Successful fitting of a prosthesis for a child amputee suffering from scleroderma.

A few anecdotal cases of limb amputations owing to scleroderma have been described in the literature. This article outlines the salient problematic features of a residual stump and provides the prosthetic considerations and appropriate design that eventually facilitated ambulation.

Rehabilitation considerations of prosthetic fittings for Kaposi's sarcoma amputees.

PURPOSE: We report on cutaneous limb manifestations of Kaposi's sarcoma and the secondary infection of these lesions that necessitated five lower-limb amputations. METHOD: The cases are briefly described and prosthetic adaptations in respect to pressure, traction and sweating on the skin are considered. RESULTS: All four patients ambulated initially; one lady died, the double amputee stopped walking owing to the excessive physical demand, and two patients ambulate freely. CONCLUSION: Special considerations to the cutaneous/prosthesis interface are necessary in order to provide these patients with optimal ambulatory ability.

Elbow joint, crutches and locomotion: special reference to persons with haemophilia.

A 52-year-old, trans-femoral amputee with haemophilia was hospitalized because of ambulatory problems arising from the osteo-arthropathic involvement of other major articulations. Reduced function in the upper limbs, caused by the effects of recurrent haemarthroses, resulted in additional problems concerning the usage of auxiliary ambulatory aids. The advantages and disadvantages of traditional and experimental crutches highlight the functional problems of ambulation in persons with concomitant upper limb pathologies.

Why did the patient choose an inappropriate orthosis?

PURPOSE/METHOD: A 70-year-old engineer, suffering from drop foot, designed and produced a strange orthosis. Although on ambulation the orthotic device elevated his foot, an abnormally strange walking pattern was required. Of his own volition the patient attended an orthotic clinic requesting that a local manufacturer produce a replica of the orthosis. The patient received an explanation pertaining to the range of regular orthotics available and in what way they would improve his functional ability. RESULTS/CONCLUSION: The patient saw all the options available and physically tried several. The patient was afforded the opportunity of free choice and chose his own, self-designed orthotic. From a professional point of view this was the most inappropriate option. The rehabilitation team erred in its psychological management of the case, for it overlooked the question of the patient's motivation and commitment to change.

The role of orthoses in the management of elbow joints in persons with haemophilia.

The elbow joint is extremely prone to haemarthroses, and when these occur the elbow requires support and rest. Supporting the limb with a simple collar-and-cuff sling, a triangular bandage either with or without a shoulder immobilization device will provide an analgesic effect without adding an unnecessary heavy orthosis. As the swelling subsides and the pain lessens a dynamic orthosis aids in the support and compression. When considering functional branching of the elbow joints there are a number of basic principles to be followed. One requires to consider problems of orthosis suspension, two dimensional motion and stabilization in the functional range of motion. This article provides the rationale for the special needs of persons with haemophilia who suffer from involvement of their elbow joints.

Increased cardiovascular disease mortality rates in traumatic lower limb amputees.

We evaluated the 24-year mortality rates of male traumatic lower limb amputees (n = 201) of the Israeli army, wounded between 1948 and 1974 compared with a cohort sample representing the general population (n = 1,832). Mortality rates were significantly higher (21.9% vs 12.1%, p <0.001) in amputees than in controls. Cardiovascular disease (CVD) mortality was the main cause for this difference. The prevalence of selected risk factors for CVD was determined in 101 surviving amputees (aged 50 to 65 years) and a sample of the controls (n = 96) matched by age and ethnic origin. Amputees had higher plasma insulin levels (during fasting and in response to oral glucose loading) and increased blood coagulation activity. No differences were found in rates of current symptoms of ischemic heart disease or of cerebrovascular disease, obesity, hypertension, altered plasma lipoprotein profile, impaired physical activity, smoking, or nutritional habits. Traumatic lower limb amputees had increased mortality rates due to CVD. Surviving amputees had hyperinsulinemia, increased coagulability, and increased sympathetic and parasympathetic responses (described previously). These established CVD risk factors may explain the excess mortality due to CVD in traumatic amputees.

Criteria for prosthetic provision: "he who pays the piper calls the tune".

Previously instituted policies regarding prosthetic limb provision had been deemed dependable. A follow-up home visit study showed that 18 of 60 patients that had been provided with prostheses, did not make use of them. Analysis showed that three categories of patients made up the large majority of the non-users; double amputees, blind persons and those with psychiatric disorders. In order to attempt to eliminate the wastage of prosthetic provision to non-ambulators a new policy decision was made. Doubtful ambulators and those from the three aforementioned categories will be initially provided with temporary prostheses. Only after a period of months of temporary prosthetic usage at home will a decision be made as to whether a permanent prosthesis will be issued.

The will to walk--a partnership involving dual dynamics.

A case report is used as an example of how the will of a patient convinced an entire rehabilitation team to alter its assessment of the patient's ambulatory potential. The question of dual dynamics is discussed in the light of the realities of the honest desire and motivation to walk and regain independence.

Why should a deformed, anaesthetic, functionless hand be wanted?

A 58-year-old woman presented at a disability assessment tribunal with a severely deformed left forearm. She had broken the arm 25 years previously and the infected open fracture had not healed. There were no sensory or motor functions in the hand, which the patient kept constantly hidden in her garments. The question of an amputation was raised and the advantages of modern prosthetics with respect to cosmesis and function failed to convince the patient that she might benefit from such surgery. One questions why a patient should want to retain this cumbersome, obviously embarrassing, burden and whether the question of surgery should have been raised.

The changing needs of patients after primary rehabilitation: an overlooked entity.

PURPOSE: The need for rehabilitation should not be viewed as a single event that may occur during a lifetime. This theme is explored. METHOD: A case of a man who lost the distal portions of all four limbs, is reported. RESULTS: He was rehabilitated and spent many years as an active member of the community. The physical changes, owing to advancing age, were overlooked. CONCLUSIONS: Attention is drawn to the fact that long term re-evaluation of function is periodically required.

A pilot study to determine the efficiency of lightweight carbon fibre orthoses in the management of patients suffering from post-poliomyelitis syndrome.

OBJECTIVES: To assess the usage of carbon fibre orthoses in assisting post-polio syndrome patients who reported advancing weakness and difficulty in maintaining their independent ambulatory status. DESIGN AND INTERVENTIONS: Carbon fibre orthoses that are 30% lighter than metal braces were constructed. SUBJECTS: Thirty patients who complained of difficulty in maintaining their ambulation using long-leg braces were provided with lightweight orthoses. RESULTS: Seventy per cent of the patients reported satisfaction with their braces. There were, however, problems in construction and use. CONCLUSIONS: Ambulation can be preserved in some patients who report advancing weakness because of post-polio syndrome.

Silicone suspension of external prostheses. A new era in artificial limb usage.

The use of silicone inner sockets, with or without the incorporation of shuttle locks, has greatly improved the function of artificial limbs. They cushion and protect the stump and provide a means for prosthetic suspension, allowing more comfortable use, especially in patients with ischaemic stumps. They also allow greater movement at the proximal joint.

Lower limb prosthetic considerations in persons with coagulopathies.

Most able-bodied amputees use artificial limbs for ambulation. Special considerations are required for persons with coagulopathies because excess pressure or friction may result in soft-tissue haemorrhages. Persons with haemophilia have multi-articular pathologies, hence the necessity to consider carefully the use of accessory walking aids. The use of walking aids results in biomechanical forces being applied through the upper limb joints and this may cause haemarthroses.

The design of two-dimensional gradient estimators based on one-dimensional operators.

Two-dimensional (2-D) gradient estimators are some of the most useful tools in image processing. A computational procedure for the extension of one-dimensional (1-D) gradient estimators to two dimensions (2-D) is presented. The procedure is equivalent to the surface fitting method. It is, however, simpler in design, as the design is 1-D rather than 2-D. Higher order derivative estimators can also be constructed by the same procedure.

Interrelationships among measures of autonomic activity and cardiovascular risk factors during orthostasis and the oral glucose tolerance test.

Overstimulation of sympathetic nervous system activity is related to atherosclerotic cardiovascular disease risk, but the role of parasympathetic activity in this association is not clear. This study evaluated sympathetic and parasympathetic function by spectral analysis of heart rate variability and plasma levels of norepinephrine (NE) epinephrine (EPI), dihydroxyphenylglycol (DHPG), dihydroxyphenylalanine (DOPA) and dihydroxyphenylacetic acid (DOPAC). It also examined the interrelationships among these parameters and established atherosclerotic cardiovascular disease risk factors in 53 men (mean age 59.5 years). During supine rest, low-frequency power correlated positively with high-frequency power (r = 0.58, p < 0.001), plasma NE correlated with plasma DHPG (r = 0.41, p < 0.001) and plasma DOPA with DOPAC (r = 0.47, p < 0.001) but neither low- nor high-frequency power was correlated with plasma levels of any catechol. Among risk factors, plasma NE correlated with fasting insulin and mean arterial blood pressure, and urine NE correlated with body mass index. Both low- and high-frequency power correlated positively with insulin levels. Orthostasis decreased high-frequency power and increased low-frequency power and plasma NE levels. During the oral glucose tolerance test, both high- and low-frequency power increased, plasma NE levels were unchanged, and plasma EPI levels decreased [88.5 +/- 18 (SEM) versus 52.5 +/- 12 pM, p = 0.001]. The results suggest that orthostasis decreases and the oral glucose tolerance test increases parasympathetic outflows, whereas both stimuli increase sympathetic outflows. Among all atherosclerotic cardiovascular disease risk factors, hyperinsulinaemia showed the strongest association with autonomic nervous system activity, especially parasympathetic activity. Estimates of sympathetic responses obtained from power spectral analysis of heart rate variability agree poorly with those from plasma levels of catechols, possibly because of a parasympathetic contribution to low-frequency power and independence of sympathoneural outflows to the arm and heart.