Chapter 12C - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles
Special Considerations: Upper-Limb Prosthetic Adaptations for Sports and Recreation
Bob Radocy, B.S., M.S.
The concept of specialized adaptive prosthetic components to enable unilateral or bilateral handless persons to access sports and recreation activities is not new. Interest in sports and recreation has always existed for the physically challenged individual, but not until the late 1970s and early 1980s were consumer pressures sufficient to influence the direction of commercial prosthetics. The interest in specialized prosthetic gear escalated throughout the 1980s and is expected to continue to increase in the 1990s.
Consumer groups (American Amputation Foundation, Little Rock, Ariz) and organizations such as the National Handicapped Sports Association (Washington, DC) are fueling this interest and fostering an increased awareness of products and the newest technology by communicating to greater populations of the disabled public. Physically challenged persons' expectations and attitudes have altered accordingly. The Olympics has incorporated wheelchair racing, and special ski programs throughout the country have dramatically improved the visibility of the disabled in the public eye. A consciousness of competition has been born. Mainstream participation in sports by the physically challenged is still a primary goal. The disabled have proved that they can be competitive with the able-bodied in many instances if they are equipped with the proper prosthetic technology.
Also encouraging this increased participation is the growth of the recreation industry itself. The rapid growth of recreation has affected all groups. Coupled with this is increased leisure time for much of the population, which furthers interest in the pursuit of sports and recreation.
Prior to the 1980s, devices commercially available specifically for sports and recreation activities were limited to the Hosmer-Dorrance prosthetic Baseball and Bowling Adapters (Campbell, Calif). Prosthetists fabricated custom devices for other activities, or the patients themselves designed adaptions for particular pursuits. Increasing demand, interest, and grass roots product developments by consumers encouraged manufacturers to begin producing commercial materials and componentry targeted for active physically challenged people with the resultant emergence of a market. Details of developments available for specific activities will be dealt with later in this chapter.
Rehabilitation programs are beginning to consider the sports and recreation needs of the patient. Rigorous activities for the unilateral or bilateral handless person cannot be considered prior to a thorough, functional physical assessment and successful completion of a basic rehabilitation program. A holistic approach to rehabilitation applied in a team environment is most effective.
Traditional rehabilitation includes physical therapy, occupational therapy, and psychological and prosthetic intervention. Recreation therapy is now also included in many progressive rehabilitation programs. It has proved to be a functional motivator for many patients and is especially effective in pediatrics.
Unfortunately, not all health professionals are aware of the importance and positive impact that sports and recreation can have on a patient's overall rehabilitation progress. Federal, state, and local rehabilitation agencies, workmen's compensation specialists, and private insurance companies often need encouragement to ensure that a holistic therapy approach that includes recreation considerations is provided to a hand amputee.
Therapy programs of all disciplines are responding by adapting to the changing attitudes and needs of the physically challenged. Some patients expect to achieve more than simple participation. They desire to be competitive, and programs are designed to meet these needs. Successful therapies analyze the patient's total potential, including recreation, and structure a rehabilitation strategy to achieve specific goals in a planned, sequential manner.
Physical therapy and prosthetic rehabilitation are integrally linked. Performance will not occur unless the person develops the proper physical attributes and capacities, i.e., range of motion, flexibility, and muscle strength, size, and endurance. Muscle hypertrophy enhances strength and can improve prosthetic suspension. Performance can also be limited unless the patient has the proper prosthetic technology to optimize his physical potential.
Optimum physical condition can be achieved through resistance exercise. Following traumatic injury physical therapy can begin with low-resistance exercises. Pool therapy is another option and provides a valuable, low-stress exercise environment.
Preprosthetic resistance exercise can be the next phase. Refer to Fig 12C-1. and Fig 12C-2. for weight harness systems that permit a wide range of upper-limb exercise conditioning. Many amputees successfully use commercial weight-conditioning equipment such as Nautilus machines, which are available at the YMCA, recreation centers, and private health clubs, as well as in some rehabilitation centers. Home training programs are valuable because they allow the patient to continue rehabilitation and physical conditioning outside the clinical environment.
Physical conditioning without a prosthesis has its limits, however. For transradial amputees, progressive resistance exercise and weight conditioning are more complete and effective while using a prosthesis.
The overall goal is functional bilateral performance. The patient has physiologic as well as sports and recreational requirements that a prosthesis must satisfy. A thorough assessment prior to design and construction is important to achieve a satisfactory result.
Numerous alternatives exist in prosthetic design, materials, and components. Harness-suspended socket designs with triceps cuffs and the accompanying hardware are traditional. Supracondylar, self-suspending sockets have experienced significant evolutionary progress over the last decade and offer many benefits for the active individual. Partially padded or fully lined sockets can enhance comfort. ISNY (Icelandic-Swedish-New York) sockets and other flexible socket designsalso offer specific advantages. Traditional suction and silicone suction suspension systems offer suspension advantages that should be considered. Ideally, a combination of the technologies available will yield the optimum design solution, depending upon the individuals morphology, physical condition, and other needs.
The choice between body power and external power is based on environmental considerations, intensity of the sports activities, function, speed, durability, performance, reliability, and cost. Body-powered prostheses are more common in sports and recreation pursuits than are externally powered prostheses due to the demands such activities place on both user and prosthesis.[*The majority of examples throughout the text illustrate body-powered prosthetic designs. The author made a number of inquiries to generate examples of externally powered prosthetics in sports and recreation but was able to verify only those that he included.] New materials and components for body-powered harnesses and cables can improve the efficiency of power transmission. Rapid-adjust buckles allow quick cable excursion adjustments that can be valuable in activities where gross motor movements are required. Synthetic cable materials such as Spectra (Allied Signal, Inc., Petersburg, Va) provide a lightweight, low-friction alternative to standard braided stainless steel cable. Axilla loop designs and materials are varied and offer greater comfort and therefore improved performance.
Materials for prosthesis construction have evolved primarily due to developments in the aerospace industry. Traditional polyester resins and nylon/Dacron laminates are being replaced by acrylic and epoxy resins with carbon fiber, Kevlar, and Spectra reinforcements. Thermoplastics like polyethylene are readily available and allow reshaping of the socket even after the prosthesis is complete, thus enhancing fit and comfort.
Terminal device choices abound. Active prehensors in the form of hands, hooks, or hybrid designs may be externally powered or body powered. Passive (nonpre-hensor) designs are now available for specific sports or recreation activities. For example, the Super Sport mitt (T.R.S., Inc., Boulder, Colo) (Fig 12C-3.) stores energy and provides a safe, flexible prosthetic option useful in contact sports.
Wrist components vary in size and design and may be divided into two types: adjustable friction or rapid disconnect. The sports prosthesis usually incorporates a rapid-disconnect wrist if the amputee plans to use more than one terminal device or prehensor. Youth-size rapid-disconnect wrists offer the same convenience. Rapid-disconnect wrist systems can be modified to allow incremental rotation by the installation of a rubber washer or O-ring onto the threaded stud of the prehensor prior to screwing on the rapid-disconnect adaptor. The elastic cushion allows incremental rotation yet does not interfere with the disconnect function. Precise device positioning may be required for optimum performance and is therefore desirable.
During prosthesis construction, additional factors that can affect performance need to be considered. Socket alignment dictates the range of elbow motion available. Wrist alignment and wrist mounting angles affect control and load bearing. External contouring can enhance or detract from function depending upon the activity. These alignments and contours should be evaluated actively on the patient prior to lamination.
Static and dynamic loads also need to be evaluated. Since pain impedes performance, evaluations should at a minimum include direct axial prosthetic loads, lifting tolerances to a distal load, and pulling and torque (rotational) tolerances on the prosthesis and limb. A prosthesis should comfortably and securely support the patient suspended from a horizontal bar or while performing a handstand or push-up.
Cosmetic or aesthetic considerations can also be important to the patient, especially if the user expects to employ the prosthesis outdoors in warm climates. Muscular contours can be simulated, and summer pigmentation may be considered so that the prosthesis is more complimentary to the natural arm.
Sports and recreation activities are function specific. Generic prosthetic devices, although versatile, may not provide adequate levels of function, strength, or control to perform optimally in a particular activity. Some people participate in sports and recreation without a prosthesis and become skilled unilaterally. However, the question arises as to whether with improved prosthetic technology they could have developed their skills more easily or performed better. Furthermore, bilateral upper-limb engagement in an activity should contribute to more balanced physiologic development and therefore be encouraged.
The remainder of this chapter will be an alphabetic exploration of sports and recreation activities. Prosthetic designs, modifications, custom aids, and commercially available components will be detailed.
Archery is a sport with a rich history dating back to before medieval times. Archery develops upper-body strength, coordination, and mental concentration. It has further value as a lifetime recreation or pastime and can stimulate organized social or club ties.
Modern archery equipment is reliable, safe, and easily adaptable to certain terminal devices with only minimal modification. A bow riser (handle) can be layered with wraps of rubber bicycle inner tube and foam to create a compressible bow grip. The bow handle must be free to center itself in the prehensor so that the prosthesis does not induce any external "torques" to the bow that will affect arrow flight. A jam pin can be used to prevent thumb opening during the "draw," or the archer can simply maintain prehension as illustrated by the bilateral amputee in Fig 12C-4..
Archers may choose traditional gear such as the longbow or the recurve or any of a number of well-designed compound bows that offer weight and draw length adjustability. A local specialized archery dealer is the best source of information regarding what is most suitable for an individual's needs. In most cases, the bow should be held with the prosthesis and the string drawn with the sound hand. The opposite is possible, however, and the string may be held with the tips of a prehensor or with a special "release aid" devised to secure the string. Some persons with a high-level arm absence or unilateral arm dysfunction have adapted to drawing the string by using a special mouth tab while holding the bow with the sound arm (Fig 12C-5.).
Archery equipment is most easily adapted to prostheses using voluntary-closing prehensors or externally powered hands that have the correct anatomic prehension configuration. Custom prosthesis adapters such as the quick-disconnect unit illustrated in Figure 12C-6 have also been devised. Note that the modern bow stores a great deal of energy. The bow and arrow, besides being recreational equipment, are also considered weapons, so safety consciousness is mandatory at all times.
Ball sports, including basketball, soccer, volleyball, and football, have unique demands. These sports develop hand and eye coordination, a variety of foot and hand skills, plus team consciousness and cooperation. Adolescents as well as adults enjoy these activities, which are often incorporated into school athletic programs.
Prostheses should provide adequate strength, freedom of movement, and safety features. Cosmetic hands and externally powered hands are reported to have been used successfully.
The Super Sport (T.R.S., Inc.) (Fig 12C-7.), an alternative device patterned after the volar surface of the hand, is capable of passive wrist flexion and extension. It absorbs shock and stores externally applied energy for safety and ball control. The Super Sport devices are passive in that they employ no cable, but their polymer construction allows safe participation in vigorous activities. A prosthesis cover fabricated from nylon-covered neoprene rubber can provide additional padded protection to opponents and user alike in sports where interpersonal contact is likely.
Baseball, part of our American heritage, is often the first organized competitive sport a youngster encounters. Playing baseball develops hand and eye coordination, agility, and upper-body strength. Prosthetic requirements vary depending upon whether the player is batting or fielding. Historically, a lack of truly functional prosthetic designs has required most amputee players to adopt one-handed techniques. The success in playing unilaterally depends a great deal on the person's arm morphology. A longer limb most often offers advantages over a shorter one when handling bats, mitts, and balls.
Batting two-handed (bilaterally) requires that the prosthesis or bat be adapted so that omnidirectional wrist/forearm action is possible so as to duplicate "wrist break" in a normal swing. This omnidirectional action allows for true bilateral control, power, and follow through, i.e., a smooth, unrestricted swing. One adaptation is the Power Swing Ring (T.R.S., Inc.) (Fig 12C-8.). The device can be engaged with almost any prehensor, body powered or externally powered. The player can use a standard grip or swing cross-handed, depending upon the stance and handedness.
Fielding requires throwing and catching skills. Throwing in virtually all instances is accomplished with the sound hand because prehension and wrist action are coordinated to deliver a powerful and accurate throw. Catching can be difficult with a prosthesis because most amputees cannot pronate or supinate the forearm. The Baseball Glove Adapter (Hossmer-Dorrance Corp.) (Fig 12C-9.) fits into a first baseman's glove and has been available for many years. It is a specialized body-powered, voluntary-opening split hook that is pulled open with a cable action and then closes the glove when the player relaxes.
The Hi-Fly Fielder (T.R.S., Inc.) in composite Fig 12C-10. offers a different approach to catching a ball. Patterned after lacrosse sticks, the device allows either forehanded or backhanded catching techniques, thereby eliminating the need for most forearm pronation/supination activity. No glove is required, nor is a cable used, so the unit is extremely lightweight. The flexible mesh pocket also allows scooping and tossing the ball in a manner similar to playing jai alai.
A tricycle was probably your first recreational vehicle. Bicycling and motorcycling are natural extensions of those first tricycling experiences. Bicycling nurtures balance and coordination and develops leg strength and cardiovascular endurance.
Upper-limb requirements include being able to grasp and control handlebars and activate gears and brakes. Safe control is the primary goal. The voluntary-opening split hook has proved less than ideal for cycle control due to the limited gripping force and hook contours. Voluntary-closing devices (Fig 12C-11.) and externally powered hands grip the handlebars securely for safe steering control.
Typically, the prosthesis is used for steering control, balance, and stability. The sound hand activates gears and brake levers. A Dual Brake Bicycle Lever (T.R.S., Inc.) is available (Fig 12C-11.) and allows one hand to control the front and rear brake systems simultaneously. (Note: The rear brake must activate first to ensure stability in stopping.) Gears can be grouped for easy access. The local bicycle pro shop can be a source for information or for modifications to ensure that the adaptations are completed safely.
Motorcycling usually requires operation of a clutch lever. Unilateral amputees can clutch and throttle with the same hand with a little practice. Brake systems can usually be combined in tandem to be activated from a single pedal, thus eliminating the front brake lever. This allows the prosthesis to be used entirely for steering control, balance, and stability. Modifications should be performed by competent mechanics, so consultation with a local motorcycle dealer is suggested to ensure safe and proper adaptations.
Bowling remains as one of the more popular indoor recreations available. Bowling environments stimulate social interaction through team and league participation. It develops hand and eye coordination as well as overall coordination and balance. Bowling is primarily a unilateral activity, so people missing one hand may not be impaired or may wish to switch hands to bowl.
Bilateral amputees and unilateral ones who do not wish to switch dominance need to use a prosthesis. If one is used, then omnidirectional wrist action is desirable. The Hosmer-Dorrance Bowling Ball Prosthetic Adapter (Fig 12C-12.) is a time-proven prosthetic aid for bowling. It incorporates a flexible coupling and a cable-activated release system so that the ball can be cast smoothly and with control.
Canoeing and kayaking are exciting and demanding recreations. These activities condition the arms, shoulders, and torso while developing balance and coordination. Gross motor bilateral upper-limb motions are emphasized, and adequate gripping power and prehension configurations are required. If a split hook is to be used, the Dorrance no. 7 Farm Hook (Hosmer-Dorrance Corp.) with at least 30 lb. of elastic band resistance is suggested. Voluntary-closing prehensors such as the Grip (T.R.S., Inc) (Fig 12C-13.) can be adapted to these activities with minimal modification. The natural gross motor patterns of paddling or rowing harmonize with the action of voluntary-closing devices and thereby create the required prehension. A simple hole bored through the end of a canoe paddle and padding the handle shaft with rubber inner tubing will improve prosthetic control. Similarly, rubber rings can be added to kayak paddles or boat oars to reduce prehensor slippage and improve control while paddling or rowing. Locking-type prehensors should never be employed in water sports activities for safety reasons.
These activities provide overall balance and coordination development while stimulating social interaction and mainstreaming. Requirements vary depending upon the specific activity, but considerations include strength, stability, flexibility, and cosmesis. Unilateral participation without a prosthesis is certainly possible, but a prosthesis may enhance performance.
Passive cosmetic hands have been used as well as padded hooks. Externally powered hands are a possibility for dance, but the rigors of gymnastics and tumbling could prohibit their application. The Super Sport mitt in Fig 12C-14. is a flexible, energy-storing alternative for these activities and can satisfy some specialized recreation niches safely.
Persons missing a hand(s) or who have a limb paralysis or dysfunction have a number of fishing options. The prosthesis must be utilized to either grasp a reel handle for line retrieving or to hold and control the fishing pole. Voluntary-closing prehensors (Fig 12C-15.) and externally powered prostheses function well with reels by providing a controlled grasp on the reel handles or rod; most split-hook systems have a tendency to pull or slip off under load. Many reels are available in either rightor left-handed retrieve models so that the amputees may select their preference. A small pair of locking needle-nose Vise Grip pliers provides an excellent accessory for handling small hooks, lures, and weights, which can prove difficult for many terminal devices or prosthetic hands.
Fig 12C-16. illustrates an adaptation that utilizes a chest support and harness system for mounting the fishing rod. These are most applicable to people with high or severe levels of dysfunction.
A novel modified reel design (Ampo-Fisher I, Bass-matic Corp., Canton, Ohio) is depicted in Fig 12C-17.. Electric reel systems (Royal Bee Corp., Pawhuska, Okla) are also available for one-handed control. Figure 12C-18 shows a prototype fly-fishing reel system that removes the reel from the rod entirely. Manually winding the line around the spool is required with this design. Automatic fly reels have been evaluated as well but exhibit difficulties in removing the line from the reel and from a lack of power in line retrieval.
Golf is one of the most popular outdoor sports. Accordingly, many persons missing a hand(s) may have an interest in playing the game. The United States Golfing Association (USGA) has established rules (USGA 14-3/15) regarding the use of artificial limbs while playing golf. Golf provides coordination, develops trunk and upper-body flexibility, and improves judgment. It is a social game into which many disabled groups have been able to mainstream easily.
Upper-limb prostheses need to attach to the club handle or grip in some fashion. A flexible or multiaxis joint is required to enable a complete bilateral swing. Persons missing one hand have played golf single-handedly, but most amputees use prostheses for bilateral assist. A standard split hook, various body-powered pre-hensors, or an externally powered hand can be used to guide a club, but without a functional wrist, the game is primarily being played unilaterally.
Many custom designs have evolved. Fig 12C-19. illustrates a Canadian modification whereby the club attaches directly to the prosthesis. Another design, the Robin-Aids golfing device (Robin-Aids Prosthetics, Inc., Vallejo, Calif), uses a flexible coupling for duplicating wrist and forearm movements. Fig 12C-20. illustrates the Amputee Golf Grip (AGG) (Recreation Prosthetics, Inc, Grand Forks, ND). This device is commercially available and meets the requirements of the USGA. Somewhat similar to the Robin-Aids device, the AGG also employs a flexible coupling linking the prosthesis to the club and utilizes a slide-on handle, adjustable for club grip diameter, that secures the club in place. Both offer improved performance because they enable the player to have an unrestricted swing allowing for a smooth follow-through. Using an unmodified club is an additional benefit. Note, however, that most of these devices function more easily depending upon handedness, and this leads to the necessity in some instances for a "cross-handed" grip to use the device successfully.
Handling firearms for self-defense, recreation, or hunting is a pastime ingrained in American life and indirectly facilitated by participation in our military services. Shooting develops hand and eye coordination, balance, timing, and judgment. A prosthesis may be used either to support, hold and control or to trigger a firearm (Fig 12C-21.). In many cases simple modifications suffice. A military sling can add stability, with the strap grasped by or wrapped around a prosthesis. Whether the prosthesis is used for control or triggering is dependent upon dominant handedness or dominant eye. Rifles are easily modified by adding a ring or custom adapter to the forearm of the stock (Fig 12C-22.). Custom handles added to the forearm of the stock can also provide excellent control and stability.
Pistols are more difficult to hold and modify due to their compactness. Voluntary-closing prehensors such as in Fig 12C-23. and externally powered hands (Fig 12C-24.) both provide significant gripping force, often controlling pistols and rifles with minimal or no modifications.
Fig 12C-25. shows the SR-77 (SR-77 Enterprises, Inc., Chadron, Neb), a complex shooting system commercially available to people with high-level bilateral arm dysfunction or absence.
Fig 12C-26. shows a shotgun heavily modified to be controlled and fired entirely with one arm. A local gunsmith is an excellent source of information and can usually customize firearms.
Hockey continues to be popular, especially in the northern latitudes of the United States and throughout Canada. Youngsters in these areas play in regulated hockey leagues much like Little League for baseball. Hockey develops strength, endurance, coordination, and balance. Prosthetic requirements include a means of holding and manipulating the hockey stick. The stick should be capable of pivoting out of the way and preferably disconnecting to prevent injury during a fall or upon contact with other players. Since safety is an issue, metal terminal devices should be used with caution. Padded or covered body-powered devices are preferable, and externally powered hands could provide the necessary functions.
Although a more select recreation, horseback riding is enjoyed by many individuals. Riding emphasizes balance and coordination combined with leg and torso strength and control. Riders must be capable of grasping either a saddle horn or the reins for control of the mount. Additionally, a rider should be able to adjust gear, bridles, saddles, and straps.
The Rein bar (Fig 12C-27.) is one simple adaptation for riding. Such a bar can be controlled by many different types of prehensors. Externally powered hands and voluntary-closing prehensors, due to their superior grip forces, can be especially useful. Either kind can also be employed to grasp the reins or horn without an adapter and provide sufficient prehension for saddle adjustments. Safety is always a consideration. The timely release of the reins or horn could be as important as grasping them and should be taken into consideration when evaluating prosthetic alternatives.
Mountaineering including rock or technical climbing is becoming more popular throughout the country, especially in the West, but remains an elite pastime. Mountaineering demands stamina and strength. It develops agility, flexibility, balance, and coordination. It can be dangerous for the novice as well as the expert, so proper instruction and safety procedures are mandatory. Demands include a reliable prosthesis with secure hardware, gripping strength to handle and manipulate >ropes and gear, and a terminal device that can stand abuse as a tool for prying, jamming, or clinging to rock surfaces. Figure 12C-28 illustrates a transradial amputee using a stainless steel Grip (T.R.S., Inc.) prehensor during a mountaineering training session. The amputee is belayed with a top rope for protection from falls.
Instrument playing is a recreation many aspire to achieve. Playing an instrument develops hand and eye skills, rhythm, coordination, and self-confidence. Music fosters socialization and provides individual and group pleasure.
Prosthetic requirements vary widely since playing is instrument specific. An adapter to play a guitar will differ dramatically from one for a violin (Fig 12C-29.) or another to play the piano (Fig 12C-30.).
Virtually all adaptations for playing musical instruments are custom-made. Externally powered hands as well as body-powered prehensors have all been adapted from time to time for instrument play. Imagination is the key to developing an adaptation that works successfully for the amputee. Communicating with a music teacher for a particular instrument is an invaluable source of inspiration. Prototyping is usually required with trial and error to develop a useful adapter.
Photography is an enjoyable hobby for many people and poses few problems for someone missing a hand. Most cameras, regardless of format, can be manipulated with externally powered or body-powered prostheses.
Custom adapters have also been developed. One specialized adapter, the AMP-U-POD (T.R.S., Inc.) (Fig 12C-31.), is designed to replace a standard terminal device and attaches directly to the prosthesis. It accepts all still and video cameras equipped with a tripod mount receptacle. Custom adapters are useful in securely balancing or stabilizing the camera to allow for easier focusing and metering adjustments prior to releasing the shutter.
Sailing can range from a quiet meditative experience to one in which the sailor is on the cutting edge of excitement. Sailing is usually a social event and easily accomplished by a person missing a hand. Most body-powered prostheses can be designed for saltwater or freshwater activities if desired. Handling ropes, controls, and gear is the primary function required.
Snowboarding is one of the fastest-growing recreations in the country, with equipment innovations occurring continually. Snowboarding, or "shredding," combines aspects of skiing, surfing, and skateboarding. It develops coordination and balance and is available to a handless person with little or no adaptation. Leg and torso control is the primary requirement. Arms can be used to initiate turns but are not absolutely necessary for turning. A prosthesis can provide shock absorption and protection from a fall while enabling the participant to make easier binding engagements and adjustments. A prosthesis can also aid in getting up following a fall. It should be chosen with safety and durability in mind. Hard, jarring falls are common for the novice. A cosmetic passive hand or Super Sport would be suitable options. An externally powered prosthesis could be used, but the force of the falls might damage the arm and hand.
As mentioned in the beginning of this chapter, skiing is a recreation that provides the physically challenged individual with the opportunity to mainstream as well as to compete. Skiing is a sport that builds self-esteem and confidence as well as the physical attributes of balance, strength, and coordination. Snow skiing does not necessarily require the use of ski poles, and many hand-less people downhill ski without these accessories. Cross-country or Nordic skiing, in contrast, is enhanced by upper-body propulsion, so poles are really more of a necessity than a convenience. Amputees have employed one pole successfully as well.
Wrist extension is required to plant a pole accurately and quickly. Split hooks have been used for skiing, with the pole strap wound or tied into the hook. This allows limited control, with the pole being manually swung forward for a pole plant. Fig 12C-32. is the Hosmer-Dorrance Ski Hand, which force-fits down over the top of a modified ski pole. The flexible polymer body allows the ski pole to be snapped forward manually like a pendulum for pole planting. The Ski Hand is manufactured in several sizes to accommodate different ages of skiers.
The All-Terrain Ski Terminal Device (AT-Ski-TD) (Fig 12C-33.) is another alternative. It is adjustable and allows for either manual or cable-activated pole plants. It incorporates a system for rapid pole disconnecting or connecting and uses a pivoting pole-mounting system to relieve stress on both prosthesis and skier during a fall.
Swimming is considered to be one of the best overall, low-stress, body-conditioning exercises. Swimming stimulates the cardiovascular system, increases flexibility, and strengthens muscle groups of the arms, torso, and legs. Many amputees swim successfully without an arm prosthesis. Competitive swimming or training may require a prosthesis to improve stroke resistance on the affected side(s). All present externally powered systems are subject to water damage. Conventional terminal devices are of little use for swimming.
Fig 12C-34. illustrates one approach that uses a commercially available swimmer's training paddle fixed to the forearm with surgical tubing. The amputee swimmer using this system is a physician who regularly swims 1,800 m with normal lap times.
Fig 12C-35. shows the POSOS/Tablada design (Professional Orthopedic Systems of Sacramento, Calif). This system uses a flat paddle and rigid prosthesis with a preflexed elbow. The flat paddle eliminated the tendency of the prosthesis to "submarine," and cause a loss of stroke volume during strokes such as the Australian crawl.
Another model illustrated in Fig 12C-36. and Fig 12C-37. is the Freestyle TSD (therapeutic swim device, T.R.S., Inc.), which is commercially available. Unlike the previous custom models, the Freestyle TSD's patented design (Robert Gabourie, Niagara Prosthetics, St. Catharines, Ontario, Canada) allows it to collapse when retrieved. This action conserves energy because water resistance is reduced after the power stroke. The device flares open for resistance and propulsion during the power stroke.
Competitive swimming generally requires a custom prosthesis. Tablada and others have demonstrated that the "resistance" device should be applied as close as possible to the end of the affected limb for best efficiency. Additionally, a prosthesis design is required that minimizes socket pistoning. The success of the physician's design also lends credence to flexible or soft socket designs that adhere closely to the shape of the limb.
This water sport can be very dangerous but is also exhilarating and develops overall balance and strength in the back, arms, and legs. Precautions are necessary to ensure safety. The amputee should never lock onto a ski rope handle with any type of prehensor and should not wear a prosthesis that requires a harness and cable. Externally powered systems are also not recommended because of potential water damage.
A waterskiing system with a single ski rope handle works with a simple shallow hook terminal device (Fig 12C-38.). A self-suspending supracondylar-style socket can usually provide adequate suspension yet be "torqued" off the skier's arm if the hook fails to twist off the handle during a fall. A ¼-in.-thick neoprene sleeve will float most arm prostheses in the water and add to the skier's stability prior to takeoff. The prototype hook illustrated was custom-fabricated from nylon.
Another approach is to install a quick-disconnect system on the ski rope at the boat and have a spotter always ready to release the rope in case of a fall to prevent injury. Falls occur without warning, so release in all cases must be immediate, or serious injury can result. An approved life vest is strongly recommended.
A unique and demanding water sport, windsurfing combines the talents of sailing, surfing, and hang gliding. It stimulates balance, coordination, dexterity, and strength. Requirements include prostheses that provide positive gripping prehension and quick-release capability as well as the ability to handle cylindrical shapes like masts and booms. Additional needs include handling rope, uphauling, and maneuvering the mast with the sail in the water.
Fig 12C-39. and Fig 12C-40. illustrate one successful body-powered system. Harnesses for body-powered systems should be worn outside wet or dry suits to allow unrestricted function. Saltwater windsurfing requires corrosionand rot-resistant prosthetic components. Externally powered systems are prohibited due to constant water exposure as in waterskiing. Caution is advised, and proper training is recommended to ensure a safe experience.
The function-specific nature and varied demands of sports and recreation activities create continuous challenges for the prosthetics profession. Consumers are becoming better informed and frequently desire a prosthesis suitable for a variety of activities.
Morphology and physiology are integrally linked with prosthetic design and construction. A thorough assessment of the patient's needs, including those for sports and recreation, will establish accurate design criteria. Specific static and dynamic stress evaluations conducted during construction of the prosthesis can help ensure a high-performance result.
Patient education and communication continue to be very important. The variety of requirements and the functional specificity of sports activities make it impossible to consider one prosthetic system or device as a viable solution to all the needs of active hand amputees. Today no single technology is either versatile or cost-effective enough to serve alone.
New designs, materials, components, and devices applicable to sports and recreation are evolving. Customized designs continue to arise, and more commercially available components are allowing easier access to specific activities.
The physically challenged person has more opportunities to mainstream and compete in activities of sports and recreation than ever before. Foresight, creativity, patience, communication, and a willingness to teach as well as to learn will inevitably lead to even greater possibilities in prosthetic rehabilitation.
The author thanks the following individuals and organizations: Ron Baird of Longmont, Colo; Bassmatic Corp. of Pawhuska, Okla; Felice Celikyol of the Kessler
Institute in West Orange, NJ; The Free Handerson Co. of Helena, Mont; Shellye B. Godfrey of Greenville, SC; Hosmer-Dorrance Corp. of Campbell, Calif; Elliot Marcus, M.D., of Huntsville, Ala; Professional Orthopedic Systems of Sacramento, Calif; Recreational Prosthetics, Inc., of Grand Forks, ND; Robin-Aids Prosthetics, Inc., of Vallejo, Calif; Royal Bee Corp. of Pawhuska, Okla; SR-77 Enterprises, Inc., of Chadron, Neb; Chuck Tieman of Blackwell, Okla; The War Amputations of Canada of Ottawa, Ontario, Canada; Bill White of Waterford, Penn; Ken Whittens of Duncan, Okla; and Biff Williams of Spokane, Wash.
- Berger N, et al: The application of ISNY principles to the below-elbow prosthesis. Orthot Prosthet 1985; 39:16-20.
- Billock JN: Northwestern University supracondylar suspension technique for below-elbow amputations. Orthot Prosthet 1972; 26:16-23.
- Billock JN: Upper limb prosthetic management hybrid design approaches. Clin Prosthet Orthot 1989; 9:23-35.
- Fillauer CE, et al: Evolution and development of the silicone suction socket (3S) for below-knee prostheses. J Prosthet Orthot 1989; 1:92:103.
- Fishman S, et al: ISNY flexible sockets for upper-limb amputees. J Assoc Child Prosth Orthot Clin 1989; 24:8-11.
- Fornuff DL: Flex-frame sockets in upper extremity prosthetics. Clin Prosthet Orthot 1985; 9:31-34.
- Radocy B: Technical note: The rapid adjust prosthetic harness. Orthot Prosthet 1983; 37:55-56.
- Radocy R: Technical note: An alternative design for a high performance below elbow prosthesis. Orthot Prosthet 1986; 40:43-47.
Chapter 12C - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles