimen (Child below 10 years of age)

Types of Leprosy Drugs used Dosage Frequency Duration of MDT

MB Leprosy Rifampicin 300 mg Once monthly 12 months
Dapsone 25 mg Daily
Clofazimine 100 mg Once monthly
Clofazimine 50 mg Twice a week
PB Leprosy Rifampicin 300 mg Once monthly 6 months
Dapsone 25 mg Daily

Source: Learning Material on Leprosy for Capacity Building of District Nucleus Staff and Medical Officers Working in
Hospital/PHC/CHC and Dispensaries. Published by Dte. General of Health Services, New Delhi in 2005.

RECONSTRUCTIVE SURGERY IN
LEPROSY
Government of India has initiated a new RCS
programme in selected centers in India wherein
10000/- is given for each case, and out of which
5000/- is given to individual for loss in wages
(BPL only) and 5000/- is given to RCS centers
for purchase of drugs, surgical goods, plasters
and dressing material. The whole RCS scheme
provides free surgical reconstruction of
deformities of face, nose, hands and feet. It is
very useful scheme to help poor and needy leprosy
cure cases who require RCS. This RCS scheme
is available in Deptt of Physical Medicine and
Rehabilitation and Deptt of Plastic Surgery, CSM
Medical University, Lucknow.
Aids and Appliances for Leprosy
Leprosy cure cases show the following dis-
abilities in their life time.
1. Loss of limb - Amputation
2. Loss of function - Claw hand
 LEPROSY: AIDS AND APPLIANCES
(Paralysis) - Foot Drop
3. Loss of sensation - Anesthetic foot leading
to Plantar ulcers
4. Adaptation - For their ADL activities
devices
Amputation
Chronic infections in the plantar surface leads to
nonhealing ulcer and if not treated properly then
in some cases amputations are performed.
Amputation in leprosy leads to anesthetic
stump which has a tendency of frequent
ulcerations on weight bearing areas of the stump.
In the Symes amputation the weight bearing area
is distal end of stump which is usually having
sensory deficiency. Similarly a BK stump in
leprosy has usually sensory deficiency hence
PTB area is the site of frequent ulceration.
Therefore the preprosthetic assessment should
include proper motor and sensory evaluation. In
case of sensory impairment, soft lining in the
socket should be provided along with thigh corset
to be attached in the below knee prosthesis.
The photographs of the Prosthesis are
available in the chapter of Lower Limb
Prosthesis.
Paralysis : For hand - The different hand splints
are available for ulnar, median and radial nerve
lesions
For Ulnar claw hand - Knuckle bender splint
For Median claw hand - Opponence splint
For Ulnar and median - Combination
claw hand
For Radial Nerve palsy- Cock-up splint/dynamic
cock-up splint
Note: The detailed description is available in the
chapter of upper limb orthosis and in Hand splints.
Foot
In leprosy frequently we come across the problem
of foot drop, anesthetic foot and non healing
ulcers.
161
For Foot Drop
Ankle foot orthosis (AFO) is given with posterior
stop ankle with orthopedic boot.
Ideal Foot Wear for Anesthetic Foot
Shoe should be little large with broad front to
accommodate toes easily
Soft lining inside the shoe
Heel should be high
Nails should not be used in fabrication of
shoes.
The following types of shoes should not be
used in leprosy cases.
Tight and pointed shoes
High heel
Rough lining inside shoes
Footwear preference: Hawaii chappels should
not be given to leprosy case. MCR padded
sandals/shoes with Velcro straps are preferred.
Details are given in chapter 19.
ANESTHETIC FOOT LESION
Mechanism
The leprosy induced neuropathy causes auto-
nomic disturbance and the result is dryness of
the foot. This persistence of dryness causes
cracks, callosities, corns which inturn become
infected due to bare foot walking and then ulcer
develops. The maximum plantar ulcer develops
in forefoot (75%) and remaining (25%) is seen
in hind foot. Therefore every leprosy cure case
should use proper, comfortable, MCR padded
sandals/shoes. He should never walk barefoot that
is without proper footwear.
Treatment
For plantar ulcer management, proper local
dressing should be provided along with various
off loading techniques like bed rest, use of
axillary crutches, walking sticks, walker, total
162 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

contact POP cast (weight relieving below knee

POP with walking iron) followed by PTB weight
relieving brace, and custom made shoes. Fig.
21.13 and 21.14.

PRESCRIPTION CRITERIA OF FOOT

WEAR IN ANESTHETIC FOOT
Foot lesion Shoe modification

1. Anesthetic foot MCR padded sandal or

without ulcer shoes
2. Plantar ulcer healed Various MT pads,
Valgoid insole/PTB
Brace
3. Loss of toes Shoe filler by sponge
Fig. 21.14: MCR sandle
rubber (Source - Alert India)
4. Foot amputations MCR padded shoes with
shoe filler/chopart
CARE OF ANESTHETIC FOOT IN
prosthesis
5. BK Amputation PTB prosthesis with soft
LEPROSY
lining inside socket with The leprosy cured case should follow foot care
thigh corset every day as given below (Figs. 21.15 A to I)
1. Daily inspection of feet.

(A) Inspect feet for injury

Fig. 21.13: MCR sandle

(B) Soak feet in water
(Source - Alert India)
Figs 21.15A and B
 LEPROSY: AIDS AND APPLIANCES 163

(C) Scrape away hard skin (D) Apply oil and massage

(E) Bandage of wound (F) Sit on chair or with legs spread

(G) Wear MCR footwear (H) Active exercise (I) Passive exercise for foot

Figs 21.15A to I : Care of feet

2. Soaking of feet in water

3. Scrubbing of sole
4. Use of petroleum jelly on sole
5. Foot exercises
6. Local dressing of foot ulcer
7. Use proper foot wear

Various Adaptation Devices for

Leprosy Cure Cases
Due to sensory impairment of hand, the leprosy (A) (B)
cases require some adaptative devices for their Figs 21.16A and B
164 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

day to day activities specially while cooking in

the kitchen. The wooden or plastic moulded
hand gripes are commonly used as adaptative
devices in various kitchenware or utensils, Figs.
21.16 A to D. These devices protect the hands
from thermal injury. They should always use some
felt, wooden/thick piece of cloth to lift hot utensils
in the kitchen. In various tools used in industry,
agriculture and in equipments, the hand held grip
should be soft and well padded to avoid injury to
the hands.

(C) FURTHER READING

(D)
Figs 21.16A to D: Photographs showing various
adaptation devices (Source - Alert India)
1. Learning material on Leprosy, published by Directorate
General of Health Services, Ministry of Health and
Family Welfare (Leprosy Division), Government of
India, 2005.
2. Vijay Kumar, AK Agarwal, AK Singh. Profile of
Reconstructive Surgery Cases in Central UP, India:
Experience of PPP Model, Indian Journal of Physical
Medicine and Rehabilitation, Vol 21, No. 2, 2010.
3. We Can, Alert India, (Association for Leprosy
Education, Rehabilitation and Treatment India) B-
9, Meera Mansion, Sion (West), Mumbai-40022,
published, 2nd Edition, 2007.
4. Guide to Leprosy, publication under National Leprosy
Eradication Programme, 2009.
5. AK Agarwal, Leprosy: Guidelines, a book published
in Hindi by UP Bhasha Sansthan , Lucknow, UP, India,
First Edition, 2011.
CHAPTER 22

Footwear in Diabetes
Mellitus
AK Agarwal
166 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
Diabetes is a chronic disease of metabolism
caused due to lack of insulin production in the
pancreas or due to inability of the available
insulin to perform its normal function. DM causes
retinopathy, nephropathy, vasculopathy and
neuropathy.
Both vasulopathy and neuropathy produce
foot lesions which can lead to loss of limb or
toes if not properly treated.
SOME FACTS REGARDING DIABETES
As per recent surgery reports, 230 million
people already affected with diabetes
worldwide. Diabetes is the worlds leading
cause of heart disease, blindness, neuropathy,
stroke and lower limb Amputations.
Asian have 5 times higher incidence as
compare to white population. Every fifth
Diabetic person globally would be an Indian
by 2025.
Further studies have shown that 57% weight
loss and physical exercises daily for half an
hour lowers the risk of developing diabetes
by nearly 60%. (rd -India .com, Nov 2008)
Diabetic foot develops due to poor circulation
and neuropathy leading to anesthetic (Loss of
sensation) skin which is very prone to even minor
injury due to loss of ability to feel pain, heat and
cold. These cases of diabetic neuropathy first
develop dryness of skin due to autonomic
dysfunction leading to cracks, corns and callosity
in the sole (weight bearing area), when infection
settles in these prone areas and if not properly
treated immediately then it turns into nonhealing
ulcer. The normal healing is further delayed due
to poor vascularity in the ulcer area.
Sites
Maximum chronic non healing ulcer occurs in
forefoot (75%) followed by mid and hind foot
(25%).
FACTORS RESPONSIBLE FOR
ULCERATION
Dryness of skin
Sensory loss
Motor weakness
Poor circulation
Mechanism
Cracks Infection ulcer
Sensory loss Blister infection ulcer
Sensory loss + Motor weakness of dorsi-
flexors High stepping gait Abnormal gait.
Pressure on MT Heels Blister Infection
Ulcer
Therefore we must educate all the cases
having diabetes to learn proper foot care and do
not walk without proper shoes.
Treatment Modality
1. Proper control of diabetes.
2. Proper care of feet
3. If ulcer has developed then provide suitable
and regular local dressing.
4. Totally avoid weight bearing on the foot
having ulcer by off loading the foot. This
off loading is done either by external means
or by internal off loading technique.
External Off Loading
By complete bed rest
By using mobility aids like crutches, walker
AFO, PTB brace, total contact cast, walking
sticks, wheel chair, etc.
By prescribing proper diabetic foot wear
By providing various types of insole
alterations in shoes like use of silicone ready
to use shoe inserts, insole made of MCR
(Microcellular rubber)
Recently Plastazote is being used in designing
of customized shoe inserts to accommodate
 FOOTWEAR IN DIABETES MELLITUS
the pressure area in sole. Plastazote provides
better off loading from abnormal pressure
points in Diabetic foot cases by providing
comfort and protection.
IDEAL DIABETIC FOOTWEAR
The shoe should be comfortable, with wide
toe box for proper toe movements.
MCR/ Plastozote insole.
Soft lining inside.
Heel should not be more than otherwise
more pressure shall come on Metatarsal heads
(MT) then on heels.
Firm heel counter for support and stability.
Sole should be firm. (Details are given in
Chapter 19, Shoe and its Modifications).
Internal Off Loading
In cases of long standing footdrop Tendo Achilles
is shortened and becomes contracted and slowly
equinus deformity develops. Therefore the person
walks on his forefoot and there is no heel to toe
gait (stance phase of gait cycle). They develop
very frequently ulcers in their forefoot (MT
heads). These are the cases where internal off
loading is done by simple lengthening of tight
T.A. tendon. The technique can be subcutaneous
tenotomy, open TA lengthening or V-Y plasty at
the junction of gastrocnemius and its tendon.
FOOT CARE IN DIABETES
The following simple steps can prevent serious
complications like amputations in Diabetes.
1. Proper control of Diabetes and lifestyle
changes like stop smoking, alcohol, heavy
meals, etc. Do active exercise, cycling,
walking, swimming. Avoid running, jumping.
Wear well protective shoes with seamless
socks.
2. Inspection of feet daily: Sometimes diabetic
case may have foot problems like cut, sores,
167
red spots, infection in toe beds, but he is not
aware of them. You can advise him to use
mirror or ask his family members to see it.
Advise him to contact his doctor for even
minor cut, sores, blister or bruise on foot.
3. Washing of feet daily: Wash the feet in water
(Normal temperature or Luke warm) followed
by scrubbing of hard/thick areas like callosity,
corn and crack, etc.
4. Use petroleum jelly: Use of moisturing lotion
or oil or petroleum jelly on top and bottom
surface of foot to keep skin soft and smooth.
Keep the skin in between toes dry.
5. Use shoes/sandals with seamless sock at
all times: Avoid walking barefoot even indoors.
The shoes are must and always check inside
the shoes before putting them so as to avoid
any foreign body or pebbles. If you do not
have seamless sock then use in reverse
manner. Always buy a shoe in late evening
when your foot has proper size due to
whole days activities. Do not use nails in shoe
repair.
6. Always protect feet: It is necessary to protect
the feet from heat, cold, broken glass and
sharp objects etc.
7. Proper vascularity of feet:
Avoid squatting and cross legged sitting
Keep feet elevated while sitting
Move your toes in shoes 4 to 5 time a day
Move your ankle up and down
Do not use tight socks, elastic, rubber
bands or garnets around leg
Do not walk more than 20-30 minutes at a
time. It is better to sit-down for few minu-
tes and this relaxes pressure from foot
Avoid smoking since it also reduces
vascularity in the foot.
8. Consult the doctor: It is essentially required
to consult a doctor who is specialized in
diabetic foot problems to prevent any serious
complication (Details of foot care is also
given in Chapter 21).
168 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

DIFFERENCE BETWEEN LEPROSY AND DIABETIC FOOT

Leprosy foot Diabetic foot
1. Cause Due to Mycobacterium Leprae Due to lack of insulin
2. Effects Neuropathy only Neuropathy + vasculopathy
3. Presentation - Dryness - Dryness
- Sensory loss - Sensory loss
- Motor weakness - Motor weakness
4. Prognosis of treatment Completely treatable by MDT No cure
5. Duration of treatment 6 M 12 M Lifelong
6. Prognosis Fair Satisfactory
7. Socio-economic status Poor class (Majority) All classes
8. Affordability of ulcer treatment Absent by themself Present themselves
9. New development Not there Present globally
10. Prevalence 1 per 10000, that too in Global, more so in developed
developing countries countries

3. Dahman R, Koomen B, Haspels R, et al. Therapeutic

FURTHER READING
footwear for nuropathic foot. Diabetes Care,
2001;24(4).
1. Doshi M. The Diabetic foot care. OPSI news letter,
4. Verma AK. The Diabetic Foot, An Overview and
2006; 4.
Rehabilitation, published in proceedings of Fourth
2. Reiber GE, et al. Footwear used by individuals with
National workshop on Diabetic Foot Care, Dec 2009.
Diabetes and history of foot ulcer. Journal of
5. Prabhakar S, Modi M. Screening, early detection and
Rehabilitation Research and Development. diagnosis of Diabetic Neuropathy, Ann Natl Acad Med
2002;39/(5). Sci, 2010;46(2):11836.
6. rd_india.com Nov 2008.
CHAPTER 23

Skeletal System

AK Agarwal
170 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

Skeletal system comprises of different types of 5. Sesamoid bones: Sometimes bones are formed
bones and joints which make frame of body. It in the tendons nearby a joint. These are very
provides protection to many soft and delicate small bones and patella is also the example of
organs of the body. It also gives proper shape to this kind but its size is quite big.
the body.
UPPER EXTREMITY
MAIN FUNCTIONS
The upper limb is attached to the trunk by
1. It provides protection and space to various shoulder girdle and clavicle. Upper limb has total
organs of the body. 30 bones as given below. Fig. 23.1
2. It gives proper and definite shape to the body. Humerus 1
3. It provides ambulation. Radius and ulna 2
4. The different muscles take origin from the Carpal bone 8
bones. Metacarpal 5
5. The skeletal system has 206 big and small Phalanges 14
bones and divided into 2 main parts.
Total 30
Skeletal System The upper limb has 3 joints shoulder, elbow
and wrist.
Skull Upper extremity
Spinal column Lower extremity
Sternum and Ribcage

Classification of the Bones

It is of 5 types:
1. Long bones: Upper and Lower limbs have
long bones. Each long bone has one shaft and
two ends which are attached to proximal and
distal joints. The long bones acts as lever and
helps in movements.
2. Short bones: It comprises of small bones
which are present in wrist and ankle joints.
The small bones of wrist are called carpal
bones which are 8 in number. Whereas the
small bones of ankle and foot are known as
tarsal bones which are 7 in number. These
bones provide different movements in the
wrist, ankle and foot. Fig. 23.1: Upper extremity
3. Flat bones: It includes scapula, pelvis, skull
and ribs. LOWER EXTREMITY
4. Abnormal shaped bones: The facial bones and The lower limb is attached to lower trunk through
vertebrae are the example. hip joint and pelvic girdle The lower limb has 30
bones as given below: Fig. 23.2.
 SKELETAL SYSTEM 171

Cervical 7
Dorsal 12
Lumbar 5
Sacral 5
Coccygeal 4
Total 33

Fig. 23.2: Lower extremity

Femur 1
Tibia and fibula 2
Tarsal bones 7
Metatarsals 5
Phalanges 14
Patella 1
Total 30
Fig. 23.3: Vertebral column
The lower limb has 3 joints, i.e. Hip, Knee
and Ankle which are weight bearing joints.
Functions
Spine (Vertebral Column)
Spine acts as strong pillar to the body and
Spine has 33 vertebrae in different regions of the vertebrae provide flexibility along with protec-
trunk as given below. Fig. 23.3. tion to spinal cord.
172 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

Joints D. Gliding type: Example: Sternoclavicular,

Articulation of 2 or more bones is called as joint. Acromiocoracoid joints.
It is of 3 types.
1. Fibrous type joint: These joints are stable Movements
and do not provide movements. The synovial type of joints has the following
Example: Bones of skull, dentition. movements:
2. Cartilaginous type joint: The cartilage is
present between 2 bones and provides some Flexion Extension
movements. Example: Articulation of verte- Abduction Adduction
bral column. Circumduction
3. Synovial types of joint: In this type synovial Rotation internal and external
membrane is attached at the site of articulation Inversion and eversion
of bones (joint). It is of the following types- Pronation and supination
A. Ball and socket type: Hip and shoulder
joints where range of movements is in all Range of movements can be restricted due to
the direction. various diseases or injury to joint.
B. Hinge type: The movement is possible
only in one direction. Example: Knee and FURTHER READING
elbow.
1. Hollinshead WH and Jenkins DB, Functional anatomy
C. Condyloid type: Example: Wrist, Temporo
of limbs and back, edition 5th, published by WB
Mandibular joint (TMJ), Metacarpophala- Saunders company, Philadelphia, 1981.
ngeal, and Mettarsophalangeal joints.
CHAPTER 24

Orthotic Management of
Post Polio Syndrome
VS Gogia
174 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
SUMMARY
Post Polio Syndrome, a well recognised clinical
entity now, has become a great challenge to the
medical and surgical rehabilitation professionals,
as more and more paralytic polio survivors age
into fourth to sixth decades of their lives. Early
diagnosis and timely rehabilitation of a person
with Post Polio Syndrome is important because
at around this age one is just reaching the prime
of ones productive life and starts consolidating
socio-economic status of self and the family.
INTRODUCTION
Following polio eradication measures on war
footing through Universal Immunization, Pulse
Polio programme, etc. the incidence of fresh
cases is coming down. Studies suggest that one
fourth to onethird of persons who had paralytic
polio in the past may be experiencing post-polio
syndrome at the present time. This proportion is
likely to increase as these persons age into fourth
to sixth decades of their lives with better health
care services and rehabilitation. Post Polio
Syndrome (PPS) has become a great challenge
to the medical and surgical rehabilitation
professionals. Considering the age and stage of
ones career early diagnosis and timely rehabili-
tation of a person with PPS is very important.
DEFINITION
There are many terms given to the problems faced
by post polio patients. These include late-onset
poliomyelitis, progressive muscular atrophy,
late progressive post-poliomyelitis muscular
atrophy, late post-poliomyelitis muscular
atrophy, progressive post-polio atrophy and
progressive post-poliomyelitis muscular
atrophy. The empirical research data is lacking
that can indicate progressive atrophy or rapid
decline in strength hence the term post-polio
syndrome has been agreed upon universally to
better describe the complaints and findings of polio
survivors and does not make unfounded
presumptions.
Clinical Picture
Halstead and Rossi and Agre et al. have described
frequently encountered complaints in Post Polio
patients that may include:
1. New Health Problems
a. Fatigue
b. Muscle Pain
c. Joint Pain
d. Weakness
i. Previously affected Muscles
ii. Previously unaffected Muscles
iii. Cold intolerance
iv. Atrophy
2. New ADL Problems
a. Walking
b. Stair climbing
c. Dressing
Diagnosis
Routine hemogram, liver and renal function tests,
blood sugar profiles and urine exams are done to
rule out other likely diagnoses to explain these
problems. Frequent clinical diagnosis given to
such patients include muscle pain related to over-
activity, overuse or myofascial pain, joint pain
related to arthritis or mechanical problems in joint
well protected by weakened muscles. PPS is
essentially a diagnosis of exclusion and can be
arrived at through the following diagnostic criteria.
Post Polio Syndrome: Diagnostic
Criteria
1. A confirmed history of paralytic polio.
2. Partial to fairly complete neurological and
functional recovery.
 ORTHOTIC MANAGEMENT OF POST POLIO SYNDROME
3. A period of neurological and functional stability
of at least 15 years duration.
4. Onset of two or more of the following health
problems since achieving a period of stability:
i. Unaccustomed fatigue.
ii. Muscle and/or joint pain.
iii. New weakness in previously affected
or unaffected muscles.
iv. Functional loss.
v. Cold intolerance.
vi. New atrophy.
5. No other medical diagnosis to explain these
health problems.
The last criterion is very important and calls
for a high index of suspicion on clinicians part
while dealing with a person of post-polio
paralysis of more than 15 years duration.
Rehabilitation Management
The treatment of PPS is based on evaluation of
the individual situation. No two such cases are
same in respect of symptomatology, severity and
extent of involvement and in other demographic
and socio-vocational aspects. Fatigue is a
common problem. The cause of this complaint
may be unknown or central origin in at least some
of the patients. Halstead and Rossi, in a survey
of 539 polio survivors, reported that complaint of
fatigue was significantly relieved by increasing
the rest time, napping or reducing the overall
activity level through the day.
In addition to these measures almost all
patients received counseling on the need to reduce
stress in their lives both physical as well as
emotional. Psychological counseling or
participation in a post-polio support group to learn
new coping skills was also recommended for
many patients. Halstead and Rossi, and Agre et
al have further recommended judicious use of
following interventions on individual need basis:
175
1. New or Modified aids - Durable products
used to improve posture, diminish pain and
enhance comfort.
a. Corsets
b. Lumber rolls
c. Neck pillows
d. Wheelchair positioners
e. Canes
f. Crutches.
2. Energy conservation techniques
3. Change in exercise programme
4. Change in orthoses
5. Weight loss
6. New/modified wheelchair
7. Gentle exercise programme
a. Aerobic exercise
b. Stretching exercise
c. Strengthening exercise
The role of exercises on PPS patients has been
found controversial in the past. A detailed
description of exercise strategies is out of
context of this chapter. Those interested may
refer to the studies available in peer-reviewed
literature. Achievement of benefits is further
subject to avoidance of excessive fatigue and
muscle & joint pains.
Orthotic Rehabilitation
Orthotic rehabilitation is aimed at either
modification of existing orthosis or addition of
new one to take care of new fatigability and/or
weakness. In cases where only fatigability is the
major symptom and there is no significant fresh
weakness, addition of walking aid like cane,
tripod or quadripod walking stick may help. They
may also require a fresh orthosis. Persons already
having significant weakness and rehabilitated with
orthosis, may have to modify the orthosis to more
extensive one say from AFO to KAFO or KAFO
to HKAFO. In addition they may need trunk
support in addition to lower limb orthosis. Here
176 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
the clinician must consider minimal possible
increase in weight of the modified or new orthosis.
To address such situations researchers have tried
newer materials and technologies. One of such
materials tried is carbon fiber orthosis that has
given encouraging results in different studies.
Among newer technology avenues, automatic
stance-control knee orthosis has been tried and
appears to improve gait biomechanics and improve
energy efficiency compared with a locked knee.
Controllable knee ankle foot orthosis has been
shown to improve gait patterns in 2 PPS patients.
The mainstays of treatment are life-style
changes to avoid overexertion and use of
lightweight orthoses and assistive aids to unload
the extremities. Exercise and surgery have a
limited role in management. The main problem in
prescribing any rehabilitation strategy lies the
uniqueness of each post-polio patient. The
Physiatrist needs to makeout patient-specific
circumstances, including the location and degree
of muscle weakness and that of subsequent
arthralgia or arthropathy. Any rehabilitation
programme should be aimed at protecting the
involved joints and weakened musculature from
overuse and the remaining joints and muscles that
can withstand greater stress from disuse.
Physiatrist has to strike a judicious balance of
strengthening and re-conditioning programme
without tiring out the weaker muscles and
stressing the joints. De-conditioning like leave
from job, excessive rest at home should never be
promoted.
Rehabilitation Outcome
Key to optimum rehabilitation is the early
diagnosis and intervention. Hence record keeping
of these patients who attend rehabilitation
services is must and at least once a year follow
up with comparison to previous muscle charting
should be a routine protocol. Compliance on part
of the patient to clinical advice, made after
Physiatric evaluation, appears to be a crucial
factor in determining outcome of the rehabili-
tation programme. Agre et al reported
improvement in 78% cases seen in follow-up
while those who did not show any improvement
were not compliant to the recommendations.
Peach and Olejnik also reported significant
improvement in compliers out of 77 patients
group divided into three sub-groups of compliers,
partial compliers and non-compliers. The
symptoms followed up included Weakness,
Fatigue, Muscle Pain and Joint Pain. Among
compliers (n=30) majority of the subjects had
either their symptoms resolved (1% for joint pain
to 28% for muscle pain) or improved (53% for
joint pain to 96% for fatigue). Among non-
compliers (n=15) majority was among no change
(57% for muscle pain to 82% for joint pain) to
increased symptoms (18% for joint pain to 36%
for weakness and fatigue) categories. This study
concluded that patients, who completely comply
with clinical recommendations and could
successfully control the factors responsible for
the neuromuscular overuse, did not lose muscle
strength and note considerable improvement in
symptoms.
CONCLUSION
If one notices fresh weakness and ADL problems
cropping up in an otherwise settled life of a post
polio survivor. Physiatrist has to be on guard to
the possibility of PPS and avoid advising more
than necessary rest from daily routine. Disuse
further promotes weakness in PPS. At the same
time exercise programme has to be tailored and
customized for each individual patient to promote
strengthening of involved muscles in such a way
so as to prevent undue fatigability. Judicious
exercise mix in the appropriate postpolio patient
(the patient who can exercise and avoid undue
fatigue, muscle pain and arthralgia) is an
 ORTHOTIC MANAGEMENT OF POST POLIO SYNDROME
important adjuvant to patients overall therapeutic
programme. Appropriate assistive device and/or
orthotic modification or prescriptions are also
important component of total rehabilitation
strategy. The aim of such prescription should be
to have minimum necessary weight of the
orthotic device. In addition taking care of the
psychosocial problem form an integral compo-
nent of any successful rehabilitation programme.
FURTHER READING
1. Speir JL, Owen RR, Knapp M, Canine JK. Occurrence
of post polio sequelae in an epidemic population. In
Halstead LS, Weichers DO (editors): Research and
Clinical Aspects of the Late Effects of Poliomyelitis.
White Plains, NY, March of Dimes Birth Defects
Foundation. 1987. pp. 39-48.
2. Codd MB, Mulder DW, Kurland LT, et al.
Poliomyelitis in Rochester, Minnesota, 1935-1955:
Epidemiology and long term sequelae: A preliminary
report: In Late Effects of Poliomyelitis. Miami,
Symposia Foundation. 1985. pp. 121-34.
3. Aston JW Jr. Post-polio syndrome. An emerging threat
to polio survivors. Postgrad Med. 1992;92(1):249-
56, 260.
4. Ramlov J, Alexander M, LePorte R, et al.
Epidemiology of post-polio syndrome. Am J
Epidemiol 1992;136:769-86.
5. Block HS, Wilbourn AJ. Progressive post polio
atrophy: The EMG findings, abstract. Neurology 1986;
36(Suppl 1):137.
6. Dalakas MB, Elder, Hallat M, et al. A long-term
follow-up study of patients with postpoliomyelitis
neuromuscular symptoms. N Engl J Med 1986;314:
959-63.
7. Dalakas MC, Sever JL, Fletcher M, et al.
Neuromuscular symptoms in-patients with post-
poliomyelitis: Clinical, virological and immunological
studies. In Late Effects of Poliomyelitis. Miami,
Symposia Foundation 1985. pp. 73-90.
8. Dalakas MC, Sever JL, Madden DL, et al. Late post-
poliomyelitis muscular atrophy: Clinical, virological
and immunological studies. Rev Infect Dis 1984;
6(Suppl 2):S562-7.
9. Kurent JE, Brooks BR, Madden DL, et al. CSF viral
antibodies: Evaluation in amyotrophic lateral sclerosis
and late onset post-poliomyelitis progressive muscular
atrophy. Arch Neurol 1979;36:269-73.
177
10. Halstead LS, Rossi CD. Post-polio syndrome: Clinical
experience with 132 consecutive outpatients. In
Halstead LS, Weichers DO (editors): Research and
Clinical Aspects of the Late Effects of Poliomyelitis.
White Plains, NY, March of Dimes Birth Defects
Foundation. 1987. pp. 13-26.
11. Halstead LS, Rossi CD. New problems in old polio
patients: results of a survey of 539 polio survivors.
Orthopedics 1985;8:845-50.
12. Agre JC, Rodriquez AA, Sperling KB. Symptoms and
clinical impressions of patients seen in post-polio
clinic. Arch Phys Med Rehabil 1989;70:367-70.
13. DeLorme TL, Schwab RS, Watkins AL. The response
of the quadriceps femoris to progressive resistance
exercises in poliomyelitis patients. J Bone Joint Surg
Am 1948;30: 824-47.
14. Gurwitsch AD. Intensive graduated exercises in early
infantile paralysis. Arch Phys Med 1950; 31:213-218.
15. Hyman G: Poliomyelitis. Lancet 1953;1:852.
16. Knowlton GC, Bennett RL. Overwork. Arch Phys Med
Rehabil 1957;38:18-20.
17. Lovett RW. The treatment of infantile paralysis:
Preliminary report, based on a study of the Vermont
epidemic of 1914. JAMA 1915;64:2118-23.
18. Mitchell GP. Poliomyelitis and exercise. Lancet 1953;
2:90-1.
19. Agre JC, Harmon RL, Carr JT, et al. Nonfatiguing
muscle strengthening exercises can safely increase
strength in post-polio patients. Med Sci Sports Exerc
1993;25(Suppl):5134.
20. Einarsson G. Muscle conditioning in late poliomyelitis.
Arch Phys Med Rehabil 1991;75:11-14.
21. Einarsson G, Grimby G. Strengthening exercises
program in in post-polio subjects. In Halstead LS,
Weichers DO (Editors): Research and Clinical Aspects
of the Late Effects of Poliomyelitis. White Plains, NY,
March of Dimes Birth Defects Foundation. 1987.
pp 275-283.
22. Feldman RM, Soskolne CL. The use of nonfatiguing
strengthening exercises in post-polio syndrome. In
Halstead LS, Weichers DO (editors): Research and
Clinical Aspects of the Late Effects of Poliomyelitis.
White Plains, NY, March of Dimes Birth Defects
Foundation. 1987. pp335-41.
23. Grimby G, Einarsson G. Post-polio management CRC
Crit Rev Phys Med Rehabil 1991;2:189-200.
24. Jones DR, Speier J, Canine K, et al. Cardio respiratory
responses to aerobic training by patients with post-
poliomyelitis sequelae. JAMA 1989;261:3255-8.
178 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
25. Dean E, Ross J. Effects of modified aerobic training on
movement energetics in polio survivors. Orthopedics
1991;14:1243-6.
26. Prins JH, Hurtung GH, Merritt DJ, et al. Effect of
aquatic exercise training in persons with poliomyelitis
disability. Sports Medn Training Rehabil
1994;5:29-39.
27. Medical Research Council. Aids to Examination of the
Peripheral Nervous System, ed. 2 rev. War
Memorandum No. 7. London, HMSO, 1943.
28. Kimishima K, Hachisuka K, Ogata H, et al.
Supracondylar knee-ankle-foot orthosis for post-polio
syndrome [Article in Japanese]. J UOEH.
1991;13(3):255-5.
29. Heim M, Yaacobi E, Azaria M. A pilot study to
determine the efficiency of lightweight carbon fibre
orthoses in the management of patients suffering from
post-poliomyelitis syndrome. Clin Rehabil.
1997;11(4):302-5.
30. Steinfeldt F, Seifert W, Gnther KP. Modern carbon
fibre orthoses in the management of polio patients
a critical evaluation of the functional aspects [Article
in German]. Z Orthop Ihre Grenzgeb.
2003;141(3):357-61.
31. Hachisuka K, Makino K, Wada F, et al. Oxygen
consumption, oxygen cost and physiological cost index
in polio survivors: A comparison of walking without
orthosis, with an ordinary or a carbon-fibre reinforced
plastic knee-ankle-foot orthosis. J Rehabil Med.
2007;39(8):646-50.
32. Brehm MA, Beelen A, Doorenbosch CA, et al. Effect
of carbon-composite knee-ankle-foot orthoses on
walking efficiency and gait in former polio patients. J
Rehabil Med. 2007;39(8):651-7.
33. Hebert JS, Liggins AB. Gait evaluation of an automatic
stance-control knee orthosis in a patient with post-
poliomyelitis. Arch Phys Med Rehabil. 2005;86
(8):1676-80.
34. Moreno JC, Brunetti F, Rocon E, et al. Immediate
effects of a controllable knee ankle foot orthosis for
functional compensation of gait in patients with
proximal leg weakness. Med Biol Eng Comput.
2008;46(1):43-53. Epub 2007 Oct 10.
35. Peach PE, Olejnik S. Effect of treatment and non-
compliance on post-polio sequelae. Orthopedics
1991;14:1199-203.
36. Agre JC. The role of exercise in the patient with post-
polio syndrome. Ann NY Acad Sci, in press, 1994.
CHAPTER 25

Materials in Rehabilitation
Aids: Present and the
Future
SK Guha
180 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
INTRODUCTION
Disability has wide diversity and a wide range of
rehabilitative aids have been designed for
management. Even simple devices require more
than one type of material, In use the aids are
subject to complex stress and a combination of
materials is required to meet the demands
imposed. Therefore a wide variety of materials
have come into use in rehabilitation. For example,
metals from structural engineering applications,
cloth from dress making; plastics of automobile
body and leather of shoe making all figure in
orthosis and prosthesis. Although some how the
situation has been managed with these materials,
a realization has come that aids for the disabled
are a special entity in themselves and need
materials specially developed for the purpose so
that optimum result are obtained. Therefore tailer
made material specifically for rehabilitation is
coming up gradually. Although such develop-
ments are few as yet, it is clear that in the near
future many more will be available. The follow-
ing text reviews the routine in rehabilitation
services and the emerging trends.
PRINCIPLES
There are three basic considerations in respect
of materials for rehabilitation devices. They are:
possibility of providing necessary motion; ability
to withstand static and dynamic forces arising in
use; and having minimal fatigue effect on
repeated materials design and selection of a
number of other criteria figure in successful
utilization and acceptability. Some of these are:
cosmetic appearance: resistance to environmental
effects and durability; toxicological compatibility
with the body especially when direct contact with
the skin is involved; ease in shaping and
manufacturability; amenability to standardization;
low cost; and ready availability. Clearly the factors
involved are many and most rehabilitation
devices are made-up materials which fall in
different classes.
MATERIAL CLASSES
The commonly used materials can be grouped
under the following classes:
a. Metals
b. Leather
c. Rubber
d. Fabrics
e. Plastics
f. Composites
In the past metals, leather, rubber and fabrics
were the main types of materials used in devices,
Later on plastic entered the field in a big way.
More recently composites are emerging not only
as improved substitutes for earlier forms of
plastics but also as competitors for metals.
Metals
Steels were the material of choice on account of
the strength (tensile strength 300 Mpa to more
than 3000 Mpa). Steels are iron based materials
having a wide range of properties depending upon
the constituents present and the method of
preparation. Elements present in steels include
carbon, manganese, phosphorus, sulfur and
silicon. Carbon is deliberately added to give
strength in compression and hardness.
Manganese and silicon are agents employed to
deoxidize the steel during melting. Sulfur is an
impurity but sometimes added to obtain specific
machining properties.
It is to be noted that the final properties of
any particular steel is very strongly dependent
upon the final preparation procedure. A particular
steel procured from the market will have quite
different mechanical as well as corrosion
resistance characteristics if it is cold forged as
compared to shaping after heating. Even the
temperature to which the steel is heated matters.
 MATERIALS IN REHABILITATION AIDS: PRESENT AND THE FUTURE 181

Additionally bending during making of the aids Leather

changes the properties. For instance steel strip
Leather is a material which has played a very
used in an orthoses is bent to give shape during
significant role in rehabilitative aids from time
assembly; the region of the bend will acquire
immemorial. As is well known, leather is
different mechanical parameters than the rest of
prepared from animal skin. The skin is cured by
the strip.
reducing the moisture content of fresh hide. This
In fact the morphology of the steel itself
process also helps to protect against bacterial and
changes. In analogy to the histopathological
enzymatic action. The leather may be stored for
pattern of body tissue, steels too have structure
years. There are a number of variations in the
at the macroscopic level which can vary in a
details of the process. However, the technology
particular specimen depending upon the handling.
has advanced so much that inspite of variabilitys
In the practice of making of orthotics and
in the original hide, standardized end products
prosthetics these issues are often overlooked
are obtained.
leading to failures. Therefore to have
In rehabilitation work, leather is extensively
products of uniform quality the composition of
used for shoes, straps and special coverings. The
the steel as well as every step in the
comfort obtained with natural leather still
processing and manufacture of the aid must be
remains unmatched by artificial materials. Some
standardized.
of the factors which contribute to the comfort
Aluminum alloys are another important class
are (i) permeability to water vapour (ii) the
of materials which generally have the advantage
characteristic that vapour from a sweating region
of low weight and resistance to corrosion. Alloys
is absorbed and distributed thereby preventing
are available in the form of castings, forgings,
the feeling of sogginess (iii) fair thermal
extrusions and rolled products. The material can
conductivity help in cooling which is a factor
be grouped in two broad types, nonheat treatable
particularly important in tropical climates.
and heat treatable. In applications where strength
Leather having many fibers hence net internal
is not important consideration, an alloy of 99%
surface area for heat dissipation is high
aluminium with the balance 1% being silicon and
(iv) intrinsic capability of increasing in dimension
iron serves. Shaping is quite easy with this alloy.
when moist thus eliminating the feel of constric-
In another form there is 111/2 % Mn; 0.6 % Si;
tion in hot and humid weather. Furthermore,
0.7 % Fe and balance of aluminium. With varying
leather withstands puncture quite well and is
degrees of cold working tensile strengths of 13000
resistant to failure on repeated cycles of bending
psi may be obtained. Thus aluminium alloys are
with small radius of curvature. From the fabri-
weaker than the steels. Also welding to form joints
cation point of view too, leather has advantages
requires special gases and electrical arc welding
that it can be cut, skived, split, perforated and
has to perform with extra care to obtain a stable
commented even molding to permanent shapes
joint.
is possible.
Aluminum per se has poor resistance to
An important point to be observed is that
abrasion. Some surface finishing methodologies
although there is no control over the source of
partially overcome this limitation. Neverthe-
the material since it is an animal product, by
less in design aluminium components have to
different processing techniques number of
be protected from rubbing against other metal
properties can be selectively arrived at. For
parts.
182 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
example, where there is contact with the skin a
nontoxic property may be obtained by vegetable
tanning.
On the other hand when skin contact is not
involved, high strength can be arrived at with
chrome tanning. The cut of leather best suited
for foot orthoses is known as top-split-grain.
This consists of the outside of the hide, or the
part that has the hair on, which is known as the
grain side, to be approximately one-third the total
thickness of the leather.
Rubber
The term rubber was originally described to
product of plant origin which had the charac-
teristic of deforming under load and recovering
the shape after removal of the load. Gradually
synthetic compounds with similar deformability
characters were also grouped in the class of
rubber. Now a more commonly used industrial
term for these materials is elastomers but in the
rehabilitation area the term rubber continues. On
account of tough resiliency and high shock
absorbing properties rubbers find important
applications in prosthetics and orthotics today.
By compounding with different materials
rubber with tailor-made properties and good tear
and abrasion resistance. Aging effects very
gradually but resistance to sunlight, water. Oils
and solvents are poor.
Therefore there is increasing trend toward
using synthetic rubbers. The butyl rubber, one of
the commonest forms of rubber, has greater
resistance to water and aging due to sunlight than
natural rubber. Another form, the bromo-butyl
rubber is virtually unaffected by water as well as
most organic solvent compounds. But these
synthetic compounds in usage are Styrene-
butadiene; butadiene acrylonitrile; chloroprene;
isobutylene; polysilozane; and polyurethane
disocynbate.
In respect of consistency there are two broad
classes (a) solid form (b) cellular or porous form.
Cellular form provides special controllable
features and so different types have emerged. One
classification groups the cellular rubbers into
(a) sponge (b) expanded rubber and (c) latex
form. In turn these are divided into open-cell or
closed cell structures. Open celled form has inter-
connecting pores through which air and liquids
can flow. In the closed cell structure the spaces
are isolated from one another. The compressi-
bility of the open cell form is more. Closed cell
forms are firmer and offer better support and are
more often used in rehabilitation work.
Silicone polymers can be made with a special
feature. When mixed with cellulose and a
blowing agent, the combination results in a
material which expands and cures at the same
time. The form produced may be shaped at very
low pressure. Thus the foam mixture may be
poured inside a prosthetic socket and allow it to
harden in 5 to 10 minutes so as to have
comfortable cushion between the end of the
stump and the socket.
Significantly the material is nontoxic so there
is no problem of maintaining contact with the
skin. Also the curing temperature is within the
skin tolerable limits so molding insitu is
permissible.
Fabrics
Fabrics of cotton, jute and synthetic materials find
a place in orthotics and prosthetics. Mostly they
are employed as coverings to provide comfort.
In another application to be discussed later,
fabrics are combined with resins for structural
components.
Plastics
The past two decades have heralded a virtual
explosion in the application of plastic in all fields
 MATERIALS IN REHABILITATION AIDS: PRESENT AND THE FUTURE
of human endeavor including aids for the
handicapped. Initially the plastics were ignored
because they were thought to be weak and
extremely susceptible to unwanted deformation
under thermal effects. Now the situation has
changed. Mechanical properties like tensile
strength of 40-100 Mpa and tensile modulus of
2-10 GPA are quite common. Also there are
plastics, mostly in industrial work, which
withstand very high temperatures.
There is no unique definition of the term
plastic. Broadly the term may be applied to any
synthetic material that can be molded, extruded,
laminated or hardened in any desired form. In
current science the word polymer figures but
this word covers both natural and synthetic
compounds. In the chemical structure there is
generally a repetitive linkage of a more simpler
chemical form. Plastics in rehabilitation may be
grouped under two major classes (a) thermo-
plastics (b) thermoset.
Thermoplastics
As the term itself indicates, the formation of these
plastics into shapes involves a thermal process.
The thermoplastics can be further subdivided into
two categories (i) low temperature requiring no
more than 80C for setting and (ii) high
temperature setting at higher temperatures. The
latter have to be shaped over molds.
High temperature thermoplastics are formed
by various processes such as injection; compre-
ssion; hollow injection; stamping; extrusion and
thermoforming. The technique adopted depends
upon the nature of the material, the shape to be
given and the ultimate physical properties to be
acquired after the shaping procedure. Frequent
usage of high temperature thermoplastics in
prosthetic and orthotics are: acrylics; polyethy-
lene; polycarbonates; acrylonitrili- butadiene-
styrene; and vinylpolymers.
183
Acrylics, a popular form being methyl
methacrylate possess qualities of light weight,
high transparency, good dimensional stability and
resistance to breakage. They are very resistant to
environmental effect. The material is available
in sheets which can be thermoformed over molds
as well as rod or block form which are amenable
to maching. A desirable feature is that the acrylics
can be joined together with solvents such as
acetone and can be polished by an oxyhydrogen
flame. A limitation is that the acrylics are combust
able.
Polyethylenes may be produced with many
different physical properties. The mechanical
properties of, for example high density
polyethylene (HDPE) are quite different from that
of low density polyethylene (LDPE), the differ-
ence being achieved by varying the molecular
weight and the linkages between the ethylene
units in the polymer. Thus LDPE can be vacuum
formed readily over a plaster of Paris mold.
HDPE can be joined by techniques similar to
welding of metals. Therefore this class of
compound serves well for diversity of needs. One
limitation is that polyethylenes cannot
conveniently be joined by means of adhesives.
Traditionally the polyvinyl chloride (PVC)
has been the vinyl compound most encountered.
Now amongst vinyl compounds the ethylene
vinylacetate (EVA) is emerging as a significant
material in orthoses. EVA is a polyofin co-
polymer. EVA is light weight and shock
absorbing. In lower densities it can be cushioning.
The densities available range from 30 to 360 kg/
cu.m.indicating the range over which a particular
compounds can be prepared.
Low temperature thermoplastic cannot be
used in applications where high stress is expected.
But in upper extremity devices where forces
comparatively low, they are quite valuable. Since
no cast is needed in fitting hence procedure is
184 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
hastened. Usually only facility needed is a bath
of hot water and scissors. An oven is to help for
some of the plastics. Now there are newer low
temperature plastics with setting temperature not
much higher than body temperature. So it is
possible to form them directly over the body.
Orfit is a trade name of one of these materials.
Composites
Composites are not new in rehabilitation. For
decades the socket of the lower extremity
prosthesis has been made with resins reinforced
by fabrics. Now the field is becoming formalized
with well structured approaches to bringing
different material together. A definition is
therefore helpful. A composite can be defined as
a material composed of two or more discrete
constituents with at least one constituent serving
as a reinforcing agent.
Bone is a natural composite where there are
long continuous fibers in a calcium phosphate
matrix. It is to be noted that metal alloys are not
composites because the constituents are not in
discrete from. Composites can be isotropic (the
same mechanical properties in all directions) or
anisotropic where mechanical properties differ
in different direction. Fiber reinforcement can be
oriented in the direction that is subject to high
loads. Hence it is possible to obtain high effective
strength with low weight of material.
The combinations of materials which can go
to form composites are many. Fabrics with epoxy
resins are popular. For high strengths carbon
fibers can be embedded in plastics. Composites
of metal fibers with plastics are also possible.
Thus combination can be designed to suit a
particular application.
CONCLUSION
Material science is now a field very closely linked
to rehabilitation of the handicapped. The outcome
of the collaboration is quite perceptible in terms
of more reliable and comfortable aids becoming
available at lower cost. Furthermore the delivery
of rehabilitative services has speeded up because
many of the newer materials can be used in
fabrication work based upon fast technique. With
the option that materials can be designed to suit
specific needs a revolution in prosthetics and
orthotics is in the offing.
FURTHER READING
1. Licht, S, Kamenetz, H.L. (Eds.). Orthotics Etcetara,
Elizabeth Licht Publishers, New Haven, 1996.
2. Redford. JB (Ed). Orthotics etcettera. William and
Wilkin, Baltimore, 1980.
3. Philips, JW. The functional foot orthosis. Churchill
Livingstone, Edinburgh, 1990.
4. Epel. JN, et al. (Eds). Engineering Plastics, ASM
International, Metals Park, 1988.
CHAPTER 26

Disability: Assessment
Guidelines as per
Notification
Ratnesh Kumar
186 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

Regd. No. DI-33004/99

THE GAZETTE OF INDIA

Extraordinary
Part-II-Section 1

PUBLISHED BY AUTHORITY
New Delhi, Wednesday,
June, 13, 2001/Jyaistha 23, 1923

GUIDELINES FOR
DISABILITY ASSESSMENT
To Quantify Permanent Physical Impairment

Reproduced in the Interest of PWDS

By
Dr Shyama Prasad Mukherjee
National Institute
For the Orthopaedically Handicapped
Kolkata-700 090

INTRODUCTION 1. Visual Impairment

In order to review the guidelines for evaluation
of various disabilities and procedure for
certification (Ministry of Welfare, Govt. of India,
1986) and to recommend appropriate modifi-
cation/alterations keeping in view the Persons with
Disabilities (equal opportunities, protection of
rights and full participation) Act 1995, Government
of India, Ministry of Social Justice and
Empowerment set up committee in 1998 under
the Chairmanships of Director General of health
services - one each in the area of mental
retardation, locomotor/orthopaedic, visual, speech
and hearing disability.
After considering the reports of committee,
guidelines for evaluation of following disabilities and
procedure for certification was notified vide no.
DI-33004/99. The Gazette of India Extraordinary
Part-II Section 1, Dated 13, June 2001.
2. Locomotor/Orthopaedic Disability
3. Speech and Hearing Disability
4. Mental Retardation
5. Multiple Disabilities
In the guidelines, the functional loss due to
permanent physical impairment resulted from
congenital condition, disease or trauma have been
evaluated. Broadly the body has been divided in
to three parts, i.e. upper limb, lower limb and
trunk. In principle the function of one part can
not be replaced by other, therefore each function
in terms of part is itself 100% and thus loss of
function is weighed as PPI 100%. On the other
hand, the whole body value cannot exceed 100%
thus in case impairment is in more than one
function or body part , total of all cannot exceed
to 100% with clear mention of function/body part
 DISABILITY: ASSESSMENT GUIDELINES AS PER NOTIFICATION
involvement. Thus a total of one or all segment
cannot exceed 100%.
What is the need of percentage in disability
certificate? The UN proclamation in 1981 and
subsequent declaration of Decade for Disabled
with Biwako Millenium Framework of actions in
2003 which has extended decade from 2003-2012,
where India is a signatory, it is binding on the
member countrys to protect rights, provide equal
opportunities and empower PWDs. The PWD
Act and recent National Policy for disabled
persons are initiatives to fulfill national and
international commitments made. In view to
physical and financial constraints, the 40% has
been taken as cutoff for various facilities and
concession eligibility. The guidelines are for
assessment of disability in the respective area/
body part and to quantify in terms of percentage
of disability to avail facilities and concessions, viz.
Reservation in job, Travel concession, Soft loan
for entrepreneurship development, Scholarship,
Income Tax/Custom rebate, Age relaxation in
employment, etc.
As per the Act, authorities to give disability
certificate will be a medical board duly consti-
tuted by the central and state government. The
medical board should consist of at least three
members. Out of which one shall be a specialist
in the concerned disability subject. The standard
guidelines and tools mentioned in the notification
187
have to be used in evaluation of disability for
proper certificate.
The certificate would be valid for a period of
five years for those, whose disability is
temporary. Here temporary means that PPI may
change to some extent: No way it means that
disability will be cured. For example after
traumatic amputation the percentage may change
due to improvement in additional factors as pain,
neuroma, scar infection, etc. For those who
acquire permanent disability, the validity can be
shown as permanent. The degree of disability
should be 40% or above to be eligible for various
concessions/benefits earmarked for disabled.
A committee for evaluation, assessment of
multiple disabilities and categorization, extent of
disability and procedure for certification was also
constituted in 1999.
The mental illnesses have also been included
in the disability and the guideline for evaluation
and assessment of mental illness and procedure
for certification were issued by notification
no 16-18/97-NI.I dated 18th February 2002
(Annexed).
For any clarification or details, you may
contact or visit us e-mail: nioh@vsnl.net, web:
niohonline.org
Dr. Ratnesh Kumar
Director, NIOH
Kolkata
188 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

MINISTRY OF SOCIAL JUSTICE AND EMPOWERMENT

NOTIFICATION
New Delhi, 1st June, 2001

Subject: Guidelines for evaluation of various disabilities

and procedure for certification

No. 16-18/97-NI.I.

1. In order to review the guidelines for evalua-
tion of various disabilities and procedure for
certification as given in the Ministry of
Welfares O.M. No. 4-2/83-HW-III, dated the
6th August, 1986 and to recommend appro-
priate modifications/alterations keeping in
view the Persons with Disabilities (Equal
Opportunities, Protection of Rights and Full
Participation) Act, 1995, Government of India
in Ministry of Social Justice and Empower-
ment, vide Order No. 16-18/97-NI. I, dated
28-8-1998, set up four committees under the
Chairmanships of Director General of Health
Services-one each in the area of mental
retardation, locomotor/orthopaedic disability,
visual disability speech and hearing disability.
Subsequently, another committee was also
constituted on 21-7-1999 for evaluation,
assessment of multiple disabilities,
categorization, extent of disability and
procedures for certification.
2. After having considered the reports of these
committees the undersigned is directed to
convey the approval of the President to notify
the guidelines for evaluation of following
disabilities and procedure for certification:
1. Visual Impairment
2. Locomotor Disability
3. Speech and Hearing
4. Mental Retardation
5. Multiple Disabilities.
Copy of the Report is enclosed herewith.
3. The minimum degree of disability should be
40% in order to be eligible for any concession/
benefit.
4. According to the Persons with Disabilities
(Equal Opportunities, Protection of Rights
and Full Participation) Rules, 1996 notified
on 31.12.1996 by the Central Government in
exercise of the powers conferred by sub-
section (1) and (2) of section 73 of the Persons
with Disabilities Act, 95 to give disability
certificate, there will be a Medical Board duly
constituted by the Central and State
Government. The State Government may
constitute a Medical Board consisting of at
least three members, out of which at least
one shall be a specialist in the particular
field for assessing locomotor/visual
including low vision/hearing and speech
disability, mental retardation and leprosy
cured as the case may be.
5. Specified tests as indicated in guidelines
should be conducted by the medical board and
recorded before a certificate is given.
6. The certificate would be valid for a period of
five years for those, whose disability is
temporary. For those who acquire permanent
disability the validity can be shown as
permanent.
7. The State Governments/UT Administrations
may constitute the medical board indicated
in para 4 above immediately, if not done so
far.
 DISABILITY: ASSESSMENT GUIDELINES AS PER NOTIFICATION
8. The Director General of Health Services,
Ministry of Health and Family Welfare will
be the final authority, should arise any
LOCOMOTOR DISABILITY
1. Definition:
i. Impairment: An impairment is any loss
or abnormality of psychological, physio-
logical or anatomical structure or function
in a human being.
ii. Functional Limitations: Impairment may
cause functional limitations which are
partial or total inability to perform those
activities necessary for motor, sensory or
mental function within the range or
manner of which a human being is
normally capable.
iii. Disability: A disability is any restriction
or lack (resulting from an impairment) of
ability to perform an activity in the manner
or within the range considered normal for
a human being.
iv. Locomotor Disability: Locomotor
disability is defined as a persons inability
to execute distinctive activities associated
with moving both himself and objects,
from place to place and such inability
resulting from affection of musculo-
skeletal and/or nervous system.
2. Categories of Locomotor Disability: The
categories of locomotor disabilities are
enclosed in subsequent paragraph.
3. Process of Certification: A disability
certificate shall be issued by a Medical Board
of three members duly constituted by the
Central and State Government out of which,
at least, one member shall be a specialist from
either the field of Physical Medicine and
Rehabilitation or Orthopaedics.
189
controversy/doubt regarding the interpretation
of the definitions/classifications/evaluations/
tests, etc.
Gauri Chatterji
Jt. Secy.
Two specimen copies of the disability
certificate for mental retardation and others
(visual disability, speech and hearing
disability and locomotor disability) are
enclosed at Annexure.
It was also decided that whenever required
the Chairman of the Board may co-opt other
experts including that of the members
constituted for the purpose by the Central and
State Government.
On representation by the applicant, the
Medical Board may review its decision
having regard to all the facts and circum-
stances of the case and pass such order in the
matter as it thinks fit.
REVISED GUIDELINES FOR
EVALUATION OF THE PERMANENT
PHYSICAL IMPAIRMENT (PPI)
1.1 Guidelines for Evaluation of Permanent
Physical Impairment of Upper Limb.
1. The estimation of permanent impairment
depends upon the measurement of func-
tional impairment and not expression of
a personal opinion.
2. The estimation and measurement should
be made when the clinical condition has
reached the stage of maximum improve-
ment from the medical treatment.
Normally the time period is to be decided
by the medical doctor who is evaluating
the case for issuing the PPI certificate
as per standard format of the certificate.
3. The upper limb is divided into two
component; the Arm Component and
Hand Component.
190 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
4. Measurement of the loss of function of
Arm Component consists of measuring
the loss of Motion, Muscle Strength and
Co-ordinated Activities.
5. Measurement of loss of function of Hand
Component consists of determining the
Prehension, Sensation and Strength. For
estimation of prehensionopposition,
lateral pinch, cylindrical grasp, spherical
grasp and hook grasp have to be assessed
as shown in Hand Component of Form-
A (Assessment Proforma for Upper
Extremity).
6. The impairment of the entire extremity
depends on the combination of the
functional impairments of both
components.
1.2 Arm component
Total value of Arm Component is 90%.
1.2.1 Principles of evaluation of Range of
Motion (ROM) of joints
1. The value of maximum ROM in
the Arm Component is 90%
2. Each of the three joints of the Arm
is weighed equally (30%)
Example:
The intra-articular fractures of the bones of right
shoulder joint may affect Range of Motion
even after healing. The loss of ROM should be
calculated the each arc of Motion as envisaged
in the Assessment Form - A (Assessment
Proforma for Upper Extremity).
Arc of ROM Normal Active Loss of
Value ROM ROM
Shoulder Flexion-extension 0-220 110 50%
Rotation 0-180 90 50%
Abduction-Adduction 0-180 90 50%
Hence the mean loss of ROM of shoulder will be
(50 + 50 + 50)/3 = 50%
Shoulder movements constitute 30% of the
Motion of the Arm Component; therefore the loss
of Motion for Arm Component will be 50 0.30
= 15%. If more than one joint of the Arm is
involved the loss of percentage in each joint is
calculated separately as above and then added
together.
1.2.2 Principles of evaluation of Strength of
Muscles:
1. Strength of muscles can be tested by
manual method and graded from 0-5
as advocated by Medical Research
Council (MRC) of Great Britain
depending upon the Strength of the
muscles.
2. Loss of muscle power can be given
percentages as follows:
Manual muscle Loss of Strength
strength grading in percentage
0 100%
1 80%
2 60%
3 40%
4 20%
5 0%
3. The mean percentage of loss of muscle
strength around a joint is multiplied by
0.30.
4. If loss of muscle strength involves
more than one joint, the mean loss of
percentage in each joint is calculated
separately and then added together as
has been described for loss of Motion.
1.2.3 Principles of evaluation of
Coordinated Activities:
1. The total value for coordinated
activities is 90%.
2. Ten different coordinated activities
should be tested as given in Form A
3. Each activity has a value of 9%.
1.2.4 Combining values for the Arm
Component: The total value of loss of
function of Arm Component is obtained
by combining the value of loss of ROM,
 DISABILITY: ASSESSMENT GUIDELINES AS PER NOTIFICATION 191

muscle Strength and coordinated activities, c. Cylindrical grasp 6%

using the combining formula. tested for
= a + b (90 a) / 90 i. Large object 3%
of 4" size
Where a = higher value, b = lower value (diameter)
ii. Small object
Example of 1" size
Let us assume that an individual with an intra (diameter) 3%
articular fracture of bones of shoulder joint in d. Spherical grasp 6%
addition to 16.5% loss of Motion in Arm, has 8.3% tested for
loss of Strength of muscles and 5% loss of i. Large object of 3%
coordination. These values should be combined 4 inches size
as follows : ii. Small object of 3%
Loss of Strength of muscles 8.3%, 1 inch size
Loss of ROM 16.5% e. Hook grasp 5%
= 16.5 + 8.3 (90 16.5) / 90 tested by asking the patient
= 23.33% to lift a bag
1.3.2. Principles of Evaluation of Sensation:
To add, loss of coordination
1. Total value of Sensation in Hand is
= 23.3 + 5 (90 23.3) / 90
= 27.0% 30%.
So total value of loss of functions in Arm 2. It should be assessed according to
Component 27.0%. distribution as below:
i. Complete loss of sensation
1.3 Hand Component: Thumb ray 9%
1. Total value of Hand Component is 90%. Index finger 6%
2. The functional impairment of Hand is Middle finger 5%
expressed as loss of Prehension, loss of Ring finger 5%
Sensation and loss of Strength. Little finger 5%
1.3.1 Principles of evaluation of Prehension: ii. Partial loss of Sensation:
1. Total value of Prehension is 30%. It Assessment should be made
includes: according to percentage of
a. Opposition 8% loss of Sensation in thumb/
Tested against finger(s)
- Index finger 2% 1.3.3. Principles of Evaluation of Strength:
- Middle finger 2% 1. Total value of Strength 30%
- Ring finger 2% 2. It includes:
- Little finger 2% i. Grip Strength 20%
b. Lateral pinch 5% ii. Pinch Strength 10%
(Tested by asking patient to hold a Strength of Hand should be tested with Hand
key between thumb and lateral side Dynamo-meter or by clinical method (grip
of Index finger) method).
192 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
Additional weightage: A total of 10%
additional weightage can be given to following
accompanying factors, if they are continuous and
persistent despite treatment.
1. Pain
2. Infection
3. Deformity
4. Mal-alignment
5. Contractures
6. Cosmetic disfiguration
7. Dominant extremity-4%
8. Shortening of upper limb -
First 1" no weightage, for each 1"
beyond first 1" -2% disability.
The extra points should not exceed 10% of
the total Arm Component and total PPI should
not exceed 100% in any case.
1.3.4. Combining values of Hand Component:
The final value of loss of function of Hand
Component is obtained by summing-up values of
loss of Prehension, Sensation and Strength.
1.3.5. Combining values for the Extremity:
Values of impairment of Arm Component and
impairment of Hand Component should be added
by using combining formula.
b (90 a)
a +
90
a = Higher value
b = Lower value
Example: Impairment of Arm - 27%
Impairment of Hand - 64%
Total of upper limb (by combining formula)
= 64 + {27 (90 64)} / 90 = 71.8%
2. Guidelines for Evaluation of permanent
physical Impairment in Lower Limb
The measurement of loss of function in lower
extremity is divided into two components:
Mobility and Stability components
2.1. Mobility Component:
1. Total value of Mobility component is
90%
2. It includes Range of Movement (ROM)
and Muscle Strength
2.1.1 Principles of Evaluation of Range of
Movement:
1. The value of maximum range of move-
ment in mobility component is 90%.
2. Each of three joints, i.e. Hip, Knee and
Foot-Ankle component is weighted
equally-30%.
Example:
A fracture of right Hip joint bones may affect
range of Motion of the Hip joint. Loss of ROM
of the affected Hip is different and should be
assessed as given in Form B (Assessment
Proforma for lower extremity).
Affected Joint-Right Hip:
Arc of Movement Normal Active Loss in
ROM ROM % age
a. Flexion-Extension 0-140 70 50
b. Abduction-Adduction 0-90 60 33
c. Rotation 0-90 30 66
Mean loss of ROM of Right Hip =
(50 + 33 + 66) / 3 = 50%
Since the Hip constitute 30% of the total
mobility component of the lower limb, the loss
of Motion in relation to the lower limb will be
50 0.30 = 15%.
If more than one joint of the limb is involved,
the mean loss of ROM in percentage should be
calculated in relation to individual joint
separately and then added together as follows to
calculate the loss of mobility component in
relation to that particular limb.
For example:
Mean loss of ROM of Right Hip 50%
Mean loss of ROM Right Knee 40%
Loss of Mobility component of
Right Lower Limb will be
(50 0.30) + (40 0.30) = 27%
 DISABILITY: ASSESSMENT GUIDELINES AS PER NOTIFICATION
2.1.2. Principle of Evaluation of Muscle
Strength:
1. The value for maximum muscle
Strength in the limb is 90%
2. Strength of muscles can be tested by
Manual Method and graded 0-5 as
advocated by MRC of Great Britain
depending upon the residual strength
in the muscle group.
3. Manual muscle grading can be given
percentage like below:
Grade of Muscle Loss of Strength
Strength in % age
0 100
1 80
2 60
3 40
4 20
5 0
4. Mean percentage of muscle strength
loss around a joint is multiplied by 0.30
to calculate loss in relation to limb.
5. If there has been a loss muscle strength
involving more than one joint the
values are added as described for loss
of ROM.
2.1.3. Combining values for mobility
component:
1. The values of loss of ROM and loss of
muscle strength should be combined
with the help of combining formula:
b (90 a)
a+
90
(a = higher value, b = lower value)
Example: Let us assume that the individual with
a fracture of right Hip bones has in addition to
16% loss of Motion, 8% loss of muscle Strength
also. To combine, Motion-16% and Strength-8%
Combined values = 16 + {8(90 16)} / 90
= 22.6%
193
2.2 Stability Component:
1. Total value of the Stability component
is 90%
2. It should be tested by clinical method
as given in Form B (Assessment
Proforma for lower extremity). There
are nine activities, which need to be
tested, and each activity has a value of
ten percent (10%). The percentage value
in relation to each activity depends upon
the percentage of loss of stability in
relation to each activity.
2.3. Extra points: Extra points have been given
for pain, deformities, contractures, loss of
sensation and shortening. Maximum points
to be added are 10% (excluding shortening).
Details are as following:
i. Deformity
a. In functional position 3%
b. In non-functional position 6%
ii. Pain
a. Severe (grossly interfering
with function) 9%
b. Moderate (moderately
interfering with function) 6%
c. Mild (mildly interfering
with function) 3%
iii. Loss of Sensation
a. Complete Loss 9%
b. Partial Loss 6%
iv. Shortening
First Nil
(for every additional)
shortening 4%
v. Complications
a. Superficial complications 3%
b. Deep complications 6%
3. Guidelines for Evaluation of Permanent
Physical Impairment of Trunk (Spine)
Basic guidelines:
1. As permanent physical impairment caused
by spinal deformity tends to change over
194 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
the years, the certificate issued in relation
to spine should be reviewed as per the
standard format of the certificate given at
Annexure.
2. Permanent physical impairment should be
awarded in relation to spine and not in
relation to whole body.
3. Permanent physical impairment due to
neurological deficit in addition to spinal
impairment should be added by combining
formula.
The local effects of the lesions of the spine
can be conventionally divided into Traumatic
and Non-traumatic. The percentage of PPI in
relation to each situation should be valued as
follows:
3.1 Traumatic Lesions
3.1.1 Cervical Spine injuries
%age of PPI in
relation of Spine
i. 25% or more compression
of one or two adjacent vertebral 20
bodies with no involvement
of posterior elements.
No nerve root involvement.
Moderate neck rigidity and
persistent soreness.
ii. Posterior element damage with
radiological evidence of moderate
partial dislocation/sub-luxation
including Whiplash injury.
a. With fusion healed, no 10
permanent motor or sensory
changes.
b. Persistent pain with radio- 25
logically demonstrable
instability
iii. Severe Dislocation:
a. Fair to good reduction with or
without fusion with no 10
residual motor or sensory
involvement:
b. Inadequate reduction with
fusion and 15
persistent radicular pain.
3.1.2 Cervical Inter vertebral
Disc Lesions %age of PPI in
relation of Spine
i. Treated case of disc lesion 10
with persistent pain and
no neurological deficit
ii. Treated case with pain 15
and instability
3.1.3. Thoracic and Thoraco-Lumbar Spine
Injuries:
i. Compression of less than 10
50% involving one vertebral
body with no neurological
manifestation
ii. Compression of more than 20
50% involving single vertebra
or more with involvement
of posterior elements,
healed, no neurological
manifestations Persistent pain,
fusion indicated
iii. Same as (b) with fusion, pain 15
only on heavy use of back
iv. Radiologically demonstrable 30
instability with fracture or
fracture dislocation with
persistent pain
3.1.4 Lumbar and Lumbo-sacral Spine:
Fracture
a. Compression of 25% or less 15
of one or two adjacent
vertebral bodies, no definite
pattern or neurological deficit
b. Compression of more than 30
25% with disruption of
posterior elements, persistent
pain and stiffness, healed with
 DISABILITY: ASSESSMENT GUIDELINES AS PER NOTIFICATION 195

or without fusion, inability to 3.2.3 Torso Imbalance: In addition to the

lift more than 10 kgs.
c. Radiologically demonstrable 35
instability in low lumbar or
Lumbo-sacral spine with pain
3.1.5. Disc lesion
a. Treated case with persistent
pain
b. Treated case with pain and
instability.
c. Treated case of disc disease
with pain, activities of lifting
moderately modified
d. Treated case of disc disease
with persistent pain and of
heavy weight stiffness;
aggravated by lifting of heavy
weight, necessitating
modifications of all activities
requiring heavy weight lifting
3.2 Non-Traumatic Lesions:
3.2.1 Scoliosis: Basic guidelines-following
modification is suggested.
The largest structural curve should be
accounted for, while calculating the PPI
and not the compensatory curve or both
structural curves.
3.2.2 Measurement of Spine Deformity:
Cobbs method for measurement of angle
of curve in the radiograph taken in
standing position should be used. The
curves have been divided into following
groups depending upon the angle of major
structural scoliotic deformity.
Group Cobbs Angle PPI in
relation to
Spine
I 0-20 Nil
II 21-50 10%
III 51-100 20%
IV 101 and above 30%
above, PPI should also be evaluated in
relation to torso imbalance. The torso
imbalance should be measured by
dropping a plumb line from C-7 spine and
measuring the distance of plumb line from
gluteal crease.
15
Deviation of Plumb line PPI
20
Up to 1.5 cms 4%
1.5-3.0 cms 8%
3.1-6.0 cms 16%
25
6.1 cms and more 32%
30
ASSOCIATED PROBLEMS WITH SPINE
Guidelines for Evaluation of Permanent Physical
Impairments (PPI) in Neurological Conditions,
may/may not be associated with Spine.
Basic Guidelines
1. Assessment in neurological conditions is not
the assessment of disease but the assessment
of its effects, i.e. clinical manifestations.
2. These guidelines should only be used for
Central and upper motor neuron (UMN)
lesions.
3. Proforma (form A and B) will be utilized for
assessment of lower motor neuron lesions,
muscular disorders and other locomotor
conditions.
4. Normally any neurological assessment for the
purpose of certification has to be done six
months after the onset of disease however
exact time period is to be decided by the
medical doctor who is evaluating the case and
has to recommend the review of certificate
as given in the standard format of certificate.
5. Total percentage of physical impairment in any
neurological condition should not exceed
100%.
6. In mixed cases the highest score will be taken
into consideration. The lower score will be
196 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

added telescopically to it by the help of Paraesthesia Loss of sensation up to

combining formula. 30% depending
7. Additional weightage of 4% will be given for Hands/feet Upon % loss sensation
dominant upper extremity. sensory loss
8. Additional weightage up to 10% can be given
Bladder disability due to neurogenic
for loss of Sensation in each extremity but
involvement
keeping a total 100%.
Bladder Involvement Physical Impairment
Neurological Status Physical Impairment
Altered sensorium 100% Mild (Hesitancy/Frequency) 25%
Moderate (precipitancy) 50%
Intellectual Impairment (to be assessed by
Severe (occasional but recurrent 75%
Psychiatrist/Clinical Psychologist)
incontinence)
Degree of IQ Range Intellectual Very Severe (Retention/total 100%
Mental Impairment incontinence)
Retardation
Post Head Injury Fits and Epileptic
Border line 70-79 25% Convulsions
Mild 50-69 59% Frequency/Severity of Physical
Moderate 35-49 75% convulsions Impairment
Severe 20-34 90%
Mild-occurrence of one Nil
Profound Less than 20 100%
convulsion only
Speech defect PPI Moderate 1-5 convulsions/ 25%
month on adequate medication
Mild dysarthria Nil
Severe 6-10 convulsions/ 50%
Moderate dysarthria 25%
month on adequate medication
Severe dysarthria 50% Very Severe more than 10 fits/ 75%
Cranial Nerve Disability month on adequate medication
Type of Cranial Nerve Physical Ataxia (Sensory or Cerebellar)
Involvement Impairment Severity of Ataxia Physical
Motor Cranial nerve 20% for each nerve Impairment
Sensory Cranial nerve 10% for each nerve Mild (detected on examination) 25%
Moderate 50%
Motor System Disability Hemiperesis
Severe 75%
Neurological Physical Very Severe 100%
Involvement Impairment
4. Guidelines for Evaluation of PPI in cases
Mild 25% of Short Stature/Dwarfism
Moderate 50% 1. Recumbent length or longitudinal height
Severe 75% below 3rd percentile or less than 2 Standard
Sensory System Disability Deviation from the mean is considered to
Anaesthesia Up to 10% for each limb have Short Stature.
Hypoaesthesia Depending upon % of 2. The evaluation of Short Statured person
loss of sensation should be considered only when it is of
 DISABILITY: ASSESSMENT GUIDELINES AS PER NOTIFICATION 197

disproportionate variety and is accom- 4. Every 1 inch. vertical height reduction

panied by an underlying pathological
conditions, e.g. Achondroplasia, Punctate,
Spondyloepiphysal dysplasia, Mucopoly
and chondrosis, etc.
3. The Indian Council of Medical Research
(ICMR) norms as enclosed should be
taken as a guidelines for the height.
should be valued as 4% Permanent
Physical Impairment (PPI).
5. Associated skeletal deformities should be
evaluated separately and total percentage
of both should be added by combining
formula.

ICMR NORMS FOR INDIAN POPULATION

Standing Heights for Indian Population (Inches) Mean and Standard Deviations
Male Female
Age Mean SD 2SD Mean SD 2SD

Less than 3 months 22.113 2.32 17.49 21.65 2.13 17.39

3 months + 24.68 1.58 21.52 23.98 2.40 21.80
6 months + 25.55 3.19 19.17 25.35 1.43 22.49
9 months + 27.36 1.77 23.82 26.26 1.52 23.22
1 year + 29.09 2.07 24.95 28.54 2.04 24.46
2 years + 32.13 2.10 27.93 31.53 2.28 26.97
3 years + 34.96 2.58 29.80 34.33 2.50 29.33
4 years + 37.80 2.65 32.50 37.20 2.50 32.20
5 years + 40.19 3.16 33.84 39.92 2.90 34.12
6 years + 42.71 2.81 37.09 42.28 3.41 35.46
7 years + 44.84 3.41 38.02 44..40 3.34 37.72
8 years + 46.96 2.89 41.18 46.53 3.03 40.47
9 years + 48.70 3.65 41.40 48.38 2.96 42.46
10 years + 48.97 3.93 41.11 50.55 3.15 44.25
11 years + 52.51 3.83 44.86 52.60 3.73 45.14
12 years + 54.45 3.99 46.47 54.80 4.03 46.74
13 years + 56.93 3.84 49.25 56.65 3.63 49.39
14 years + 59.10 3.95 51.20 58.07 3.82 50.43
15 years + 61.22 3.94 53.34 58.89 3.27 52.35
16 years + 62.79 3.84 55.11 59.44 2.80 53.84
17 years + 63.54 4.11 55.32 59.64 2.95 53.74
18 years + 64.21 3.76 56.69 59.72 2.31 55.10
19 years + 64.37 3.79 56.72 59.72 2.31 55.19
20 years + 64.60 2.75 59.10 59.72 2.32 55.08
21 years 64.64 2.40 59.84 60.24 2.24 55.76
198 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

5. Guidelines for Evaluation of PPI in 3. In case of amputation in more than one

Amputees: limb percentage of each limb is added by
combining formula and another 10% will
Basic Guidelines:
be added but when only toes or fingers
1. In case of multiple amputees if the total
are involved only 5% will be added.
sum of permanent physical impairment is
4. Any complication in form of stiffness of
above 100%, it should be taken as 100%
proximal joint, neuroma, infection, etc.
only.
should be given upto a total of 10%
2. If the stump is unfit for fitting the
additional weightage.
prosthesis, additional weightage of 5%
5. Dominant upper extremity should be given
should be added to the value.
4% additional weightage.

Upper Limb Amputations PPI and loss of physical

function each limb

1. Fore-quarter amputation 100%

2. Shoulder Disarticulation 90%
3. Above Elbow upto upper 1/3 of Arm 85%
4. Above Elbow upto lower 1/3 of Arm 80%
5. Elbow disarticulation 75%
6. Below Elbow upto upper 1/3 of Forearm 70%
7. Below Elbow upto lower 1/3 of Forearm 65%
8. Wrist disarticulation 60%
9. Hand through carpal bones 55%
10. Thumb through C.M. or 1st MC joint 30%
11. Thumb disarticulation through MC Joint or phalanx 25%
12. Thumb disarticulation through IP joint or distal phalanx 15%

Index Middle Ring Little

Finger Finger Finger Finger
(15%) (5%) (3%) (2%)

13. Amputation through Prox Phalanx or 15% 5% 3% 2%

Disarticulation through MP
14. Amputation through middle Phalanx or 10% 4% 2% 1%
Disarticulation
through PIP joint
15. Amputation through distal Phalanx or
through DIP joint 5% 2% 1% 1%
 DISABILITY: ASSESSMENT GUIDELINES AS PER NOTIFICATION 199

6 Lower Limb Amputations: 3. In case of amputation in more than one

Basic Guidelines:
1. In case of multiple amputees if the total
sum of permanent physical impairment
is above 100%, it should be taken as
100% only.
2. If the stump is unfit for fitting the
prosthesis, additional weightage of 5%
should be added to the value.
limb percentage of each limb is added
by combining formula and another
10% will be added but when only toes
or fingers are involved only 5% will be
added.
4. Any complication in form of stiffness
of proximal joint, neuroma, infection,
etc. should be given upto a total of 10%
additional weightage.

Lower Limb Amputations PPI and loss of physical function each limb

1. Hind quarter 100%

2. Hip disarticulation 90%
3. Above Knee up to upper 1/3 of thigh 85%
4. Above Knee up to lower 1/3 of thigh 80%
5. Through Knee 75%
6. BK up to 8 cm 70%
7. BK up to lower 1/3 of leg 60%
8. Through Ankle 55%
9. Symes amputation 50%
10. Up to mid-foot 40%
11. Up to fore-foot 30%
12. All toes 20%
13. Loss of first toe 10%
14. Loss of second toe 5%
15. Loss of third toe 4%
16. Loss of fourth toe 3%
17. Loss of fifth toe 2%

7. Guidelines for evaluation of PPI of Congenital Deficiencies of the Limbs.

7.1 Transverse Deficiencies:
1. Functionally congenital transverse limb deficiencies are comparable to acquired amputations
and can be called synonymously as congenital amputation, however, in some cases revision
of amputation is required to fit prosthesis.
2. The transverse limb deficiencies therefore should be assessed on basis of the
guidelines applicable to the evaluation of PPI in cases of amputees as given in the preceding
chapter.
200 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
For example :
Deficiency
1. Transverse deficiency at Arm complete
2. Transverse deficiency at thigh complete
3. Transverse deficiency proximal Upper Arm
4. Transverse deficiency at lower thigh
5. Transverse deficiency fore arm complete
6. Transverse deficiency lower forearm
7. Transverse deficiency Carpal complete
8. Transverse deficiency Metacarpal complete
7.2 Longitudinal Deficiencies:
7.2.1 Basic Guidelines
1. In cases of longitudinal deficiencies of
limbs, due consideration should be
given to functional impairment.
2. In upper limb, loss of ROM, Muscle
Strength and Hand functions like
Prehension, etc. should be tested while
assessing the case for PPI.
3. In lower limb clinical method of
assessing the Stability component and
Shortening of lower limb should be
given due weightage.
4. Apart from functional assessment the
lost joint/part of body should also be
valued as per distribution given in
chapter Guidelines for Evaluation of
PPI in Upper and Lower Extremity.
The values so obtained should be
added with the help of combining
formula.
Example: Congenital absence of Humerus where
Forearm bones directly articulate with Scapula.
There will be mild reduction in ROM and
Strength of muscles in the existing joints apart
from loss of body part.
Loss of shoulder joint can be given-30%
Loss of ROM of Elbow/Shoulder and Wrist
Equivalent to amputation PPI
(Shoulder disarticulation) 90%
(Hip disarticulation) 90%
(Above Elbow amp.) 85%
(Above Knee amp. Lower 1/3) 80%
(Elbow dis-articulation) 75%
(Below Elbow amp) 65%
(Wrist disarticulation) 60%
(Disarticulation through carpal bones) 55%
All the components should be added together
by the combining formula as mention earlier.
7.2.2. In case of loss of single bone in forearm
the evaluation should be based on the
principles of evaluation of Arm compo-
nent which include evaluation of ROM,
Muscle Strength and Coordinated Activi-
ties. The values so obtained should be
added together with the help of
combining formula.
7.2.3. In case of loss of single bone in leg the
evaluation should be based on the princi-
ples of evaluation of Mobility component
and Stability components of the Lower
Extremity. The values obtained should be
added together with the help of combining
formula.
8. Guidelines for Evaluation of Physical
Impairment due to Cardiopulmonary
Diseases.
8.1 Basic Guidelines:
1. Modified New York Heart Association
subjective classification should be
utilized to assess functional disability.
2. The assessing physician should be alert
to the fact that patients who come for
disability claims are likely to exaggerate
 DISABILITY: ASSESSMENT GUIDELINES AS PER NOTIFICATION
their symptoms. In case of any doubt
patients should be referred for detailed
physiological evaluation.
3. Disability evaluation of cardiopul-
monary patients should be done after
full medical, surgical and rehabilitative
treatment available because most of
these diseases are potentially treatable.
4. Assessment of cardiopulmonary impair-
ment should also be done in diseases,
which might have associated cardio-
pulmonary problems, e.g. Amputees,
Myopathies, etc.
5. For respiratory assessment, routine
respiratory functions test should be
done. However, in cases of interstitial
lung diseases, diffusion studies may be
done.
6. In cases of Angina Pectoris (chest pain)
base line studies in resting ECG should
be done. When there is persistence of
symptoms, exercise or stress test should
be done.
8.2 Proposed classification with loss of
function is as follows:
Group 0 : A patient with cardiopulmo-
nary disease who is asympto-
matic (i.e. has no symptoms of
breathlessness, palpitation,
fatigue or chest pain).
Group 1 : A patient with cardiopulmo-
nary disease who becomes
symptomatic during his ordi-
nary physical activity but has
mild restriction (25%) of his
physical activities.
Group 2 : A patient with cardiopul-
monary disease who becomes
symptomatic during his
ordinary physical activity and
201
has 25-50% restriction of his
ordinary physical activities.
Group 3 : A patient with cardiopulmo-
nary disease who becomes
symptomatic during less than
ordinary physical activity so
that his ordinary physical
activities are 50-75% restric-
ted.
Group 4 : A patient with cardiopul-
monary disease who is sympto-
matic even at rest or on mildest
exertion so that his ordinary
physical activity are severely
or completely restricted (75-
100%)
Group 5 : A patient with cardiopul-
monary disease who gets inter-
mittent symptoms at rest
(i.e. patients with Bronchial
Asthma, Paroxysmal nocturnal
dyspnoea, etc.)
MULTIPLE DISABILITIES
1. Definition: Multiple disabilities means a
combination of two or more disabilities as
defined in clause 1 of Section 2 of the Persons
with Disabilities (Equal Opportunities,
Protection of Rights and Full Participation) Act,
1995, namely:
I. Locomotor disability including
leprosy cured
II. Blindness/Low vision
III. Speech and Hearing Impairment
IV. Mental Retardation
V. Mental Illness.
2. Guidelines for Evaluation: In order to
evaluate the multiple disability, the same
guidelines shall be used as have been
developed by the respective sub-committees
of various single disability, viz Mental
202 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
retardation, Locomotor disability, Visual
disability, and Speech and Hearing disability,
and recommended in the meeting held on
29.2.2000 under the chairmanship of Dr. S.P.
Agarwal, Director General of Health Services,
Government of India, with reference to Order
No. 16-18/96-NI.I, dated 28th August, 1998
and communicated to Ministry of Social
Justice and Empowerment, Government of
India, vide letter No. S-13020/4/98-MH, dated
26th March, 2000.
However, in order to arrive at the total
percentage of multiple disability the
combining formula , as given in the Manual
for Doctors to Evaluate Permanent Physical
Impairment developed by Expert Group
meeting on Disability Evaluation, shall be
used, where a will be the higher score and
b will be the lower score. However, the
maximum total percentage of multiple
disabilities shall not exceed 100%.
For example, if the percentage of hearing
disability is 30% and visual disability is 20%,
then by applying the combining formula given
above, the total percentage of multiple
disability will be calculated as follows:
3. Procedure for Certification of Multiple
disabilities: The procedure will remain the
same as has been developed by the respective
sub-committees on various single disabilities
and finalized in a meeting under the
chairpersonship of Dr SP Agarwal held on
29.2.2000. The final disability certificate for
multiple disability will be issued by Disability
Board which has given higher score of
disability by combining the score of different
disabilities using the combining formula, i.e.
a+b (90-a)/90
In case where two scores of disability are
equal, the final certificate of multiple disabi-
lities will be issued by any one of them as
decided by local authority.
 DISABILITY: ASSESSMENT GUIDELINES AS PER NOTIFICATION 203

Annexure-B

STANDARD FORMAT OF THE CERTIFICATE

NAME AND ADDRESS OF THE INSTITUTE/HOSPITAL

ISSUING THE CERTIFICATE

Certificate No. Date .........................................

CERTIFICATE FOR THE PERSONS WITH DISABILITIES

This is to certify that Shri/Smt/Kum .............................................................................................

................................... son/wife/daughter of Shri.........................................................................

............................................ Age ................. yrs old male/female,

Registration No. ................................................ is a case of ....................................................... .

He/She is Physically disabled/Visual disabled/Speech and Hearing disabled and has ................. %

( ........................................................................ percent) permanent (physical visual /speech and

hearing impairment) in relation to his/her .................................................................................... .

Note:
1. This condition is progressive/likely to improve/not likely to improve*
2. Re-assessment is not recommended/ recommended after a period of .............. months/years.*
*Strike out which is not applicable

Sd/- Sd/- Sd/-

(DOCTOR) (DOCTOR) (DOCTOR)
Seal Seal Seal

Signature/Thumb impression of the patient.

Countersigned by the
Medical Superintendent/CMO/Head of
Hospital (with seal)

Recent Attested Photograph

showing the disability affixed here
204 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

Following Format may be used for record of assessment of

PPI of Lower/Upper Ext. Ortho-disability

DISABILITY EVALUATION FORM (DARK-NIOH)

Regd. No. ____________________________ Date _______________ Age / Sex ________________

Name _______________________________ S/o, D/o, W/o _________________________________

Address ______________________________ Diag ________________________________________

Disability (%) __________________________ MI __________________________________________

In Words _____________________________ Validity-Temp/Permanent _______________________

I. Mobility Component (Total Value 90%) for Lower Exteremity

Regd. No. Component Normal Value Rt. Side Lt. Side
(Degree)
Date Joint

I Range of Hip 30% 1. Flexion-Extension arc 0 - 140

Movement 2. Abd - Add arc 0 - 90
(Active) 90% 3. Rotation 0 - 90

Knee 30% 1. Flexion-Extension arc 0 - 125

Ankle 30% 1. Dorsi planterflexion arc 0 - 70
and
Foot 2. Eversion arc 0 - 60

II Muscle Hip 30% 1. Flexor Muscles 0-5

Strength 90% 2. Extensor Muscles 0-5
3. Abductor Muscles 0-5
4. Adductor Muscles 0-5
5. Rotator Muscles External 0-5
Internal 0-5

Knee 30% 1. Flexor Muscles 0-5

2. Extensor Muscles 0-5

Ankle 30% 1. Planterflexor Muscles 0-5

and 2. Dorsiflexor Muscles 0-5
Foot 3. Invertor Muscles 0-5
4. Evertor Muscles 0-5
 DISABILITY: ASSESSMENT GUIDELINES AS PER NOTIFICATION 205

II. Stability Component (90%) 10% given to each Factor:

Yes No With difficulty
1. Walking on plain surface
2. Walking on slope
3. Climbing stairs
Yes = 0, No = 10 4. Standing on both legs
and Partial = 5 5. Standing on affected leg
6. Squatting on floor
7. Sitting cross leg
8. Kneeling
9. Taking turns

III. Additional Weightage (10%) To be given to the following factors:

I Infection Superficial Deep No
II Deformity Functional Non Functional Position No
III Loss of sensation Yes No Partial
IV Pain Yes / Severe No Mild / Mod.
V Shortening 1/2 or Less 1/2- 1 1- 1 1 - 2
VI Complications Superficial Deep No

Total = Stability + Mobility (by combining formula) + Additional weightage

Name ___________________________ Signature _________________

206 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

DISABILITY EVALUATION FORM (DARK-NIOH)

ORTHO-DISABILITY
Regd. No. ____________________________ Date _______________ Age / Sex ________________

Name ________________________________ S/o, D/o, W/o _________________________________

Address ______________________________ Diag ________________________________________

Disability (%) __________________________ MI __________________________________________

In Words _____________________________ Validity-Temp/Permanent ________________________

Date For Upper Extremity Disability Assessment Proforma

Regd. No. Component Total Component Normal Value Rt. Side Lt. Side
ARM Value 90% (Degree)

I Range of Shoulder A 1. Flexion-Extension arc 0 - 220

Movement 2. Rotation arc 0 - 180
(Active) 3. Abd-Adduction arc 0 - 180

Value 90% Elbow B 1. Flexion-Extension arc 0 - 150

2. Supi-pronation arc 0 - 180
Wrist C 1. Dorsifle-Palmarflex arc 0 - 160
2. Rad-Ulnardeviation arc 0 - 55
II Muscle Shoulder D 1. Flexion 0-5
Strength 2. Extension 0-5
Value 3. Rotation - Ext 0-5
90% 4. Rotation - Int. 0-5
5. Abduction 0-5
6. Adduction 0-5

Elbow E 1. Flexion 0-5

2. Extension 0-5
3. Pronation 0-5
4. Supination 0-5
Wrist F 1. Dorsiflexion 0-5
2. Palmar flexion 0-5
3. Radial deviation 0-5
4. Ulnardeviation 0-5
 DISABILITY: ASSESSMENT GUIDELINES AS PER NOTIFICATION 207

Regd. No. ARM Component Component Yes = 0 Normal Loss of % Loss of %

Date No =, Partial = 4.5 Value Rt. Side Lt. Side
(Degree)

Coordinated activities 1. Lifting overhead object 0 - 9% Yes No Partial Yes No Partial

value 90% G remove and placing at
same time
2. Touching nose with end 0 - 9%
of the extremity
3. Eating Indian style 0 - 9%
4. Combing and plaiting 0 - 9%
5. Putting on shirt/kurta 0 - 9%
6. Ablution Indian style 0 - 9%
7. Drinking glass of water 0 - 9%
8. Buttoning 0 - 9%
9. Tie Nara/Dhoti 0 - 9%
10. Writing 0 - 9%

30% H 1. Hand Yes = 0, No = 2, 5, 3, 5 Normal Yes No Partial Yes No Partial

Prehension Movement Partial = 1, 2, 5, 1.5, 2.5 Value

A. Opposition 1. Index 2
(8%) 2. Middle 2
B. Lateral Pinch 3. Ring 2
(5%) 4. Little Key Holding 2
C. Cylindrical
grasp
D. Spherical
grasp
E. Hook grasp
2. Sensation 5
a. Large object (4) 3
b. Small object (1) 3

a. Large object (4) 3

b. Small object (1) 3
Lifting Bag 5 Yes No Partial Yes No Partial
30% Thumb radial side 4.8
30% Yes = 0 Thumb ulnar side 1.2
208 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

Sensations No = 4.8 and 1.2 Index radial side 4.6

Partial = 2.4 and 0.6 Index ulnar side 1.2
Middle radial side 4.8
Middle ulnar side 1.2
Ring radial side 4.8
Ring ulnar side 1.2
Little radial side 4.8
Little ulnar side 1.2
30% J 3. Strength 1. Grip Strength 20% Yes No Partial Yes No Partial
30% 2. Pinch Strength 10%

Additional Weightage 10% To be given to the following factors:

1. Infection Superficial Deep No
2. Deformity Func Nonfunc No
3. Malalignment Func Nonfunc No
4. Contractures Acceptable Non-acceptable Normal
5. Cosmetic Appearance Acceptable Non-acceptable Normal
6. Abnormal Mobility Acceptable Non-acceptable No
7. Extremity Dominant Non-
Dominant

Total = Disability % of Additional weightage

Name ___________________________

Signature ________________________
CHAPTER 27

Multiple Choice Questions

and Answers
AK Agarwal
210 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

1. Types of Disability as per PWD Act 1995? 10. When KAFO is being prescribed?
a. 4 types b. 5 types a. When all muscles around hip, knee and ankle
c. 6 types d. 7 types are weak
b. When all muscles around knee and ankle are
2. Polio is prevented by:
weak only
a. Vitamin A b. Protein c. When all muscles around ankle are weak only
c. Vitamin D d. Polio drops d. All above
3. Accident leads to which type of disability? 11. When HKAFO is being prescribed?
a. Amputation b Stiffness of joints a. When all muscles around hip, knee and ankle
c. Deformity d. All above are weak
4. Polio drops is given in which group? b. When all muscles around knee and ankle are
weak only
a. 0 to 5 years b. 6 to 10 years
c. When all Muscles around ankle are weak
c. 10 to 15 years d. Above 15 years
only
5. Vitamin D deficiency leads to: d. All above
a. Night blindess b. CP
12. Which is the example of ball and socket?
c. Rickets d. Brainfever
a. Hip joint b. Knee joint
6. Which disease is caused by deficiency of c. Ankle joint d. Elbow joint
Vitamin A?
13. Which is the example of Hinge joint?
a. Rickets b. Night blindness
a. Hip joint b. Knee joint
c. Brainfever d. CP
c. Shoulder joint d. Ankle joint
7. Write types of Polio virus?
14. How many vertrebrae are in the spinal column?
a. Type I b. Type II
a. 33 b. 34
c. Type III d. All above
c. 35 d. 36
8. Caliper is usually given in which stage of Polio?
15. How many parts are in the Spinal Column?
a. Acute stage b. Recovery stage
a. 3 b. 4
c. Residual stage d. All above c. 5 d. 6
9. When BK Caliper is being prescribed? 16. Rickets is due to deficiency of:
a. When all muscles around hip, knee and ankle a. Protein b Carbohydrate
are weak c. Fat d. Vitamin D
b. When all muscles around knee and ankle are
weak only 17. Which disease causes nonhealing ulcer of foot?
c. When all muscles around ankle are weak only a. Diabetes b. Leprosy
d. All above c. MMC d. All above

Answers 1. d. 7 types 2. d. Polio drops 3. d. All above 4. a. 0 to 5 yr 5. c. Rickets

6. b. Night 7. d. All above 8. c. Residual 9. c. ankle 10. b. knee
11. a. hip 12. a. Hip joint 13. b. Knee joint 14. a. 33 15. c. 5
16. d. Vitamin D 17. d. All above
 MULTIPLE CHOICE QUESTIONS AND ANSWERS 211
18. Foot Drop is due to which disease? 26. Which brace is given in place of Taylors brace
a. Polio b. Leprosy presently?
c. CP d. All above a. ASH Brace
19. When PTB prosthesis is being prescribed? b. Milwaukee Brace
a. AK stump b. BK stump c. SOMI Brace
c. TK stump d. All above d. Lumbo-saccral -corset

20. When Symes prosthesis is being prescribed? 27. The artificial limb has been named as capital of
a. AK Stump b. BK Stump which State in India?
c. TK Stump d. Symes stump a. Uttar Pradesh b. Bihar
c. Rajasthan d. Maharashtra
21. When AK prosthesis is being prescribed?
a. AK Stump b. BK Stump 28. The artificial limb is famous in the name of
c. TK Stump d. All above which Capital city in India?
22. Which spinal brace is being prescribed for a. Lucknow b. Delhi
scoliosis? c. Jaipur d. Mumbai
a. ASH brace 29. Name the material which is used in Jaipur limb?
b. Milwaukee brace a. Wood b. Rubber
c. Taylors brace
c. Plastic d. Aluminium steel
d. Lumbo-saccral-corset
30. Name the wood which is most suitable for
23. Which spinal brace is being prescribed for
fabrication of prosthesis?
Kyphosis?
a. ASH brace a. Mango b. Neem
b. Milwaukee brace c. Peple d. Tun
c. Taylors brace 31. What are the characteristics of Jaipur foot?
d. Lumbo-saccral-corset
a. Shape is like foot
24. Which Brace is being prescribed presently in b. Used without shoe
place of Milwaukee Brace? c. Water resistant
a. ASH brace d. All above
b. Underarm plastic spinal brace
c. Taylors brace 32. Which material is being used in fabrication of
d. Lumbo-saccral-corset artificial limb?
a. Wood b. Resin
25. Which brace is given to stop movements of
c. Leather d. All above
cervical spine?
a. Cervical collar 33. When AK weight relieving Caliper is being
b. Corrective collar prescribed?
c. SOMI brace a. Hip lesion b. Shoulder lesion
d. Taylors brace c. Elbow lesion d. Ankle lesion

Answers 18. d. All above 19. b. BK stump 20. d. Symes stump 21. a. AK Stump 22. b. Milwaukee
23. a. ASH 24. b. UPSB 25. c. SOMI 26. a. ASH Brace 27. c. Rajasthan
28. c. Jaipur 29. d. Aluminium 30. d. Tun 31. d. All above 32. d. All above
33. a. Hip
212 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

34. In which state, incidence of upper limb c. Mental illness

amputation is maximum? d. Hearing disability
a. Punjab b. West Bengal 44. In which year PWD-Act was made?
c. Kerala d. Andhra Pradesh
a. 1994 b. 1995
35. What is the natural source of Vitamin D? c. 1996 d. 1997
a. Water b. Sunlight 45. Bamboo is used in making which Rehabili-
c. Air d. Mountain tation appliances?
36. What is needed for absorption of Calcium? a. Caliper b. Prosthesis
a. Vitamin A b. B Complex c. Axillary crutches d. All above
c. Vitamin D d. Vitamin E
46. How CP is being recognized?
37. What are the deformities of spine? a. Spasticity in limb b. Scissor gait
a. Kyphosis b. Scoliosis c. Delayed milstones d. All above
c. Lordosis d. All above
47. AK Extension orthosis is being prescribed in
38. What are the methods of Disability Prevention which disease?
in general? a. Polio
a. One method b. Two method b. CP
c. Three method d. four method c. Brain fever
d. Congenital limb deficiency
39. What material is being used in fabrication of
the artificial limb? 48. Brail is used by whom?
a. Metal b. Resin a. Mental retardation
c. HDPE d. All above b. Locomotor handicapped
c. Speech and hearing handicapped
40. What is the etiology of Leprosy?
d. Visually handicapped
a. Virus b. Bacteria
c. Lack of Vitamin d. Fungus 49. What should not be done in Acute polio-
myelitis?
41. What are the early symptoms in Leprosy?
a. Massage b. Injection
a. Hypopigmented anesthetic patch c. Active exercise d. All above
b. Loss of sensation
c. Thickening of peripheral nerves 50. In which lesions CP like presentation is seen?
d. All above a. Birlh asphexia b. Brain fever
c. Head injury d. All above
42. Name the rehabilitation aids given to leprosy
case? 51. What are the facilities available to handi-
a. Caliper b. Prosthesis capped?
c. Hand splint d. All above a. Concession in rail journey
43. Which type of disability is in leprosy? b. Reservation in service
c. free aids/appliances to poor disabled
a. Mental Retardation
d. All above
b. Leprosy cure

Answers 34 . a. Punjab 35 . b. Sunlight 36 . c. Vitamin D 37 . d. All above 38 . c. Threemethod

39 . d. All above 40 . b. Bacteria 41 . d. All above 42 . d. All above 43 . b. Leprosy
44 . b. 1995 45 . d. All above 46 . d. All above 47 . d. Congenital 48 . d. Visually
49 . d. All above 50 . d. All above 51 . d. All above
 MULTIPLE CHOICE QUESTIONS AND ANSWERS 213
52. Which appliances is given in case of foot drop? 59. After correction in case of CTEV (1112
a. AFO b. PTB prosthesis Months) which of the following advised?
c. HKFO d. Taylors Brace a. Night boot b. Day shoe
c. Exercises d. All above
53. What is the shoe alteration in pes planus?
a. TCE heel with Medial heel wedge 60. What is being prescribed for Pes planus?
b. Foam in heel a. TCE Heel with medial heel wedge
c. MT pad b. Valgoid insole
d. MT bar c. Exercise
d. All above
54. What is being given in painful heel?
a. TCE heel with medial heel wedge 61. What is being prescribed for pes cavus?
b. Foam in heel a. MT pad
c. MT pad b. Heel foam
d. MT Bar c. TCE heel with MHW
d. Lateral heel wedge
55. What is being prescribed for Anterior
metatarsalgia ? 62. What is being given in a case of wrist drop?
a. TCE heel with medial heel wedge a. Cock-up splint
b. Heel foam b. Abductor splint
c. Metatarsal pad c. Opponens splint
d. Valgoid in sole d. Knuckle duster hand splint
56. What is being prescribed for knock knee? 63. What are the causes of wrist Drop?
a. Medial heel wedge a. Wrong injection in a nerve
b. Lateral heel wedge b. Injury to nerve
c. Posterior heel wedge c. Leprosy
d. All above d. All above
57. What is shoe alteration for Genu Vara? 64. What is the cause of claw hand?
a. Medial Heel wedge a. Leprosy b. Rickets
b. Lateral Heel wedge c. Tuberculosis d. All above
c. Posterior Heel wedge 65. Name the material used in fabrication of cock-
d. All above up splint?
58. When day shoe is given in correction of CT EV a. Plastic b. Metal
case? c. POP d. All above
a. 03 months 66. What are the modalities of treatment used in
b. 46 months claw hand?
c. 710 months
d. 11 months a. Hand splint b. Physiotherapy
c. Surgery d. All above

Answers 52. a. AFO 53. a. TCE heel 54. b. Foam in 55. c. Metatarsal 56. a. Medial
57. b. Lateral 58. d. 11 Months 59. d. All above 60. a. TCE 61. a. MT pad
62. a. Cock 63. d. All above 64. a. Leprosy 65. d. All above 66. d. All above
214 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

67. What are the modalities of treatment used in c. AK stump should be 1/2 of normal thigh
wrist drop? d. AK stump should be 1/4 of normal thigh
a. Cock-up splint b. Physiotherapy 75. How PTB prosthesis is attached to body?
c. Surgery d. All above
a. Thigh corset b. Brim contour
68. What are the characteristics of good stump? c. Supracondylar d. All above
a. Proper size of stump
76. How AK prosthesis is attached to body?
b. Firm musculature in stump
c. No deformity a. Selesian belt
d. All above b. Pelvic belt with hip joint
c. Suction valve
69. What are the characteristics of bad stump? d. All above
a. Painful and improper size
77. Which prosthesis is given for BK stump?
b. Loose musculature of stump
c. Deformed stump a. PTB prosthesis
d. All above b. PTB prosthesis with thigh corset
c. Bent knee prosthesis
70. What are the common causes of amputation? d. All above
a. Accidents
b. Cancer 78. Name the material used in fabrication of
c. Lack of blood supply Jaipur Limb?
d. All above a. Wood b. Aluminium
c. Bamboo d. Copper
71. How to achieve maturation in the stump?
a. Stump strapping b. Stump exercises 79. Name the prosthesis given to ideal BK stump?
c. Stump training d. All above a. PTB prosthesis
b. PTB prosthesis with thigh corset
72. In which of the following stump weight bearing c. Bent knee prosthesis
is taken on distal end of the stump? d. PTB symes prosthesis
a. Symes and TK stump
b. BK stump 80. Write full name of SACH Foot?
c. AK stump a. Solid ankle cushion heel
d. All above b. Solid ankle cavus heel
c. Straight ankle cushion heel
73. What should be ideal length of BK stump in
d. Solid ankle cushioned heel
case of 6 feet height?
a. 10 long from joint line 81. How many parts are in a AK prosthesis?
b. 8 long from joint line a. 6 parts b. 7 parts
c. 6 long from joint line c. 8 parts d. 9 parts
d. 4 long from joint line
82. How many parts are in a PTB prosthesis?
74. What should be ideal length of AK stump? a. 4 parts b. 5 parts
a. AK stump should be 2/3 of normal thigh c. 6 parts d. 7 parts
b. AK stump should be 1/3 of normal thigh

Answers 67. d. All above 68. d. All above 69. d. All above 70. d. All above 71. d. All above
72. a. Symes 73. c. 6 long 74. b. AK stump 75. d. All above 76. d. All above
77 . d. All above 78 . b. Aluminium 79 . a. PTB 80 . a. Solid 81 . a. 6 parts
82. a. 4 parts
 MULTIPLE CHOICE QUESTIONS AND ANSWERS 215

83. Which prosthesis is given for bad BK stump? 91. Maximum calcium is present in which of the
a. PTB prosthesis with thigh corset following eatable:
b. Bent knee prosthesis a. Butter milk b. Curd
c. PTB prosthesis c. Cow milk d. Cheese paneer
d. All above 92. Maximum calcium is present in which of the
84. Pathological fractures are seen in which of the following dry fruits?
following? a. Almond b. Cashew nuts
a. Bone tumor b. Osteoporosis
c. Osteomylitis d. All above c. Walnut d. Groundnut

85. Which of the following splints are used in First 93. Which of the following modality is used to
correct the deformity?
Aid?
a. Physiotherapy b. POP
a. Lateral elbow splint
c. Surgery d. All above
b. Long liston splint
c. Posterior leg splint with foot piece 94. Which of the following bone surgery is done
d. All above to correct the deformity?
a. Osteotomy b. Arthrodesis
86. What precautions are being taken in
c. Arthroplasty d. All above
splinting?
a. Keep cotton/foam on joints 95. What are the common causes of deformity after
b. Bandage should neither be tight nor loose birth?
c. Acting movements of fingers/toes a. Accidents
d. All above b. Nutritional deficiency
c. Rh arthritis
87. Low cost splints are made of? d. All above
a. Wood b. Steel
96. Which joint is involved in genu recurvatum?
c. Aluminium d. Copper
a. Knee b. Shoulder
88. What are common causes of accidents? c. Hip d. Wrist
a. Rail road b. Agriculture 97. What is being done in bariatric surgery?
c. Earthquake d. All above
a. Gastric bypass
89. Obstetric Paralysis is seen: b. Stappling
a. Upper cord b. Lower cord c. Removal of a portion of stomach
c. Whole limb d. All above d. Use of inflatable silicone band around top
of stomach
90. What are the treatment modalities in obstetric
paralysis? 98. Which of the following deformity occur since
birth?
a. Physiotherapy b. Splints
c. Surgery d. All above a. CTEV b. CDH
c. Phocomelia. d. All above

Answers 83. a. PTB 84. d. All above 85. d. All above 86. d. All above 87. b. Steel
88. d. All above 89. d. All above 90. d. All above 91. d. Cheese 92. d. Ground
93. d. All above 94. d. All above 95. d. All above 96. a. Knee 97. d. Use of
98. d. All above
216 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

99. Manus varus is seen in which joint? 108. Amputation is seen maximum in which of the
a. Wrist b. Elbow following?
c. Hip d. Knee a. Single b. Double
c. Triple d. All 4 limbs
100. Cubitus varus is seen in which joint?
a. Wrist b. Elbow 109. Amputation is seen maximum in which limb?
c. Hip d. Knee a. Upper limb. b. Lower limb
c. Equal in both d. All above
101. Tallipes word is used for which joint?
a. Ankle b. Knee 110. Amputation is maximum due to which cause?
c. Hip d. Shoulder a. Accident b. Tumor
c. Vascular d. Infection
102. Genu varum denotes deformity of which joint?
a. Hip b. Knee 111. Wrist drop is due to:
c. Ankle d. All above a. Radial nerve injury
b. Median nerve injury
103. Coxa vara denotes deformity of which joint?
c. Ulnar nerve injury
a. Hip b. Knee d. None as above
c. Ankle d. Shoulder
112. What is full name of AIDS?
104. Which of the following disability is maximum
a. Acquired immuno deficiency syndrome
in India?
b. Acquired immuno defective syndrome
a. Locomotor c. Acquired immuno deformity syndrome
b. Visually handicapped d. None as above
c. Hearing
d. Mental retardation 113. What is full name of HIV?
a. Human immuno virus
105. What is the full name of CAD?
b. Hereditary immuno virus
a. Computer added design c. Human immuno deficiency virus
b. Computer assisted design d. All above
c. Computer and design
d. Computer and diagram 114. What is commonest presentation of PPRP in
lower limb?
106. What is the full name of CAM?
a. Flexion, abduction and Ext. Rot, at hip
a. Computer added making b. Flexion at knee
b. Computer and making c. Equinus at ankle
c. Computer added manufacturing d. All above
d. Computer and make
115. What is the commonest presentation in CP?
107. Amputation is seen maximum in which of the
a. Spastic
following:
b. Flaccid
a. Male b. Female c. Ataxia
c. Equal in both d. All above d. Mixed

Answers 99. a. Wrist 100. b. Elbow 101. a. Ankle 102. b. Knee 103. a. Hip
10 4. a. Locomotor 10 5. a. design 10 6. c. Manufac. 10 7. a. Male 10 8. a. Single
10 9. b. Lower limb 11 0. a. Accident 11 1. a. Radial 11 2. a. Deficiency 11 3. c. Deficiency
114. d. All above 115. a. Spastic
 MULTIPLE CHOICE QUESTIONS AND ANSWERS 217
116. Incidence of sero negative Rh. Arthritis? 125. PTB Brace is advised in case of:
a. 0-25% b. 25-50% a. BK amputee b. Plantar ulcer
c. 50-70% d. Above 75% c. Syme amp d. All above
117. Contraindication of SWD. 126. Calcium is maximum in which vegetable?
a. Sensory impairment a. Methi b. Palak
b. Metal implant c. Cauliflower d. Anjeer
c. Ischaemic tissue
127. Buergers disease is due to which of the
d. All above
following?
118. Milwaukee brace is known by: a. Protein
a. Name of author b. Name of hospital b. Fat
c. Name of place d. Name of material c. Smoking
d. All above
119. Denis Brown splint is given in which case?
a. CTEV b. CDH 128. Common causes of osteoporosis?
c. Vertical talus d. Genu vara a. Disuse
b. Deficiency of calcium
120. de-Quervain disease involves:
c. Drug
a. Tendons of ABD PL and EPB d. All above
b. ECRL
c. ECU 129. Which of the following drug causes
d. EPL Osteoporosis?
a. Heparin
121. Which is not NSAID in the following?
b. Methotrexate
a. Ibuprofen b. Indomethacin c. Glucocorticoids
c. Ieflunomide d. All above d. All above
122. Which is NSAID in the following? 130. Which of the following endocrine abnormalities
a. Ibuprofen b. Indomethacin cause osteoporosis?
c. Celecoxib d. All above a. ACTH
123. Early loss of ROM in PA shoulder? b. Estrogen deficiency
a. Initial ROM b. Middle ROM c. Testosterone deficiency
c. Terminal ROM d. All above d. All above

124. What is involved in tennis Elbow? 131. Vitamin D supplementation is advised:

a. Medial epicondyle of humerus a. During chemotherapy
b. Lateral epicondyle of humerus b. During anti seizure therapy
c. Radial styloid c. During ATT
d. Ulnar styloid d. All above

Answers 116. a. 0-25 % 117. d. All above 118. c. Name of place 119. a. CTEV 120. a. Tendons
121. c. Ieflunomide 122. d. All above 123. c. Terminal ROM 124. a. Medial 125. b. Plantar
126. a. Methi 127. c. Smoking 128. d. All above 129. d. All above 130. d. All above
131. d. All above
218 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

132. What is Mallet finger? 139. Causes of AIDS?

a. Avulsion of long extensor tendon at DIP Joint a. Infected Blood b. Infected needle
of finger c. Multiple partners d. All above
b. Avulsion of long flexor tendon at DIP joint of
140. How AIDS can be avoided?
finger
c. Both above a. Safe sex
d. None above b. Use disposable needle
c. Proper and safe blood transfusion
133. What is the deformity in the mallet finger? d. All above
a. Flexion at DIP joint
141. HIV is not spread by:
b. Flexion at PIP joint
c. Hyper extension at PIP joint a. Sharing toilets
d. All above b. Mosquito bite
c. Using same utensils
134. What is the Trigger thumb? d. All above
a. Stenosing tenovaginitis of FPL
142. In which of the following game, calorie
b. Stenosing tenovaginitis of EPL
expenditure is maximum?
c. Stenosing tenovaginitis of FPB
d. Stenosing tenovaginitis of EPB a. Table tennis b. Golf
c. Badminton d. Squash
135. What is the deformity in trigger thumb?
143. In which of the following activities calorie
a. Flexion deformity at IP joint of thumb?
expenditure is maximum?
b. Hyper extension at IP joint
c. Both above a. Strolling (1 mph) b. Walking (3 mph)
d. None above c. Running (5.5 mph) d. Cycling (10 mph)

136. Treatment of trigger finger? 144. Aims of reconstructive surgery in leprosy?

a. Injection HC b. Surgery a. To correct deformity of hand and feet
c. Physiotherapy d. All above b. To reduce social stigma
c. To help in closing of eyes
137. Treatment of mallet finger? d. All above
a. Immobilization b. Surgery
145. How much off loading occurs while using foot
c. All above d. None
wear?
138. What is full name of LASER? a. 5% b. 10%
a. Light amplification by stimulated emission c. 20% d. 25%
of radiation
146. Which of the following nerve shows entrap-
b. Low amplification by stimulated emission of
ment?
radiation
c. Least amplification by stimulated emission a. Median nerve
of radiation b. Ulnar nerve
d. None above c. Radial nerve
d. All above

Answers 13 2. a. Avulsion 13 3. a&c. Flexion 13 4. a. Stenosing 13 5. a. Flexion 13 6. d. All above

13 7. c. All above 13 8. a. Light 13 9. d. All above 14 0. d. All above 14 1. d. All above
142. d. Squash 143. c. Running 144. d. All above 145. d. 25% 146. d. All above
 MULTIPLE CHOICE QUESTIONS AND ANSWERS 219
147. Saturday night palsy is due to involvement of 154. What are the types of contractions?
which nerve in upper limb? a. Isometric b. Isotonic
a. Median nerve b. Ulnar nerve c. Eccentric d. All above
c. Radial nerve d. All above
155. Extension/hyper extension occurs maximum at
148. Carpal Tunnel syndrome is due to entrapment which area of spine?
of which nerve? a. Cervical b. Dorsal
a. Median nerve b. Ulnar nerve c. Lumbar d. All above
c. Radial nerve d. All above
156. What is the full name of ADL ?
149. Ulnar neuropathy occurs at which of the a. Activities of daily life
following site: b. Adaptation in daily life
a. In palm b. At wrist c. Action of daily life
c. At elbow d. All above d. All above
150. Tarsal Tunnel syndrome occurs due to 157. What are the indication of hemispiral AFO
entrapment of which nerve? (Plastic)?
a. Posterior tibial nerve a. Weakness of evertors and dorsiflexor of foot
b. Femoral nerve b. Moderate spasticity
c. Peroneal nerve c. Medio-lateral instability
d. All above d. All above
151. Compression neuropathy of common 158. What are the contraindications of hemispiral
personal nerve occurs due to which of the AFO (Plastic)?
following cause? a. Severe spasticity b. Fluctuating edema
a. Direct trauma b. Fixed deformity d. All above
b. Tight plaster cast
159. What are the indications of AFO (Plastic)?
c. Prolong cross legged sitting
d. All above a. Flail foot
b. Severe spasticity
152. The Pyrisformis syndrome is due to c. Adequate hip and knee strength
compression of which nerve? d. All above
a. Sciatic nerve b. Femoral nerve
160. Automatic hyperreflexia occurs in SCI cases
c. Post tibial nerve d. All above
having lesion.
153. Which of the following test is most sensitive a. Above D5 b. Between D5-D12
test for CTS? c. D/L junction d. Below LI
a. Radiology
161. Diagnosis of autonomic hyperrflexia is based
b. Blood test
on:
c. Sensory fiber conduction
d. All above a. High BP b. Severe sweating
c. Bradycardia d. All above

Answers 147. c. Radial Nerve 148. a. Median 149. d. All above 150. a. Posterior 151. d. All above
152. a. Sciatic 153. c. Sensory 154. d. All above 155. c. Lumbar 156. a. Activities
15 7. d. All above 15 8. d. All above 15 9. d. All above 16 0. a. Above D5 16 1. d. All above
220 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

162. What are the objectives of Physical Medicine 169. Which of the following material is thermo-
in the treatment of degenerative joint plastics?
discover? a. Cellulose b. Acrylic resins
a. Relief of pain c. Polyethylene d. All above
b. Maintenance of ROM of joints and muscle
170. Prolonged bed rest leads to which of the
power around joint
following disorder?
c. Off loading against wear and tear
d. All above a. Osteoporosis
b. Loss of muscle tone
163. Milkman Syndrome, triradiate pelvis, c. Negative nitrogen balance
fractures and biconcave vertebra are seen in d. All above
which of the following disease?
171. Which of the following is primary disability?
a. Osteomalacia b. AS
c. Rh Arthritis d. All above a. Paraplegia due to SCI
b. Quadriplegia due to SCI
164. CPK is raised in which of the following c. Hemiplegia due to cerebral vascular
condition? accidents
a. Myopathy b. SCl d. All above
c. AS d. All above
172. Which of the following gait is advised for a
165. Stereotactic technics is being used in which of case having inability to bear full weight on
the following disease. both legs?
a. Parkinsonism b. SCI a. Four point gait b. Three point gait
c. AS d. All above c. Swing-through gait d. All above
166. Which of the following drug used during 173. For every additional half inch shortening
pregnancy causes congential Limb deficiency. what percentage of disability is given ?
a. Thalidomide b. PCM a. 4% b. 5%
c. Vitamin D d. Calcium c. 6% d. 7%
167. A case of CTEV is often associated with which 174. What percentage of disability is given for
of the following defects? everyone inch vertical height reduction?
a. MMC b. Cleft lip a. 4% b. 8%
c. CDH d. All above c. 12% d. 16%
168. Which of the following material is thermo- 175. What are the presentation of post polio
setting plastics? syndrome?
a. Phenolics a. Weakness of muscles
b. Melamine b. Fatigue
c. Epoxies c. Pain
d. All above d. All above

Answers 16 2. d. All above 16 3. a. Osteomalacia 16 4. a. Myopathy 16 5. a. Parkinsonism 16 6. a. Thalidomide

167. d. All above 168. d. All above 169. d. All above 170. d. All above 171. d. All above
172. c. Swing 173. a. 4% 174. a. 4% 175. d. All above
 MULTIPLE CHOICE QUESTIONS AND ANSWERS 221
176. In Golfers elbow which part of lower end of c. Unreduced posterior dislocation of hip
humerus is involved? d. All above
a. Medial epicondyle b. Lateral epicondyle 183. What are the causes of localized increase of
c. Olecranon process d. All above dorsal kyphosis?
177. How walker improves balance? a. Traumatic b. Potts disease
a. By increasing base of support c. Secondaries d. All above
b. By supporting weight of the patient 184. What are the causes of generalized increase
c. By increasing lateral instability in dorsal kyphosis?
d. All above
a. AS b. Osteomalacia
178. Which of the following is the complication of c. Pagets disease d. All above
axillary crutch?
185. What are the signs of gangrene?
a. Brachial plexus injury
a. Loss of temperature and pulsation
b. Suprascapular, radial and ulnar nerve
b. Loss of sensation and function
injury
c. Change of color
c. Axillary artery injury
d. All above
d. All above
186. Perthes test (Modified) is performed to
179. Which of the following gait is advised for a
determine status of which of the following?
case having inability to bear full weight on
one leg? a. Deep veins b. Artery
c. Lymphatics d. All above
a. Four point gait b. Three point gait
c. Two point gait d. Swing to gait 187. The position of Policeman receiving a tip
indicates involvement of which part of brachial
180. What is Housemaids knee?
plexus ?
a. Pre-patellar bursitis
a. C5, 6 b. C8 T1
b. Infrapatellar bursitis
c. C5, 6, 7, 8 and T1 d. All above
c. Subsartorial bursitis
d. All above 188. Book test is performed for which nerve in the
hand?
181. Triple displacement of knee is seen in which
of the following? a. Median nerve
b. Ulnar nerve
a. Tuberculosis of knee
c. Radial nerve
b. Suppurative arthritis of knee
d. None
c. Both above
d. None 189. Pen test is used to test which Nerve in the hand?
182. What are the causes of increase lumbar a. Median nerve
lordosis? b. Ulnar nerve
c. Radial nerve
a. Fixed flexion deformity of hip
d. None
b. TB hip

Answers 17 6. a. Medial... 17 7. d. All above 17 8. d. All above 17 9. b. Three point... 18 0. a. Pre...

18 1. c. Both above 18 2. d. All above 18 3. d. All above 18 4. d. All above 18 5. d. All above
18 6. a. Deep veins 18 7. a. C5, 6 18 8. b. Ulnar nerve 18 9. a. Median nerve.
222 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

190. Winging of scapula occurs due to involvement 198. In Kohlers disease which tarsal bone is
of which Nerve ? involved?
a. Axillary nerve b. Long thoracic nerve a. Calcaneum b. Talus
c. Radial nerve d. Median nerve c. Cuboid d. Navicular
191. Ape-thumb deformity is due to involvement 199. In Mortons metatarsalgia, which planter
of which nerve? digital nerve is commonly involved ?
a. Median N b. UInar nerve a. Ist digital nerve b. 2nd digital nerve
c. Radial nerve d. Axillary N c. 3rd digital nerve d. 4th digital nerve
192. Mc Murrays test is performed to assess 200. Complete claw hand is due to involvement of
damage of which structure in knee joint? which nerve?
a. Median semilunar cartilage a. Ulnar b. Median
b. Lateral semilunar cartilage c. Ulnar and median d. Radial
c. Ant cruciate ligament
201. In Dupuytrens contracture which finger is
d. Posterior cruciate ligament
commonly involved?
193. Anterior Drawers test is performed to assess a. Index b. Middle
damage of which structure in knee joint? c. Ring d. Little
a. Median semilunar cartilage
202. Which one of the following electrophysio-
b. Lateral semilunar cartilage
logical tests is not useful to measure the
c. Anterior cruciate ligament
degree of spasticity?
d. Posterior cruciate ligament
a. The conduction velocity of the peroneal
194. In Painful are syndrome of shoulder which nerve
range in painful? b. The F wave
a. Initial range b. Mid range c. The flexor withdrawal responses
c. Extreme range d. All above d. The tonic vibration reflex
e. The H reflex
195. In Carrying angle measurement of which joint
is done ? 203. Which one of the following is not included in
a. Elbow b. Wrist the criteria for the diagnosis of complex
c. Shoulder d. All above regional pain syndrome?
a. Pain that develops after an initial event that
196. In March or stress fracture which metatarsal
may or may not have been traumatic
is affected commonly?
b. Distribution of the painful area is limited to
a. First MT b. Second MT the distribution of a simple peripheral nerve
c. Third MT d. Fourth MT c. History of edema, skin blood flow abnorma-
197. In Severs disease which tarsal bone is involved? lities or sudomotor abnormalities in the
a. Calcaneum b. Talus painful region
c. Cuboid d. None d. No other concomitant conditions account for
the pain
e. Hyperalgesia or spontaneous pain is present

Answers 19 0. b. Long thor... 19 1. a. Median N 19 2. a. Median... 19 3. c. Anterior... 19 4. b. Mid range

19 5. a. Elbow 19 6. b,c. 19 7. a. Calcaneum 19 8. d. Navicular 19 9. c. 3rd digital
20 0. c. Ulnar 20 1. c. Ring 20 2. a. The cond... 20 3. e. Hyperalgesia.
 MULTIPLE CHOICE QUESTIONS AND ANSWERS 223
204. When measuring the range of motion of the 208. Regarding therapeutic exercise, only one of
wrist flexion, one uses: the following is correct.
a. The sagittal plane a. Low repetition and high resistance increase
b. The transverse plane endurance in isotonic exercise
c. The frontal plane b. High repetition and low resistance increase
d. The axis on the ventral surface of the wrist strength in isotonic exercise
e. The shaft parallel to the midline of the c. During isometric exercise there is an increase
proximal phalanx in blood pressure
d. In isokinetic exercise constant force is
205. The failure of motor planning and execution
exerted at a variable angular speed
of movements without deficits of strength,
e. High resistance, low repetitive exercises
coordination or sensation is called:
improve endurance
a. Agnosia b. Apraxia
c. Aphasia d. Anosmia 209. The commonest aetiologies for cerebral palsy
e. Ataxia include all of the following except:
a. Prematurity
206. Which of the following statements on
b. Cerebral ischemia
parkinsonism is not correct?
c. Cerebral hypoxemia
a. The tremor in Parkinsons disease occurs with d. Vitamin C deficiency
a frequency of 2025 Hz e. Hyperbilirubinemia
b. Parkinson plus is a term used to describe a
group of multisystem disorders that exhibit 210. The characteristic spastic gait of the hemi-
signs of parkinsonism along with other plegic patient does not include:
neurologic deficits a. Pelvic rotation
c. The tremor may be intensified by the move- b. Circumduction of the leg
ment of the opposite limb c. Equinovarus of the foot
d. Movements in Parkinsons disease are d. Scissoring gait
usually slow e. Short stride length on the side of the affected
e. Many patients have micrographia extremity
207. In Parkinsons disease, physical therapy 211. Which of the most common language
should not include: disorders are seen in traumatic brain injury:
a. Relaxation techniques a. Aphasia
b. Passive stretching b. Nominal dysphasia (impaired word finding)
c. Flexibility exercises c. Stereotypes
d. Control of spasticity d. Echolalia
e. Functional activity training e. Jargon

Answers 20 4. a. The sagittal...20 5. b. Apraxia 20 6. a. The tremor... 20 7. e. Functional... 20 8. e. High resis...

20 9. d. Vitamin C... 21 0. d. Scissoring... 21 1. b. Nominal dysphasia.
224 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
212. Which one of the following propositions in
delayed-onset muscle soreness (DOMS) is not
correct?
a. It occurs after 2448 hours of exercise
b. It is associated with elevated plasma muscle
enzymes
c. It is associated with myoglobinuria
d. Higher levels of DOMS are associated with
concentric rather than eccentric activity
e. It may be associated with structural damage
to the contractile filament
213. Which of the following statements in
exertional compartment syndrome of the leg
is true?
a. The anterior and deep posterior compart-
ments are the most commonly involved
b. The lateral and deep posterior compartments
are the most commonly involved
c. The tibial nerve runs through the lateral
compartment, and may be compromised by
lateral compartment syndrome
d. Acute exertional compartment syndrome is
most commonly seen in professional athletes
e. It is associated with activity-related pain
mostly seen after starting exercises
214. Which one of the following statements in
plantar fasciitis is not correct?
a. The pain associated with plantar fasciitis is
usually caused by a local calcaneal spur
b. Plantar fasciitis is usually associated with
progressive heel pain during the day
c. It is always associated with pes planovalgus
d. It may be treated with a shock-absorbing heel
pad
e. It can be treated by extracorporeal shock
wave therapy
Answers 21 2. d. Higher lev... 21 3. a. The anteri... 21 4. c. It is always... 21 5. b. Normal...
21 7. b. A high capillary.
215. Which one of the following statements is not
correct in patellofemoral syndromes?
a. The Q-angle is measured by determining the
center point of the patella and drawing a line
to the anterior superior iliac spine proximally
and through the tibial tubercle distally
b. Normal Q-angles range from 810 in females
and 1216 in males
c. An increased Q-angle is associated with
patella subluxation
d. The Q-angle may be reduced by orthotics in
standing subjects
e. When the knee is extended, the vastus
medialis muscle counteracts the tendency of
the patella to displace laterally
216. Only one of the following statements concern-
ing the supraspinatus muscle is correct, which
one?
a. The supraspinatus muscle is innervated by
the dorsal scapular nerve
b. It is commonly affected in middle trunk
brachial plexus injuries
c. The supraspinatus tendon inserts into the
greater tuberosity of the humerus
d. The supraspinatus muscle is an external
rotator of the arm
e. It receives the majority of its innervation from
the C7 nerve root level
217. Which of the following propositions concern-
ing fast-twitch motor units are correct?
a. A high anaerobic capacity and a low aerobic
capacity
b. A high capillary density
c. A fast contraction time
d. A rapid fatigability
e. A high force of contraction
21 6. c. The supras...
 MULTIPLE CHOICE QUESTIONS AND ANSWERS
218. A patient complains about intermittent
excruciating pain in the lateral part of the
forefoot, with a feeling of electrical shock
radiating to the third and fourth toe. The
patient is much more comfortable barefooted.
What is your most likely diagnosis?
a. Plantar neuroma (Mortons toe)
b. Lumbar disk hernia
c. Synovial hernia of the MTP joints three and
four
d. Stress fracture of the metatarsal three and four
e. Plantar fasciitis
219. Which of the following statements concerning
exercise in rheumatoid arthritis is not
correct?
a. Steroid-induced mypathy can be improved
by strengthening exercises
b. Strength training improves muscle strength
c. Strength training improves activities of daily
life
d. Aerobic exercises deteriorate activities of
daily life
e. Hydrotherapy exercises increase endurance
220. Which statement concerning psoriatic
arthritis is not correct?
a. It occurs in the majority of psoriatic patients
b. Both tendinitis and synovitis occur
c. Fingernail pitting is an important symptom
d. Onycholysis usually occurs
e. If affects both peripheral and sacroiliac joints
221. Which treatment is not prescribed for a
posttraumatic thoracic spine compression
fracture due to osteoporosis?
a. Cold application in the acute phase
b. 3-point contact brace
c. Flexion exercises of the thoracic spine
d. Analgesics
e. Biphosphonates
Answers 21 8. a. Plantar... 21 9. d. Aerobic...
22 3. b. It is expen... 22 4. a. Hot pack...
225
222. Which one of the following statements is not
correct in lumbar spinal stenosis?
a. Symptoms are relieved by sitting or adopting
a posture of flexion of the waist
b. Patients prefer to walk with a straight posture
c. Walking uphill is easier than downhill
d. Low back pain
e. Absence of tendon reflexes in the lower limbs
223. Only one of the following characteristics is
correct for an air-filled villous wheelchair
cushion (Roho)?
a. It is indicated for general use
b. It is expensive but it gives excellent pressure
relief
c. Heat dissipation is not optimal
d. It assures a suboptimal sitting stability
e. It has excellent durability
224. Which combination concerning the type of
heating modality, depth of penetration and
form of energy transfer treatments is not
appropriate?
a. Hot pack deep convection
b. Paraffin baths superficial conduction
c. Ultrasound deep conversion
d. Shortwave deep conversion
e. Radiant heat superficial radiation
225. Which of the following is not a physiological
effect of cold?
a. Immediate cutaneous vasoconstriction
b. Decreased acute inflammation
c. Decreased conduction velocity
d. Increased maximal isometric strength
e. Decreased pain
226. In clinical muscle testing active movement,
full ROM against gravity is graded as:
a. 1 b. 2
c. 3 d. 4
e. 5
22 0. a. It occurs... 22 1. c. Flexion exer... 22 2. b. Patients...
22 5. c. Decreased... 22 6. c. 3.
226 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

227. Which of the following muscle(s) is or are the a. Poliomyelitis

key muscle(s) to test the C7 symptom? b. Spinal cord injury
a. The deltoid c. Traumatic brain injury
b. The elbow flexors d. Burn injury
c. The wrist extensors e. Serious infections
d. The elbow extensors 233. Which of the following symptoms is rare in
e. The flexor of the middle finger amyotrophic lateral sclerosis?
228. Which of the following dermatomes has its a. Muscle wasting
sensory keypoint at the midpoint of the b. Muscle cramp
inguinal ligament? c. Dysarthria
a. T9 b. T10 d. Pain
c. T11 d. T12 e. Respiratory insufficiency
e. LI 234. Which of the following is not prescribed as a
229. What is the recommended management for treatment for trigger finger?
a continent SCI patient with a reflex bladder, a. Local corticosteroid injection
with residual volumes less than 100 ml, and b. Passive range of motion exercises
with a bladder pressure less than 45 mm Hg? c. Splinting
a. Electrical stimulation d. Ergonomic advices
b. Pharmacological treatment e. Surgery
c. Intermittent catheterization 235. Which statement concerning wrist ganglion
d. Condom-catheter cysts is correct?
e. Suprapubic tapping/bladder training
a. Surgical resection is not indicated
230. Which of the following statements concerning b. They arise from tendon sheaths, ligaments
pregnancy in SCI patients is true? and joint capsules
a. There is a low incidence of prematurity c. The scapholunate ligament is rarely involved
b. There is an increase in spontaneous abortion d. Local infiltration with corticosteroids is not
c. Fertility is normal effective
d. An intrauterine device is a common e. Asymptomatic ganglion cysts should also be
contraceptive treated
e. Pregnancy is usually uncomplicated 236. Which statement concerning Raynaud
231. A pressure ulcer described as a full-thickness phenomenon is not true?
lesion through the dermis down to subcuta- a. It is associated with connective tissue
neous tissue is classified as: diseases
a. Stage I b. Stage II b. It is associated with anti-migraine medication
c. Stage III d. Stage IV c. It is associated with cold temperature
e. Stage V d. It is associated with vibration (e.g. rock
drillers)
232. Heterotopic ossification is found in the e. It is associated with decreased blood viscosity
following conditions, except in:

Answers 22 7. d. The elbow... 22 8. d. T12 22 9. e. Suprapubic... 23 0. c. Fertility... 23 1. c. Stage III...

23 2. a. Poliomy... 23 3. d. Pain 23 4. b. Passive... 23 5. b. They arise... 23 6. e. It is assoc...
 MULTIPLE CHOICE QUESTIONS AND ANSWERS 227
237. A 50-year-old female dentist with carpal tunnel a. Motor planning impairment
symptoms with no thenar weakness or thenar b. Ideomotor apraxia
atrophy, and no denervation signs on EMG asks c. Feeding apraxia
your advice on treatment. The most appropriate d. Left unilateral neglect
treatment is: e. Left hemisensory deficit
a. An open division of the transverse ligament 241. Which of the following is not related to an effect
b. An endoscopic division of the transverse of non-steroidal anti-inflammatory drugs?
ligament
a. Hypertension
c. A local corticosteroid injection
b. Cholecystitis
d. Splinting
c. Interstitial nephritis
e. Change of job
d. Edema
238. After a peripheral nerve lesion with e. Elevated serum creatinine
axonotmesis nerve regrowth usually occurs
242. Which of the following muscles are the most
at a speed of:
important for axillary crutch walking?
a. 35 mm/day
a. Latissimus dorsi and lower trapezius
b. l3 mm/day
b. Posterior deltoid and subscapularis
c. 0.10.3 mm/day
c. Middle deltoid and pectoralis major
d. Less than0.1 mm/day,
d. Anterior deltoid and biceps
e. More than 5 mm/day
e. Middle deltoid and biceps
239. A patient, complains of difficulties on stair
243. Exercises for cardiovascular conditioning
descent. You expect to find weakness of the:
should involve the following components
a. Quadriceps muscles except:
b. Gastrocnemius muscle
a. A large isotonic component
c. Hip adductors
b. A large isometric component
d. Gluteus medius muscle
c. A walk-jog-run component
e. Iliopsoas muscle
d. A cycling component
240. A 57-year-old man has a right hemisphere e. Circuit training
infarct. He has a mildly increased tone on the
244. Which of the following modalities is least
left side with 3/5 muscle strength at the
likely to be prescribed for fibromyalgia?
shoulder, elbow and hand. He has a mildly
decreased response to pinprick and proprio- a. Correction of poor posture
ception throughout the left side. He is noted b. Evaluation of the workplace
to use his right hand exclusively for feeding c. Stress management techniques
tasks and he leaves some food untouched on d. Strenuous exercise training to improve
the left side of his plate. The most likely endurance
reason for this patients difficulty with eating e. Cognitive-behavioral treatment
is:

Answers 23 7. d. Splinting... 23 8. b. l3 mm/... 23 9. a. Quadriceps... 24 0. d. Left unil... 24 1. b. Cholecy...

24 2. a. Latissimus... 24 3. b. A large... 24 4. d. Strenuous.
228 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
245. The risk of foot ulceration in diabetic patients is
increased by all of the following except:
a. Increased mobility of the subtalar joint
b. The presence of plantar foot callosities
c. The loss of deep sensation
d. Metatarsophalangeal subluxation and foot
pad migration
e. A history of foot ulceration
246. The most common cause of hypotonia in a
full-term baby is:
a. Infantile motor neuron disorders
b. Central nervous system disorders
c. Congenital myasthenia gravis
d. Congenital myopathies
e. Electrolyte abnormalities
247. A physical treatment program for a
patient with osteoarthritis of the knee should
include:
a. Stair climbing
b. Lateral slide exercises
c. Rowing
d. Closed kinetic chain exercises with knee
flexion less than 25
e. Cross-country running
248. A 43-year-old female hairdresser complains of
right shoulder and arm pain lasting for 6 weeks.
The pain is located in the anterior and lateral
shoulder region, radiating laterally toward the
elbow. She complains of bilateral arm heaviness
while at work. She experiences also a vague
feeling of numbness in her right hand, worse
during the night. The pain occurs primarily
while working and is relieved when the patient
is recumbent. The most likely diagnosis is:
a. Impingement syndrome of the shoulder
b. Adhesive capsulitis of the shoulder
Answers 24 5. a. Increased... 24 6. b. Central...
25 0. a. The semim... 25 1. b. The pressure...
c. A suprascapular nerve lesion
d. A thoracic outlet syndrome
e. Anterior shoulder instability
249. During an epidural corticosteroid injection at
L4-L5 level a 31-year-old woman becomes less
responsive. Her pulse is 45 per minute,
respirations 18 per minute and blood pressure
100/60 mm Hg, and she appears pale. The most
likely diagnosis is:
a. Hypoglycemic crisis
b. Adverse reaction to corticosteroid
c. Vasovagal reaction
d. Dural puncture
e. Spread of anesthetic to the cervical region
250. Which of the following statements concerning
the anatomy of the hamstring muscles is
correct?
a. The semimembranosus and semitendinosus
are part of the internal or medial hamstrings
b. The semimembranosus muscle receives its
nerve supply from the peroneal portion of
the sciatic nerve
c. The long and short heads of the biceps
femoris muscles receive their predominant
nerve supply from the L4L5 level
d. The biceps femoris inserts below the knee
into the pes anserinus
251. The algometer or dolorimeter measures:
a. The temperature of the affected limb
b. The pressure required to produce pain
c. The electrical potentials on the skin
d. The strength of muscle tension during
contraction
e. The number of nociceptors per square inch
24 7. d. Closed... 24 8. d. A thoracic... 24 9. c. Vasovagal...
 MULTIPLE CHOICE QUESTIONS AND ANSWERS
252. During an electrophysiological examination,
somatosensory evoked potentials evaluate the
integrity of the:
a. Tractus spinothalamicus lateralis
b. Tractus spinothalamicus ventralis
c. Fasciculus gracilis and fasciculus cuneatus
d. Tractus corticospinalis lateralis
e. Tractus pyramidalis
253. Which one of the following statements about
the FIM-instrument scale is incorrect:
a. It is an ordinal scale with 18 items
b. Each item is scored from 1 to 7
c. The reliability is good
d. Validity is not well documented
e. Areas of evaluation include self-care, sphin-
cter control, transfers, locomotion, communi-
cation and social cognition
254. Assessment in rehabilitation focuses on all of
the following major areas except:
a. Physical capabilities and activities of daily
living
b. Social behavior
c. Personality and psychology
d. Epidemiology
e. Communication
255. Which of the following statements concerning
muscle physiology is true?
a. Isotonic contraction produces the maximum
possible force
b. A muscle is not efficient in an elongated
position
c. Static exercise requires normal glycogen
stores without an oxygen debt
d. Concentric contraction produces more force
than eccentric contraction
e. Isometric contraction produces more force
than concentric contraction
Answers 25 2. c. Fasciculus... 25 3. d. Validity is... 25 4. d. Epidemi...
25 7. a. Neuropsy... 25 8. c. Decreased... 25 9. b. The disease.
229
256. Which of the following statements concerning
the Barthel index is incorrect?
a. It is used for comparison between services
b. It has predictive value
c. It measures cognitive function
d. It assesses 10 aspects of daily life
e. Its validity has been studied extensively
257. In traumatic brain injury patients the
Functional Independence Measure (FIM) is
insufficient in which of the following areas:
a. Neuropsychological b. Self-care
c. Sphincter, control d. Mobility
e. Locomotion
258. The pathophysiological effect of botulinum
toxin type A in reducing spasticity is mediated
through:
a. Non-reversible blockade of acetyl-choli-
nesterase activity
b. Decreased calcium ion uptake by the
presynaptic motor nerve
c. Decreased acetylcholine release from the
presynaptic nerve terminal
d. Degradation of muscle endplate acetylcholine
receptors
e. Reduced sodium channel opening in the
motor nerve
259. Which statement concerning cystic fibrosis
(CF) is not true?
a. A CF-patient suffers from combined
obstructive-restrictive pulmonary disease
b. The disease presents with exclusively respi-
ratory features
c. Chest physiotherapy is indicated one to four
times a day
d. The patient is best managed in a home setting
e. The abnormal viscosity of the mucus is
caused to a great extent by degenerating
neutrophils
25 5. e. Isometric... 25 6. c. It measures...
230 ESSENTIALS OF PROSTHETICS AND ORTHOTICS
260. Which one of the following does not contribute
to the development of Chronic Obstructive
Pulmonary Disease (COPD):
a. Sedentary lifestyle
b. Genetic predisposition
c. Allergic disease (e.g. asthma)
d. Cigarette smoking
e. Asbestosis
261. A 63-year-old man with chronic obstructive
pulmonary disease is admitted for rehabili-
tation. When discussing precautions with the
physical therapist, the following instructions
should be given:
a. Adjust the level of exercise to keep the pulse
rate below 100
b. Stop exercise if there are more than six
premature beats per minute
c. Start the use of supplemental oxygen as soon
as the oxygen saturation drops below 75%
d. Avoid the use of hand-held respiratory
muscle trainers
e. Maintain the heart rate at no more than 70%
of maximum as determined by exercise
testing
262. Which of the following cannot prevent
retention of secretions and atelectasis in the
quadriplegic patient?
a. Sitting in a wheelchair
b. Turning the patient frequently
c. Breathing exercises
d. The use of incentive spirometry
e. Chest percussion
263. Which of the following conditions is not a
potential contraindication for entry into a
cardiac exercise program:
a. Unstable angina
b. Resting diastolic blood pressure > 100 mm Hg
Answers 26 0. a. Sedentary... 26 1. b. Stop exe...
26 5. c. Program... 26 6. d. Oxybutinin.
c. Aortic stenosis
d. Active pericarditis
e. Well-controlled diabetes
264. In patients with bladder filling problems due
to (striated) external sphincter insufficiency,
which of the following is contraindicated?
a. Alphablocker medication
b. Physiotherapy with biofeedback
c. Perineal muscular electrostimulation
d. External permanent urine collection device
e. Ephedrine
265. An active, 77-year-old woman suffers from
urinary incontinence following a stroke. She
does not have a urinary infection and her post-
micturition residual volume is not significant.
The skin is moderately red. What is your first
measure to take or prescribe?
a. Oxybutinin 5 mg three times a day
b. Intermittent catheterization
c. Programmed toileting with a fluid balance
chart
d. A permanent indwelling catheter
e. Urodynamic studies
266. A 26-year-old woman with complete T6 para-
plegia has managed her bladder since the
injury using intermittent self-catheterization.
Three months after spinal cord injury she
develops leakage. What pharmacological
agent is likely to be most useful in controlling
this?
a. Ephedrine (noradrenergic)
b. Bethancol (cholinergic)
c. Prazosine (alpha-sympathetic blocker)
d. Oxybutinin (anticholinergic)
e. Baclofen (gamma aminobutyric acid)
26 2. a. Sitting in... 26 3. e. Well-contr... 26 4. a. Alphabloc...
 MULTIPLE CHOICE QUESTIONS AND ANSWERS
267. Which one of the following neurological signs
is not usually observed in elderly patients?
a. Hand tremor
b. Babinski sign
c. Primitive reflexes in 20 to 25% of people
d. Increased muscle tone
e. Diminished distal vibratory sense
268. All of the following measurement tools are
used in the assessment of pain except one:
a. Pressure algometry
b. Visual analogue scale
c. Somatosensory evoked potentials
d. Verbal scale/questionnaire
e. Pain drawings
269. When considering the implantation of an
electrical spinal cord stimulator, which one of
the following propositions is correct:
a. The cause of symptoms is not related to
expected effectiveness
b. A trial stimulation should be performed
c. Patients addicted to narcotics do particularly
well
d. Nearly 100% of patients will return to work
e. Infection is not a limiting factor
270. Which statement is applicable to cardiac
transplant patients?
a. The resting heart rate is usually around 100
beats per minute
b. Immunosuppression causes hypertension
c. Peak heart rates are 2025% lower than those
seen in healthy age-matched controls
d. Typically, these patients have generalized
muscle weakness
e. All of the above statements are true
271. Which of the following is not a contra-
indication to vertebral manipulation
techniques?
a. Minor vertebral dysfunction
Answers 26 7. b. Babinski... 26 8. c. Somatos... 26 9. b. A trial...
27 2. d. Muscle... 27 3. b. Weakness... 27 4. d. Typically...
231
b. Joint hypermobility
c. Anticoagulant therapy
d. Inexperience in manipulative skills
e. Severe osteoporosis
272. Which one of the following is no indication
for the long-term use of patella tendon-
bearing orthoses?
a. Delayed or non-union of fractures
b. Avascular necrosis of the talar body
c. Degenerative arthritis of the subtalar or ankle
joint
d. Muscle cramps in the calf
e. A diabetic foot ulcer
273. A 22-year-old woman has a 6-month history
of anterior knee pain. It is intermittent in
nature and increases after running long
distances or climbing stairs. On physical
examination there is malalignment of the
patella. Which one of the following physical
findings is most likely to be found as part of
your examination?
a. Excessive foot supination
b. Weakness of the vastus medialis
c. Genu varum
d. Tight hamstring muscles
e. Gastrocnemius and soleus weakness
274. Which of the following is not true about
medial epicondylitis?
a. The pain is in the medial humeral epicondylar
region
b. The most common age of onset is 4060
years
c. A typical sign is tenderness over the common
tendon attached to the medial humeral epi-
condyle
d. Typically, resisted wrist dorsiflexion
produces pain
e. The pathology is a strain or partial tear of
the tendon at the tendoperiosteal junction
27 0. e. All of the... 27 1. a. Minor...
232 ESSENTIALS OF PROSTHETICS AND ORTHOTICS

275. Ankle sprains typically occur when the foot and d. It should always be considered when a young
ankle are plantar-flexed. The first structure athlete between the ages of 8 to 12 years
injured due to a combined inversion and plantar presents with knee discomfort
flexion stress is generally: e. It is clinically manifested by automatic
external rotation during passive flexion of the
a. The anterior talofibular ligament
hip
b. The posterior talofibular ligament
c. The calcaneofibular ligament 279. Electromyographic studies for low back and
d. The tibiocalcaneal ligament leg pain may be helpful in diagnosing all of
e. The tibionavicular ligament the following conditions, except:
a. Spinal root dysfunction
276. The reduction in bone mass noted on the b. Prostate cancer
paralyzed side in a hemiplegic patient is due to: c. Lumbar spinal stenosis
a. A significant loss of bone formation d. Neurogenic pain
b. A significant increase in bone resorption e. Lumbar plexopathy
c. An increase in blood flow 280. A patient with 40% body surface area burns,
d. A loss of sensation has been losing range of motion in his right
e. The presence of spasticity arm for the past 7 to 10 days. Which one of
the following procedures is the most
277. Which of the following conditions is not
appropriate?
associated with cerebral palsy?
a. Order a diagnostic ultrasound or MRI
a. Seizures b. Order a complete blood cell count and
b. Neurogenic bladder erythrocyte sedimentation rate
c. Learning disability c. Order a splint to immobilize the joint
d. Oral motor problems d. Instruct the therapists to more aggressively
e. Communication problems move the arm through the full range
e. Order ice application to the joint three times
278. In a child with a slipped capital femoral epiphysis a day
only one of the following items is incorrect:
281. Postpolio syndrome is a diagnosis of exclusion.
a. The pain may be referred to the knee
The hallmark of postpolio syndrome is:
b. The child is walking with an internally rotated
a. Unusual fatigue b. Cold intolerance
leg
c. New weakness d. History of falls
c. Occasionally, the condition is initially only
e. Myalgias
manifested by knee pain

Answers 27 5. a. The anteri... 27 6. b. A significant inc.. 277. b. Neurogenic... 278.b. The child...
27 9.b. Prostate... 28 0. a. Order a diagn... 281. c. New weakness.
 MULTIPLE CHOICE QUESTIONS AND ANSWERS 233
282. In which following condition, intradiscal c. Lifting 20 kg with back bent but knee straight
pressure is lowest? d. Lifting 20 kg with back straight and knee bent
a. Supine b. Supine intraction 284. Which of the following is proper bending and
c. Erect with corset d. All above lifting technique?
283. In which following condition, intradiscal a. Straight back with knee bent
pressure is maximum? b. Straight back and keeping knee straight
a. Bilateral straight leg raising in supine c. Both
b. Sit up exercises d. None

Answers 28 2. b. Supine... 28 3. c. Lifting 20... 28 4. a. Straight back.

Source: European PRM Board Examination, 2003, Mcq from 203 to 280
Leprosy Guidelines, First Ed, 2011
Prosthetic and Orthotics in PMR, 1997