Whither Prosthetics and Orthotics?
George T. Aitken, M.D. *
The publicity concerning scientific and technical advances keeps us constantly
aware of man's increasing competence to master his environment. The
technologies available make possible a wide variety of mechanisms that expand
man's sphere of activity and make possible comfortable living in environments
previously considered undesirable. Some of the modern techniques, when
applied in the biological fields, have eliminated some diseases, controlled others,
and have made possible medical and surgical procedures that extend the life
expectancy of persons of all ages. Continuing research undoubtedly is going to
demonstrate eventually the etiological factors in other disease entities and
thus permit the development of a nonsymptomatic approach to therapy.
Many of the current scientific advances have been the result of interdisciplinary
effort, where two or more separate disciplines have worked together,
hopefully synergistically. This interdisciplinary effort in prosthetics and orthotics
has produced what is often described as a bioengineering effort. In the past
twenty years increasing emphasis has been placed on the engineering aspects of
this specific problem. These years have witnessed a rapid advance in the
development of new industrial materials and hardware that have been readily
applicable to artificial limbs and braces. Many improvements in previous
fabrication techniques and components were facilitated by using these newly
available industrial developments, and thus some advances were made in upgrading
the quality of prosthetic and orthotic devices.
There have been varying degrees of concurrent fundamental research in the
biological aspects of this interdisciplinary approach.
It seems at times, though, that the glamour of technology has overshadowed
the purely biological problems. Research activities involving these glamour
areas have been more attractive to many, and funds for such research have
been more available in these sometimes esoteric areas.
At times it would seem that many involved in prosthetics and orthotics
research and development have failed to see the entire problem. Basically, it is
the problem of achieving the optimum man-machine interface. The ultimate
resolution of the problem is the production of designs that result in comfort,
maximum function, and reasonable cosmetic restoration.
There is little question that much has been accomplished. Certainly we have
available currently biological and engineering techniques that are capable, in a
high percentage of cases, of producing improved function and cosmesis. Continuing
intelligent modification of techniques and components produces more
and more improvement in all of these areas. It is fair to assume that amputees
and others with orthopaedic impairments are now better served than ever
before.
Unfortunately, many in the field of prosthetics and orthotics research and
development seem to have a tendency to relegate the patient to a secondary
position. They appear to be bent on the perfection of the machine without due
consideration to the education or alteration, or both, of the man to perfect the
interface.
It seems timely to give consideration to some of the areas in which continuing,
accelerated investigation is desirable.
Research in amputation surgery to provide more functional stumps and
consequently more comfort to the patient has been significantly lacking. There
is a multiplicity of amputation techniques. Myoplastic and osteoplastic techniques
either alone or in combination have been recommended to promote
comfort and improved function. In this country there has been no well-organized
clinical evaluation of these claims made primarily from abroad. It seems
logical that such procedures be investigated and evaluated thoroughly. There
are good theoretical reasons to justify consideration of these procedures so that
they not be simply rejected because of dissimilar training and experience.
Cineplastic procedures were critically investigated, and well-established
criteria have been developed for their use. A similar review should be made of
some of the other surgical problems.
The immediate postsurgical fitting of sockets with or without early weightbearing
currently is being investigated. Undoubtedly, the results of this wellorganized
investigation will develop proper indications and techniques for this
procedure. Hopefully, such techniques will be of positive value in influencing
the man aspect of the man-machine interface.
There are in addition many areas of basic biological research that need
further investigation. The problem of biological signal sources for control of
external power comes to mind immediately. Other, perhaps less exotic, problems,
such as analysis of joint motions to permit more satisfactory alignment
and construction of braces, or the metabolic problems incident to amputation
and use of prostheses as well as analogous problems in the orthotics field, need
further investigation. These are but a few of the many fundamental problems
that need clarification.
In the truly engineering area, there is a large volume of continuing research
and development of systems, components, and techniques to produce better
artificial limbs and better braces. Much of this work is in the newer areas of
technology and has increasing emphasis on the problems related to the use of
external power in prostheses and orthotic devices.
There may be a need to review some of our accepted designs in the light of
our recent progress and perhaps an effort should be made to determine whether
previously acceptable items are really the best that can be developed in relation
to some of our improvements in materials and techniques. It may be the time
to review terminal-device design. It is possible that we now need (particularly
in the light of external power) to redefine the functional requirements of a
terminal device and arrive at some design criteria that will permit more efficient
utilization of our technical improvements in power sources and transmission.
With an increasing emphasis on prosthetic restoration in congenitally limbdeficient
children, it may develop that there must be a redefinition of goals,
in the case of the upper-extremity patient, as related to age, rather than as
related to the needs of an adult. Possibly a careful analysis of the functional
needs of pre-school and primary and secondary school children would permit
us to develop components for a system that would be more effective than simply
using scaled-down adult components and systems.
An overall review of research and development in prosthetics and orthotics
over the past twenty years cannot help but emphasize that people requiring
prostheses and orthotic devices are being increasingly better served. There
seems little question but that the efforts of our schools of prosthetics and
orthotics education have produced a marked upgrading of the skills in prescribing
and fitting these devices as well as greater competency in the training of
the patient in the use of such devices.
As a clinician, I am very pleased with the improvement of patient care in
these areas. As an interested participant in research and development endeavors,
I am increasingly aware that there is much more that remains to be
done. There exist the technical facilities to do both better research and better
development. What is needed is the wisdom to direct our efforts in such a way
that we adequately explore all areas of this man-machine problem and so correlate
our activities that the result—the functioning man-machine combine—
is a continually improving biomechanical unit.
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