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Section 1: General Topics
Figure 12
Committee of the Red Cross transtibial concave
pylon and alignment disk with a convex surface for tilting and a sliding surface for shifting.
(Courtesy of Helen Cochrane, CPO(c), MSc, Manila, Philippines.)
Photograph of an I nternational
disarticulation and knee disarticulation
can be addressed with the system using a modified foot or knee joint with a
low-profile attachment coupling.
In the lower limb system, a wide
range of alignment adjustments are
possible through the attachment/alignment couplings. This includes convex/
concave disks for tilt/shift, as well as
sliding surfaces for shifting and rotation
(Figure 12). The various sections are
locked in place during alignment using
bolts and secured with plastic welding
after the alignment process is complete.
Allowing for alignment changes from
standard bench alignment throughout the dynamic alignment process
and even after the prosthesis is fitted
represents an important functional
advantage in achieving optimized and
energy- efficient gait.
The upper limb system offers
body-powered split-hook terminal
Figure 13
with a split hook terminal device. (Courtesy of Helen Cochrane, CPO(c), MSc, Manila, Philippines.)
Figure 14
of the Red Cross transhumeral prosthesis with a manual locking elbow. (Courtesy of Helen Cochrane, CPO(c), MSc, Manila, Philippines.)
devices (Figure 13) and passive hands in
a range of sizes. The transradial prosthesis can be used with a self- suspending
socket or with harness suspension,
double- wall construction for fabrication of the forearm, a control harness
as appropriate, and a bicycle brake cable acting as a control cable to connect
the harness to the terminal device. The
transhumeral system uses a manual
locking elbow (Figure 14) and standard
socket designs, harnessing, and control
systems.
Although the ICRC scaled back
its involvement in the production of
Photograph of an International Commit tee of the Red Cross transradial prosthesis
Photographs show a nterior (A) and lateral (B) views of an International Commit tee
prosthetic (and orthotic) components,
the system continues to be manufactured and sold to nongovernmental
organizations via private vendors. The
cost for this system is generally less than
for other commercially available prosthetic parts. Sockets are typically drapeformed from polypropylene sheets,
which limits the range of raw materials
that must be stored. The need for chemical storage and the regulation of ambient temperature frequently associated
with composite/lamination materials,
which can be a challenge in LRSs, is also
reduced. These simple, standardized
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
132
Chapter 10: Prosthetic Rehabilitation in Less-Resourced Settings
Figure 15
thetic foot. (Courtesy of Helen Cochrane,
CPO(c), MSc, Manila, Philippines.)
Photograph of a Jaipur pros-
manufacturing methods can improve
the consistency of outcomes, resulting
in lighter and more durable prostheses
than can be achieved and maintained by
locally made devices fabricated in LRSs.
Another benefit is that the interchangeable parts can be used across
many amputation levels, further limiting the range of materials that must
be kept in inventory. This simplifies
the supply chain, and for organizations
that import parts, this system offers a
simple, cost-effective way to manage
high-volume individual needs. Studies
of prosthetic systems in LRSs indicate
that the ICRC system is appropriate
for both transtibial and transfemoral
applications.
9
Jaipur Foot
The Jaipur Foot is part of a prosthetic
limb system linked with several prosthetic/orthotic centers in India. It has
also been used within short-term international fitting camps in other countries.
The Jaipur Foot (Figure 15) was first
developed in 1968 to meet the sociocultural needs of individuals with disabilities in India. The foot was designed to
allow the user to squat; sit cross-legged;
walk on uneven terrain; work in wet,
muddy fields; and walk without shoes.
The foot does not have a central keel
and aims to allow a wide range of motion through the foot-ankle assembly.
This vulcanized rubber foot is reported
to be waterproof. Its design is culturally appropriate, low cost, and widely
used in India.26 It has higher rates of
Figure 16
thesis. (Courtesy of Helen Cochrane, CPO(c), MSc, Manila, Philippines.)
deformation in independent static loading tests and higher rates of delamination when compared with other feet
during cyclical load tests.20 However,
the technical quality of the Jaipur Foot
can be considered acceptable and is better than that observed and reported by
ISPO for some SACH foot designs aimed
at low-income countries.
The Jaipur transtibial prosthetic
system uses high-density polyethylene
pipes for both the socket and shank
and is an exoskeletal design (Figure
16). The system is designed for quick
fitting (usually within 1 day) but offers limited dynamic alignment and
maintenance. The Jaipur transfemoral prosthesis is also fabricated from
high-density polyethylene pipes and
offers a single-axis knee with or without a lock.
Photographs show a nterior (A) and lateral (B) views of a Ja ipur transtibial foot pro s-
In a study in three countries that
examined 172 transtibial amputees approximately 2 years after being provided with Jaipur transtibial
prostheses, craftsmanship and fit
were poor in 56% of cases.27 In another study that examined 72 transfemoral prosthesis users in the same three
26
countries approximately 2.5 years after
being provided with Jaipur transfemoral prostheses, craftsmanship and fit
were assessed as being poor in 86% of
cases.28 Fabrication and fitting in the
three projects were performed by individuals who had limited background
training in prosthetics. The outcome
was considered unsatisfactory both
technically and clinically. This was
considered a reflection of the inadequacies of the prosthetic construction
26
and the inadequate training of those
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
133
Section 1: General Topics
involved in fitting and fabrication of
the devices.
27, 28
The Jaipur foot program has been
working to improve its components, as
shown by the recent involvement with
the ReMotion Knee, a four-bar polycentric knee, which improves stability in
stance and improves gait when compared with single-axis designs.
26
Summary
An LRS is usually a low- or middleincome geographic area that is at a stage
of economic and/or social development
in which resources are insufficient to
meet the needs of a population. There
are many strategies that can be used to
help meet the needs of individuals who
could benefit from prosthetic services
in an LRS. When resources are scarce,
optimizing the efficiency of services is
vital. Training a professional work force
is important for the delivery of appropriate services; WHO and ISPO have
developed international standards and
guidelines for such training. Because the
range of appropriate, available technology and access to materials and equipment are limited in an LRS, further
research and development are needed
to identify technologies, materials,
methods, and equipment that are cost
effective and do not adversely affect the
quality of services provided to individuals with prosthetic and orthotic needs.
References
1. Executive Summary: Guidelines
on the Provision of Manual Wheelchairs in Less Resourced Settings.
NCBI Bookshelf. Available at: http://
www.ncbi.nlm.nih.gov/books/
NBK143785/#fm.s8. Accessed March
10, 2015.
2. World Health Organization, United
States Agency for International
Development: Joint Position Paper
on the Provision of Mobility Devices
in Less Resourced Settings. Geneva,
Switzerland, World Health Organization, 2011.
3. World Health Organization, e
World Bank: World Report on Dis-
ability. Geneva, Switzerland, World
Health Organization, 2011.
4. United Nations: Convention on the
Rights of Persons with Disabilities.
Available at: http://www.un.org/dis-
abilities/convention/conventionfull.
shtml. Accessed March 15, 2015.
5. Prosthetic and Orthotics Programme
Guide: Implementing P&O Services
in Low-income Settings. Available at:
http://www.ispoint.org/sites/default/
les/img/programme_guide_nal_
version.pdf. Accessed March 10, 2015.
6. World Health Organization: Concept
note: Opening the GATE for Assistive Health Technology: Shiing
the Paradigm. Available at: ht t p://
www.ispoint.org/sites/default/les/
gate_concept_note_1.pdf. Accessed
March 10, 2015.
7. Borg J, Lindström A, Larsson S:
Assistive technology in developing countries: A review from the
perspective of the Convention on the
Rights of Persons with Disabilities.
Prosthet Orthot Int 2011;35(1):20-29.
Medline DOI
8. Wyss D, Lindsay S, Cleghorn WL,
Andrysek J: Priorities in lower
limb prosthetic service delivery
based on an international survey
of prosthetists in low- and high-income countries. Prosthet Orthot Int
2013;December 13 [Epub ahead of
print]. Medline
9. Ikeda AJ, Grabowski AM, Lindsley
A, Sadeghi-Demneh E, Reisinger KD:
A scoping literature review of the
provision of orthoses and prostheses
in resource-limited environments
2000–2010: Part two. Research
and outcomes. Prosthet Orthot Int
2014;38(5):343-62. Medline DOI
10. Durocher J, Lord J, Defranco A:
Disability and global development.
Disabil Health J 2012;5(3):132-135.
Medline DOI
11. World Health Organization, International Society for Prosthetics and
Orthotics: Guidelines for Training
Personnel in Developing Countries
for Prosthetic and Orthotics Services.
Geneva, Switzerland, World Health
Organization, 2005.
12. World Health Organization: e
Global Burden of Disease: 2004
Update. Geneva, Switzerland, World
Health Organization, 2008.
13. Sexton S, Shangali H, Munissi B:
Prosthetic & Orthotic Impact Assessment: East Africa: Tanzania, Kenya
and Uganda. e impact of training
personnel to the minimum standards
ISPO Category I & II: Tanzania
Training Centre for Orthopaedic
Technologists. Available at: http://
www.ispoint.org/sites/default/les/
sections/partnership/ispo_impact_
assessment_tatcoteast_africa_with_
appendices.pdf. Accessed March 10,
2015.
14. Pearlman J, Cooper RA, Krizack
M, et al: Lower-limb prostheses
and wheelchairs in low-income
countries. IEEE Eng Med Biol Mag
2008;27(2):12-22. Medline DOI
15. Mitra S, Findley PA, Sambamoorthi
U: Health care expenditures of living
with a disability: Total expenditures,
out-of-pocket expenses, and burden,
1996 to 2004. Arch Phys Med Rehabil
2009;90(9):1532-1540. Medline DOI
16. World Bank Group: Data: Low
Income. Available at: http://data.
worldbank.org/income-level/LIC.
Accessed March 10, 2015.
17. Harkins CS, McGarry A, Buis A:
Provision of prosthetic and orthotic
services in low-income countries:
A review of the literature. Pros-
thet Orthot Int 2013;37(5):353-361.
Medline DOI
18. International Society for Prosthetics
and Orthotics: Education: Programmes. Available at: http://www.
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
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Chapter 10: Prosthetic Rehabilitation in Less-Resourced Settings
ispoint.org/programmes. Accessed
March 10, 2015.
19. Bundoc JR: e challenge of “walking
free” from disability. Acta Med
Philipp 2010;44(2):13-16.
20. Jensen JS, Sexton S: Appropriate
Prosthetic and Orthotics
Technologies in Low Income
Countries (2000-2010). December,
2010. Available at: http://www.
ispoint.org/sites/default/les/
archives/appropriate_prosthetic_
orthotic_technologies_in_low_
Accessed March 10, 2015.
21. Medicines and Healthcare Products
Regulatory Agency: Single-use
medical devices: Implications
and consequences of reuse. 2013.
Available at: https://www.gov.uk/
government/uploads/system/uploads/
attachment_data/le/403442/Singleuse_medical_devices_implications_
and_consequences_of_reuse.pdf.
Accessed March 10, 2015.
22. ISO: ISO 10328:2006. Prosthetics:
Structural testing of lower-limb
prostheses. Requirements and test
methods. Available at: https://www.
iso.org/obp/ui/#iso:std:iso:10328:ed1:v1:en. Accessed March 10, 2015.
23. Day HJ: A review of the consensus
conference on appropriate prosthetic
technology in developing countries.
Prosthet Orthot Int 1996;20(1):15-23.
Medline
24. Jensen JS, Heim S: Evaluation of
polypropylene prostheses designed by
the International Committee of the
Red Cross for trans-tibial amputees.
Prosthet Orthot Int 2000;24(1):47-54.
Medline DOI
25. International Committee of the Red
Cross: Manufacturing guidelines:
Trans tibial prosthesis. Physical
Rehabilitation Programme. Available at: https://www.icrc.org/eng/
assets/les/other/eng-transtibial.pdf.
Accessed March 10, 2015.
26. Jaipur foot. Available at: http://
jaipurfoot.org. Accessed March 15,
2015.
27. Jensen JS, Craig JG, Mtalo LB, Zelaya
CM: Clinical eld follow-up of high
density polyethylene (HDPE)-Jaipur
prosthetic technology for transtibial amputees. Prosthet Orthot Int
2004;28(3):230-244. Medline
28. Jensen JS, Craig JG, Mtalo LB, Zelaya
CM: Clinical eld follow-up of high
density polyethylene (HDPE)-Jaipur
prosthetic technology for trans-femoral amputees. Prosthet Orthot Int
2004;28(2):152-166. Medline DOI
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
135
Upper Limb
Section 2Section 2
Chapter 11
Upper Limb Body-Powered Components
Andrea Hess, CP
Abstract
Body-powered prostheses remain the most commonly prescribed category of upper limb
prosthesis. A range of terminal devices, including both hooks and hands, are commercially
available, along with a number of dierent wrist, elbow, and shoulder joints. A comprehensive
understanding of the various features, benets, and limitations of these component options
will allow the rehabilitation team to match their detailed prosthetic recommendations to
the needs and preferences of the individual user.
Keywords: body-powered components; cable-driven; conventional
prosthesis; upper-limb prosthetic components
Introduction
Body-powered prostheses are the most
commonly prescribed upper limb
prostheses for individuals with amputations and limb differences. They
have been used for centuries and remain popular among clinicians and
users. In contrast to externally powered prostheses, which draw power
from an external, nonanatomic source
such as a battery to drive the motors of
prosthetic components, body-powered
prostheses use gross body movements
to operate the prosthetic components.
These motions increase the distance
between two points on the body,
and this linear increase is referred to
as excursion. The excursion is captured with a harness and transmitted through a cable system to cause
movement of the hand, hook, wrist, or
elbow. For this reason, body-powered
prostheses are sometimes referred to
as cable-driven prostheses. Different
components require various amounts
of excursion to open, close, or otherwise operate.
Neither Ms. Hess nor any immediate family member has received anything of value from or has
stock or stock options held in a commercial company or institution related directly or indirectly to
the subject of this chapter.
Body-powered designs have remained popular over the years because
they offer many advantages over other
systems. They are low cost, lightweight,
and reliable. Many users prefer their
mechanical simplicity and predictable
response. Because the user can feel the
cable tension and force during operation, body-powered systems offer a level
of proprioception not generally available with externally powered prostheses. These benefits, combined with the
fine prehension offered by hooks, result
in an extremely functional device for
everyday tasks. Body-powered systems
also are suitable for heavy-duty activities
and for use in dirty, wet, and corrosive
environments.
Body-powered prostheses also have
many disadvantages. Some methods of
operating cable-controlled systems require substantial force and effort. Some
harnessing approaches used to anchor
the control cable can compress the axilla
on the contralateral side, which can be
uncomfortable and may lead to nerve
compression over time. Individuals with
a high-level limb absence usually find it
difficult to generate the excursion and
power necessary to operate a bodypowered hand and elbow. Similarly,
shorter limbs have reduced lever arms
and smaller areas over which forces can
be distributed, potentially resulting in
difficulty generating the necessary operating power or creating discomfort from
the extreme forces on the limb.
Despite these challenges, and even
in the presence of advancing externally
powered technologies, body-powered
designs maintain an important place
in the prescription of upper limb prostheses. A recent survey of clinicians
reported that those with the most experience in upper limb prosthetics were
less likely to believe body-powered prostheses were outdated.
1
Terminal Devices
The terminal device is the most distal
component of an upper limb prosthesis
and is designed to replace the functions
of the human hand. Terminal devices
are available in many shapes, sizes, and
designs, each with its own benefits,
drawbacks, and specific uses. Passive
terminal devices are static, whereas active terminal devices have some type of
grasping capability.
Passive Prostheses
The terms passive and cosmetic are often used interchangeably, but they do
not have the same meaning. The term
passive is a functional description that
indicates the terminal device or prosthesis does not have an actively controlled
grasping capability. Cosmetic is a visual
and aesthetic description indicating the
terminal device or prosthesis is visually
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
139
Section 2: Upper Limb
Figure 1
dard Passive Hand. (Courtesy of Hosmer, Chattanooga, TN.)
Photograph of an adult Stan-
appealing or lifelike. A passive prosthesis may or may not be cosmetically
appealing depending on its design and
purpose. A prosthesis also may contain
passive and active elements (for example, a body-powered terminal device
with a passive elbow or shoulder).
Passive terminal devices include
hands, mitts, and devices designed
specifically for sports, recreation, or
vocation. Specially shaped devices that
facilitate targeted activities, such as
swimming, playing baseball, or holding a nail, are included in this cate gory
because they do not have an active,
cable-controlled grasp. Passive terminal devices are lightweight and typically do not require a harness; however,
a harness may be needed in high-level
amputations.
Passive hands are available in various
sizes, shapes, and configurations (Fig-
ures 1, 2, and 3). Many passive hands
have bendable or spring-loaded fingers
that provide a static grasp when positioned appropriately by the contralateral
hand. In some cases, the prosthetist can
Figure 2
Rubber Hand. This hand was originally designed for use with motorcycles and bicycles.
Oriented in opposition, the thumb releases the
handle bar in the event of a fall or crash. (Courtesy of RSL Steeper, Leeds, England.)
Photograph of a Heavy Duty
adjust the force required to open the
hand to meet the needs of the patient.
The natural appearance, lightweight
design, and minimal (or no) harness is
appealing to many patients (Figures 1
and 2). Most passive hands position the
thumb and fingers in opposition, but
other designs are available (Figure 3).
Despite lacking an active grasp,
passive hands and other cosmetic prostheses can perform many important
functions. Patients may use them to
support and stabilize objects and to restore some bimanual activities. Utensils,
tools, and grooming instruments can be
wedged between the fingers and used
effectively. The functional extension of
the residual limb to anatomic length
allows the patient to use the prosthesis
to push, pull, carry, hold, and balance
objects more easily. One study reported
that, for nonmanipulative actions, passive prostheses were used functionally
during everyday tasks as frequently as
those with an active grasp.
2
Figure 3
Hand with sta tic, curved ngers an d the passive
thumb in radial abduction to allow lateral or
key grip. This hand is also available with hinged
wooden ngers. (Courtesy of RSL Steeper,
Leeds, England.)
Photograph of the Steeplon
Active Prehensor Devices
The two primary characteristics to
consider when choosing a terminal
device with active prehension are the
mode of operation and the shape of
the device. Body-powered systems
have a voluntary-opening (VO) or
voluntary-closing (VC) mode of operation or control strategy. These designations refer to the resting state of the
terminal device and whether it opens
or closes when the user pulls on the
control cable.
VO terminal devices are closed at
rest, and pulling on the control cable
opens the device. Grip strength is a
product of the force generated by the
rubber bands or springs holding the ter
minal device closed and remains constant unless the device is held open and
modulated by the user. In contrast, VC
terminal devices are naturally open at
rest and are pulled closed by the control
cable. Grip strength is determined by
Atlas of Amputations and Limb Deciencies, Fourth Edition © 2016 American Academy of Orthopaedic Surgeons
140
Chapter 11: Upper Limb Body-Powered Components
the amount of tension the user exerts
on the control cable, which allows continuously variable grip strength.
Both strategies have advantages and
disadvantages. The grip strength of VO
terminal devices must be configured
to provide the strongest grasp that the
user needs and can repeatedly generate
through the harness and control cable.
This factor has important implications
because every time users open the terminal device they must overcome the
full grip strength of the device irrespective of the strength needed for a given
task. In addition, when handling delicate objects, users must maintain appropriate tension on the cable to prevent
crushing the object within its grasp.
These related requirements can lead to
fatigue, muscle strain, and compression
of the contralateral axilla.
Higher pinch forces can be achieved
in VC systems, because they are not
limited by rubber bands or springs.
The pinch force can be light or strong
because it is determined by the user
rather than the mechanical design. In
addition, the graded prehension in proportion to applied effort may offer greater proprioception than other control
mechanisms. Manipulation of delicate
items often requires less overall work
because the user needs only to maintain sufficient tension to hold an object
and can relax the tension without fear
of crushing it.
If the VC terminal device does not
contain an associated locking mechanism, the user must apply continuous cable tension to maintain grasp.
Although this process is normal physiologically, some patients find this requirement objectionable and prefer
other terminal devices. This drawback
can be addressed with a system such as
the Sure-Lok Voluntary Closing Locking
Mechanism (TRS). A small switch on
the forearm of the unit clamps down
on the cable and holds the terminal device in the desired prehensile position
(Figure 4).
Although overall power requirements
for VC systems may be lower, excursion requirements are greater because,
whereas VO systems can be opened only
part way with minimal excursion and
still be useful for many activities, VC
systems require full excursion to closely
approximate the opposing grip surfaces in a similar manner. Therefore, care
should be taken when prescribing VC
systems for patients with more proximal
amputations who desire active elbow
control. The harness design also must
conserve as much excursion as possible. Acceptance for VC terminal devices has been greatest in children and
individuals with unilateral transradial
amputation, particularly those with long
residual limbs.
Members of the rehabilitation team
should understand that the choice between a VO and a VC terminal device
is not merely a selection of device characteristics. Rather, it will affect the entire mode of operation of the prosthesis
across all of the user’s activities.
VO Hooks
The original split-hook design was created in 1912 by David W. Dorrance, an
upper limb amputee, to provide active
prehension as opposed to the thentraditional, passive C-shaped pirate
hook. The split-hook design has two
fingers or tines that meet side by side
and hold objects between them.
VO hooks vary in construction
materials, size, configuration, coating
options, and tension mechanisms. An
extensive variety of VO hook is available (Figure 5). Although VO hooks
were originally made of stainless steel,
aluminum hooks have become increasingly common because of their reduced
weight and are sufficient for most users.
For individuals who require a more durable material than aluminum but find
steel too heavy, titanium constructs are
available. As material technology and
manufacturing improve, hooks are becoming available in composite materials
Figure 4
untary Closing Locking Mechanism. (Courtesy
of TRS, Boulder, CO.)
Photograph of the Sure-Lok Vol-
that are lightweight and resistant to corrosion (Figure 6).
Hooks are available in a range of infant to adult sizes. The most common
shape is the canted design, which allows
users to roll objects into their grasp with
good visibility, but this design is less
suited to picking up very small objects
such as pins (Figure 5, A). An alternative style has a symmetric, rounded interior with lyre-shaped fingers, which are
better suited for grasping cylindric objects and picking up small items; however, it can partially obstruct the user’s
ability to see what they are manipulating
from some angles (Figure 5, B). Because
most amputees find the canted approach
satisfactory, the lyre shape tends to be
more commonly prescribed for individuals with bilateral upper limb amputations for use on the nondominant side
to provide an alternative prehension pattern optimized for cylindric objects. The
combination of one canted hook and one
lyre-shaped hook offers the individual
with bilateral upper limb loss the ability
to grasp objects with different shapes.
A variation on the canted design is
the farmer’s hook, characterized by a
wider opening than other hooks to facilitate holding shovel handles and similar objects (Figure 7, A). This type of
heavy-duty, stainless steel hook is commonly prescribed as a terminal device
for adult men who perform manual labor. The specialized fingers have several
subtle contours that facilitate holding,
grasping, and carrying objects such as
buckets, chisels, knives, and carpentry
tools. This design is also available with
© 2016 American Academy of Orthopaedic Surgeons Atlas of Amputations and Limb Deciencies, Fourth Edition
141
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