Chapter 24B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
Special Considerations: Adaptations for Sports and Recreation
Bernice Kegel, R.P.T.
Do what you can, with what you have, where you are.
Sports often improve the physically challenged persons attitude toward himself by changing a negative attitude for what his body cannot do to pride in what it can do. This text is written to facilitate the clinicians role in helping individuals with lower-limb amputation find the appropriate sport for their level of ability. Fortunately, the prosthetic field has improved extensively and is much more willing and able to accommodate the specialized needs of todays amputee. Where appropriate, addresses are given for more detailed information. The information presented is based both on firsthand experiences of individual amputees, as well as research. While some of the adaptive procedures are widely applicable, others are not. Every adaptation mentioned will not necessarily work for every individual. An overall physical fitness program is essential before engaging in any new sport.
The concept of amputee skiing originated in Austria and Germany in 1948. The Swiss subsequently introduced "crutch skiing." In 1967, the National Amputee Ski Association was formed in the United States. Now amputee skiing is being taught in organized classes in most states under the umbrella organization of National Handicapped Sports (NHS). Competitive events are held annually, with regional qualifiers followed by a national event.
The unilateral transtibial amputee has two options available for skiing. He can ski with or without a prosthesis. Most transfemoral amputees ski on the intact leg only and use the three-track skiing technique. The bilateral transtibial amputee skis with a four-track technique and uses two prostheses, two skis, and outriggers. The bilateral transfemoral amputee could use short prostheses without knee mechanisms or can switch to a sled or monoski.
The Transtibial Skiing Prosthesis
To achieve skiing proficiency, it is important that the skier's center of gravity be located ahead of the ball of the foot for proper balance, ease in turning, and adjustment of speed. While individuals with two sound legs maintain balance by increased ankle dorsiflexion and a forward lean, which most ski boots are designed to encourage, the skier with an amputation may require certain adaptations.
A conventional prosthesis can be adapted by placing a 2.54-cm (1-in.) wedge under the heel of the ski boot to achieve the desired forward cant. The resultant increase in socket flexion, however, may raise the socket's posterior brim in relation to the patellar tendon bar, thus causing excessive and painful pressure on the hamstring tendons. To relieve this excess pressure on the hamstring tendons, the prosthetist can make a ski prosthesis. First, the prosthesis is aligned in the conventional manner. The socket is then moved forward in a linear manner so that the anterior part of the brim falls approximately 2.54 cm (1 in.) behind the toe of the prosthetic foot (Fig 24B-1., A and B). Moving the socket forward has a detrimental effect on cosmesis and causes an anterior bulge on the front of the leg. The overall length of the prosthesis is reduced to equal the length of the intact lower limb when the ankle is dorsiflexed roughly 25 degrees. The skier can now adjust his center of gravity more easily.
For the beginning skier a solid-ankle cushion-head (SACH) foot may be adequate. The SACH foot permits the selection of a sufficiently soft plantar flexion resistance, is available in a variety of sizes, and is compatible with virtually every lower-limb prosthesis. For more proficient skiers who desire greater flexibility, dynamic-response feet may be more appropriate. The flexibility of the Greissinger foot in the sagittal plane enables the skier to bend more deeply over his skis, which improves control at higher speeds. The lower third of the socket to the base of the foot should be reinforced with carbon fiber to prevent breakage caused by the skier leaning forward over the tip or tail of the skis when adapting to different terrain.
Flexion and extension at the knee and hip are basic to the activity of skiing and create a rather unusual residual limb-socket interaction. The interface used should offer as much protection and cushioning as possible, such as that provided by the silicone gel insert. The insert acts like a protective layer of fatty tissue and distributes pressure evenly. If displacement of the silicone is of concern, another option is nickelplast.
To reduce the reaction time between leg movement and movement of the prosthesis, minimal piston action is important. The skiing prosthesis is often fabricated with a thigh lacer and waist belt pickup strap. Additional suspension techniques are the active sleeve or neoprene sleeve. An inverted figure-of-8 suprapatellar cuff may also be added. These suspension mechanisms also help prevent one from losing a prosthesis while sitting on the chairlift. Some skiers choose to cut a hole in their ski pants, wear the waist belt on the outside of their clothing, and thread the pickup strap through the hole so that they can easily make adjustments to the suspension. A lightweight ski boot is usually recommended.
The skiing prosthesis is specialized, and for this reason, a conventional prosthesis is still needed for walking and after ski activity.
Those who ski without a prosthesis are advised to pad the residual limb for protection against cold and injury.
For transtibial amputees, several stump socks are usually adequate.
Transfemoral amputees may prefer to have a modified socket fabricated. This protective device is made to match the knee length of the intact leg, thus making it easier to rest by kneeling and then to get up from the ground.
Some skiers like to attach a removable pylon to the socket so that they can walk around on the snow when not skiing (Fig 24B-2.). When skiing, the pylon is detached and stored in a padded backpack, or it can be left in the lodge. While riding the chairlift, exercising the residual limb helps to maintain proper circulation.
The three-track skier needs a good-quality ski because all body weight is on one ski. A "three-tracker's ski tote" was developed to allow the skier with amputation to carry his ski over the shoulders while using outriggers. The ski tote has a thick felt pad to protect clothing from the ski's sharp edges, three Velcro closure straps (adjustable to any binding length) to hold the ski in place, and a strong, one-piece carrying strap.
Ski stabilizers are frequently used in four-track skiing and also for skiing with two skis and two poles. They hold the tips of two skis together for those who lack the leg power to do so. Ski stabilizers can be handcrafted with bungie cord or purchased commercially. Even though the skis are hooked together, flexibility of movement is allowed while maintaining a constant position of the skis, approximately 3 or 4 in. apart at the tip of the skis. The skier can do a snowplow, parallel ski, and train. If necessary, ski stabilizers can also be attached to the tail end of the skis (Fig 24B-3.).
Outriggers are specially adapted ski poles that are a cross between a crutch and a miniski and enable a person to balance and maneuver better than with standard poles. They are made from a pair of Lofstrand crutches attached to 50-cm ski tips and allow approximately 30 degrees of motion at the junction. The outriggers should be adjusted to a length that allows the skis to hang 2.5 to 5 cm (1 to 2 in.) above the snow surface when the skier is standing erect and holding the outrigger handles. The skier should be wearing a ski boot and ski when making this length test. Two general types of outriggers are available: those that allow the ski tip to flip up for walking (Flipski) and those that do not (standard). The Flipski changes from a skiing outrigger to a skid-resistant walking crutch (Fig 24B-4.). The amputee merely squeezes a cord located at the handgrip, and the ski flips up to lock in a vertical position and produce a walking crutch. Metal claws attached to the tail end of the outrigger skis provide additional braking action. Some amputees add a semicircular disk just behind the vertical part of the crutch. When the Flipski is in the walking position, this disk prevents the outriggers from sinking in soft snow. The Flipski makes it easy for the amputee to get around when not actually skiing, and in using them, the skier finds that he has more energy remaining to ski. Manufacturing one's own outriggers is feasible, provided that access to a machine shop is available.
When using outriggers, the three-track skier puts considerable pressure on his hands. Blood circulation could become impaired and the hands get very cold. Mittens are suggested since they are warmer than gloves, and hand exercises should be done.
Skiing for the Bilateral Transfemoral Amputee.-
Some bilateral transfemoral amputees are able to ski on short prostheses and skis.
Another option is to sit-ski in a lightweight molded fiberglass kayak-like sled (Fig 24B-5.). The amputee lowers himself into the sit-ski and then adjusts a waterproof cover over the lower portion of the body. Turning is done via a combination of leaning, weight shifting, and the use of short ski poles. A way to practice on land would be to make a "roller sled" and poles, which is essentially a sled ski-skateboard combination. Transferring into a sit-ski from a wheelchair can be difficult, so the skier should practice indoors on a dry surface until the movements are mastered.
It is important when sit-skiing to find a hill with a good slope. Without enough momentum it is more difficult to initiate turns with the sled. Another factor to consider is flat areas. The sledder must use the upper part of the body to pull himself through the snow with ski poles. The sledder must cross-country ski to reach the next fall line. The sit-skier usually skis with a partner or "tetherer." The tetherer does not control the ride unless the sit-skier needs help. The sit-skier, particularly when learning in a tethered situation, should avoid crowded ski runs because of the amount of space needed by the sit-skier and tetherer. The sit-skier should be aware that due to his close proximity to the snow, visibility on the mountain is decreased. He should be sure to rest in places that are clearly visible to other skiers. The sit-skier also realizes that he cannot see other skiers as well as standing skiers can.
For getting around in wheelchairs on the snow, trail bike tires for wheelchairs are suggested. To provide better friction, short segments of bicycle chain can also be wrapped around the wheelchair wheels.
It is possible to load a sit-ski on a chairlift, but this needs to be done with the aid of a lift attendant. When loading the sledder in his sled, the tetherer and one other skier approach the double chairlift. The lift is slowed while the sledder is pushed to the loading area with a skier on either side of him. Neither lifter should be carrying ski poles, and the sit-skier should have his poles inside the sit-ski. Each lifter grabs one side of the sled and lifts it as the chairlift continues to move up from behind. The sledder is set down on the chair alongside the skier who is closest to the lift terminal. The skier closest to the lift line waits for the next chair. The sit-skier should have the chairlift securing mechanism out and ready to use by laying it across his lap. As soon as the sled is on the chairlift, the securing mechanism is attached to the chair from the rear of the sled. The securing mechanism is designed for quick attachment and removal. The fact that the weight of the sit-skier rests far back in the chair ensures a safe ride. Each sit-ski is equipped with an evacuation harness should the necessity arise for the sled to be lowered to the ground.
When the unloading area is approached, the lift is slowed, the securing mechanism released, and the sit-ski pushed off when it is closest to the ground. The assistant stays slightly behind the sit-skier to prevent the chairlift from hitting the sit-skier in the back of the neck. The assistant may need to help push the sit-ski away from the chair. The instructor holds on to the tethering rope to make sure that the sledder reaches a safe area before beginning down the slope. With practice, many sit-skiers can load and unload from the chairlifts without stopping or slowing the lift.
The first thing to learn when sit-skiing is how to turn. Three of the most common methods are (1) spikes or brass knuckles, (2) the kayak method, and (3) the short swing. When using the spike method, short poles are used. The pole is planted with the arm outstretched to the side and slightly behind the skier. As the sled turns, the skier leans forward and then leans and plants the opposite pole to turn in the opposite direction.
The kayak method is similar to the short-spike method, but a long pole or two poles tied together are used. Both poles are held by both hands, similar to a kayaking paddle.
The swing uses two longer poles and is more difficult. The amputee moves his hips by using the muscles of the lower portion of his torso. It is difficult to do smoothly, and this technique is usually used on steep hills with large moguls.
For each technique, the skier needs to lean forward to prevent the ski from spinning and heading the skier down the hill backward.
The quickest way to stop the sit-ski is to roll it on its side. The tetherer can also stop the sit-ski in several different ways. If going at a slow speed, merely snow-plowing will be effective. An alternative stop that can be executed is the swing hockey stop. The tetherer, who is following behind the sit-ski, swings out to the side and down next to the sit-skier. The sit-skier will be turned sideways to the ski slope.
The sit-skier should choose layered clothing for extra warmth. A T-shirt, long underwear, turtleneck sweater, water-resistant windbreaker, and down parka are recommended. Since sit-skier's hands are often in the snow, waterproof mittens are desirable. Downhill sit-skiers should wear safety helmets.
By far the most popular and promising device available at the present time is the monoski (Fig 24B-6.,A and B). Monoskis were introduced in the United States in 1985. This is a much faster device than the sit-ski. It consists of a bucket or shell that rides on a specially reinforced ski that is capable of withstanding great pressure. The monoskis frame mechanism is constructed of aircraft tubing and cables to provide a suspension over the ski. With the use of short outriggers the user can maneuver the ski to carve a turn.
The monoskier can "unweight" himself with an outrigger while being aided onto the chairlift by a ski partner. The frame mechanism pivots upward and allows the seat portion to slide onto the chairlift without interrupting normal operation. The user can unload from the chairlift without assistance from others.
Sit-skiing as a competitive event has been in existence in the United States since 1979.
The Disabled Nationals Competition now hosts 5-, 15-, and 25-km races. For the skier with a transtibial amputation, a prosthesis with a thigh lacer or Ac-tivsleeve is helpful in providing more control while turning. Most skiers find that using a prosthesis 2 to 3 cm shorter than standard will increase turning power. If the prosthesis is too long, extending the leg backward adequately can be difficult. Another challenge is maintaining control of the ski when it is extended to the rear. This backsliding prevents the skier from keeping on top of his skis and results in a loss of kick and forward leg drive. To avoid backsliding, a piece of elastic nylon can be looped over the top of the foot and attached to the ski at approximately 3.8 cm (1½ in.) behind the heel plate. This nylon strap effectively stops the prosthesis from being lifted more than a few inches off the heel plate, thus preventing backsliding (Fig 24B-7.). While the strap also limits stride length, the skier with lower-limb amputation can compensate for this by developing a strong upper body to obtain a longer stride.
Selection of terrain is important. Carrying a 6-m (20-ft) length of rope is helpful. If the terrain gets too arduous, the rope can be attached to a partner around the waist, who can then serve as a tow.
Cross-country skiing in a sit-ski is a vigorous activity. The ideal surface for sit-skiing is relatively flat, with hard packed snow, and the trail should be 5 to 8 ft wide. For steep, uphill trails, it is helpful to install a rope along the side of the trail so that the skier can pull himself up when necessary. The cross-country sled skier should experiment to determine the most efficient pole length for his needs. Poles vary in length between 50 and 135 cm. Beginning skiers usually use short poles, while experienced skiers prefer longer ones for more push length per stride. Double poling is used- long pushes for flat terrain and short jabs for uphill. For control going downhill, small spikes are mounted on the back of the hand with a Velcro and leather strap.
Snowmobiling is possible for most amputees. It is especially appealing because it offers access to remote areas that may not be otherwise accessible. A buddy system is strongly recommended. Most transtibial amputees prefer a snowmobile with a relatively elevated seat. If the seat is too low, the knees have to be bent more than 90 degrees, which causes discomfort in the popliteal area. Keeping one's prosthetic foot on the footrest can be difficult. The ideal footrest provides good support but does not limit leg movement. Many amputees choose to custom-make their own footrests, against which they brace their prosthesis.
Swimming provides a freedom of motion to the physically challenged that they are often deprived of in daily activities. Several options are available:
- Swimming without a prosthesis
- Peg legs for use on the beach and possibly for swimming as well
- Sockets attached directly to swim fins (Fig 24B-8.)
- The swimming leg, which is worn while in the water
The decision to use a prosthesis while swimming depends on the individual. Many amputees perform competitively without a prosthesis. When swimming without a prosthesis, the three intact limbs do most of the work. The backstoke is usually the easiest to accomplish, with the main difficulty being the ability to maintain one's direction of choice. One disadvantage to swimming without a prosthesis is that the amputee may have difficulty getting the prosthesis back on after swimming because the residual limb may become slightly edematous.
Swimming with a prosthesis is an excellent way to exercise the residual-limb musculature. (This does not necessarily mean that one will swim more proficiently with a prosthesis.) In addition, the ability to climb a ladder out of a swimming pool, increased stability when diving, and some protection against injury to the residual limb are other reasons to use a prosthesis. Some people are also embarrassed to appear in public without a prosthesis.
The Beach or Utility Prosthesis
This prosthesis is used for walking along the beach, standing in a pool, or wading through streams while fishing. In addition, this prosthesis can be used in the shower, thereby eliminating the need for a stool or grab bars. The prosthesis is waterproof and can be worn with or without a shoe. If a SACH foot is used, some adaptations need to be made to the heel to allow the amputee to walk barefoot. A removable "heel leveler" fabricated from polypropylene molded over the SACH foot can be used. An alternative would be to use a plantigrade postoperative foot (Kingsley), which would allow the amputee to change readily from street shoes to tennis shoes for other activities.
The VAPC Swim/Walk Ankle
The Veterans Administration's Prosthetic Center (VAPC) of New York developed the swim-walk ankle (Fig 24B-9.,A and B). The prosthetic ankle is constructed to lock at 90 degrees (neutral) for walking and at 120 degrees (30 degrees plantar flexion) for swimming. Each position is controlled by a spring-loaded pin that automatically locks in place. The swimmer can easily activate this prosthesis via a ring located in the posterior portion of the device's calf area. The amputee can walk into the water and change the foot from a walking to a swimming mode. The VAPC unit is constructed of polypropylene, so it is waterproof and resists corrosion in salt water. The Kingsley Syme foot, which is ideal for this activity, is fitted to the ankle joint. All other components, such as screws and tubes, are constructed of stainless steel. This leg is available for veterans but is not commercially available. The commercial equivalent to this unit is the Activankle (Fig 24B-10.,A-C), which is a multiposition sports ankle designed to allow the amputee to participate more easily in swimming, rowing, and downhill skiing. Materials that are corrosion resistant like Dupont's Delrin and stainless steel are used. A locking pin is used to maintain stability when walking. The pin can be removed to allow full ankle mobility. Activankle can be used with most endoskeletal prostheses and can also be mounted in any Symes-style SACH feet.
Otto Bock-style Swimming Leg
The German firm provides technical information on how to construct the Otto Bock transtibial swimming leg with an airspace between the two walls of the prosthesis shanks (Fig 24B-11.). A hole drilled through the ankle block allows the airspace between the two walls to partially fill with water during swimming and to drain when on land. The draining process is rapid and does not cause any cosmetic problem. This filling process increases the weight of the prosthesis and therefore reduces its buoyancy enough to permit effective swimming action. The limb is weighted to facilitate proper balancing between the shank and the toe of the prosthesis. When the airspace fills with water, the toe will point at the correct angle to provide an effective swimming "kick." The swimmer may also wear a swim fin with this device. Because of their increased strength characteristics, acrylic resins rather than polyesters are generally used to fabricate the limb. If a supracondylar cuff is used, it should be constructed of a pliable plastic material that is impervious to water.
A transfemoral swimming leg can be similarly designed. A quick-release knee lock mechanism and a waterproof nylon axle are used. For convenient storage, the amputee may disassemble the prosthesis into two parts by removing the axle. The knee mechanism, which is completely functional in water, has a friction lock especially designed for walking or sitting on the beach. For suspension, a light harness can be made out of waterproof material. Some suction socket wearers manage to keep the limb on with no harness at all.
The Turfking chair is designed to be used both on the beach and in the water. When in the water, rear pontoons give lateral stability. Propulsion in the water is by hand-operated flippers. The occupant can also release a small anchor to hold the chair in one place. The backrest can be used as a life vest. The amputee can then swim out of the chair while being tethered to the chair by a 20-ft tether cord. The Turfking can also be used while fishing (Fig 24B-12.).
The transtibial amputee often skis on one ski, with the specialized prosthetic leg placed behind the intact leg. The waterproofed prosthetic leg can be made a little shorter to place weight further back on the ski. The prosthetic knee can be outset and externally rotated to allow space for clearance of the knee of the opposite limb. If using two skis, the prosthetic ski should be kept 3 to 6 in. ahead of the other ski. If the skier starts with the artificial limb trailing behind, it will usually be wrenched off by the force of the water. Another alternative would be to start off on two skis but to place the residual limb in the socket without tightening the suspension mechanism. Once up and stable, the amputee could release not only the second ski but the prosthesis as well. Water ski bras can also be used to provide better control of two skis.
Many amputees prefer to ski without a prosthesis. A broad, square-backed ski will give the largest planing area and best stability for a beginning skier. A deep slalom ski fin is helpful. For maximum control, the fin should be placed between the heel of the binding and the rear of the ski. Once up, the residual limb should not wave about but be kept close either to the side or in front of the sound leg. By "hugging" the sound leg, the muscles of the residual limb reinforce those of the sound limb, thus minimizing fatigue.
For the bilateral amputee, a commercially available Hydro Slide works well. The Hydro Slide resembles a surfboard, and the amputee utilizes it either in the sitting or kneeling position. Other devices designed specifically for the disabled are the monoski (Fig 24B-13.), the water ski seat, and the Kanski.
Skills required for this activity include the amputee transporting himself, equipment, and boat to the launching area, as well as portage and self-rescue. River banks are often steep, rocky, and slippery. Most amputees keep their prostheses on since hopping any distance while carrying equipment is exhausting.
For getting into a boat from a wheelchair, a hydraulic hoist (Hydro Hoist) may be useful. The hoist lifts the boat out of the water onto pontoons. Lateral motion of the boat is prevented. The gunwale is now level with the wheelchair seat. The amputee slides from the wheelchair to the gunwale to the pilot's seat. Once in the boat the amputee usually encounters no significant problems.
Kayakers may fear being trapped during a capsize because of the protrusion of the prosthetic foot. Because of this, some amputees prefer to strap their prosthesis to the boat rather than to their body. Also for this reason, the amputee may chose to use a peg leg.
Some people use a seatbelt to secure themselves. An airplane kind of buckle is recommended, with a rope attached to the buckle release. The rope hangs outside the spray skirt so that when it is pulled, both spray skirt and seatbelt release at the same time. Boarding a canoe is simpler from a sitting than a standing position. The legs are placed in the canoe first, as close to the center as possible, and after that the rest of the body is positioned into the craft. Lowering the seat height slightly may help to lower the center of gravity, thus improving balance. For extra back support, attaching the top portion of a plastic stacking chair to the canoe seat may be useful. For wheelchair users planning overnight trips, it is important to ensure that the wheelchair fits into the canoe being used, that the user is able to transfer the chair into and out of the canoe, and that the wheelchair is secure should the craft capsize. Because canoes are lightweight, even a person confined to a wheelchair can support one end of the craft to help transport it to the water.
For rowing, the Veterans Administration has designed an ankle unit that permits free ankle movement while in the boat but allows a stable foot for facility while walking on the dock. Stability during walking is obtained by using rubber tubing instead of dorsiflexion and plantar flexion bumpers as used in single-axis prosthetic feet (Fig 24B-14.). Once in the boat, the rower can remove the tubing. This prosthesis is waterproof and buoyant, and its posteroproximal brim is fabricated to allow maximum knee flexion with minimal or no discomfort in the area of the hamstring tendons.
For sailing, the British-designed trimaran the Challenger can be handled safely by the physically challenged. A slide hooked onto the main beam connecting the three hulls eases the transfer from wheelchair to cockpit. Virtually no body movement is required to steer the craft because the tiller is within easy reach of the helmsman.
The "Able Sailor" is a device that allows the leg-disabled sailor to change sides within a boat without assistance, thus enabling him to helm the boat much as his able-bodied counterpart would. The Able Sailor consists of a contoured seat that sits on a semicircular track and runs on rollers. When the control cord is pulled, the seat runs free to the opposite side of the boat. The seat can be installed or removed from a standard boat without the use of special tools. The National Ocean Access Project (NOAP) universal adaptive seat was developed for the United States yacht racing union's championship race for disabled persons in Boston in September 1990. It is lightweight, built of fiberglass, and easy to install, thus making almost any boat adaptable for sailing by a disabled sailor. It can rotate freely from port to starboard and allow the sailor to tack in a comfortable, safe, and workable environment.
The major challenge is getting oneself and one's equipment to the water. In most cases this requires assistance, although some amputees can manage alone by diving from a boat. When returning to the boat, the diver removes the gear in the water so that people on board the boat can pull it aboard. They then assist the diver into the boat.
With an efficient arm stroke, the person with lower-limb amputation might very likely consume less oxygen than the able-bodied diver because the use of arm muscles demands less oxygen than the use of leg muscles. With proper instruction and equipment together with a well-developed arm stroke, the person with amputation can scuba dive well as long as the hands are free. Such individuals are encouraged to use webbed neoprene hand fins. These fins are called "power gloves."
Buddy breathing, or sharing air from a single tank, is frequently necessary. For the able-bodied, buddy breathing is done face to face when descending and side by side when swimming. For divers who are unable to propel themselves with their legs, the side-by-side method is difficult because it requires that both hands be used to pass the regulator from one diver to the other. A better prospect is for the divers to position themselves one on top of the other, in piggyback fashion. While the diver on the bottom provides the locomotion, the diver on top manages the breathing apparatus. Even better is the octopus adaptor and other dual regulators that allow both the diver on top and bottom some locomotion.
The unilateral lower-limb amputee has relatively few problems playing golf. Bending over to "tee up" requires a greater-than-normal sense of balance. The amputee may achieve a little less distance due to the lack of follow through in his swing and difficulty in rotating on the prosthesis. It is very important that the prosthetic shank used have a rotational component. Nylon (DAW) sheaths may also be used to decrease friction and protect the skin at the residual limb-socket interface. Some amputees prefer not to wear golf shoes with spikes because this further decreases their ability to rotate on the prosthetic limb. The Swivel Golf Shoe developed by the War Amputations of Canada has some merit (Fig 24B-15.). This is a device built into a regular golf shoe to provide the golfer with more rotation ability on his prosthetic side.
The right-handed golfer who has left-leg amputation should begin his swing with the foot rotated inward. The person with a right-leg amputation who is also right-handed is at a disadvantage. He may tend to keep all weight on the left leg during a swing. It may be better for this person to play left-handed.
Some amputees prefer to play without their prostheses. The bilateral transfemoral amputee who experiences difficulty maintaining balance might consider modifying a standard camera tripod by placing a bicycle seat on top (where the camera would normally be). In this way the golfer can sit on the seat while bearing some weight on his legs (Fig 24B-16.). One can also play from a wheelchair by using a thick pillow under the buttocks. On approaching the green, the golfer gets out of the chair and sits on the ground. Golf can also be played from a sitting position in an electric cart equipped with a swivel seat, or one can play from a standing position while leaning against the golf cart for support. Golfers operating from a seated position should use clubs that have a flatter lie than normal. This reduced angle is helpful because of the flat swing plane induced by the seated position.
The amputee golfer should also consider terrain. Walking 18 holes will cover approximately 5 miles, and even riding a cart leaves about 2 miles covered on foot. Electric golf carts are worth considering.
The National Amputee Golf Championship event has been in existence for 41 years and fields about 130 participants. The field is broken down into seven divisions based on type of amputation and two special divisions, ladies and juniors. The National Amputee Senior Golf Championship (over 50 years of age) has been in existence for 14 years.
Ten years ago, running was considered an impossibility for the amputee. Diehards were limited to a hop-skip-and-run technique where they begin with one step on the prosthetic leg, followed by two steps on the sound limb. Other runners used crutches but no prosthesis. The technique is similar to running with a prosthesis-crutch, skip; crutch, skip, skip. . . . Terry Fox's marathon "Run of Hope" across Canada provoked an interest in running and brought about the development of the prototype for the Terry Fox running prosthesis, which has a "pogo stick" effect. The telescoping pylon, which is incorporated into the shank section of a transfemoral prosthesis, functions by absorbing some of the ground impact and by shortening the prosthesis on weight bearing. The knee mechanism used has a stanceand swing-phase control (Fig 24B-17.).
Subsequent research at the University of Washington showed that lower-limb amputees are capable of running short distances at speeds of 4 to 5 m/sec and of maintaining paces of approximately 3 m/sec for distances of a half mile or more. These amputees were running with conventional prostheses. They usually extended the knee on the prosthetic side during heel contact and thus reduced the shock absorption function of the residual limb and placed unnatural stress on the knee, hip, and vertebral column. Restricted range of motion of the intact limb and the knee and hip during swing phase was also seen. Recovery of the limb with so little knee flexion could only be accomplished by additional contraction of the quadriceps muscles and resulted in unnecessary fatigue. For walking, the vertical ground reaction force is rarely greater than body weight. During running, this force reaches two to three times body weight. To reduce some of these difficulties, dynamic-response feet emerged. These feet provide varying amounts of push-off at the beginning of swing phase, thus being much more effective choices for the athlete. The transfemoral amputee Jeff Keith, who completed a cross-country run from Boston to Los Angeles in 1984, was wearing a Seattle foot on his prosthesis. The Activsleeve suspension system is helpful in reducing pistoning for the transtibial amputee (Fig 24B-18.,A and B). Activsleeve is made of natural rubber with a ribbed design at the top of the sleeve and a straight tubular design. The ribbed portion creates a seal around the thigh to produce a suction-type suspension, which is very popular with the active amputee population. Activsleeve can be worn as low as 3 to 4 in. above the knee and inhibits water from entering the socket when swimming or showering.
Dennis Oehler, an amputee sprinter from the United States, is able to do the 100 m in 11.3 seconds, the 200 in 24.37 seconds, and the 400 m in 56.25 seconds. His 100-m time is within 1.8 seconds of the able-bodied world record (Fig 24B-19.).
Transfemoral sockets have also improved, so discomfort on the medial part of the brim and rotation of the socket are less of a problem. Amputees are moving toward narrow mediolateral and flexible sockets. For children, the Oklahoma cable above-knee running system involves using upper-limb cable systems to help bring the shank of the prosthesis forward more efficiently during the swing phase of running. The proximal end of the cable is attached to a belt similar to a Silesian bandage, and the distal end is attached to the proximoante-rior shank section of the prosthesis. At toe-off, tension in the cable causes a dynamic extension moment at the knee. In other words, power is being transferred to the knee joint directly from the action of hip flexion, similar to the action of the quadriceps muscle (Fig 24B-20.). Wheelchair road racing has become a well-established entity, and the design of racing chairs has developed into a fine art. It appears that the three-wheeled sports chair is here to stay (Fig 24B-21.). In 1985, Rick Hansen completed his "Man in Motion World Tour" in a wheelchair. Between January and July 1989, Bill Duff wheeled 5,000 miles from Los Angeles to New York and created even more publicity for wheelchair racing. It is now 14 years since wheelchair athletes first entered the Boston Marathon. The 1989 winner was Philippe Couprie, 26 years of age, who won it in 1:36:04. This averages 3 minutes and 40 seconds to the mile. The women's division was won by Connie Hanson, 24 years old, with a time of 1:50:06. In 1977 the time differential between men and women was 1:06:51. In 1989 it was 14:02.
There are some 10,000 pilots with physical disability in the nation's skies. Rode Rodewald is a wheelchair pilot who soloed on a trip that took him around the globe in 1984. He was recently inducted into the Colorado Aviator Hall of Fame. Flying requires skill and judgment, but very little strength. Four intact limbs are not necessary.
The choice of an aircraft depends on the ability to get in and out. Amputees in wheelchairs do best with a low-wing Piper Cherokee, which has a door beside the wing and a baggage area large enough to accommodate the wheelchair. The Grumman American and Ercoupe also have low wings, but a sliding canopy requires entrance over the side. Struts on high-winged aircraft such as the Cessna 172 interfere with wheelchairs, but an amputee who can stand can move around them. The Cessna Cardinal does not have wing struts and may work well. Other aircraft being flown by amputees include the Mooney Ranger and the Beechcraft Muscatee Bonanza.
For those who fly without hand controls, modification of the prosthetic foot may be necessary to prevent the foot from hitting the brake pedal while operating the rudder pedal. The Navy Prosthetics Research Laboratory in Oakland, California, has designed a two-part SACH foot. When flying, the toe section can simply be removed and then replaced for normal walking later on (Fig 24B-22.). Another adaptation is to attach a webbing strap to the rudder controls to allow them to be operated in a push-pull fashion with the sound leg.
Most amputees jump without a prosthesis and use protective padding for the residual limb. A detachable pylon is also helpful, especially when navigating on the ground after a jump.
Ordinary static line jumping requires no adaptation for disability. For free-fall jumping, the amputee may have difficulty maintaining a stable position because the body surface presented to the air must be symmetrical. The transtibial amputee can either bend both knees to his chest or extend the hips and bend both knees to a right angle. The transfemoral amputee needs to build a knee length extension to his residual limb by using either a residual-limb protector or an old socket. He then jumps in the same way as a transtibial amputee. The use of the arms may also be necessary to prevent spinning.
In 1981, a group of amputees called "Pieces of Eight" performed an eight-way free-fall formation. It took them 15 attempts to accomplish, and the formation was held for 4.66 seconds.
Scandinavia and Great Britain pioneered in promoting riding for the handicapped. Now the North American Riding for the Handicapped Association (NARHA) serves about 4,000 riders a year in the United States and Canada.
Saddle, bridle, and reins do not require modification, but rolled leather hand holds can be attached across and in front of the pommel of an English saddle to help the beginner maintain balance. They can buckle to heavy-duty square D's under the saddle skirt slightly behind the D's used for the breastplate or martingale.
The main concern with stirrups is that they do not trap the prosthetic foot in a fall. It is best to use Devonshire boots (stirrups that look like a boot toe) or safety stirrups that come with a safety latch to release in the event of a fall. They fit only on English saddles. Western saddles are more stable but do not have the safety stirrup options. Rubber inserts for stirrups and rubber-soled boots may help keep the prosthetic foot in place, especially for transfemoral amputees.
Transtibial amputees generally wear a prosthesis for riding. The outside of the prosthesis needs to be checked so that there are no rough edges that could irritate the flank of the horse. Possible modifications to the prosthesis are lowering the popliteal brim, flattening the medial aspect of the calf, and aligning so that the heel is canted inward and the toe upward and outward. Transfemoral amputees can ride with a prosthesis, although the gluteal tissue often gets pinched between the prosthesis and the saddle. A very short residual limb would also be reason for riding without the prosthesis. Transfemoral amputees do need to have the ability to abduct the residual limb at the hip joint. If wearing their prosthesis, they will also usually need a string or strap from the heel of the boot to the upper part of the prosthesis or to the waist to keep the knee flexed. A locking device, as on the Mauch S-N-S knee, may also be used to keep the knee flexed at a desirable angle.
Amputees with bilateral transfemoral amputations or hip disarticulations usually need bucket-type devices- seats with leather sockets. Unilateral amputees need them only rarely.
If riding without a prosthesis, the amputee might need some type of "residual-limb stirrup" to facilitate balance on the horse. This socket-stirrup assembly will need to release the limb in a fall (Fig 24B-23.).
Mounting from a wheelchair may require a ramp (16 by 4 ft with a platform 4 X 6 ft). An ambulatory rider, especially one with left-sided amputation, might need a twoto three-step mounting platform.
Transtibial amputees ride easily with a prosthesis. Some put the prosthetic heel on the pedal for a more effective push. Others use a toe clip to keep the prosthesis on the pedal, although caution is needed to prevent the toe from being trapped.
Transfemoral amputees have several options. Some avoid using the prosthesis because they feel that it offers no additional power. Others wear the prosthesis for cosmetic needs and use the prosthetic leg as a landing strut. A toe strap is often used on the sound side and the bike operated in a push-pull fashion. Bicycle shoes also help with the upstroke. The Mauch S-N-S hydraulic knee is effective for bicycling. The free-swinging mode is best unless a leg-strengthening resistance is required. This can be obtained by using the stance control. Prostheses without hip joints and pelvic bands allow more comfortable straddling of the saddle. Foam-covered endoskeletal prostheses must be protected from pedal damage.
A hip disarticulation amputee may chose to ride with his abdomen on the saddle, sound leg on one pedal, opposite hand on the other pedal, and sound-side hand on the handlebars. This is precarious, but works. David Kiefer, a hip disarticulation amputee, has ridden across America twice on his bicycle and has set the world handicapped cross-country record at about 15 days.
A good-quality bike with many gear options is obviously desirable. Both hands must be kept on the handlebars while exerting power because the arms and hands compensate for the imbalance of one-legged power. Gear levers must be handlebar mounted and operable with three fingers while the palm and other fingers continue to grip the handlebar. Other options to consider are removing the unused pedal or crank, extra padding on the saddle, and turning the saddle slightly away from the sound leg. The racing handlebar position may be uncomfortable, and conventional handlebars may be better. To prevent friction between limb and socket, Spenco Second Skin (made from a breathable hydrogel) can be held in place with tape and a stump sock. Second Skin is available from most sporting good stores.
Hand-powered, hand-controlled tricycles may work for the child amputee.
The wheelchair Cycl-one is a hand-operated device that attaches directly to a standard wheelchair and allows the rider to travel at 10 to 15 mph. The assembly weighs about 17 lb and fits into most auto trunks (Fig 24B-24.).
The Rowcycle is a hand-operated mix between a bicycle and a rowing machine that uses arm and back muscles. The cycle seat slides back and forth or can be locked in one position. It is steered by the weight-shift rotation of the seat, which turns the front wheel. The center of gravity is adjustable and allows the rider to "pop wheelies" for quick turns. One size can be used by the child or adult.
The Sunburst and the Counterpoint are two-wheeled tandem bikes combining armand foot-powered recumbent cycling in the front and standard cycling in the back (Fig 24B-25.). The back rider controls the rear caliper brake with a hand lever. Both riders activate the front hub brake by backpedaling. The front rider pedals with any combination of arms or legs. The front rider can stop and rest, while the back rider continues to pedal. The Handbike, a two-wheeled cycle with two small caster wheels projecting from each side of the frame, gives balance and stability to the bike for boarding.
For stationary bicycles, the Schwinn Air-Dyne is recommended because it allows arm as well as leg operation, either separately or together.
For young children with bilateral limb deficiencies, the skateboard provides a recreational outlet and can be an appealing alternative to the wheelchair.
Many amputees play baseball, usually with a prosthesis and always on an able-bodied team. Two notable people are Bert Sheppard, a transtibial amputee who successfully pitched for the Washington Senators, and Monte Stratton, a transfemoral amputee who pitched for the Chicago White Sox. Most transtibial amputees play any position, but transfemoral amputees are usually too slow for the outfield. Shortstop could be a difficult position because of decreased lateral mobility. Catcher is a good choice if the amputee has a strong arm, can get down on his haunches with the prosthetic leg to the side, and can get up quickly. Pitcher and first baseman are other possibilities. Batting with the stronger leg behind is best; right-sided amputees may bat left-handed. Some amputees defer to a substitute runner after they get on first base.
The United States Amputee Athletic Association sponsors a tournament featuring six to eight teams for stand-up basketball competition in which conventional rules apply. Since there are so few disabled teams, most people play on able-bodied teams. Most use a prosthesis with a dynamic-response foot and additional prosthetic suspension. The Activsleeve would be a good choice for the transtibial amputee because it creates a suction-type suspension.
The transfemoral amputee might consider a total elastic suspension (TES) belt in addition to a suction socket.
To protect the skin from friction, it is wise to use a nylon sheath, Spenco Second Skin, or an ointment like Ampu-Balm or Amp-Aid. Occasionally an amputee will play by hopping without a prosthesis, but probably not for a whole game.
Wheelchair basketball is very well established and features over 150 men's teams and a few women's teams. There are also summer wheelchair basketball camps.
A new sport well suited to wheelchair players and able-bodied alike is bankshot basketball. It is a pure shooting sport that involves no running or contact. The player moves along a course made up of 12, 15, or 18
baskets on variously shaped backboards, each requiring a different and increasingly difficult shooting strategy. The game can be played alone or competitively.
An ambulatory amputee can bowl by standing at the foul line or using a twoto four-step approach. Steps may be short and jerky. A right-handed bowler with a right amputation (or a left-hander with a left prosthesis) is in the best situation-he can slide to the foul line on the sound leg and release the ball in the usual way. When handedness and prosthesis are opposite, the bowler may prefer to stand with feet together about a meter behind the foul line and lean forward to advance the ball. A prosthesis similar to that described for rowing may be helpful. This type of prosthesis would also work for the sport of curling.
Amputee soccer (Fig 24B-26.) originated in the Seattle area and has now expanded into national and international competitions, with teams coming from England, Canada, the Soviet Union, El Salvador, and Brazil. The 1991 championships were held in the Soviet Union. Players use standard Canadian forearm crutches and no prosthesis. A "pogo stick"-type crutch is in the prototype stages of development. This crutch will help absorb some of the force absorbed by the upper limbs and has more padding than a regular crutch. Goal keepers are arm amputees.
Gardening usually requires kneeling, which is difficult to achieve because the prosthetic ankle does not allow sufficient plantar flexion. Once in the kneeling position, the upper portion of the body seems to be pushed forward, and gardeners with transtibial amputations may feel pressure in the popliteal fossa area. One solution is to use planter boxes supported so they can be reached at waist level or, for those in wheelchairs, at a lower level. Knee pads can be fabricated by a pros-thetist. The pad for the sound leg should be thicker to raise the hips and allow more toe clearance on the prosthetic side. Homemade pads can be constructed from foam rubber in a heavyweight plastic bag and sealed with waterproof tape. A kneeling stool called an Easy Kneeler is available. When turned over it becomes a portable seat.
The transtibial skiing prosthesis can be adapted for roller or ice skating. The suspension system on the prosthesis needs to be secure to support the extra weight of the skating boot. The skating boot may be difficult to put on without a nylon hose or plastic bag over the prosthetic foot to help it slide. The Hein-A-Ken Skate Aid, a walker-type device, can be helpful to the beginning skater (Fig 24B-27.). There is a 28-in. children's model and a 35-in. adult model.
The outrigger skate aid is another possibility (Fig 24B-28.). A figure skating blade is mounted to a forearm or similar crutch. Two of these outriggers improve support and balance. Skates on the lower limbs maintain continual contact with the surface, while the outriggers are used for propulsion.
Ice sledding is a good alternative for the bilateral amputee.
Climbing is possible, with or without a prosthesis. If a prosthesis is used, a nylon sheath is invaluable for decreasing friction. An ankle unit such as the stationary-ankle, flexible-endoskeleton (SAFE) foot may be useful because it adapts well to uneven terrain. For the trans-tibial amputee, ice climbing crampons can be adapted to clip to the prosthetic shank, such as those used by the bilateral transtibial amputee Hugh Herr in all his expeditions. Transfemoral amputees generally prefer to climb without their prosthesis and to rely on specially adapted forearm crutches for added grip and stability, such as those used by Don Bennett when he climbed Mount Rainier. Sarah Doherty, a hip disarticulation amputee, followed Mr. Bennett's challenge a few years later. In August 1984, she went on to climb Alaska's Mt. McKinley, the highest point in North America. Her crutches featured a convex basket with spikes at the lower end that are used as crampons (Fig 24B-29.,A). A modified ice pick is attached to the forearm portion of the crutch (Fig 24B-29.,B). The ice pick is covered with a sheath when not in use. This crutch was modified by Drew Hittenberger, C.P.
The disadvantage of this method of climbing is the limited use of the hands for handholds and the necessity for the amputee to carry his prosthesis on his back for use on level ground.
Levesque and Gauthier-Gagnon have designed a transfemoral prosthesis for rock climbing. It provides grip close to the knee by using an additional prosthetic foot close to the knee joint, as well as full outward rotation of the leg for grip on the medial border of the shoe. It is made of titanium components to reduce weight and features a conventional socket, multiaxial pelvic band and thigh rotation system placed under the socket to increase mobility, a protruding foot just above the knee axis, a modular polycentric knee, and a SACH foot (Fig 24B-30.).
A book entitled A Man and His Mountains by Norman Croucher is about a bilateral transtibial amputee who has climbed and led expeditions in almost all the major mountain ranges in the world. Croucher has received the Man of the Year Award and the International Award for Valour in Sport.
Most amputees wear a prosthesis, preferably one with considerable rotation capabilities. For tennis, doubles play reduces the amount of running required. Wheelchair tennis and racquetball are two of the most up and coming wheelchair sports. Wheelchair tennis tournaments have been held since 1975, and in 1980, the National Foundation for Wheelchair Tennis was formed. In this sport, it is very easy for the able-bodied and disabled to play together. The only modification of the rules is that the wheeler gets two bounces before he has to return the ball.
The first World Amputee competition was held in 1979 in Stoke Mandeville, England. Competition in the United States began in 1981. Events usually include swimming, track and field, weight lifting, air pistol, volleyball, and table tennis. Other events may include sit-down volleyball, lawn bowling, stand-up basketball, and pentathlon.
For swimming, no prosthesis is allowed. For discus, javelin, or shotput, a prosthesis is worn if the competitor wears one for everyday use. No crutches or other assistive devices are allowed. Individuals with bilateral transfemoral amputations who are wearing prostheses may throw from behind a hip-high barrier, but the discus, javelin, or shotput must be airborne before contact is made with the barrier. For high jump, wearing a prosthesis is optional, but the competitor must take off from ground level on one foot. Arnold Boldt is an amputee from Canada who dominates in this sport. He is able to jump 1.94 m. For long jump, participants jump without a prosthesis from a standing position at the take-off line. For table tennis, a prosthesis is worn, but crutches are not allowed. Bilateral amputees can compete from a wheelchair.
For weight lifting, participants are weighed in the nude without prostheses 1 hour before the event. Those with amputation then add l/16th of their body weight for each transtibial amputation, l/9th of their body weight for each transfemoral amputation, and l/6th of their body weight for each hip disarticulation.
For amputees who choose to weight lift in nondis-abled events, a good-quality prosthesis is of extreme importance. To do the squat and dead lift, a prosthesis offering a wide base of support is important. While the base of support has to be wide, it also has to remain vertical without causing too much stress on the knee ligaments. The foot needs to have some flexibility so that it stays flat. The prosthesis needs to be fabricated from material that will tolerate the torques and stresses applied to it by the excess weight. Arlon has proved to be a more adequate laminating material than fiberglass or acrylic.
For competitive snow skiing, National Handicapped Sports would be the best resource. A division for the physically challenged was added to the National Standard Race (NASTAR) program during the 1985-1986 season. NASTAR enables amputees to compare themselves with others in the world with similar disabilities or to top professional skiers.
For wheelchair sports, the Paralympic Games began in 1960, guided by Dr. Ludwig Guttman. The eighth Paralympics were held in October 1989 in Seoul, Korea. Approximately 4,000 athletes from 60 countries participated in the games and established 971 new world records. The next Paralympic event will be in Barcelona, Spain in September 1992. Nassau County, New York, was the site of the 1984 International Games for the Disabled and drew 1,700 participants from 45 countries. In August 1985 the top eight 1,500-m male and the top eight 800-m female wheelchair track athletes in the world competed in an exhibition event at the Los Angeles Olympics. Fifteen hundred-meter exhibition events were also held at the 1990 Goodwill games in Seattle.
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Abilities: Canada's Journal of the Disabled. 5090 Explorer Dr, Suite 502, Mississauga, Ontario, Canada, L4W 9Z9.
Ability Magazine. Majestic Press Inc, PO Box 5311, Mission Hills, CA 91345. (805) 366-1552.
Accent on Living. Cheever Publishing Inc, PO Box 700, Bloomington, IL 61701. (309) 378-2961.
Disabled Outdoors Magazine. 5223 S. Lorel Ave, Chicago, IL 60638.
Mainstream. PO Box 2781, Escondido, CA 92025.
Mobility. A Magazine for People With Mobility Impairments. 401 Linden Center Dr, Fort Collins, CO 80524. (303) 484-3800.
Outdoors Forever. PO Box 4811, East Lansing, MI 48823.
Palaestra. The Forum of Sport, Physical Education, and Recreation for the Disabled. PO Box 10, Carthage, IL 62321.
Products to Assist the Disabled Sportsman. JL Pachner Ltd, 33012 Lighthouse Ct, SJ Capistrano, CA 92675. (714) 661-2132.
Sports 'N Spokes. Paralyzed Veteran's of America, 5201 North 19th Ave, Suite 111, Phoenix, AZ 85015. (602) 246-9426.
S.Q.U.LD. (Scuba Quarterly Undersea International Digest). Handicapped Scuba Association, 116 West El Portal, Suite 104, San Clemente, CA 92672. (714) 439-6128.
The Gimp Exchange. National Handicap Motorcyclist Association, 32-04 83rd St, Jackson Heights, NY 11370.
Two-Bounce News. National Foundation of Wheelchair Tennis, 3857 Birch St, No. 411, Newport Beach, CA 92660.
Systems and Hardware, Ltd Colgrims Mede, Aviary Rd Pyrford, Woking, Surrey GU22 8th Great Britain
Achilles Track Club 9 East 89th St New York, NY 10128
Activsleeve Rampro, Inc PO Box 3256 Santa Monica, CA 90403
Suspension system helpful in reducing pistoning and suction-type suspension for the transtibial amputee.
Adaptive Sports Program Kinesiotherapy Clinic c/o Dr Leonard Groninger University of Toledo 2801 West Bancroft St Toledo, OH 43606 (419) 537-2755
Adolescent Amputee Camp Physical Therapy Department c/o Gay Gregg
Children's Hospital of Pittsburgh 125 DeSoto St Pittsburgh, PA 15213 (412) 647-5480
Advisory Panel on Water Sports for the Disabled The Sports Council 70 Brompton Rd London SW3IEX England
American Academy of Sports Medicine for the Physically Disabled
Dr Philip J. Stevens 1102 Bergan Rd Oreland, PA 19075
American Alliance for Health, Physical Education, Recreation and Dance Programs for the Handicapped c/o Dr Razor, Executive Vice President 1900 Association Dr Reston, VA 22091 (703) 476-3561
American Amputee Foundation, Inc c/o Jack M. East PO Box 250218 Little Rock, AR 72272 (501) 666-2523
American Canoe Association Disabled Paddler's Committee 8580 Cinderbed Rd, Suite 1900 PO Box 190 Newington, VA 22122-1190
American Special Recreation Association c/o John Nesbitt, Ed. D Recreation Education Program University of Iowa Iowa City, IA 52240 (319) 353-2121
American Therapeutic Recreation Association, Inc c/o Peg Conley 3417A Sapula Rd, Box 377 Sand Springs, OK 74063 (904) 644-6014
American Waterski Association Phil Martin, Chairman Disabled Ski Committee 681 Bailey Woods Rd Dacula, GA 30211
American Wheelchair Bowling Association Daryl Pfister
N54 W 15858 Larkspur Lane Menomonee Falls, WI 53051 (414) 781-6876
American Wheelchair Pilot's Association c/o Dave Graham 1621 East 2nd Ave Mesa, AZ 85204
American Wheelchair Table Tennis Association Jennifer Johnson 23 Parker St Port Chester, NY 10573 (203) 629-6283
Amputee Competitive Sports
U.S. Amputee Athletic Association Jan Wilson, Executive Director PO Box 560686 Charlotte, NC 28256
Amputee Soccer International
Bill Barry, Program Administrator, Coaching Director Suite 107, 1110 North 175th St Seattle, WA 98133 (206) 546-3770
Amputee Sports Association c/o George C. Beckmann, Jr 11705 Mercy Blvd
Savannah, GA 31419 (912) 927-5406
Amputees in Motion International c/o Jerry Dahlquist PO Box 1736 Fallbrook, CA 92028 (619) 725-6195 or (619) 723-8003 Baseball Information
National Wheelchair Softball Association
John Speake, Commissioner
PO Box 22478
Minneapolis, MN 55422
Bert Sheppard 8014 Bangor Hesperia, CA 92345
For Fun Cycles Corporation 966 N. Elm St Orange, CA 92667-5471 (714) 997-1952
Harper Handbike, Harper Mfg 3125 W. Hampden Ave Englewood, CO 80110 (303) 756-4050
Mr. Kenneth Kozole, OTR
Clinical Rehabilitation Engineer Rehabilitation Engineering Program Room 1441
Northwestern University 345 E Superior St Chicago, IL 60611
New England Handcycles, Inc 228 Winchester St Brookline, MA 02146
Rifton Equipment Division of Community Playthings Society of Brother, Inc Rifton, NY 12471 (914) 658-3141
American Canoe Association
Committee for Disabled Paddlers 8580 Cinderbed Rd, Suite 1900 PO Box 1190
Newington, VA 22122-1190 (703) 550-7495
Boating for the Handicapped/Guidelines for the Physically Disabled by Eugene Hedley, Ph.D., 1979 Research and Utilization Institute Human Resources Center Albertsen, NY 11507
Disabled Sailing Association of British Columbia 1300 Discovery St Vancouver, BC V6R4L9 Canada 222-3003
Environmental Travelling Companions (ETC) Fort Mason Center Landmark Bldg C San Francisco, CA 94123 (415) 474-6772
Nantahala Outdoor Center
Bunny Johns, Head of Instruction
Bryson City, NC 28713
Norwegian Arctic Tours PO Box 700 Enfield, NH 03748
Philadelphia Rowing Program for the Disabled (PRPD) Attn: Sean Riordan/Pat Standley 858 Bailey St Philadelphia, PA 19130 (215) 763-5815
Sailing Accessories, Inc 2712 Irwin Rd Redding, CA 96002 (916) 221-7197
Shake-A-Leg PO Box 1002 Newport, RI 02840-0009 (305) 858-5550 (401) 849-8898
Shake-A-Leg International Water Sports and Training Center 2600 South Bayshore Dr Miami, FL 33133
U.S. Association for Disabled Sailors Keith Lark, President Southern California Chapter 901 Fathom Ave Seal Beach, CA 90740 (213) 431-4461
Wilderness Inquiry 11 1313 Fifth St SE, Box 84 Minneapolis, MN 55414 (612) 379-3858
Boy Scouts of America
Scouting for the Handicapped c/o John E. Hunt
PO Box 16030
Dallas-Ft Worth Airport
Dallas, TX 75261
Breckenridge Outdoor Education Center Mike Mobley, Executive Director PO Box 697
Breckenridge, CO 80424 (303) 453-6422
British Amputee Ski Association Box 1373
Banff, Alberta TOL OCO Canada
British Disabled Water Ski Association Warren Wood, the Warren Ashtead, Surrey KT212 SN England
California Wheelchair Aviators c/o Bill Blackwood 1117 Rising Hill Way Escondido, CA 92025
Canadian Wheelchair Sports Association 1600 James Naismith Dr Gloucester, Ontario Canada K1B5N4 (613) 748-5685
Committee for Handicap Sailing Baerum Seilforening Strandalleen 8 1320 Stabelk Norway
Committee on Athletes with Physical Disabilities Dr Michael Asken Cowley Associates Plaza 21
425 North 21st St Camp Hill, PA 17011 (717) 761-7400
Committee on Recreation and Leisure
President's Committee on Employment of the Handicapped c/o Gerald Hitzhusen, Chairman Washington, DC 20210 (202) 653-5044
Competitive Wheelchair Sports
Achilles Track Club 9 East 89th St New York, NY 10128 (212) 967-9300
International Wheelchair Road Racing Club Joseph M. Dowling, President 30 Myano Lane Stamford, CT 06902 (203) 967-2231
National Wheelchair Athletic Association 1604 East Pikes Peak Ave Colorado Springs, CO 80909 (719) 635-9300
National Wheelchair Marathon c/o Bob Hall 15 Marlborough St Belmont, MA 02178 (717) 439-3246
United States Wheelchair Weightlifting Federation Bill Hens 39 Michael Place Levittown, PA 19057 (215) 945-1964
Wheelchair Athletics of America Judy Einbinder 8114 Buffalo Speedway Houston, TX 77025 (713) 668-5376
Cooperative Wilderness Handicapped Outdoor Group (C. Hog) c/o Thomas Whittaker Box 8118
Idaho State University Pocatello, ID 83209 (208) 236-391
The Counterpoint (or Sunburst)
Angle Lake Cyclery
20840 Pacific Highway S
Seattle, WA 98198-5999
(206) 878-7457 FAX (206) 824-3038
Two-wheeled tandem bikes.
3915 Golden Valley Rd Golden Valley, MN 55422 (612) 588-0811
Access Designs, Inc. 627 S.E. 53rd Ave Portland, OR 97215 (503) 238-0049 or PO Box 216 Independence, OR 97351
Hand-operated device attached to the wheelchair.
Disabled Outdoors Foundation 320 Lake St Oak Park, IL 60302 (312) 284-2206
Eastern Amputee Athletic Association Jack Graff, President Mike Doanals, Vice President 2080 Ennabrock Rd North Bellmore, NY 11710 (516) 826-8340
Gardener's Supply Co 133 Elm St Winooski, VT 05404 (802) 655-9006
Kneeling stool for gardening.
The 52 Association
350 5th Ave, Room 1829 New York, NY 10118 (212) 563-9797
American Wheelchair Pilots Association c/o Dave Graham
1621 East Second Ave Mesa, AZ 85204
CA Wheelchair Aviators c/o Bill Blackwood 1117 Rising Hill Way Escondido, CA 92025 (619) 746-5018
The Soaring Society of America, Inc. PO Box 66071 Los Angeles, CA 90066 (213) 390-4448
Girl Scouts U.S.A.
Scouting for the Handicapped Service c/o Cindy Ford
830 Third Ave
New York, NY 10022
Amputee Sports Assoc c/o George C. Beckmann, Jr. 11705 Mercy Blvd Savannah, GA 31419
Golf for Life
Shirlee C. Hicks 7595 Carlow Way Dublin, CA 94568 (415) 829-9576 (415) 971-2661
International Senior Amputee Golf Society c/o Dale Bourisseau 14039 Ellesmere Dr Tampa, FL 33624 (813) 961-3275
National Amputee Golf Association PO Box 1228 Amherst, NH 03031 (800) 633-NAGA
Project Fore, Golf for the Physically Disabled c/o John Klein Singing Hills Country Club 3007 Dehesa Rd El Cajon, CA 92021 (619) 442-3425
Susan J. Grosse Physical Education Specialist Milwaukee Public Schools 7252 West Wabash Ave Milwaukee, WI 53223 (414) 354-8717
Groundgrabbers K and R Specialties 2809 Charles Court NW Rochester, MN 55901 (507) 281-1351
Snow chains for wheelchairs.
Hand Controls for Flying
Aircraft Inspection and Maintenance 2680 E Wardlow Rd Long Beach, CA 90807 (213) 595-5738
Permanent hand controls.
Union Aviation, Inc. PO Box 207 Sturgis, KY 42459 (502) 333-5918
FAA-approved portable hand controls for certain
Cessna and Grumman aircraft.
Rehabilitation R and D Center
VA Medical Center
3801 Miranda Ave
Palo Alto, CA 94304
(415) 493-5000, ext. 4473
Two-wheeled cycle. Mr. Schwandt can also be contacted for information on the Counterpoint or Sunburst bikes.
Handicapped Scuba Association Jim Gatacre
116 West El Portal, Suite 104 San Clemente, CA 92672 (714) 498-6128
Hein-A-Ken Skate Aid Hein-A-Ken, Inc 102 Fosse Ct
Thief River Falls, MN 56701 Skating boot.
Breckenridge Outdoor Education Center Mike Mobly, Executive Director PO Box 697
Breckenridge, CO 80424 (303) 453-6422
International Council on Therapeutic Ice Skating PO Box 13
State College, PA 16801 (814) 865-2563
International Foundation of Wheelchair Tennis Peter Burwash
2203 Timberloch Place, Suite 126 The Woodlands, TX 77380 (713) 363-4707
International Games for the Disabled c/o Tony Giustino Eisenhower Park East Meadow, NY 11554 (516) 542-4420
International Senior Amputee Golf Society, Inc c/o Dale Bourisseau 14039 Ellesmere Dr Tampa, FL 33624 (813) 961-3275
International Sports Organization for the Disabled International Stoke Mandeville Games Federation Stoke-Mandeville Spinal Injury Center Aylesbury England
International Sports Organization for the Disabled S-12387 RARSTA Sweden
International Wheelchair Aviators Mindy Desens, President Bill Blackwood, Secretary 1117 Rising Hill Escondido, CA 92025 (619) 746-5018
International Wheelchair Road Racers Club, Inc Joseph M. Dowling, President 30 Myano Lane Stamford, CT 06902 (203) 967-2231
International Wheelchair Tennis Federation Brad Parks, President 940 Calle Amanacer, Suite B San Clemente, CA 92672 (714) 361-6811
A Man and His Mountains by Norman Croucher Available from David and Charles, Inc North Pomfret, VT 05053
Mission Bay Aquatic Center 1001 Santa Clara Point San Diego, CA 92109 (610) 488-1036
Beneficial Designs, Inc 5858 Empire Grade Rd Santa Cruz, CA 95060 (408) 429-8447
Enabling Technologies, Inc 2411 N. Federal Blvd Denver, CO 80211 (303) 455-3578
Innovative Recreation, Inc PO Box 159 Sisters, OR 97759 (503) 549-7022
Magic in Motion 20604 84th Ave South Kent, WA 98032 (800) 342-1579 (206) 872-072
Mobility Systems 861 Robinwood Ct Traverse City, MI 49684 (616) 941-4626
Motorcycling Information The Wheelchair Motorcycle Association, Inc 101 Torrey St
Brockton, MA 02401
106 Lynch Creek Way, Suite 8 Petaluma, CA 94954-2380 (707) 769-9417
A modified ice pick is attached to the forearm portion of the crutch.
Georgia Prosthetic, Inc c/o Rick Riley 398 14th St N.W. Atlanta, GA 30318
National Amputee Golf Association PO Box 1228
Amherst, New Hampshire 03031 (800) 633-NAGA
National Association of Handicapped Outdoor Sportsmen, Inc
RR 6, Box 25 Centralia, IL 62801
National Association of Swimming Clubs for the Handicapped
63 Dunnegan Rd Eltham, London SE9 England
National Council for Therapy and Rehabilitation Through Horticulture c/o Charles Richman, Executive Director 9041 Comprint, Suite 103 Gaithersburg, MD 20877 (301) 948-3010
National Handicap Motorcyclist Association (NHMA) Bob Nevola, President 35-34 84th St #F8 Jackson Heights, NY 11372
National Handicapped Sports Kirk Bauer, Executive Director 451 Hungerford Drive, Suite 100 Rockville, MD 20850 (301) 217-0960 (301) 217-0968 FAX
National Ocean Access Project 410 Severn Ave, Suite 107 Annapolis, MD 21403 (301) 280-0464
National Wheelchair Athletic Association 1604 East Pikes Peak Ave Colorado Springs, CO 80909
National Wheelchair Basketball Association Stan Labanowich 110 Seaton Bldg
University of Kentucky Lexington, KY 40506 (606) 257-1623
National Wheelchair Racquetball Association (NWRA) Gary Baker 1 Desavage St Jeannette, PA 15644 (412) 744-3320 or 815 North Weber, Suite 101 Colorado Springs, CO 80903
National Wheelchair Shooting Federation Deanna Greene, President PO Box 18251 San Antonio, TX 78218-0251
National Wheelchair Softball Association Jon Speake, Commissioner 1616 Todd Ct
Hastings, MN 55033 (612) 437-1792
The Netherlands Sport Association for the Disabled PO Box 622 3800 AP Amersfoort The Netherlands
NOAP Universal Adaptive Seat National Ocean Access Project 410 Severn Ave, Suite 107 Annapolis, MD 21403 (301)280-0464
Ted Fay, Nordic Director U.S. Disabled Ski Team PO Box 186 Hanover, NH 03755 (802) 295-3625
North American Riding for the Handicapped Association PO Box 33150 Denver, CO 80233 (303) 452-1212
North American Wheelchair Athletic Association PO Box 26 Riverdale, NY 10471 (212) 796-5084
Oita Sports Association for the Disabled c/o Japan Sun Industries Kamegawa Beppu Oita, 87401 Japan
Enabling Technologies 2411 North Federal Blvd Denver, CO 80211 (303) 455-3578
Physically Challenged Swimmers of America Joan Karpuk 22 William St, #225 South Glastonbury, CT 06073 (203) 548-4500
POINT (Paraplegics on Independent Nature Trips) Shorty Powers, Director 3200 Mustang Dr Grapevine, TX 76051 (817) 481-0119
B.G. Water Sports 530 Sixth St
Hermosa Beach, CA 90254 (213) 372-5063 Scuba hand fins.
John Barber, CP(C), FCBC, Chief Prosthetist J.A. Pentland Limited 82239 Main St
Vancouver, British Columbia V5X 3L7 Canada (604) 324-4011 A swim-scuba prosthesis has also been developed.
Project FORE, Golf for the Physically Disabled c/o John Klein Singing Hills Country Club 3007 Dehesa Rd El Cajon, CA 92021 (619) 442-3425
United States Wheelchair Racquet-Sports Association
1 Desavage St
Jeannette, PA 15644
Rampro, Inc PO Box 3256 Santa Monica, CA 90403 (213) 828-6781 Activankle, a multiposition sports ankle.
Recreation and Athletic Rehabilitation-Education Center c/o Brad Hedrick University of Illinois 1207 South Oak St Champaign, IL 61820 (217) 333-4606
Recreation Center for the Handicapped c/o Janet Pomeroy, Director 207 Skyline Blvd San Francisco, CA 94132 (415) 665-4100
Research and Training Center for the Physically Disabled Dr Robert Steadward Department of Physical Education and Sport Studies
The University of Alberta Edmonton, Alberta T6G 2H9 Canada
North American Riding for the Handicapped Assn PO Box 100 Ashburn, VA 22011
Outback Ranch Outfitters Attn: Ken Wick Box 384
Joseph, OR 97346 (503) 432-1721
Winslow Therapeutic Riding Unlimited Virginia G. Mazza, President 3408 S Rte 94 Warwick, NY 10990
Rock Climbing Transfemoral Prosthesis Montreal Rehabilitation Institute Claude Levesque, CP(C) Prosthetics and Orthotics Division 6300 Darlington Ave Montreal, Quebec H3S 2J4 Canada
3188 North Marks, #107
Fresno, CA 93722
Hand-operated device (combination of bicycle and rowing machine).
Rowing Ankle Unit
Prosthetics Research Study 720 Broadway Seattle, WA 98122 (206) 328-3116
Running Club Achilles Track Club 9 East 89th St New York, NY 10128 (212) 967-9300
Amputee running club.
Schwinn Air-Dyne Schwinn Bicycle Co 1856 N Kostner Ave Chicago, IL 60639 (312) 292-2900
Scottish Sports Association of the Disabled c/o Scottish Sports Council 1 St. Colme St Edinburgh EH36 AA Scotland
Scuba Diving Information Diving for Disabled People British Sub-Aqua Club 16 Upper Woburn Place
London WC1QW England
Handicapped Scuba Assoc c/o Jim Gatacre 116 West El Portal, Suite 104 San Clemente, CA 92672 (714) 439-6128
A videotape, "Freedom in Depth," is also available.
Robinson, J, and Fox, D: Scuba Diving with Disabilities Leisure Press PO Box 5076 Champaign, IL 61820 (217) 351-5076
Shake-a-Leg, Inc PO Box 1002 Newport, RI 02840
Shake-A-Leg International Water Sports and Training Center 2600 South Bayshore Dr Miami, FL 33133
Mountain Man 720 Front St Bozeman, MT 59715 (406) 587-0310
Skating Association for the Blind and Handicapped (SABAH) c/o Sibleys, Boulevard Mall Store Niagara Falls Blvd Amherst, NY 14226
Ski Instruction Manuals
Alpine Manual by Jerry Johnston and Susan Clift, 1988 Canadian Association for Disabled Skiing Box 307
Kimberly, British Columbia V1A2Y9 Canada
Bold Tracks: Skiing for the Disabled, by Hal O'Leary (1987)
Winter Park Handicap Program
PO Box 36
Winter Park, CO 80482
Ski Instruction Organizations
Canadian Association for Disabled Skiing (CADS) Box 307
Kimberly, British Columbia VIA 2Y9 Canada (604) 427-7712
52 Association, Inc
350 5th Ave, Room 1829 New York, NY 10118 (212) 563-9797
National Handicapped Sports 1145 Nineteenth St Suite 717
Washington, DC 20036 (301) 652-7505
Winter Park Handicapped Skier Program
Winter Park Sports and Learning Center
PO Box 36
Winter Park, CO 80482
(303) 726-4101, ext 179
These are some organizations that help the disabled individual get started or restarted in skiing.
United States Parachute Assn Mike Johnston 1440 Duke St Alexandria, VA 22314 (703) 836-3495
Ski-Eze USA, Inc
Lansing, MI 48910
A device to facilitate ski turning ability and the ski stabilizer.
War Amputations of Canada 2277 Riverside Dr, Suite 210 Ottawa, Ontario K1H7X6 Ski stabilizer device.
S.O.A.R. (Shared Outdoor Adventure Recreation) c/o Linda Besant PO Box 14583 Portland, OR 97214 (503) 238-1613
South Africa Sports Association for the Physically Disabled 1 Stellenberg Rd Somerset West 7130 South Africa
S'PLORE (Special Populations Learning Outdoor Recreation and Education) c/o Patti Mulvihill, Executive Director 255 East 400 South, Suite 107 Salt Lake City, UT 84111 (801) 363-7130
The Steed Jerry Selness 4724 Point Loma Ave San Diego, CA 92107 (619) 224-2619
A 30-ft sloop for disabled sailors.
Swivel Golf Shoe The War Amputations of Canada Armand Viau or Cliff Chadderton 2277 Riverside Dr, Suite 210 Ottawa, Ontario K1H7X6 Canada
TES Belt Syncor, Ltd PO Box 540022 Houston, TX 77254-0022
Three Tracker's Ski Tote NHS of California c/o Betty Lessard 5946 Illinois Ave Orangevale, CA 95669 (916) 989-0402
Transfemoral Prosthesis for Skiing
Professor Dr Rene F. Baumgartner
Orthopadische Universitatsklinik Balgrist
Professor Baumgartner is developing a transfemoral prosthesis designed and aligned specifically for skiing.
Cheeseman Biffins Boat Yard Staines Bridge Staines, Middlesex England TW1830N
Turfking Aquatic Chairs Beach Wheels, Inc 1555 Shadowlawn Dr Naples, FL 33942 (813) 777-1078
Forward Motion Sand-rik PO Box 782
Mechanicsville, VA 23111 (804) 746-4088
Fred Davis, President Box 890
Ketchum, ID 83340 (208) 788-9666
United States Swimming Handbook for Adapted Competitive Swimming (1989) United States Swimming 1750 East Boulder St Colorado Springs, CO 80909
United States Wheelchair Racquet-Sports Association (NWRA) Gary Baker 1 Desavage St Jeannette, PA 15644 (412) 744-3320
United States Wheelchair Weightlifting Federation Bill Hens 39 Michael Place Levittown, PA 19057 (215) 945-1964
US Amputee Athletic Association Jan Wilson, Executive Director PO Box 560686 Charlotte, NC 28256 (704) 598-0407
US Association of Disabled Sailors Southern California Chapter Mike Watson PO Box 15245 Newport Beach, CA 92659 (714) 534-5717
US Rowing Association
Adaptive Rowing Committee Richard Tobin 11 Hall Place Exeter, NH 03833 (603) 778-0315
Voyageur Outward Bound School c/o Ted Mooras PO Box 250 Long Lake, MN 55356
The War Amputations of Canada c/o Cliff Chadderton 2277 Riverside Dr, Suite 210 Ottawa, Ontario K1H7X6 Canada
Water Ski Devices Magic in Motion c/o Jim Martinson 20604 84th Aves. Kent, WA 98032 (800) 342-1579
Mission Bay Aquatic Center c/o Tod Bitner 1001 Santa Clara Point San Diego, CA 92109 (619) 488-1038
Ski Seat Water Sports Industries 10230 Freeman Ave Santa Fe Springs, CA 90670 (213) 946-1323
Water Ski Information
American Waterski Association Disabled Ski Committee Phil Martin, Chairman 681 Bailey Woods Rd Dacula, GA 30211 (916) 868-5733
Christian Family Ski School c/o Fred and Wanda Horrell PO Box 7425 Winter Haven, FL 33880 (813) 299-4044
Northwest Adaptive Water Skiers PO Box 1478 Granite Falls, WA 98252
Weight lifting Prosthesis
Nashville Orthotic and Prosthetic Services, Inc c/o Jim McElhiney, CPO 1904 Hayes St Nashville, TN 37203 (615) 327-1546
Welsh Sports Association for the Disabled c/o E. Roberts Crosswinds 14 CAE GAM HEOL-Y-CYW Bridgend, Mid-Glamorgan, Wales
Western Australia Disabled Sport Association PO Box 1162 East Victoria Park 6101 Western Australia
Wheelchair Athletics of the USA Judy Einbinder 1475 West Gray, #161 Houston, TX 77019
Wheelchair Bankshot Basketball
Rabcan Associates 485 5th Ave New York, NY 10017
National Wheelchair Basketball Association 110 Seaton Bldg University of Kentucky Lexington, KY 40506 (606) 257-1623
Wheelchair Bowling Association, Inc c/o Daryl Pfister, Chairman N54 W 15858 Larkspur Lane Menomonee Falls, WI 53051 (414) 781-6876
Wheelchair Motorcycle Association Dr. Eli Factor 101 Torrey St Brockton, MA 02401 (508) 583-8614
International Foundation of Wheelchair Tennis c/o Brad Parks, Director 3857 Birch St, Box 111 Newport Beach, CA 92660
Peter Burwash International, Ltd 1909 Ala Wai, Suite 1507 Honolulu, HI 96815 (808) 946-1236
Wilderness Inquiry 11 c/o Greg Lais, Director 2929 Fourth Ave S, Suite O Minneapolis, MN 55408
Winter Park Sports and Learning Center c/o Hal O'Leary PO Box 36
Winter Park, CO 80482 (303) 726-5514, ext 179
Chapter 24B - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles