REHABILITATION ENGINEERING

MATERIAL

DEPARTMENT OF BIOMEDICAL ENGINEERING

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 UNIT I

INTRODUCTION TO REHABILITATION & REHABILITATION TEAM

Topics:
What is Rehabilitation, Epidemiology of Rehabilitation, Health, Levels of Prevention, Preventive
Rehabilitation, Diagnosis of Disability, Functional Diagnosis, Importance of Psychiatry in
Functionaldiagnosis, Impairment disability handicap, Primary & secondary Disabilities,
Rehabilitation team-Classification of members, The Role of Psychiatrist, Occupational therapist,
Physical therapist,Recreation therapist, Prosthetist - Orthotist, Speech pathologist, Rehabilitation
nurse, Social worker,Corrective therapist, Psychologist, Music therapist, Dance therapist &
Biomedical engineer.

WHAT IS REHABILITATION?

Rehabilitation focuses on the existing capacities of the handicapped person, and brings
him to the optimum level of his or her functional ability by the combined and coordinated use of
medical, social, educational and vocational measures .It makes life for the handicapped
individual more meaningful, more productive and therefore adds more life to years.
It is the third phase of medical care; after preventive and curative.
Preventive medicine is the first phase where a disease is prevented from occurring, by avoiding
the interaction between agent, host and environment.
Curative medicine, the second phase focuses on attempting to cure the disease. Most doctors
practice curative medicine. However there are several conditions like rheumatoid arthritis which
has no cure, and others, like poliomyelitis in which the agent causing the disease has been
eliminated from the host, but residual effects like paralysis still persist. Therefore, there is a need
for a third phase, namely rehabilitation, which is not just medical but also a social responsibility.
Rehabilitation must, be started at the earliest possible time in order to ensure the best
results. It is administered in conjunction with specific medical or surgical treatment of the
precipitating disease.
Rehabilitation may be medical or socio-vocational. Medical rehabilitation is the
utilization of medical and paramedical skills to help treat the patient. The role of medical
rehabilitation is to limit disability. Socio-vocational rehabilitation follows, or sometimes is
delivered simultaneously along with medical rehabilitation. The role of socio-vocational
rehabilitation is to limit handicap.

MEDICAL REHABILITATION

Importance of Physiatry
Medical and socio-vocational rehabilitation is the responsibility of a team
of professionals headed by a Physiatrist , the key person in the guidance of the rehabilitation
program. These professionals combine and coordinate to uplift the handicapped (Fig. 1.1).
The difference in the clinical evaluation by a physiatrist is that the physiatrist views the
patient with social and vocational background in addition to the medical background. He tries to
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get a clear picture of how an illness has affected a person’s life—what he or she can no longer do
and how to get over the problem.
The other team members in medical rehabilitation are the physio-therapist, the
occupational therapist, and many others while the social worker and vocational counselor are in
the socio-vocational team

Figure 1.1:The importance of physiatry and rehabilitation services ensures functional

independence, without which the patient remains partially dependent throughout his life

Epidemiology of Rehabilitation

The word epidemiology is derived from the Greek word epidemios; meaning “among the
people” In the early 20th century, CO Stallybross defined epidemiology as “the science which
considers infectious disease—their course, propagation and prevention.”
Epidemiology is concerned with the study of the causative factors of disease and the
means to prevent or eradicate it. If complete prevention or total eradication is not possible,
containment is the second choice.
WH Welch defined epidemiology as “the study of the natural history of disease.”
Lillienfeld described it as the study of “the distribution of a disease or condition in a
population, and of the factors that influence this distribution.”

Health
The definition of health put out by the World Health Organization runs as follows:
“A state of complete physical, mental and social wellbeing and not merely the absence of
disease or infirmity.” The fundamental goal of medical science is not to produce an immortal
being but to maintain him in optimum health as long as possible, ideally until death.

It is often said “The fundamental goal of rehabilitation is to add life to years;not years to life”.It
is now known that disease is caused by simultaneous interaction of host, agent and environment
(Fig. 1.2).

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Figure 1.2: In the pre-pathogenesis period, the interaction between host agent and environment
causes disease, which passes from the subclinical stage to the clinical manifestation of disease.
The client slides down the health status scale from health to suboptimal health to overt illness.
This could either be treated successfully on to recovery or, sometimes the patient succumbs to
the disease. On the other hand, in some diseases the patient lands in a zone of disability from
where he needs to be rehabilitated

PREVENTIVE REHABILITATION
Prevention of disability does not start only at birth, at the onset of disease or after a
primary disability occurs. Sometimes it may be done even before the child is born, by
anticipating disability due to genetic defects or blood group incompatibility and can be prevented
by means of genetic counseling. For example in Duchennes muscular dystrophy, it is possible to
counsel the parents on having another child who might later display the symptoms of the disease.
Current population growth, particularly of the aged, naturally would result in a sharp rise
in people with disability in the near future. It is a paradox that because of the tremendous strides
that medical science has taken, the number of patients surviving a potentially fatal condition like
brain injury is much more. It therefore follows that with a fall in mortality levels there is arise in
morbidity levels. Rehabilitation deals with morbidity; it deals with quality of life .Unfortunately
there is a great shortage of medical and paramedical professionals to care for the persons with
disability, and this gap keeps widening. In recent years, specialists in neurology, orthopedic
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surgery, and pediatrics are increasingly getting involved with and have a vital role to play in the
field of rehabilitation medicine. This phenomenon shows the recognition and importance that is
being given by other specialties to rehabilitation medicine. Unless more effective methods of
prevention are developed to protect the population from primary disability in the future, the
newly detected persons with disability will face a critical situation. The cumulative shortage
of health manpower will cause them to be without benefit of rehabilitation services, and
superimposed secondary disabilities will render them totally dependent on society for everything.
This will result not only in personal tragedy, but will create infinite economical problems for
families, communities, and nation.
Consider a nuclear family where husband and wife are working for a living or for a
professional career. The presence of a disabled child or senior member would rob this family of
all its happiness, its leisure, and time available. A lot of personal sacrifice will be required by
each one of its members to take care of the patient. The medical community must act to prevent
epidemics of disability in much the same manner that we are now able to prevent communicable
diseases.
Levels of Prevention
Any health care that tries to halt a person’s slide down the slope of the health status scale
is termed preventive health care and any attempt to push it up towards the peak, i.e. optimum
health, is called therapeutic health care. This total spectrum is classified into three levels of
prevention by the World Health Organization (Fig. 1.3)

Figure 1.3: Levels of prevention: Primary, secondary and tertiary

Primary Prevention:
It is explained as a measure taken before the onset of any disease, e.g. immunization
against childhood infections or chlorination of drinking water. It is designed to promote general
health and improve the quality of life. It incorporates health education for bringing about
awareness of health problems before it occurs. This is similar to the first phase of medicine, i.e.
preventive medicine.
Secondary Prevention:
It is a measure taken to arrest the progression of a disease while it is still in the early
asymptomatic stage of the disease. It involves early diagnosis and immediate treatment, e.g.
ergonomic intervention to prevent clinical symptoms in a patient with spondylosis.
Tertiary Prevention:
It is explained as a measure taken to minimize the consequences of a disease or injury
once it has become clinically manifested, e.g. prevention of pressure sores in a paraplegic by
turning the patient over regularly. Tertiary prevention is an integral part of Rehabilitation
Medicine
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The Economic Impact:
Every year, several crores of rupees are spent on maintaining disabled people. If they are
rehabilitated to a level of self-dependence, there is a tremendous saving to the national
exchequer. The economics also can be gauged by the fact that successful rehabilitation ‘sets
free’ the able-bodied person taking care of his disabled relative. In nuclear families today, when
the breadwinner of the family becomes handicapped, it becomes a severe financial burden for the
rest of the family, and any effort in making the patient take care of his daily activities like
feeding or toileting can release the able bodied spouse to take up some work. It is often said that
a handicapped individual means a handicapped family, since most of the resources, time and
efforts of the family members go into his maintenance.
Impairment, Disability and Handicap

The World Health Organization’s International Classification of Impairments, Disabilities and

Handicaps (ICIDH 1980) defines these terms as follows:
Impairment:
Any loss or abnormality of psychological, physiological, or anatomical structure or
function, for example the loss of a finger, loss of conduction of impulses in the heart, or loss of
certain chemicals in the brain leading to Parkinsonism. Not all impairments lead to disability; for
example the loss of the pinna of the ear, an impairment, would not lead to loss of hearing but
merely a cosmetic deficiency.
Disability:
Any restriction or lack of ability to perform an activity in the manner or within the range
considered normal for a human being resulting from impairment, e.g. difficulty in walking after
lower limb amputation. It must be noted here that strenuous or rarely indulged in feats like rock
climbing or wind surfing are not included in activities to be considered for disability. To be
considered disabled a person should not be able to perform day to day activities considered
normal for his age, sex or physique.
Handicap:
A disadvantage for a given individual in his or her social context resulting from
impairment or a disability that limits or prevents the fulfillment of a role that is normal for him or
her. This depends on the age, sex, social and cultural factors for that individual. Many
socioeconomic factors like family background, skills achieved and financial stability come into
play while determining handicap. Various governments all over the world have recognized the
social impact of handicap and are more inclusive in their approach
Impairment is a manifestation of a problem at the tissue or organ level, disability, at the level of
the individual, while handicap in the translation of the problem at the societal level (Fig. 1.4).

Figure 1.4: Impairment Disability and Handicap: Their impact at various levels affecting the
organ, the person and society as a whole

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 On completing the conventional clinical evaluation of a person with disability, the
physician treating the patient often can answer the following questions:“Why does the person
have the problem?” (i.e. the etiologic diagnosis or impairment), and “What does he suffer from?”
(The pathophysiological diagnosis or disability). Examples of impairments are: weakness due to
polio, ankylosis of a joint, and so on. Most impairments lead to disability. The physiatrist comes
into the picture to assess the extent of disability. The questions he would have to seek answers to
are “How does the problem affect the person’s life?” or “What can he do in his day to day
activities?” (i.e. the functional diagnosis).
In fact, it is these complaints with which the patient approaches the doctor in the first
place. To the patient, the functional consequences—what he or she is prevented from doing (e.g.
typing, cooking, playing tennis)—are of more importance than the diagnosis. For example, a
lady with periarthritis of the shoulder would complain of inability to toilet herself or to wear her
blouse, in addition to reduce the pain that she is experiencing.
Furthermore, the relationship may be in both directions, for example, inability to walk
due to polio, a disability, may lead to muscle weakness and contractures, which are impairments.
Not every impairment leads to disability.

Diagnosis of Disability:
All specialties in therapeutic medicine require early and precise diagnosis in order to
institute the most effective treatment. The same logic applies to rehabilitation, and the disabled
should be given early evaluation and intensive treatment to prevent permanent disability. The
total person, physically, emotionally, vocationally and socially, must be considered in the
diagnosis. The patient is evaluated as a human being and not as a “case”.
Patients with multiple disabilities need to be handled sensitively. Diagnosis of disability
may be expressed either in terms of the amount of disability (disability evaluation) or in terms of
the amount of remaining function (functional diagnosis).

Disability Evaluation
The quantum of disability evaluation varies according to the method used. The most
common method of disability evaluation is given as a figure in either percentage or digits based
on a specific scale. A Disability Rating rates the patient’s inability to do any substantial gainful
activity compared to what he was able to do before the onset of the problem. It is calculated by
performing general physical, orthopedic, physiatric and neurological examinations of the patient
in the rehabilitation center. It helps in identifying the extent of handicap in a person in order to
make him or her eligible for certain concessions offered by the Government from time to time.

Functional Diagnosis
The diagnosis of the condition of the patient when he comes in to rehabilitation is usually
known, but the amount of remaining function is not. Rehabilitation professionals are trained to
arrive at a functional diagnosis to evaluate the residual capabilities of the individual and
strengthen them. The functional diagnosis should be:

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  Objective, using measurable factors so that the results are statistically more
reliable
 Descriptive so that the actual situation is accurately reflected.
 Simple enough so that rapid evaluation is possible.
 Reproduced, so that constancy may be maintained.
 Comprehensive, so that the diagnosis is complete and specifically utilized in the
direct care of the patients and is relevant for epidemiological investigation.
An example would be in the diagnosis of cerebral palsy. While the diagnosis of cerebral
palsy conveys very little in terms of the clinical picture, it would be ideal to functionally
diagnose a child so that the following questions are answered:
What is the type of cerebral palsy?
How many limbs are affected—i.e. Is the child diplegic or quadriplegic?
Is there associated mental abnormality, communication impairment or hearing and visual
impairment?
The answers to the above would certainly influence the outcome of rehabilitation.

Multiple Disabilities
About 12 percent of individuals with disability suffer from more than one type of
disability
For example, a child with cerebral palsy would probably have, in addition to the delayed
milestones and motor problems, damage of the part of the brain responsible for sight and
hearing. In addition it may have mental subnormality. As a consequence to these impairments, it
may display temper tantrums and not cooperate with the therapist
Primary and Secondary Disabilities
Disabilities that are direct consequences of a disease or condition are called primary
disabilities. Paraplegia following spinal cord injury or inability to walk following hip fracture are
examples of primary disability.
On the other hand, disabilities that did not exist at the onset of the primary disability but
develop subsequently are called secondary disabilities. Secondary disability is indirectly related
to the disease or condition that is responsible for the primary disability. Examples are joint
contracture in poliomyelitis, subluxation of shoulder joint in hemiplegia, tendo-Achilles
contracture in cerebral palsy and pressure sores in paraplegia. Elderly people and those who have
had a primary disability for an extended period is more susceptible to a secondary disability.
Further, when pain or spasticity accompanies the disease or condition causing the primary
disability, the prevalence of secondary disability increases. Negligence or ignorance on the part
of paramedical personnel or family members results in placing the person with disability in
positions that promote secondary disability.
In general, the greater the size of the body segment and the longer the period of
immobilization, the greater the intensity of the pathological condition and the number of organ
systems that become involved.
Immobilization due to what ever cause has a major impact on disability and many a
patient on the road to recovery encounters a road block on account of the secondary effects of
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disability. For example disuse atrophy occurs very rapidly, especially on muscles which are
hardly ever used. One study found that muscle wasting was found even within three days
following immobilization. It occurs much faster in antigravity muscles than in their antagonists.
It has been shown that disuse atrophy is more for a muscle held in a shortened position. There
was a greater degree of loss of strength when compared to the amount of muscle atrophy, as
measured by reduction in muscle girth. In other words, the muscle was weaker than expected
based just on the measurements of its bulk (Fig. 1.5).

Figure 1.5: The vicious cycle of inactivity and immobilization due to disability leading to
increase of morbidity and thence to secondary disability

Disability Limitation
The role of medical rehabilitation is disability limitation. Disability limitation refers to
preventing an increase in the intensity or scope of an existing disability. This measure, therefore,
becomes necessary after termination of active medical or surgical treatment. For example, a
patient with stroke gets admitted under a neurologist during the acute phase, which ensures that
he survives the stroke. When he or she gets discharged from hospital, he needs to be taken
through the recovery phase. This may take weeks or months. Disability limitation is particularly
indispensable for those who are chronically ill or disabled and absolutely mandatory for geriatric
patients.

THE REHABILITATION TEAM

The Medical Team
Physiatrist: Physiatry, also known in some hospitals as the specialty of Physical medicine
and rehabilitation has developed recently in to a very comprehensive and holistic field. There are
very few trained physicians in the field of Physiatry today. The physiatrist is the leader of the
rehabilitation team. The functions of the physiatrist are, to clinically assess the patient, arrive at a
functional diagnosis and coordinate with other members of the team to chart out a line of
management.
The physical medicine specialist or Physiatrist is qualified in the evaluation of disability,
prescription of physiotherapy, occupational therapy programs, orthoses and prostheses. He often
needs to involve the vocational counselor for vocational evaluation, counseling, training and job
placement, or with the architect to design barrier free environment for the person with disability.
During the course of his review, he would need to interact with his peers in other fields like
neurology or orthopedics. On the academic side, he needs to work on improving the specialty
and do some original work, and teach other members of his team (or even learn from them)
wherever required.
The physiatrist is in the best position to guide the patient and his relatives through the
challenging course of rehabilitation. He keeps in mind the residual abilities of his patient,
matches them with the skills of his team and limits the final disability of the patient. It is
imperative that the physiatrist has the knowledge sufficient enough in each of the paramedical,
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medical and socio vocational specialties relevant to rehabilitation to be able to provide the best
possible course of therapy to the patient. He is seen as friend, philosopher and guide to his team
members and patients. By nature a physiatrist must be compassionate, empathetic and
understanding. He must be able to bring out the best in his team and listen patiently to individual
opinions. The other members of the medical team bring in their specialized skills for individuals
needing them, on a case to case basis (Fig. 1.6)

Figure 1.6: The interaction between physiatrist and other core members of the rehabilitation team

Occupational Therapist

The WHO defines occupational therapy as “the art and science of directing mans
participation in selected activities to restore, reinforce and enhance function or performance or
decrease disability and thus, to promote health
.”The occupational therapist is involved with function. His duty is to evaluate and train
the patient in self-care activities, such as dressing, eating, bathing, and personal hygiene to
maximize independence. During the course of the treatment he would aid in maintaining and
improving joint range of motion, muscle strength, endurance, and coordination, generally of the
upper limbs. This helps the patient explore vocational skills and a vocational interests. The
occupational therapist would thus have to work with the vocational counselor when a change in
employment is anticipated. For those confined to home he would provide holistic training in
home management skills, using simple self help aids to minimize fatigue and conserve energy.
The occupational therapist would evaluate the home and suggest modifications to provide a
barrier-free environment, and train the patient to compensate for sensory and perceptual deficits
taking personal social and cultural tastes into consideration. He would train the patient to use
orthoses, self help aids or adaptive equipment when necessary and educate the patient’s family
by demonstrating techniques designed to maintain patient’s independence and to minimize over
protection. In upper limb amputees, and severely handicapped patients he trains the functional
use of prosthesis or of environmental control systems and collaborates with the physiotherapist
in achieving set goals using ‘activities’ instead of movements and with the orthotist in making
splints.

Physical Therapist
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 The physical therapist assists the patient in movement restoration. He is a very important
member of the rehabilitation team. He has to perform a thorough muscle strength evaluation and
quantification, spasticity assessment, and measurement of joint range. On the therapeutic side he
would have to perform exercises to maintain and increase joint range of motion, train sitting and
standing balance, or increase strength, endurance, and coordination for specific muscle groups or
the entire body. During the course of therapy he would have to use various therapy modalities,
such as heat and cold, as well as hydrotherapy techniques, electrical stimulation, traction and
massage for pain relief. For those confined to home he would visit them and aid in home
evaluation to make the environment barrier free and accessible. The use of various mobility aids
including the wheelchair and its maintenance has to be taught to the patient. For those who are
not ambulant the physiotherapist does progressive gait training with or without ambulatory aids.

Recreational Therapist

The recreational therapist uses recreational activities to improve social and emotional
behavior and promote the development of the patient.
The first step is, assessing in detail the patient’s interests, social capability, cognitive and
emotional functioning, level of orientation and awareness. His physical limitation and abilities,
resources, perceived barriers in his immediate environment, also will help plan out his
recreational activities.
Next, the therapist goes about educating patients in leisure activities, with specialized
equipment, adapted sports, and alternatives to existing life styles, acquiring new skills. This is
particularly beneficial to kids who would love to have a session of cricket instead of a session
with the physical therapist!
These recreational activities like tours, adventure trips, picnics, games and dramatics
have several benefits. They help to increase attention span, concentration, maintain physical
strength, social skills and motivation.
They assist in family and patients adjustment to disability and thus decrease unwanted
behavior, like depression. A group of special children playing in the part provides the much
needed community integration, more than one would expect from awareness lectures.
Thus recreation therapy reinforces other forms of therapy.
Play and recreation enhance functioning level and thus improve the quality of life after
discharge from the rehabilitation center

Prosthetist-orthotist

The prosthetist-orthotist is responsible for the design, fabrication, and fitting of the
orthosis or brace and prosthesis (artificial limbs).
He makes certain that the device functions and fits properly and that the patient adjusts
well to it. The patient and his family are instructed in the maintenance of the prosthesis. He
coordinates with the physiatrist, physiotherapist, occupational therapist and biomedical engineer,
to decide the best appliance to be given. Before giving the appliance he would take

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measurements, fabricate them, making modifications and changes in design where required.
Once ready he fits it to the patient in static and dynamic alignment, repairs it when needed. He
often needs to work with the biomedical engineer in the research and development of new
material and design.

Speech Pathologist:
The speech pathologist helps the patient in the area of communication and swallowing, by:
 Evaluation and treatment of neurological communication problems
 Vocal re-education
 Preoperative counseling prior to laryngectomy, glossectomy, and otherprocedures that
will potentially influence communication abilities
 Laryngeal speech training (esophageal speech or use of a prosthetic larynx)
 Retraining speech in patients with intra oral defects
 Cognitive retraining
 Training the patient in the use of communication devices
 Patient and family education
 Evaluation of swallowing function and management of dysphagia.
Rehabilitation Nurse
The rehabilitation nurse maintains the health of the bed ridden patient and helps him
reach short and long-term goals. She takes care of his nursing needs during hospitalization and in
the rehabilitation ward. In some cases she makes house visits and looks after the self-care
activities of the inmate. She is responsible for:
 Transfers to and from the bed, wheelchair, chair, and couch
 Environmental factors such as sanitation, heat and noise, control of personal property,
hygiene and safety
 The use and maintenance of adaptive equipment needed by patients to communicate, eat,
move, defecate, dress, and ambulate
 Specific preventive measures to minimize the effects of inactivity and promote
independence
 Integrating various therapies into his daily activities
 Medication and follow-up.
Social Worker
The social worker has a very important role in socio-vocational rehabilitation. This is because he
has to interact with the patient, family and rehabilitation team. He has a major role:
 To evaluate the patient’s living situation, including lifestyle, family, finances, and
community resources, and assessing the impact of the disease or disability on these areas.
If there is any need to change the living conditions, he would suggest alternatives.
 Study of the home condition, family, interpersonal relations, and jobsituation. The
aptitudes of the patient, i.e. his scholastic performance, hisattitudes, hobbies, and interest
are combined with the psychiatrist’sfindings, and physical examination for the purpose of
chalking outeducation or career

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  To explain to the family the patient’s problem and the treatment recommended by the
psychiatrist or psychologist.
 Help the patient and the family to work out a way for a more adequate social adjustment
and plan group activities with the family members for imparting knowledge about the
illness and care of the patient
 Whenever possible, to pool in the community resources for the benefit of the patient in
terms of financial aid or material aid so as to promote better medical and psychiatric care.
He also has to keep in touch with other social agencies so that a proper coordination of
services could be offered to them.
 Teach nursing students and staff, medical students, school teachers on social aspects of
rehabilitation
 Community contacts: As a part of public education, the social worker keeps in touch with
the community through audiovisual methods, radio, TV, press, write ups in periodicals
 To maintain case records, registers, files, correspondence for future guidance and
research purposes. A well-maintained record often helps in statistical analysis and brings
out some useful information from social research point of view. It also helps in long-term
follow-up over a period, the social worker becomes almost like a part of the family, and
helps in placement of the patient in a suitable job after training or to help seek a suitable
life partner

Psychologist and Child Development Specialist

The psychologist prepares the patient and his or her family members for full participation
in rehabilitation. He conducts tests dealing with personality, style and studies the patient’s way
of dealing with stress. The problem-solving skills, memory and intelligence of the patient are
also assessed. Any psychosis or neurosis is diagnosed and treatment initiated.
He then starts sessions in counseling. He would be required to counsel adolescents to
adjust to body changes as age advances, job aspirants to develop problem-solving skills and
alcoholics to get out of their habit. Marriage, sexual counseling and handling the disability itself
which can give rise to a sense of inadequacy or depression, need to be handled with empathy.
Music Therapist
Who does not love music? Music is one of the finest of the fine arts. It can transport one
to the highest plane of ecstasy.
The intervention of the music therapist may involve instrumental or vocal performance
by the person with disability or helping him appreciate music or attend musical events. This goes
a long way in helping children or adults with cerebral palsy or other paralytic conditions. Playing
an instrument like the keyboard or the violin improves fine motor skills while dancing or
exercising to music (creative movement therapy) is a novel way to improve gross motor

milestones. Some children with Down syndrome respond naturally to music. Music helps in
relaxation, sedation, or control of pain or anxiety, for those who sing, it improves speech through
articulation training or melodic intonation
In those who are immensely talented and in those whose disability enhances musical
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aptitude, like the visually impaired, music therapy prepares selected patients for music related
careers. It improves socialization skills, self-confidence, and esteem through group music
activities. For patients in palliative care, it provides the much needed respite

Creative Movement Therapist/Dance Therapist/ Play Therapist (Figs 1.7 to 1.9)

Dance therapy and play therapy is practiced more often with mental healthpatients than with
physically disabled patients. The dance therapist sometimescalled a movement therapist focuses
on rhythmic body movement as a physicaland psychological medium to:

Figure 1.7: Play therapy is introduced among children for building team spirit, improve-ment of
concentration, coordination and muscle power; it is great fun too!

Figure 1.8: Drama and creative movement help in involving the child inself expression and gross
motor skills

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 Figure 1.9: Dance as a form of therapy

 Improve gross motor control

 Relieve stress and improve awareness of tension in the body, expression of emotions, and
communication, especially when verbal expression is limited.
 Improve body image and awareness
 Classify and describe body movements
 Improve group activity and competitiveness.

Biomedical Engineer

The field of rehabilitation is an interface between the medical and engineering profession.
With the advance of technology, we have newer user friendly environment control units,
communication aids, orthoses and limbs. All these have to be designed by electronic and
mechanical engineering professionals. The role of the biomedical engineer is to interact with the
physiatrist orthotist or speech pathologist to design a piece of equipment, which will be of use to
the persons with disability. In many cases the design will have to be unique or customized.
Examples of technology used for the handicapped include environment control systems, voice
activated wheelchairs and carbon fiber prostheses.

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 UNIT- II
PRINCIPLES OF REHABILITATION ENGINEERING
Topic
Introduction, The Human Component, Principles of Assistive Technology Assessment, Principles of
Rehabilitation Engineering- Key Engineering Principles, Key Ergonomic Principles - Practice of
Rehabilitation and Assistive Technology

INTRODUCTION

Since the late 1970s, there has been major growth in the application of technology to ameliorate the
problems faced by people with disabilities. Various terms have been used to describe this sphere of
activity, including prosthetics/orthotics, rehabilitation engineering, assistive technology, assistive device
design, rehabilitation technology, and even biomedical engineering applied to disability. With the
gradual maturation of this field, several terms have become more widely used, bolstered by their use in
some federal legislation.
The two most frequently used terms today are assistive technology and rehabili-tation engineering.
Although they are used somewhat interchangeably, they are not identical. In the words of James
Reswick (1982), a pioneer in this field, ‘‘rehabilitation engineering is the application of science and
technology to ameliorate the handicaps of individuals with disabilities.’’ In contrast, assistive
technology can be viewed as a product of rehabilitation engineering activities. Such a relationship is
analogous to health care being the product of the practice of medicine.
One widely used definition for assistive technology is found in Public Law 100-407. It defines
assistive technology as ‘‘any item, piece of equipment or product system whether acquired
commercially off the shelf, modified, or customized that is used to increase or improve functional
capabilities of individuals with disabilities.’’ Notice that this definition views assistive technology as a
broad range of devices, strategies, and/or services that help an individual to better carry out a functional
activity. Such devices can range from low-technology devices that are inexpensive and simple to make
to high-technology devices that are complex and expensive to fabricate. Examples of low-tech devices
include dual-handled utensils and mouth sticks for reaching. High-tech examples include computer-
based communication devices, reading machines with artificial intelligence, and externally powered
artificial arms (Fig. 2.1).
Several other terms often used in this field include rehabilitation technology and orthotics and
prosthetics. Rehabilitation technology is that segment of assistive technol-ogy that is designed
specifically to rehabilitate an individual from his or her present set of limitations due to some disabling
condition, permanent or otherwise. In a classical sense, orthotics are devices that augment the function
of an extremity, whereas prosthetics replace a body part both structurally and functionally. These two
terms now broadly represent all devices that provide some sort of functional replacement. For example,
an augmentative communication system is sometimes referred to as a speech prosthesis.

16
History

A brief discussion of the history of this field will explain how and why so many different yet similar
terms have been used to denote the field of assistive technology

Figure 2.1 Augmentative communication classification system (from Church and Glennen, 1992).

17
and rehabilitation. Throughout history, people have sought to ameliorate the impact of disabilities by
using technology. This effort became more pronounced and con-certed in the United States after World
War II. The Veterans Administration (VA) realized that something had to be done for the soldiers who
returned from war with numerous and serious handicapping conditions. There were too few well-trained
artificial limb and brace technicians to meet the needs of the returning soldiers. To train these much-
needed providers, the federal government supported the establish-ment of a number of prosthetic and
orthotic schools in the 1950s.
The VA also realized that the state of the art in limbs and braces was primitive and ineffectual. The
orthoses and prostheses available in the 1940s were uncomfortable, heavy, and offered limited function.
As a result, the federal government established the Veterans Administration Prosthetics Research Board,
whose mission was to im-prove the orthotics and prosthetic appliances that were available. Scientists
and engineers formerly engaged in defeating the Axis powers now turned their energies toward helping
people, especially veterans with disabilities. As a result of their efforts, artificial limbs, electronic travel
guides, and wheelchairs that were more rugged, lighter, cosmetically appealing, and effective were
developed.
The field of assistive technology and rehabilitation engineering was nurtured by a two-pronged
approach in the federal government. One approach directly funded research and development efforts that
would utilize the technological advances created by the war effort toward improving the functioning and
independence of injured veterans. The other approach helped to establish centers for the training of
prosthetists and orthotists, forerunners of today’s assistive technologists.
In the early 1960s, another impetus to rehabilitation engineering came from birth defects in infants
born to expectant European women who took thalidomide to combat ‘‘morning sickness.’’ The societal
need to enable children with severe deform-ities to lead productive lives broadened the target population
of assistive technology and rehabilitation engineering to encompass children as well as adult men.
Subse-quent medical and technical collaboration in research and development produced externally
powered limbs for people of all sizes and genders, automobiles that could be driven by persons with no
arms, sensory aids for the blind and deaf, and various assistive devices for controlling a person’s
environment.
Rehabilitation engineering received formal governmental recognition as an engin-eering discipline
with the landmark passage of the federal Rehabilitation Act of 1973. The act specifically authorized the
establishment of several centers of excellence in rehabilitation engineering. The formation and
supervision of these centers were put under the jurisdiction of the National Institute for Handicapped
Research, which later became the National Institute on Disability and Rehabilitation Research (NIDRR).
By 1976, about 15 Rehabilitation Engineering Centers (RECs), each focusing on a different set of
problems, were supported by grant funds totaling about $9 million per year. As the key federal agency in
the field of rehabilitation, NIDRR also supports rehabilitation engineering and assistive technology
through its Rehabilitation Re-search and Training Centers, Field Initiated Research grants, Research and
Demon-stration program, and Rehabilitation Fellowships (NIDRR, 1999).
The REC grants initially supported university-based rehabilitation engineering research and provided
advanced training for graduate students. Beginning in the mid-1980s, the mandate of the RECs was
broadened to include technology transfer and service delivery to persons with disabilities. During this
period, the VA also established three of its own RECs to focus on some unique rehabilitation needs of
veterans. Areas of investigation by VA and non-VA RECs include prosthetics and orthotics, spinal cord
injury, lower and upper limb functional electrical stimulation, sensory aids for the blind and deaf, effects

18
of pressure on tissue, rehabilitation robotics, technology transfer, personal licensed vehicles, accessible
telecommunications, applications of wireless technology, and vocational rehabilitation. Another
milestone, the formation of the Rehabilitation Engineering Society of North America (RESNA) in 1979,
gave greater focus and visibility to rehabilitation engineering. Despite its name, RESNA is an inclusive
professional society that welcomes everyone involved with the development, manufacturing, provision,
and usage of technology for persons with disabilities. Members of RESNA include occupational and
physical therapists, allied health professionals, special educators, and users of assistive tech-nology.
RESNA has become an adviser to the government, a developer of standards and credentials, and, via its
annual conferences and its journal, a forum for exchange of information and a showcase for state-of-the
art rehabilitation technology. In recognition of its expanding role and members who were not engineers,
RESNA modified its name in 1995 to the Rehabilitation Engineering and Assistive Technology Society
of North America.
Despite the need for and the benefits of providing rehabilitation engineering services, reimbursement
for such services by third-party payers (e.g., insurance com-panies, social service agencies, and
government programs) remained very difficult to obtain during much of the 1980s. Reimbursements for
rehabilitation engineering services often had to be subsumed under more accepted categories of care
such as client assessment, prosthetic/orthotic services, or miscellaneous evaluation. For this reason, the
number of practicing rehabilitation engineers remained relatively static despite a steadily growing
demand for their services.
The shortage of rehabilitation engineers with suitable training and experience was specifically
addressed in the Rehab Act of 1986 and the Technology-Related Assis-tance Act of 1988. These laws
mandated that rehabilitation engineering services had to be available and funded for disabled persons.
They also required an individualized work and rehabilitation plan (IWRP) for each vocational
rehabilitation client. These two laws were preceded by the original Rehab Act of 1973 which mandated
reason-able accommodations in employment and secondary education as defined by a least restrictive
environment (LRE). Public Law 95-142 in 1975 extended the reasonable accommodation requirement to
children 5–21 years of age and mandated an individ-ual educational plan (IEP) for each eligible child.
Table 1 summarizes the major United Stated Federal legislation that has affected the field of assistive
technology and rehabilitation engineering.
In concert with federal legislation, several federal research programs have at-tempted to increase the
availablity of rehabilitation engineering services for persons with disabilities. The National Science
Foundation (NSA), for example, initiated a program called Bioengineering and Research to Aid the
Disabled. The program’s goals were (1) to provide student-engineered devices or software to disabled
individuals that would improve their quality of life and degree of independence, (2) to enhance the
education of student engineers through real-world design experiences, and (3) to allow the university an
opportunity to serve the local community. The Office of Special Education and Rehabilitation Services
in the U.S. Department of Education funded special projects and demonstration programs that addressed
identified needs such as model assessment programs in assistive technology, the application of technol-
ogy for deaf–blind children, interdisciplinary training for students of communicative

19
 TABLE .1 Recent Major U.S. Federal Legislation Affecting Assistive Technologies

Legislation Major Assistive Technology Impact

Rehabilitation Act of 1973 Mandates reasonable accommodation and least restricted

As environment in federally
funded employment and higher education; requires both assistive
Amended technology devices
and services be included in state plans and Individualized Written
Rehabilitation
Plans (IWRP) for each client; Section 508 mandates equal access t
electronic office
equipment for all federal employees; defines rehabilitation
technology as
rehabilitation engineering and assistive technology devices and
services; mandates
rehabilitation technology as primary benefit to be included in IWR
Recognizes the right of every child to a free and appropriate
Individuals with Disabilitie education; includes
Education Act Amendmen concept that children with disabilities are to be educated with their
of peers; extends
reasonable accommodation, least restrictive environment (LRE), a
1997 assistive
technology devices and services to age 3–21 education; mandates
Individualized
Educational Plan for each child, to include consideration of assist
technologies; also includes mandated services for children from
birth to 2 and expanded emphasis on educationally related assistiv
technologies
Assistive Technology Act of 1998 First legislation to specifically address expansion of assistive
(replaced Technology Related technology devices and services; mandates consumer-driven
Assistance for Individuals with assistive technology services, capacity building, advocacy
Disabilities Act of 1998) activities, and statewide system change; supports grants to expand
Developmental Disabilities and administer alternative financing of assistive technology
Assistance and Bill of Rights Act systems
Provides grants to states for developmental disabilities councils,
university-affiliated programs, and protection and advocacy
Americans with Disabilities Act activities for persons with developmental disabilities; provides
(ADA) of 1990
training and technical assistance to improve access to assistive
technology services for individuals with developmental disabilities
Prohibits discrimination on the basis of disability in employment,
Medicaid state and local government, public accommodations, commercial
facilities, transportation, and telecommunications,

20
 Mandatory service for children from birth through age 21;
Early Periodic Screening includes any required or
optional service listed in the Medicaid Act; service need not
Diagnosis, and Treatmen included in the
Program state’s Medicaid plan
Major funding source for assistive technology (durable medi
Medicare equipment); includes
individuals 65 or over and those who are permanently and
totally disabled;
federally administered with consistent rules for all states

From Cook and Hussey (2002).

disorders (speech pathologists), special education, and engineering. In 1993, NIDRR committed $38.6
million to support Rehabilitation Engineering Centers that would focus on the following areas: adaptive
computers and information systems, augmenta-tive and alternative communication devices,
employability for persons with low back pain, hearing enhancement and assistive devices, prosthetics
and orthotics, quantification of physical performance, rehabilitation robotics, technology transfer and
evaluation, improving wheelchair mobility, work site modifications and accom-modations, geriatric
assistive technology, personal licensed vehicles for disabled persons, rehabilitation technology services
in vocational rehabilitation, technological aids for blindness and low vision, and technology for children
with orthopedic disabilities. In fiscal year 1996, NIDRR funded 16 Rehabilitation Engineering Re-
search Centers at a total cost of $11 million dollars and 45 Rehabilitation Research and Training Centers
at a cost of $23 million dollars (NIDRR, 1999).

2 Sources of Information
Like any other emerging discipline, the knowledge base for rehabilitation engineer-ing was scattered in
disparate publications in the early years. Owing to its interdis-ciplinary nature, rehabilitation engineering
research papers appeared in such diverse publications as the Archives of Physical Medicine &
Rehabilitation, Human Factors, Annals of Biomedical Engineering, IEEE Transactions on Biomedical
Engineering, and Biomechanics. Some of the papers were very practical and application specific,
whereas others were fundamental and philosophical. In the early 1970s, many important papers were
published by the Veterans Administration in its Bulletin of Prosthetic Research, a highly respected and
widely disseminated peer-reviewed peri-odical. This journal was renamed the Journal of Rehabilitation
R&D in 1983. In 1989, RESNA began Assistive Technology, a quarterly journal that focused on the
interests of practitioners engaged in technological service delivery rather than the concerns of engineers
engaged in research and development. The IEEE Engineering in Medicine and Biology Society founded
the IEEE Transactions on Rehabilitation Engineering in 1993 to give scientifically based rehabilitation
engineering research papers a much-needed home. This journal, which was renamed IEEE Transactions
on Neural Systems and Rehabilitation Engineering, is published quarterly and covers the medical
aspects of rehabilitation (rehabilitation medicine), its practical design con-cepts (rehabilitation
technology), its scientific aspects (rehabilitation science), and neural systems.

21
3. Major Activities in Rehabilitation Engineering
The major activities in this field can be categorized in many ways. Perhaps the simplest way to grasp its
breadth and depth is to categorize the main types of assistive technology that rehabilitation engineering
has produced (Table 2). The develop-ment of these technological products required the contributions
of mechanical, material, and electrical engineers, orthopedic surgeons, prosthetists and orthotists, allied
health professionals, and computer professionals. For example, the use of voice in many assistive
devices, as both inputs and outputs, depends on digital signal processing chips, memory chips, and
sophisticated software developed by electrical and computer engineers. Figures 2.2 through 2.4 illustrate
some of the assistive technologies currently available. As explained in subsequent sections of this
chapter, the proper design, development, and application of assistive technology devices
TABLE 2 Categories of Assistive Devices
Prosthetics and Orthotics
Artificial hand, wrist, and arms
Artificial foot and legs
Hand splints and upper limb braces
Functional electrical stimulation orthoses
Assistive Devices for Persons with Severe Visual Impairments
Devices to aid reading and writing (e.g., closed circuit TV magnifiers, electronic Braille, reading
machines, talking calculators, auditory and tactile vision substitution systems)
Devices to aid independent mobility (e.g., Laser cane, Binaural Ultrasonic Eyeglasses, Handheld
Ultrasonic Torch, electronic enunciators, robotic guide dogs)
Assistive Devices for Persons with Severe Auditory Impairments
Digital hearing aids
Telephone aids (e.g., TDD and TTY)
Lipreading aids
Speech to text converters
Assistive Devices for Tactile Impairments
Cushions
Customized seating
Sensory substitution
Pressure relief pumps and alarms
Alternative and Augmentative Communication Devices
Interface and keyboard emulation
Specialized switches, sensors, and transducers
Computer-based communication devices
Linguistic tools and software
Manipulation and Mobility Aids
Grabbers, feeders, mounting systems, and page turners
Environmental controllers
Robotic aids
Manual and special-purpose wheelchairs
Powered wheelchairs, scooters, and recliners
Adaptive driving aids

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Modified personal licensed vehicles
Recreational Assistive Devices
Arm-powered cycles
Sports and racing wheelchairs
Modified sit-down mono-skin

require the combined efforts of engineers, knowledgeable and competent clinicians, informed end users
or consumers, and caregivers.

Topic: THE HUMAN COMPONENT

Period: 11

2 THE HUMAN COMPONENT

To knowledgeably apply engineering principles and fabricate devices that will help persons with
disabling conditions, it is necessary to have a perspective on the

Figure 2.2 Add-on wheelchair system (from Church and Glennen, 1992).

23
Figure 2.3 Environmental control unit using radio frequency (RF) control (from Church and
Glennen, 1992).
human component and the consequence of various impairments. One way to view a human being is as a
receptor, processor, and responder of information (Fig. 2 .5). The human user of assistive technology
perceives the environment via senses and res-ponds or manipulates the environment via effectors.
Interposed between the sensors and effectors are central processing functions that include perception,
cognition, and movement control. Perception is the way in which the human being interprets the
incoming sensory data. The mechanism of perception relies on the neural circuitry found in the
peripheral nervous system and central psychological factors such as memory of previous sensory
experiences. Cognition refers to activities that underlie problem solving, decision making, and language
formation. Movement control utilizes the outcome of the processing functions described previously to
form a motor pattern that is executed by the effectors (nerves, muscles, and joints). The impact of the
effectors on the environment is then detected by the sensors, thereby providing feedback between the
human and the environment. When something goes wrong in the information processing chain,
disabilities often result. Table 3 lists the prevalence of various disabling conditions in terms of
anatomic locations.
Interestingly, rehabilitation engineers have found a modicum of success when trauma or birth defects
damage the input (sensory) end of this chain of information processing. When a sensory deficit is
present in one of the three primary sensory channels (vision, hearing, and touch), assistive devices can
detect important environ-mental information and present it via one or more of the other remaining
senses. For example, sensory aids for severe visual impairments utilize tactile and/or auditory outputs to
display important environmental information to the user. Examples of such sensory aids include laser
canes, ultrasonic glasses, and robotic guide dogs. Rehabilitation engineers also have been modestly
successful at replacing or aug-menting some motoric (effector) disabilities (Fig. 2.6). As listed in Table
2, these include artificial arms and legs, wheelchairs of all types, environmental controllers, and, in the
future, robotic assistants.

24
 However, when dysfunction resides in the ‘‘higher information processing centers’’ of a human
being, assistive technology has been much less successful in ameliorating the resultant limitations. For
example, rehabilitation engineers and speech patholo-gists have been unsuccessful in enabling someone
to communicate effectively when that person has difficulty formulating a message (aphasia) following a
stroke. Despite the variety of modern and sophisticated alternative and augmentative communication
devices that are available, none has been able to replace the volitional aspects of the human being. If the
user is unable to cognitively formulate a message, an augmentative communication device is often
powerless to help.
An awareness of the psychosocial adjustments to chronic disability is desirable because rehabilitation
engineering and assistive technology seek to ameliorate the consequences of disabilities. Understanding
the emotional and mental states of the person who is or becomes disabled is necessary so that offers of
assistance and recommendations of solutions can be appropriate, timely, accepted, and, ultimately, used.

One of the biggest impacts of chronic disability is the minority status and socially devalued position
that a disabled person experiences in society. Such loss of social

Alternative keyboards can replace or operate in addition to the standard keyboard.

(a) Expanded keyboards have a matrix of touch-sensitive squares that can be grouped
together to form larger squares. (b) Minikeyboards are small keyboards with a matrix of closely
spaced touch-sensitive squares. (c) The small size of a minikeyboard ensures that a small
range of movement can reach the entire keyboard. (d) Expanded and minikeyboards use
standard or customized keyboard overlays. (e) Some alternative keyboards plug directly into

25
 the keyboard jack of the computer, needing no special interface or software (from Church and
Glennen, 1992).

Figure 2 .5 An information processing model of the human operator of assistive technologies.

Each block represents a group of functions related to the use of technology.

TABLE 3 Prevalence of Disabling Conditions in the United States

45–50 million persons have disabilities that slightly limit their activities 32% hearing
21% sight
18% back or spine
16% leg and hip
5% arm and shoulder
4% speech
3% paralysis
1% limb amputation
7–11 million persons have disabilities that significantly limit their activities 30% back or spine
26% leg and hip
13% paralysis
9% hearing
8% sight
7% arm and shoulder
4% limb amputation
3% speech
Data from Stolov and Clowers (1981).
status may result from the direct effects of disability (social isolation) and the indirect effects of
disability (economic setbacks). Thus, in addition to the tremendous drop in personal income, a person
who is disabled must battle three main psychological consequences of disability: the loss of self-esteem,
the tendency to be too dependent on others, and passivity.
For individuals who become disabled through traumatic injuries, the adjustment to disability generally
passes through five phases: shock, realization, defensive retreat or denial, acknowledgment, and
adaptation or acceptance. During the first days after the onset of disability, the individual is usually in
shock, feeling and reacting minimally

26
Figure 2.6 (a) This system generates temporal signatures from one set of myoelectric
electrodes to control multiple actuators. (b) Electrical stimulaton of the forearm to provide force
feedback may be carried out using a system like this one (from Webster et al., 1985).
with the surroundings and showing little awareness of what has happened. Counsel-ing interventions or
efforts of rehabilitation technologists are typically not very effective at this time.
After several weeks or months, the individual usually begins to acknowledge the reality and
seriousness of the disability. Anxiety, fear, and even panic may be the predominant emotional reactions.
Depression and anger may also occasionally appear during this phase. Because of the individual’s
emotional state, intense or sustained intervention efforts are not likely to be useful during this time.

In the next phase, the individual makes a defensive retreat in order to not be psychologically
overwhelmed by anxiety and fear. Predominant among these defenses is denial—claiming that the
disability is only temporary and that full recovery will occur. Such denial may persist or reappear
occasionally long after the onset of disability.

27
 Acknowledgment of the disability occurs when the individual achieves an accurate understanding of
the nature of the disability in terms of its limitations and likely outcome. Persons in this phase may
exhibit a thorough understanding of the disability but may not possess a full appreciation of its
implications. The gradual recognition of reality is often accompanied by depression and a resultant loss
of interest in many activities previously enjoyed.
Adaptation, or the acceptance phase, is the final and ultimate psychological goal of a person’s
adjustment to disability. An individual in this phase has worked through the major emotional reactions
to disability. Such a person is realistic about the likely limitations and is psychologically ready to make
the best use of his or her potential. Intervention by rehabilitation engineers or assistive technologists
during the acknow-ledgment and acceptance phases of the psychosocial adjustment to disability is
usually appropriate and effective. Involvement of the disabled individual in identifying needs, planning
the approach, and choosing among possible alternatives can be very benefi-cial both psychologically and
physically.
3 PRINCIPLES OF ASSISTIVE TECHNOLOGY ASSESSMENT

Rehabilitation engineers not only need to know the physical principles that govern their designs, but
they also must adhere to some key principles that govern the applications of technology for people with
disabilities. To be successful, the needs, preferences, abilities, limitations, and even environment of the
individual seeking the assistive technology must be carefully considered. There are at least five major
misconceptions that exist in the field of assistive technology:

Misconception #1. Assistive technology can solve all the problems. Although assistive devices can
making accomplishing tasks easier, technology alone cannot mitigate all the difficulties that accompany
a disability.
Misconception #2. Persons with the same disability need the same assistive devices. Assistive
technology must be individualized because similarly disabled persons can have very different needs,
wants, and preferences (Wessels et al., 2003).

Misconception #3. Assistive technology is necessarily complicated and expensive. Sometimes low-
technology devices are the most appropriate and even preferred for their simplicity, ease of use and
maintenance, and low cost.
Misconception #4. Assistive technology prescriptions are always accurate and optimal. Experiences
clearly demonstrate that the application of technology for persons with disabilities is inexact and will
change with time. Changes in the assistive technology user’s health, living environment, preferences,
and circum-stances will require periodic reassessment by the user and those rehabilitation professionals
who are giving assistance (Philips and Zhao, 1993).
Misconception #5. Assistive technology will always be used. According to data from the 1990 U.S.
Census Bureau’s National Health Interview Survey, about one-third of the assistive devices not needed
for survival are unused or abandoned just 3 months after they were initially acquired.

28
In addition to avoiding common misconceptions, a rehabilitation engineer and tech-nologist should
follow several principles that have proven to be helpful in matching appropriate assistive technology to
the person or consumer. Adherence to these principles will increase the likelihood that the resultant
assistive technology will be welcomed and fully utilized.
Principle #1. The user’s goals, needs, and tasks must be clearly defined, listed, and incorporated as early
as possible in the intervention process. To avoid overlooking needs and goals, checklists and premade
forms should be used. A number of helpful assessment forms can be found in the references given in the
suggested reading list at the end of this chapter.
Principle #2. Involvement of rehabilitation professionals with differing skills and know-how will
maximize the probability for a successful outcome. Depending on the purpose and environment in which
the assistive technology device will be used, a number of professionals should participate in the process
of matching technology to a person’s needs. Table 4 lists various technology areas and the responsible
profes-sionals.
Principle #3. The user’s preferences, cognitive and physical abilities and limitations, living situation,
tolerance for technology, and probable changes in the future must be thoroughly assessed, analyzed, and
quantified. Rehabilitation engineers will find that the highly descriptive vocabulary and qualitative
language used by nontechnical professionals needs to be translated into attributes that can be meas-ured
and quantified. For example, whether a disabled person can use one or more upper limbs should be
quantified in terms of each limb’s ability to reach, lift, and grasp.

Principle #4. Careful and thorough consideration of available technology for meeting the user’s needs
must be carried out to avoid overlooking potentially useful solutions. Electronic databases (e.g., assistive
technology websites and websites of major technology vendors) can often provide the rehabilitation
engineer or assis-tive technologist with an initial overview of potentially useful devices to prescribe,
modify, and deliver to the consumer.
Principle #5. The user’s preferences and choice must be considered in the selection of the assistive
technology device. Surveys indicate that the main reason assistive technology is rejected or poorly
utilized is inadequate consideration of the user’s

TABLE 4 Professional Areas in Assistive Technology

Technology Area Responsible Professionals*

Academic and
vocational skills Special education
Vocational rehabilitation
Psychology
Augmentative
communication Speech–language pathology
Special education
Computer access Computer technology
Vocational rehabilitation
Daily living skills Occupational therapy

29
 Rehabilitation technology
Specialized
adaptations Rehabilitation engineering
Computer technology
Prosthetics/orthotics
Mobility Occupational therapy
Physical therapy
Seating and positioning Occupational therapy
Physical therapy
Written communication Speech–language pathology
Special education

*Depending on the complexity of technical challenges encountered, an assistive technologist or a

rehabilitation engineer can be added to the list of responsible professionals.

needs and preferences. Throughout the process of searching for appropriate tech-nology, the ultimate
consumer of that technology should be viewed as a partner and stakeholder rather than as a passive,
disinterested recipient of services.
Principle #6. The assistive technology device must be customized and installed in the location and
setting where it primarily will be used. Often seemingly minor or innocuous situations at the usage site
can spell success or failure in the application of assistive technology.
Principle #7. Not only must the user be trained to use the assistive device, but also the attendants or
family members must be made aware of the device’s intended purpose, benefits, and limitations. For
example, an augmentative communication device usually will require that the communication partners
adopt a different mode of communication and modify their behavior so that the user of this device can
communicate a wider array of thoughts and even assume a more active role in the communication
paradigm, such as initiating a conversation or changing the con-versational topic. Unless the attendants
or family members alter their ways of interacting, the newly empowered individual will be dissuaded
from utilizing the communication device, regardless of how powerful it may be.
Principle #8. Follow-up, readjustment, and reassessment of the user’s usage pat-terns and needs are
necessary at periodic intervals. During the first 6 months
following the delivery of the assistive technology device, the user and others in that environment learn
to accommodate to the new device. As people and the environ-ment change, what worked initially may
become inappropriate, and the assistive device may need to be reconfigured or reoptimized. Periodic
follow-up and adjust-ments will lessen technology abandonment and the resultant waste of time and
resources.

30
4 PRINCIPLES OF REHABILITATION ENGINEERING

Knowledge and techniques from different disciplines must be utilized to design technological
solutions that can alleviate problems caused by various disabling condi-tions. Since rehabilitation
engineering is intrinsically multidisciplinary, identifying universally applicable principles for this
emerging field is difficult. Often the most relevant principles depend on the particular problem being
examined. For example, principles from the fields of electronic and communication engineering are
para-mount when designing an environmental control system that is to be integrated with the user’s
battery-powered wheelchair. However, when the goal is to develop an implanted functional electrical
stimulation orthosis for an upper limb impaired by spinal cord injury, principles from neuromuscular
physiology, biomechanics, bio-materials, and control systems would be the most applicable.
A systematic approach is essential to successfully complete a rehabilitation project. Key elements of
the design process involve the following sequential steps: analysis, synthesis, evaluation, decision, and
implementation.
Analysis
Inexperienced but enthusiastic rehabilitation engineering students often respond to a plea for
help from someone with a disability by immediately thinking about possible solutions. They overlook
the important first step of doing a careful analysis of the problem or need. What they discover after
much ineffectual effort is that a thorough investigation of the problem is necessary before any
meaningful solution can be found. Rehabilitation engineers first must ascertain where, when, and how
often the problem arises. What is the environment or the task situation? How have others performed the
task? What are the environmental constraints (size, speed, weight, location, physical interface, etc.)?
What are the psychosocial constraints (user prefer-ences, support of others, gadget tolerance, cognitive
abilities, and limitations)? What are the financial considerations (purchase price, rental fees, trial
periods, maintenance and repair arrangements)? Answers to these questions will require diligent investi-
gation and quantitative data such as the weight and size to be lifted, the shape and texture of the object
to be manipulated, and the operational features of the desired device. An excellent endpoint of problem
analysis would be a list of operational features or performance specifications that the ‘‘ideal’’ solution
should possess.Such a list of performance specifications can serve as a valuable guide for choosing the
best solution during later phases of the design process.

Synthesis
A rehabilitation engineer who is able to describe in writing the nature of the problem is likely
to have some ideas for solving the problem. Although not strictly sequential, the synthesis of possible
solutions usually follows the analysis of the problem. The synthesis of possible solutions is a creative
activity that is guided by previously learned engineering principles and supported by handbooks, design
magazines, product cata-logs, and consultation with other professionals. While making and evaluating
the list of possible solutions, a deeper understanding of the problem usually is reached and other,
previously not apparent, solutions arise. A recommended endpoint for the synthesis phase of the design
process includes sketches and technical descriptions of each trial solution.

31
Evaluation
Depending on the complexity of the problem and other constraints such as time and money, the two or
three most promising solutions should undergo further evaluation, possibly via field trials with mockups,
computer simulations, and/or detailed mechan-ical drawings. Throughout the evaluation process, the end
user and other stakeholders in the problem and solution should be consulted. Experimental results from
field trials should be carefully recorded, possibly on videotape, for later review. One useful method for
evaluating promising solutions is to use a quantitative comparison chart to rate how well each solution
meets or exceeds the performance specifications and operational characteristics based on the analysis of
the problem.
Decision
The choice of the final solution is often made easier when it is understood that the final solution usually
involves a compromise. After comparing the various promising solutions, more than one may appear
equally satisfactory. At this point, the final decision may be made based on the preference of the user or
some other intangible factor that is difficult to anticipate. Sometimes choosing the final solution may
involve consulting with someone else who may have encountered a similar problem. What is most
important, however, is careful consideration of the user’s preference (principle 5 of assistive
technology).
Implementation
To fabricate, fit, and install the final (or best) solution requires additional project planning that,
depending on the size of the project, may range from a simple list of tasks to a complex set of scheduled
activities involving many people with different skills.

4.1 Key Engineering Principles

Each discipline and subdiscipline that contributes to rehabilitation engineering has its own set of key
principles that should be considered when a design project is begun. For example, a logic family must be
selected and a decision whether to use synchro-nous or asynchronous sequential circuits must be made
at the outset in digital design. A few general hardware issues are applicable to a wide variety of design
tasks, including worst-case design, computer simulation, temperature effects, reliability, and product
safety. In worst-case design, the electronic or mechanical system must continue to operate adequately
even when variations in component values degrade performance. Computer simulation and computer-
aided design (CAD) software often can be used to predict how well an overall electronic system will
perform under different combinations of component values or sizes.
The design also should take into account the effects of temperature and environ-mental conditions on
performance and reliability. For example, temperature extremes can reduce a battery’s capacity.
Temperature also may affect reliability, so proper venting and use of heat sinks should be employed to
prevent excessive temperature increases. For reliability and durability, proper strain relief of wires and
connectors should be used in the final design.
Product safety is another very important design principle, especially for rehabili-tative or assistive
technology. An electromechanical system should always incorporate a panic switch that will quickly halt

32
a device’s operation if an emergency arises. Fuses and heavy-duty gauge wiring should be employed
throughout for extra margins of safety. Mechanical stops and interlocks should be incorporated to ensure
proper interconnections and to prevent dangerous or inappropriate movement.
When the required assistive device must lift or support some part of the body, an analysis of the static
and dynamic forces (biomechanics) that are involved should be performed. The simplest analysis is to
determine the static forces needed to hold the object or body part in a steady and stable manner. The
basic engineering principles needed for static and dynamic analysis usually involve the following steps:
(1) Deter-mine the force vectors acting on the object or body part, (2) determine the moment arms, and
(3) ascertain the centers of gravity for various components and body segments. Under static conditions,
all the forces and moment vectors sum to zero. For dynamic conditions, the governing equation is
Newton’s second law of motion in which the vector sum of the forces equals mass times an acceleration
vector (F ¼ ma).

4.2 Key Ergonomic Principles

Ergonomics or human factors is another indispensable part of rehabilitation engineer-ing and assistive
technology design. Applying information about human behavior, abilities, limitations, and other
characteristics to the design of tools, adaptations, electronic devices, tasks, and interfaces is especially
important when designing assistive technology because persons with disabilities generally will be less
able to accommodate poorly designed or ill-fitted assistive devices. Several ergonomic principles that
are especially germane to rehabilitation engineering are discussed in the following sections.

Principle of Proper Positioning

Without proper positioning or support, an individual who has lost the ability to maintain a stable posture
against gravity may appear to have greater deformities and functional limitations than truly exist. For
example, the lack of proper arm support may make the operation of even an enlarged keyboard
unnecessarily slow or mistake prone. Also, the lack of proper upper trunk stability may unduly limit the
use of an individual’s arms because the person is relying on them for support.
Figure 2.8 Patient exercising his shoulder extensor muscles with wall pulleys (from Le Veau, 1976).

33
 During all phases of the design process, the rehabilitation engineer must ensure that whatever
adaptation or assistive technology is being planned, the person’s trunk, lower back, legs, and arms will
have the necessary stability and support at all times (Fig. .9). Consultation with a physical therapist or
occupational therapist familiar with the focus individual during the initial design phases should be
considered if postural support appears to be a concern. Common conditions that require consider-ations
of seating and positioning are listed in Table 5.5.

Principle of the Anatomical Control Site

Since assistive devices receive command signals from the users, users must be able to reliably indicate
their intent by using overt, volitional actions. Given the variety of switches and sensors that are
available, any part of the body over which the user has reliable control in terms of speed and
dependability can serve as the anatomical control site. Once the best site has been chosen, an appropriate
interface for that

Figure 2.9 Chair adaptations for proper positioning (from Church and Glennen, 1992).

TABLE 5 Conditions That Require Consideration of Seating and Positioning

Condition Description and Seating Considerations

Characteristics

Cerebral palsy Nonprogressive neuromuscular

Increased tone (high Fixed deformity, decreased Correct deformities, improve
tone) movements, abnormal patterns alignment, decrease tone
Decreased tone (low Subluxations, decreased active Provide support for upright
tone) movement, hypermobility positioning, promote
development of muscular control
Athetoid (mixed tone) Excessive active movement, Provide stability, but allow
decreased stability controlled mobility for function
Muscular dystrophies Degenerative neuromuscular
Duchenne Loss of muscular control proximal Provide stable seating base, allow
to distal person to find balance point
Multiple sclerosis Series of exacerbations and Prepare for flexibility of system to
remissions follow needs
Spina bifida Congenital anomaly consisting of a Reduce high risk for pressure

34

Spinal cord injury
Osteogenesis imperfecta
Orthopedic impairments
deficit in one or more of the
vertebral arches, decreased or
absent sensation
Insult to spinal cord, partial or
complete loss of function below
level of injury, nonprogressive
once stabilized, decreased or
absent sensation, possible
scoliosis/kyphosis
Connective tissue disorder, brittle
bone disease, limited functional
range, multiple fractures
Fixed or flexible
concerns, allow for typically
good upper extremity and head
control
Reduce high risk for pressure
concerns, allow for trunk
movements used for function
Provide protection
If fixed, support, if flexible, correc

Traumatic brain injury Severity dependent on extent of Allow for functional

central nervous system damage, improvement as rehabilitation
may have cognitive component, progresses, establish a system that
nonprogressive once stabilized is flexible to changing needs

Elderly Typical aged Often, fixed Provide comfort and visual

kyphosis, decreased bone mass, and orientation, moisture-proof,
decreased strength, incontinence accommodate kyphosis

Aged secondary to Example—older patients with Provide comfort, support

primary disability cerebral palsy may have fixed deformities
deformities

Adapted with permission from Evaluating, Selecting, and Using Appropriate Assistive Technology, J.
C.Galvin, M. J. Scherer, p. 66, 1996 Aspen Publishers, Inc.
site can be designed by using various transducers, switches, joysticks, and keyboards. In addition to the
obvious control sites such as the finger, elbow, shoulder, and knee, subtle movements such as raising
an eyebrow or tensing a particular muscle can also be employed as the control signal for an assistive
device. Often, the potential control sites can and should be analyzed and quantitatively compared for
their relative speed, reliability, distinctiveness, and repeatability of control actions. Field trials using
mock-ups, stopwatches, measuring tapes, and a video camera can be very helpful for collecting such
performance data.
When an individual’s physical abilities do not permit direct selection from among a set of possible
choices, single switch activation by the anatomical control site in combination with automated row-
column scanning of a matrix is often used. In row-column scanning, each row of a matrix lights up
sequentially from the top to the bottom. When the row containing the desired item is highlighted, the
user selects it using a switch. Then each item in that row is scanned (from left to right) until the desired
item is chosen by a second switch activation. The speed with which a two-dimensional array can be
used to compose messages depends on the placement of the letters in that array.

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Principle of Simplicity and Intuitive Operation
The universal goal of equipment design is to achieve intuitively simple operation, and this is especially
true for electronic and computer-based assistive devices. The key to intuitively simple operation lies in
the proper choice of compatible and optimal controls and displays. Compatibility refers to the degree
to which relationships between the control actions and indicator movements are consistent,
respectively, with expectations of the equipment’s response and behavior. When compatibility relation-
ships are incorporated into an assistive device, learning is faster, reaction time is shorter, fewer errors
occur, and the user’s satisfaction is higher. Although people can and do learn to use adaptations that do
not conform to their expectations, they do so at a price (producing more errors, working more slowly,
and/or requiring more attention). Hence, the rehabilitation engineer needs to be aware of and follow
some common compatibility relationships and basic ergonomic guidelines, such as:
 The display and corresponding control should bear a physical resemblance to each other.
 The display and corresponding control should have similar physical arrange-ments and/or be
aided by guides or markers.
 The display and corresponding control should move in the same direction and within the same
spatial plane (e.g., rotary dials matched with rotary displays, linear vertical sliders matched with
vertical displays).
 The relative movement between a switch or dial should be mindful of population stereotypic
expectations (e.g., an upward activation to turn something on, a clockwise rotation to increase
something, and scale numbers that increase from left to right).
Additional guidelines for choosing among various types of visual displays are given in Table 5.6.
Principle of Display Suitability
In selecting or designing displays for transmission of information, the selection of the sensory modality
is sometimes a foregone conclusion, such as when designing a warning signal for a visually impaired
person. When there is an option, however, the rehabilitation engineer must take advantage of the
intrinsic advantages of one sensory modality over another for the type of message or information to be
conveyed. For example, audition tends to have an advantage over vision in vigilance types of warnings
because of its attention-getting qualities. A more extensive comparison of auditory and visual forms of
message presentation is presented in Table 7.
Principle of Allowance for Recovery from Errors
Both rehabilitation engineering and human factors or ergonomics seek to design assistive technology
that will expand an individual’s capabilities while minimizing errors. However, human error is
unavoidable no matter how well something is designed. Hence, the assistive device must provide some
sort of allowance for errors without seriously compromising system performance or safety. Errors can
be classified as errors of omission, errors of commission, sequencing errors, and timing errors.
A well-designed computer-based electronic assistive device will incorporate one or more of the
following attributes:

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 The design makes it inherently impossible to commit the error (e.g., using jacks and plugs that can fit
together only one way or the device automatically rejects inappropriate responses while giving a
warning).
 The design makes it less likely, but not impossible to commit the error (e.g., using color-coded wires
accompanied by easily understood wiring diagrams)
 The design reduces the damaging consequences of errors without necessarily reducing the likelihood
of errors (e.g., using fuses and mechanical stops that limit excessive electrical current, mechanical
movement, or speed).
TABLE 6 General Guide to visual Display Selection

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 TABLE 7 Choosing Between Auditory and Visual Forms of
Presentation

Use Auditory Presentation Use Visual Presentation if

The message is simple. The message is complex.

The message is short. The message is long.
The message will not be
referred to later. The message will be referred to late
The message deals with even The message deals with location in
in time. space.
The message calls for The message does not call for
immediate action. immediate action.
The visual system of the pers
is overburdened. The auditory system of the person i
overburdened.
The message is to be perceiv The message is to be perceived by
by persons not in someone very
the area. close by.
Use artificially generated Use visual display if the message
speech if the listener contains
cannot read. graphical elements.
Adapted and modified from Saunders and McCormick (1993, p. 53, Table 3-1).

 The design incorporates an ‘‘undo,’’ ‘‘escape,’’ or ‘‘go-back’’ command in devices that involve
the selection of options within menus.
Principle of Adaptability and Flexibility
One fundamental assumption in ergonomics is that devices should be designed to accommodate the
user and not vice versa. As circumstances change and/or as the user gains greater skill and facility in
the operation of an assistive device, its operational characteristics must adapt accordingly. In the case
of an augmentative electronic communication device, its vocabulary set should be changed easily as
the user’s needs, skills, or communication environment change. The method of selection and feedback
also should be flexible, perhaps offering direct selection of the vocabulary choices in one situation
while reverting to a simpler row-column scanning in another setting. The user should also be given the
choice of having auditory, visual, or a combination of both as feedback indicators.
Principle of Mental and Chronological Age Appropriateness
When working with someone who has had lifelong and significant disabilities, the rehabilitation
engineer cannot presume that the mental and behavioral age of the individual with disabilities will
correspond closely with that person’s chronological age. In general, people with congenital disabilities
tend to have more limited variety, diversity, and quantity of life experiences. Consequently, their
reactions and behavioral tendencies often mimic those of someone much younger. Thus, during
assessment and problem definition, the rehabilitation engineer should ascertain the functional age of

38
 the individual to be helped. Behavioral and biographical information can be gathered by direct
observation and by interviewing family members, teachers, and social workers.
Special human factor considerations also need to be employed when designing assistive technology
for very young children and elderly individuals. When design-ing adaptations for such individuals, the
rehabilitation engineer must consider that they may have a reduced ability to process and retain
information. For example, generally more time is required for very young children and older people to
retrieve information from long-term memory, to choose among response alternatives, and to execute
correct responses. Studies have shown that elderly persons are much slower in searching for material in
long-term memory, in shifting attention from one task to another, and in coping with conceptual,
spatial, and movement incongruities.
The preceding findings suggest that the following design guidelines be incorpor-ated into any
assistive device intended for an elderly person:
 Strengthen the displayed signals by making them louder, brighter, larger, etc.
 Simplify the controls and displays to reduce irrelevant details that could act as sources of
confusion.
 Maintain a high level of conceptual, spatial, and movement congruity, i.e., compatibility between
the controls, display, and device’s response.
 Reduce the requirements for monitoring and responding to multiple tasks.
 Provide more time between the execution of a response and the need for the next response. Where
possible, let the user set the pace of the task.
 Allow more time and practice for learning the material or task to be performed.

5 PRACTICE OF REHABILITATION ENGINEERING AND ASSISTIVE TECHNOLOGY

5.1Career Opportunities
As efforts to constrain health care costs intensify, it is reasonable to wonder whether career
opportunities will exist for rehabilitation engineers and assistive technologists. Given an aging
population, the rising number of children born with cognitive and physical developmental disorders,
the impact of recent legislative mandates (Table 5.1), and the proven cost benefits of successful
rehabilitation, the demand for assistive technology (new and existent) will likely increase rather than
decrease. Correspond-ingly, employment opportunities for technically oriented persons interested in
the development and delivery of assistive technology should steadily increase as well.
In the early 1980s, the value of rehabilitation engineers and assistive technologists was
unappreciated and thus required significant educational efforts. Although the battle for proper
recognition may not be entirely over, much progress has been made during the last two decades. For
example, Medi-Cal, the California version of the federally funded medical assistance program, now
funds the purchase and customiza-tion of augmentative communication devices. Many states routinely
fund technology devices that enable people with impairments to function more independently or to
achieve gainful employment.

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 Career opportunities for rehabilitation engineers and assistive technologists cur-rently can be found
in hospital-based rehabilitation centers, public schools, vocational rehabilitation agencies,
manufacturers, and community-based rehabilitation technol-ogy suppliers; opportunities also exist as
independent contractors. For example, a job announcement for a rehabilitation engineer contained the
following job description (Department of Rehabilitative Services, Commonwealth of Virginia, 1997)
.Provide rehabilitation engineering services and technical assistance to persons with disabilities, staff,
community agencies, and employers in the area of employment and reasonable accommodations.
Manage and design modifications and manufacture of adaptive equipment. . . . Requires working
knowledge of the design, manufacturing techniques, and appropriate engineering problem-solving
techniques for persons with disabilities. Skill in the operation of equipment and tools and the ability to
direct others involved in the manufacturing of assistive devices. Ability to develop and effectively
present educational programs related to rehabilitation engineering. Formal training in engineering with
a concentration in rehabilitation engineering, mechanical engineering, or biomedical engineering or
demonstrated equivalent experience a requirement.
The salary and benefits of the job in this announcement were competitive with other types of
engineering employment opportunities. Similar announcements regu-larly appear in trade magazines
such as Rehab Management and TeamRehab and in newsletters of RESNA.
An example of employment opportunities in a hospital-based rehabilitation center can be seen in the
Bryn Mawr Rehabilitation Center in Malvern, Pennsylvania. The Center is part of the Jefferson Health
System, a nonprofit network of hospitals and long-term, home care, and nursing agencies. Bryn
Mawr’s assistive technology center provides rehabilitation engineering and assistive technology
services. Its geriatric rehabilitation clinic brings together several of the facility’s departments to work
at keeping senior citizens in their own homes longer. This clinic charges Medicare for assessments and
the technology needed for independent living. Support for this program stems from the potential cost
savings related to keeping older people well and in their own homes.
Rehabilitation engineers and assistive technologists also can work for school districts that need to
comply with the Individuals with Disabilities Education Act. A rehabilitation engineer working in such
an environment would perform assess-ments, make equipment modifications, customize assistive
devices, assist special education professionals in classroom adaptations, and advocate to funding
agencies for needed educationally related technologies. An ability to work well with nontech-nical
people such as teachers, parents, students, and school administrators is a must.
One promising employment opportunity for rehabilitation engineers and assistive technologists is in
community-based service providers such as the local United Cere-bral Palsy Association or the local
chapter of the National Easter Seals Society. Through the combination of fees for service, donations,
and insurance payments, shared rehabilitation engineering services in a community service center can
be financially viable. The center would employ assistive technology professionals to provide
information, assessments, customized adaptations, and training.
Rehabilitation engineers also can work as independent contractors or as employees of companies
that manufacture assistive technology. Because rehabilitation engineers understand technology and the
nature of many disabling conditions, they can serve as a liaison between the manufacturer and its
potential consumers. In this capacity, they could help identify and evaluate new product opportunities.
Rehabilitation engineers, as independent consultants, also could offer knowledgeable and trusted
advice to consumers, funding agencies, and worker compensation insurance companies. Such

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consultation work often involves providing information about relevant assistive technologies,
performing client evaluations, and assessing the appropriateness of assistive devices. It is important
that a rehabilitation engineer who wishes to work as an independent consultant be properly licensed as
a Professional Engineer (PE) and be certified through RESNA as described in the next section. The
usual first step in attaining the Professional Engineer’s license is to pass the Fundamentals of
Engineer-ing Examination given by each state’s licensing board.

5.2 Rehabilitation Engineering Outlook

Rehabilitation engineering has reached adolescence as a separate discipline. It has a clearly defined
application. For example, rehabilitation engineering research and development has been responsible
for the application of new materials in the design of wheelchairs and orthotic and prosthetic limbs, the
development of assistive tech-nology that provides a better and more independent quality of life and
better employ-ment outcomes for people with disabilities, the removal of barriers to
telecommunications and information technology through the application of universal design principles,
the development of hearing aids and communication devices that exploit digital technology and
advanced signal processing techniques, and the com-mercialization of neural prostheses that aid hand
function, respiration, standing, and even limited walking.

Beginning with the Rehabilitation Act of 1973 and its subsequent amendments in 1992 and 1998,
rehabilitation engineering in the United States has been recognized as an activity that is worthy of
support by many governments, and many universities offer formal graduate programs in this field. Fees
for such services have been reim-bursed by public and private insurance policies. Job advertisements
for rehabilitation engineers appear regularly in newsletters and employment notices. In 1990, the
Americans with Disabilities Act granted civil rights to persons with disabilities and made reasonable
accommodations mandatory for all companies having more than 25 employees. Archival journals
publish research papers that deal with all facets of rehabilitation engineering. Student interest in this
field is rising. What is next?
Based on some recent developments, several trends will likely dominate the prac-tice of
rehabilitation engineering and its research and development activities during the next decade.
 Certification of rehabilitation engineers will be fully established in the United States.
Certification is the process by which a nongovernmental agency or professional association
validates an individual’s qualifications and knowledge in a defined functional or clinical
area. RESNA is leading such a credentialing effort for providers of assistive technology.
RESNA will certify someone as a Professional Rehabilitation Engineer if that person is a
registered Professional Engineer (a legally recognized title), possesses the requisite relevant
work experience in rehabilitation technology, and passes an examination that con-tains 200
multiple-choice questions. For nonengineers, certification as an Assis-tive Technology
Practitioner (ATP) or Assistant Technology Supplier (ATS) is available. Sample questions
from RESNA’s credentialing examination are pro-vided at the end of the chapter.

41
 Education and training of rehabilitation technologists and engineers will expand worldwide.
International exchange of information has been occurring infor-mally. Initiatives by
government entities and professional associations such as RESNA have given impetus to
this trend. For example, the U.S. Department of Education supports a consortium of several
American and European universities in the training of rehabilitation engineers. One indirect
goal of this initiative is to foster formal exchanges of information, students, and
investigators.
 Universal access and universal design of consumer items will become common-place.
Technological advances in the consumer field have greatly benefited people with
disabilities. Voice-recognition systems have enabled people with limited movement to use
their computers as an interface to their homes and the world. Telecommuting permits gainful
employment without requiring a dis-abled person to be physically at a specified location.
Ironically, benefits are beginning to flow in the opposite direction. Consumer items that once
were earmarked for the disabled population (e.g., larger knobs, easy-to-use door and cabinet
handles, curb cuts, closed-caption television programming, larger visual displays) have
become popular with everyone. In the future, the trend toward universal access and products
that can be used easily by everyone will expand as the citizenry ages and the number of
people with limitations increases. Universal design—which includes interchangeability,
component modularity, and user friendliness—will be expected and widespread.
 Ergonomic issues will play a more visible role in rehabilitation engineering. When designing
for people with limitations, ergonomics and human factors play crucial roles, often
determining the success of a product. In recognition of this, IEEE Transactions on
Rehabilitation Engineering published a special issue on ‘‘Rehabili-tation Ergonomics and
Human Factors’’ in September 1994. The Human Factors and Ergonomics Society has a
special interest group on ‘‘Medical Systems and Rehabilitation.’’ In the next decade, more
and more rehabilitation engineering training programs will offer required courses in
ergonomics and human factors. The understanding and appreciation of human factors by
rehabilitation engineers will be commonplace. The integration of good human factors
designed into specialized products for people with disabilities will be expected.
 Cost-benefit analysis regarding the impact of rehabilitation engineering services will become
imperative. This trend parallels the medical field in that cost containment and improved
efficiency have become everyone’s concern. Econo-metric models and socioeconomic
analysis of intervention efforts by rehabili-tation engineers and assistive technologists will
soon be mandated by the federal government. It is inevitable that health maintenance
organizations and managed care groups will not continue to accept anecdotal reports as
sufficient justifica-tion for supporting rehabilitation engineering and assistive technology
(Gelder-bom & de Witte, 2002; Andrich, 2002). Longitudinal and quantitative studies in
rehabilitation, performed by unbiased investigators, will likely be the next major initiative
from funding agencies.
 Quality assurance and performance standards for categories of assistive devices will be
established. As expenditures for rehabilitation engineering services and assistive devices
increase, there will undoubtedly be demand for some objective assurance of quality and skill
level. One example of this trend is the ongoing work of the Wheelchair Standards
Committee jointly formed by RESNA and the American National Standards Institute.

42
 Another example of this trend is the drive for certifying assistive technology providers and
assistive technology suppliers.
 Applications of wireless technology will greatly increase the independence and capabilities
of persons with disabilities. For example, navigational aids that utilize the Global
Positioning System, Internet maps, cellular base station tri-angulation, and ubiquitous radio
frequency identification tags will enable the blind to find their way indoors and outdoors as
easily as their sighted counter-parts. Wireless technology also will assist people with
cognitive limitations in their performance of daily activities. Reminders, cueing devices,
trackers and wandering devices, and portable personal data assistants will enable them to
remember appointments and medications, locate themselves positionally, follow common
instructions, and obtain assistance.
 Technology will become a powerful equalizer as it reduces the limitations of manipulation,
distance, location, mobility, and communication that are the common consequences of
disabilities. Sometime in the next 20 years, rehabili-tation engineers will utilize technologies
that will enable disabled individuals to manipulate data and information and to alter system
behavior remotely through their voice-controlled, Internet-based, wireless computer
workstation embed-ded in their nuclear-powered wheelchairs. Rather than commuting daily
to work, persons with disabilities will or can work at home in an environment uniquely
suited to their needs. They will possess assistive technology that will expand their abilities.
Their dysarthric speech will be automatically recognized and converted into intelligible
speech in real time by a powerful voice-recogni-tion system. Given the breathtaking speed at
which technological advances occur, these futuristic devices are not mere dreams but
realistic extrapolations of the current rate of progress.

Students interested in rehabilitation engineering and assistive technology R & D will be able to
contribute toward making such dreams a reality shortly after they complete their formal training. The
overall role of future practicing rehabilitation engineers, however, will not change. They still will need
to assess someone’s needs and limita-tions, apply many of the principles outlined in this chapter, and
design, prescribe, modify, or build assistive devices.

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 UNIT III

THERAPEUTIC EXERCISE TECHNIQUE

TOPICS:
Co-ordination exercises, Frenkels exercises, Gait analyses-Pathological Gaits, Gait Training,
Relaxation exercises-Methods for training Relaxation, Strengthening exercises-Strength training,
Types of Contraction, Mobilization exercises, Endurance exercises.

Introduction:
Exercises performed on a patient to achieve therapeutic benefit are called Therapeutic
Exercises. These exercises are classified as follows:

 Coordination exercises
 Balance training
 Gait training
 Relaxation exercises
 Re education exercises
 Strengthening exercise
 Mobilization exercises
 Endurance exercises
 Postural correction
 Ergonomic
 Hydrotherapy
 Suspension therapy
Apart from these exercises, there are some skills imparted to the exercise therapist, like
manipulation, taping massage and other alternative healing techniques.

COORDINATION EXERCISES

Coordination is needed for performing purposeful movement that is both smooth and
precise involving simultaneous activity of many muscles superimposed on a background of good
posture. Motor units of multiple muscles are activated with simultaneous inhibition of all other
muscles in order to carry out a desired activity.
Components of Coordinated Activity

Volition - The patient must have the voluntary control to perform the activity; the ability to
initiate, maintain or stop it

Perception - to be effective, proprioception that is, the peripheral sensation of the joints must be
intact to integrate the motor impulses and sensory feedback with the sub cortical centers. When
proprioception is affected it is compensated with visual feedback. This is the basis for
Romberg’s phenomenon, when the person starts swaying when he stands and closes his eyes.
44
Engram Formation - An engram represents the neurological organization of muscular activity
developed in the extra pyramidal system. Most of the activities we do involve many muscle
groups, and the brain perceives the final movement objective rather than individual muscles’
performance. Research has proved that 20,000 to 30,000 repetitions of precise performance must
be performed in order to develop an engram. This is why, to perfect an activity such as driving, it
is necessary to keep practicing it over and over again till it becomes an engram. Once perfected,
the brain goes almost into ‘autopilot’, and can concentrate on more demanding situations while
still continuing the engram pattern. This is how one can talk while driving or read the paper
while eating breakfast.

Indications for Coordination Training

Lesions of cerebellum resulting in cerebellar ataxia form the motor component of ataxia.
On the other hand lesions in the posterior column of the spinal cord result in sensory ataxia. In
coordination may also result from lesions affecting the muscle, the peripheral nerve or the upper
motor neurons. In these cases since the incoordination is the result of muscle weakness,
hypotonicity or hypertonicity, it is not primary incoordination and the predisposing factors are
treated, instead of labeling it as incoordination.

General Principles of Coordination Training

A suitable learning environment, i.e. an environment which provides for attention to tasks, is
created. A list of activities is prepared. The activities are broken down into components that are
simple enough to be performed correctly. If the patient has very poor coordination, it may be
necessary to completely break down the multi muscular movement and practice the contraction
of an individual prime mover. The patient is given instructions to perform these simple
components which are then welded together to form the final job performance. Whenever a new
movement is trained, various inputs are given simultaneously, like oral instruction (auditory),
with touch (sensory stimulation), or positions in which the patient can view the movement
(visual stimulation). If necessary the therapist may demonstrate with a passive movement on the
patient which will provide a kinesthetic feedback. The physiotherapist assists in the movement
where ever necessary, for precise Placement of feet during training in coordination functions so

45
that the patient concentrates on sensations produced by theactivity. As stated before, several
repetitions of precise performance must beperformed for the engram to form (Fig. 3.1).

Figure 3.1: Placement of feet during training in coordination

The technique progresses in complexity by

 Increasing the speed of contraction

 Increasing the complexity where more muscles get involved
 Increasing the range of movement during the activity.
 Removing the sensory feedback that is given.

The rate of performance should be slowed with each new addition to a pattern. Fatigue may
occur during attempts for precision and may decrease the concentration of the patient. The
patient should therefore have a short rest after two or three repetitions.

Frenkel’s Exercises
Dr HS Frenkel was a physician from Switzerland who propagated the concept of using
sensations of sight, sound and touch to establish control of voluntary of movement. This is by
compensation for the kinesthetic sensory loss .

Principles

 Each patient should have individual attention, and should not be left unattended in case
he should fall and injure himself.
 The patient should be adept in each exercise or set of exercises, before he is allowed to
proceed to a more difficult one.

46
  Strong muscle contractions should not be given since progression is by complexity, not
strength.
 The patient should practise exercises first with his eyes open, and then with eyes closed.
 In the beginning movements in full range are preferred to those in small range
 Such movements should be given rapidly, then more slowly
 Exercises are prescribed for the upper and lower extremities in various positions—sitting,
lying, and so on.
Sometimes all this is quite boring especially for children. Diversionary activities such as
playing with putty, building with toy bricks, or drawing on a blackboard, tailing the donkey
lead to more useful movements such as using a knife and fork, doing up buttons and doing
the hair. Transfers of objects from one container to the other, playing cricket or throw ball are
examples of play therapy improving coordination

BALANCE TRAINING
Almost all our daily activities are performed under the influence of gravity. Most of our
effort and time is spent in reacting to the effects of gravity upon the body. Protective
responses in maintaining balance are considered to have survival value by preventing us from
falling as well as enabling us to maintain our sense of verticality.
Posture is the term used to describe a position of the human body. The human body is
capable of several postures like lying, sitting, crawling, and standing. In all these postures the
body needs to be stable in order to do its activities. Stability depends on whether the base and
the position of the centre and line of gravity are either balanced in equilibrium or not.
Balance and posture are interrelated.
Balance is maintained at a subconscious level, by integrating sensory inputs from the
eyes, the vestibular apparatus, and the proprioceptors and superimposing them on a basic
amalgam of posture and postural reflexes in the normal individual. While retraining a
patient’s balance he is given stimulito which he must react. This is more important than his
making a conscious effort to maintain equilibrium.
There are two types of balance - static balance and dynamic balance. Both of these are
needed for normal activities. It need not be thought that balance training need be done only
for neurological deficit. On the contrary balance retraining is an integral part of all gait
training exercises or rehabilitation programs.
Static Balance
Static balance is the rigid stability of one part of the body on another. Even a person
standing immobile is contracting his muscles in an isometric fashion. There is also
contraction of muscles equally. As a general principle balance is developed progressively by
moving from the more stable to the lesser stable position, for example from forearm support
prone lying to sitting without support. In the development of a child head control is the first
to develop. This reinforces the fact that stability and control of the head should be given
priority as it is needed in all positions. Later, the extensors of the neck and back and also

47
 spinal stabilizers can be stimulated to reinforce muscle contraction elsewhere, e.g. righting
reactions, which are involuntary movement responses to stimuli, serving to maintain the
alignment of the head and body in its normal upright posture.
Dynamic Balance
The body, unless it is fully supported and relaxed, like lying down, is in a constant state
of adjustment to maintain its posture and its equilibrium. The force of gravity acts on it
threatening to destabilize it. Maintaining balance means having the centre of gravity of the
body within the base of support, i.e. with the trunk aligned over the feet. A soldier at
attention might appear completely still, but he continuously transfers his weight and
oscillates trying to maintain his center of gravity within his base. He is able to do this
because of his sense of proprioception which provides feedback on the status of the body
internally whether the body is moving and if so how, and whether the various parts of the
body are located properly in relation to each other.
Equilibrium Reactions
These are involuntary automatic responses to a disturbance or destabilization in the
structure of the body that serves to maintain or regain balance during posture and movement.
These balance reactions may occur by an adjustment in tone or an adjustment in posture
Method of Stimulation
For balance to improve in a position, the patient must be assisted to assume that position.
Man’s body axis is vertical, and it is in the vertical position, that he needs the ability to
withstand the effects of gravity. Analysis of balance reactions and body alignment in
responses to shifts in weight will identify the deficient areas, which require specific
stimulation. For example, if a person is pushed to his right, he moves his head and trunk in
the opposite direction with corresponding compensatory reactions of the pelvis and lower
limbs to bring his center of gravity within his base of support. Any one or all of the
components of balance may be missing and must be stimulated by the therapist. Alternate
tapping stimulates balance in antigravity positions. Gentle taps are applied alternately to the
upper trunk with the body in normal alignment. The effect should be to displace the patient
slightly off balance in alternate directions, which will stimulate the necessary adjustments. It
must be stressed that the displacement should be small so as to stimulate only fine
adjustments.
Maintenance of Position
The patient is instructed to maintain the position, for example, prone kneeling, sitting or
standing against the therapist’s tapping technique to displace him backwards, forwards and
laterally. The use of a moving support is valuable in some positions. Objects used include
balance boards, rolls which are made of a cardboard tube, and therapeutic balls. If balance
reactions fail, protective extension (parachute reflex) of the arms is one of the most important
reactions. In general, movement for balance is stimulated smoothly and steadily, ina small
range initially, gradually increasing the range as the patient gains more control. Any position
can be made more stable by using pressure and approximation and by providing the patient a

48
 wider base by giving more than one fixed point of stability. Too much emphasis on stability
would prevent the patient from moving or trying to move. On the other hand, too much
stimulation of movement might result in loss of balance and the confidence to regain it. The
use of weights worn by the patient on the trunk or lower limbs is sometimes suggested as a
means of improving movement control.
Balance Boards consist of a platform, which may be either rectangular or circular, resting
on a hemispherical base. They re-educate balance and increase strength of the muscles of the
leg. The patient is given various positions on the balance board and he should learn to
maintain his balance while sitting, kneeling or standing on it, while it is displaced in different
directions. The Bobath ball is very useful in this training

GAIT
Gait or human locomotion, may be described as a translatory progression of the body as a
whole, produced by coordinated movements of body segments. It is the forward progression
of the center of gravity (a point in front of the2nd sacral vertebral body) of the body, based
on the reciprocal movements of the lower extremities. Man is the only animal among
vertebrates, possibly other than some primates who walks on two limbs. Each person has his
own characteristic gait pattern.
Normal human gait needs good muscle power in the lower limbs, translatability, good
proprioception, good balance and vision. The movement is rhythmic and smoothened out in
to an elegant and sinuous pattern.
Gait Cycle (Fig. 3.2)
The gait cycle is a series of documented movements during walking which by convention is
measured from the point of initial heel contact of one lower extremity to the same point when
it occurs again, that is the point at which the heel of the same extremity contacts the ground
again. It is divided into2 phases stance and swing

Figure 3.2:Phases of gait cycle

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 When movement is initiated it is called acceleration and when stopping it is called
deceleration. Energy is consumed in both phases but more during deceleration. The path
taken by the centre of gravity determines the energy expenditure and efficiency of gait.
Given the situation, the ideal path should be a sinusoidal curve with minimum displacement.
Stance, when the foot is in contact with the ground is the longer component of the gait cycle,
using up to 60 per cent of the duration. Swing, which is when the foot is off the ground,
forms the rest 40 percent of the cycle. There is a period called double stance covering 11
percent of the cycle when both legs are on the ground.

Studying Normal Human Locomotion

In the analysis of the walking pattern of a person the external effects like the force of
gravity, or inertia and internal effects like forces exerted by muscular contraction or angular
relationship between the segments, are studied.
Kinematic is the division of mechanics, which deals with the motion of bodies. It does
not study the forces acting to produce the motion. Kinetics is the division of mechanics that
deals with forces acting on bodies.
Gait Analysis
Gait analysis commonly involves the measurement of the subjects given above, like the
movement of the body in space (kinematics) and the forces involved in producing these
movements (kinetics). It is done in a gait lab. Earlier, the analysis used to be done (and still is
done in some places) by photography. Strobe lighting at a predetermined frequency was used
in the past to aid in the analysis of gait on single photographic images. Another method is to
use reflective balls as marker systems which are recorded simultaneously through cameras,
placed at strategic positions. The patients made to walk in a straight line on a modified floor
embedded with force plates or transducers, which measure force systems, notably the ground
reaction force and its magnitude and direction. The system then can calculate the forces and
torques about each joint, and the power exerted by muscle groups, throughout the gait cycle.
The cameras also measure joint angles and velocities. This information is then analyzed in a
software that gives the parameters in 3 dimensions. It is possible for a gait researcher to
generate information on the gait pattern and gait variables, description of all gait deviations,
energy expenditure and endurance. Based on the analysis of the deviations he will be able to
predict the patient’s ambulatory capacity, in the home and community environment.
Observational Gait Analysis
Clinically it is possible to make a study of the gait. The physiatrist makes study of the
patient’s history and condition. Having arrived at a diagnosis, he proceeds to analyze the way the
patient walks. If we wish to observe the gait clinically, we need to:
 Measure the distance that the patient has to cover.
 Have an unobstructed view of the patient – in front and by the side
 The joint or segment to be assessed is selected.

50
  Observe during the initial part of the stance phase and follow through the entire
gait cycle.
 Perform observations on both sides (right and left).
 These observations are recorded for one segment at a time throughout each phase
of the gait cycle. For example the physician concentrates on knee extension
during the swing phase and records it on a video camera or even on his mobile
phone
 Repeat the process until all joints and segments are completed.
 Check if the gait is normal; if not note the deviations.
Qualitative Gait Analysis
Different reference systems are used in the qualitative gait analysis:
Absolute spatial system: The environment is used as a reference, and the movement of the body
in relation to the environment is studied.
Relative system: The relative system describes the position of one body segment in relation to
another body segment.
Absolute reference system: The body is given a reference to the x and y and z axis and all
segments moving are described in reference to the verticalor horizontal position of the body.
Electrogoniometry: A goniometer is similar to a protractor and measures the angles between the
moving segments of the joint at a predetermined point approximately at the center of the joint. In
a clinical set up it is measured manually but using an electrical transducer or a rotational
potentiometer, it is possible to get more accurate measurements.

Determinants of Gait
The factors modifying the path taken by the centre of gravity, to smoothen outits extreme
movements and reduce the amplitude of displacement, sidewaysand vertically, are called
Determinants of Gait.
They are:
Pelvic rotation:
While walking, the pelvis rotates by 4 degrees on either side.This reduces the excursions
of the center of gravity and elevates it by 6/16′′.
Pelvic tilt:
The pelvis drops on the side of the unsupported or swinging legduring walking and this
saves vertical rise of the center of gravity by 3/16"
Knee flexion:
During mid stance, the knee bends minimally on the stance leg.This decreases its length
and therefore the height of center of gravity by 7/16". Thus the total saving in the vertical
excursion of center of gravity7/16′′ + 3/16′′ + 6/16′′ = 1 inch.

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 Knee and ankle movement:
There are movements between the knee, ankle, subtalar and mid tarsal joints which act to
smoothen out the amplitude of the center of gravity to 2" by flexing, extending, pronating and
supinating these joints in a coordinated fashion. While some determinants act on the amplitude
of movements of the center of gravity, there are others which are given below smoothen out the
movement of the center of gravity into a sinusoidal curve, and which make the gait energy
efficient and sometimes attractive.
Pelvic sway:
This is the sideways sway of pelvis, which brings the center of gravity over one leg
during stance and produces a side to side sinusoidal curve.
Limb rotation:
The leg describes a 25 degree internal rotation on stance and external rotation on swing,
smoothening out the sideways curve of the center of gravity

PATHOLOGICAL GAITS
Pathological gaits (Fig. 3.3) may be due to neurological or orthopedic causes as a result of:

Figures 3.3A to C: Pathological gaits. (A) Spastic gait: Usually occurring in cerebral palsy;(B)
Propulsive/retropulsive gait or Festinant gait: Usually occurring in Parkinson’s disease;(C) High
steppage gait or Foot drop gait: Typically occurs in paralysis of the dorsiflexors of the foot
 Pain during movement
 Loss of muscle power
 Increased or fluctuating muscle tone
 Incoordination of muscles
 Skeletal deformities

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GAIT TRAINING
Crutch Walking: Patterns of Gait
A crutch is a staff or support used by the physically handicapped or disabled as an aid in gait,
often used in pairs. To select the pattern of gait to be employed by a particular patient, the
following must be evaluated
The ability of the patient to:
 Bear weight and to keep his balance on one or both lower limbs.
 Push his body off the ground by pressing down on both crutches.
 Step forward with either one or both feet
 Generate and sustain the increased expenditure of energy required in all assisted gaits.
The partial weight-bearing gaits using crutches (either axillary or elbow) require more
energy (nearly a third more) than normal walking, whereas about70 percent more energy is
required by the three point and swing through gaits. Each patient must be encouraged to walk
even if he does not use a recognized pattern of gait. Any mobility is better than immobility.
There are six different patterns of crutch gait.
They are:
 Four-point gait
 Two-point gait
 Three-point gait
 Swing to gait
 Swing through gait
 Tripod gait.
The type of crutch gait to be taught to the disabled person will of course, depend on
several factors like type, extent degree of disability and residual patterns of weakness.
Sometimes the patient with lesser disability will find even the so-called difficult gaits easy to
perform while the severely disabled will find the simplest gait difficult.
Four-point alternating gait:
The four-point gait is the most stable of all the gait patterns, providing three points of
support while one limb or an assistive device is moving. The person will start by moving one
ambulatory aid, such as a cane or crutch, about 1-1/2 feet ahead, followed by the opposite foot
forward. Next the opposite assistive device is moved forward, and finally the other foot is
brought forward. The sequence is as follows: right crutch, left foot, left crutch, right foot. The
feet always stay about six or seven inches behind the crutch. The center of gravity falls between
the four points of support. The four point gait is most easily performed using hip hiking in which
progression is accomplished by successive forward advance of each point. This gait is often
taught to paraplegics.

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Two-point gait:
The two point gait is a natural progression from the four point gait. It requires more
balance and stability, but has a natural rhythm and arm motion that resembles normal gait. With
a two point gait, the person advances one assistive device and a foot at the same time. Adequate
power of hip muscles (flexors, extensors and abductors) is essential for two point gait. It can be
accomplished in two ways, either the crutch and foot on the same side advance together or the
crutch on one side advances with the foot on the otherside. The latter is more stable as weight is
borne on both sides. At the beginning of the stance phase of one limb, the assistive device on the
opposite side simultaneously makes contact with the floor and provides support.
Three-point gait:
The three-point gait is used where a single lower extremity is affected, like a fracture of
the hip. The gait pattern is either non-weight bearing or partial weight bearing on that side. The
assistive devices move forward with the involved limb. As the unaffected limb begins the swing
phase, and is placed on the floor in front of the involved lower limb, the body weight is shifted to
the loco motor aid. So the three points would be both crutches, normal limb and involved limb.
Swing to gait:
To perform the swing to gait pattern, the initial phase requires balancing momentarily on both
legs as the crutches are moved forward simultaneously. This is followed by shifting the weight to
the arms and hands, and forcefully depressing the scapula as the weight is shifted to the hands.
Both legs are then brought forward until the feet are evenly placed at the level of the crutches or
slightly behind. At the end of the step the person should be in normal crutch stance, ready to take
the next ‘step’.
Swing through gait:
This is an extension of the swing to gait mentioned earlier. It is practiced by some amputees and
paraplegics on gaining expertise with the swing to gait. It provides a much more rapid means of
ambulation than the other crutch gaits. It is the least stable of the gait patterns, and therefore
requires practice and balance to perform safely. When the weight is taken on the arms the legs
swing forward through the crutches, landing on the floor ahead of them. As a result, the crutches
are behind the patient when the feet touch the ground. Immediately the crutches have to be
brought forward before the hip and trunk lose balance and lead to a fall (Figs 3.7and 3.8).
Tripod gaits:
This is used by paraplegics and polio patients. The sequence is right crutch, left crutch and
drag the body. This can also be modified as follows: Both crutches at the same time in front of
the body then drag the body. The feet rarely leave the ground so that a tripod base is constantly
maintained, which provides the extra balance and stability. Sometimes gaits are taught within a
walking frame or parallel bar (Figs 3.9 and 3.10) to ensure better stability

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RELAXATION EXERCISES AND MANAGEMENT OF SPASTICITY
Definition:
‘Relaxation’ is defined as a state in which the muscles of the body are comparatively free from
tension. This is because functioning muscles can never be completely free from tension as they
retain a certain degree of tension known as muscle tone.

Figure 3.7: Stabilization after swing through

Figures 3.8 A to E: Swing through gait training with elbow crutches

55
Figure 3.9: Gait training in parallel bars for a paraplegic Figure 3.10: Standing frame

Indications:

Relaxation exercises are indicated whenever there is muscle spasm due to acute or chronic pain,
mental stress that is due to any cause, e.g. systemic disease, stressful lifestyle, certain
psychological disorders orhypertonicity resulting from an upper motor neuron lesion.

General Principles

 A position that ensures full support to the body (which reduces mechanical tension on
muscles or ligaments) should be selected. Conditions of individual patients should be
kept in mind, e.g. for aged patients with in spiratory disorders—prone lying may not be
ideal

 Constrictive clothing or orthosis such as corsets and belts should be removed

 The treatment room should be as quiet as possible

 Strong colors and bright lights should be avoided. The room should have dim, diffuse light

 The manner of the physiotherapist should be pleasant and understanding

 The therapist explains gently what is going to be done to the patient so that any fear is
removed

 Attention to minor irritants like a full bladder emptied before treatment can ensure a very
cooperative patient.

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METHODS FOR TRAINING RELAXATION

These methods may be of two types:

 Methods for general relaxation - which relax the total body.
 Methods for local relaxation - which relax a specific part of the body
Meditative Techniques for General Relaxation
Mental techniques:

Meditative techniques focus on the mind and comfort level, where the patients’
thinking is the major component. It involves bringing all the thinking processes to one point and
later letting go. The mind is kept blank which surprisingly is a very daunting task. It is very
nearly impossible to keep the mind free of thoughts and emotions. Elton and Stanley described
the use of imagery for persons who find creating a blank mind difficult. The trainer tries and
projects images on to the patients mind which need to be pleasant and relevant to the patient.
Benson’s controlled breathing produces relaxation response, which produces in the patient a state
of deep quietness that significantly changes one’s physical mental and emotional responses to
stress. It slows heart rate, decreases blood pressure, and muscle tension.

Transcendental meditation is a technique described by Maharishi Mahesh Yogi in which the

practitioner is taught methods to subdue his thoughts and bring it to a state of peace. A mantra or
sequence of syllables that may make no meaning to the meditator is taught. The mantra is
utilized as a focus in the meditation process, and the individual’s attention is directed naturally
away from the surroundings to a quieter state of mental activity (inactivity). The meditator is said
to have transcended his being or body state.

Visual imagery is based on the assumption that individuals have the ability to think up images
that affect functions of the mind and body, like blood pressure or cardiac rate. Audio recordings
promoting this imagery are commercially available. When a person thinks of beautiful scenery
like a star studded sky or a tranquil lake it induces relaxation and encourages self healing. It has
been tried out in patients with anxiety, those undergoing surgery and results have shown
decreased length of time spent in the hospital when imagery was used. Studies of brain activity
during imagery show that the same region of the brain is activated whether a subject imagines an
image of an object, or whether the object is actually seen. This concept can be extended to
inducing relaxation by listening to soothing music.

Consciousness of breathing:

The patient is asked to breathe deeply, slowly and regularly with a slight pause between
expiration and inspiration. He is asked to concentrate on his own rhythm of breathing. During
expiration, he is instructed to feel like ‘letting go’ of the whole body. Respiratory control is
also encouraged with instruction directed towards diaphragmatic and lateral costal breathing.

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PHYSICAL TECHNIQUES

Jacobson’s Progressive Relaxation:

This method encourages the patients to tense, and then relax sequentially, groups of
muscles while concentrating onto the components of tension and relaxation that are being
experienced. The rationale is that by teaching the patient to contract a muscle and recognize the
symptom or feeling of tension, reduction of tension in daily life would be possible. The method
appears to be of clinical value, particularly in hypertension, epilepsy and respiratory distress. The
muscle groups targeted in this method are shoulder depressors, elbow extensors, shoulder
abductors, finger and thumb extensors in the upper limb and hip lateral rotators ankle dorsi-
flexors, trunk flexors, neck extensors.

Mitchell’s Simple Physiological Relaxation:

This is based mainly on the physiological principle that in an action involving group
muscles, there is reciprocal innervations of opposing groups, whereby contraction in agonist
muscles is accompanied by reflex relaxation of antagonists. This eliminates tension while
preserving ones awareness about relaxed posture.

Rhythmical Passive Movement:

Passive movements of the limbs and head may assist in general relaxation in some cases.
Group movements of joints are preferable.

Local Relaxation:

If the joint is the source of pain - passive movements should be given in the pain free
range. Deep rhythmical massage also helps in relaxing the area where it is given. Hold relax and
contract relax techniques are given to muscles under tension in the area of pain or their
antagonists. First they are put into isometric contraction by applying maximal resistance, and
then the patient is instructed to voluntarily relax those muscles.

Progressive Relaxation Training (PRT):

The trainee is asked to focus attention on a particular group of muscles. This group of
muscles is held tense for 5 – 7 seconds during which the trainee concentrates on the sensation of
muscle contraction. On a predetermined word ‘release’, ‘let go’, the muscle group is relaxed.

Passive Neuromuscular Relaxation:

The client imagines that he or she is relaxed and is asked to state the phase, “I am
relaxed”, and repeats it every time he breathes out. The technique consists of one continuous
wave of relaxation which begins at the crown of head and progresses down.

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The Alexander Technique:

Alexander was an actor and teacher who found outa process called respiratory
reeducation in which breathing and vocalization improved respiratory function.This evolved into
a method to treat other physical problems through movement posture and breathing. A person’s
posture is the way that individual habitually holds himself against the forces of gravity. This can
become distorted by emotional and physical influences. This technique re-educates the body to
perform and conserve energy. For example, commands are given “keep your neck free, bring
your head forward and up, lengthen and widen your back and shoulder“ This technique deals
with the psychological and physical coordination of the whole person, called as “the use of the
self”.

Feldenkrais Technique:

Moshe Feldenkrais was an engineer, in whose view the body functions like a machine
which could be programmed to work with minimum effort but maximum efficiency. He
therefore formed exercises to reinforce new patterns in the brain, a sort of awareness through
movement. In the process, the brain develops an ‘image’ of how movements should be made and
recognizes strain is produced on muscles and joints if faulty.

STRENGTHENING EXERCISES

Strength

It is referred to as the ability of a muscle/muscle group to produce a force in one

maximal effort either dynamically or statically. The strength of a muscle varies relatively upon
the demands placed by it. Strengthening exercises area set of exercises that are used widely by
the physiotherapist in improving the power of the muscle or muscle groups.

Strength Training

To strengthen a muscle, its contraction must be loaded or resisted so that increasing

levels of tension develops. The force output of a muscle is directly proportional to the amount of
tension developing in the muscle.

The muscle undergoes adaptive changes in response to strengthening, like increase in

the size of muscle fibers, amount of stored nutrients, contractile act in and myosin filaments and
the amount of enzymes used for metabolism inside the muscle.

59
 In the nervous system too, there are changes, like synchronization of motor units so
maximum number of motor units produce maximum tension in the muscle. Also there is more
activation of the CNS and more number of muscle fibers recruited with inhibition of central
neural inhibitory mechanisms, which will result in increased force output.

The body undergoes other physiological adaptations, for example, in the bone there is an
increase in the mineral content, while in connective tissue there is an increase in strength of
tendons and ligaments. Strengthening is done whenever there is weakness due to a lesion in
anterior horn cells, e.g. poliomyelitis, or in efferent motor pathways, like neuropraxia, as a
consequence of muscle injuries or disuse atrophy due to prolonged immobilization.

General Principles

 When designing a strengthening program, the therapist must always consider the overall
level of fitness of the patient, the type of injury or disease, the stage of healing after injury
and, most importantly the desired functional outcome.

 Specificity of training—exercises incorporated should mimic the desired function in terms

of range, types of contraction, and velocity of contraction of muscle work, e.g. training a
person for coming down stairs should include training in descending steps, one leg after the
other.

 If the activity needs endurance also, then endurance exercises are given accordingly.

Types of Contraction
Eccentric Contraction:

An eccentric contraction occurs when a muscle is contracting and an external force is

trying to lengthen the muscle. It is a common cause for muscle strain. Muscles working
eccentrically become longer and thinner as they pay out and allow their attachments to be drawn
apart by force producing the movement. For example the extensors of the back elongate while
doing abdominal crunches, and this can lead to lumbosacral strain.

The muscle spindle is stretched throughout eccentric movement and provides additional
peripheral reflex support for contraction. Eccentric training improves only the eccentric strength
of the muscle. Control is easily learnt in eccentric activity of muscle.

Isometric Contraction:

The length of the muscle remains the same throughout the muscle work and no
movement results. The hold period for this contraction should be at least 6 seconds for maximal
recruitment of motor units. It has been suggested that isometric training of a weak muscle would
strengthen the muscle only up to 5 weeks, and after this period, it maintains the strength gained
during the training.

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 Isometric strength gains occur at the specific angle of the joint at which the muscle is
strengthened. Therefore, for the muscle to function better throughout the available range,
isometric strengthening at 4 or 5 angles throughout the ROM is essential.

Concentric Muscle Work

Muscles working concentrically become shorter and thicker as their attachments are
drawn closer together and joint movements results. A patient doing concentric muscle work
performs a movement and in so doing overcomes some force which offers resistance such as
friction, gravity, manual pressure by the physiotherapist, or some other form of mechanical
resistance.

The physiological cost of this type of work is high, as only about a quarter of the energy
liberated during contraction is available as mechanical work. Concentric muscle work, e.g. lifting
weights, is used to build up muscle power.

Intensity of Training

The absolute level of overload will vary according to the individual. It has been
suggested that a certain threshold point of intensity must be exceeded for strengthening to occur.
The threshold for isometric training is generally40 percent of the maximum load that the patient
can lift.

Velocity of Training

In the case of concentric contraction as the velocity increases, force output from the
muscle decreases. Therefore when a weak muscle is rehabilitated, low velocities are used so that
it can generate more force and later the velocity is progressively increased. In the case of
eccentric contraction as the velocity decreases force output from the muscle increases.

Range of Muscle Work (Fig. 3.11)

The outer range of muscle work is used extensively in muscle re-education and strengthening of
a weak muscle, as concentric contraction is initiated more easily from stretched position of a
muscle. Middle ranges can be used for training eccentric contractions. Inner range is added to the
program as a progression.

Inner Range:

The muscle works either concentrically from the position in which it is partially
contracted to a position of full contraction or vice versa if it works eccentrically. Exercise in the
inner range is used to gain or maintain movement of a joint in the direction of the muscle pull.

Outer Range:

The muscles work concentrically from the position in which they are fully stretched to a
position in which they are partially contracted, or viceversa if working eccentrically. It is used
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extensively in muscle re-education for good initiation of contraction in full stretch.

Figure 3.11: Range of contraction (elbow flexion)

Middle Range:

The muscles are never either fully stretched or fully contracted. Exercises in this range
maintain muscle tone and power but full joint movement is never achieved during the exercises.
Facilitatory techniques which inhibit the central mechanism and result in the increased force
output of the muscle such as tapping, verbal prompts, manual contact and repetitions are used.
Recovery from active exercise has been shown to be more rapid with light exercise following a
strengthening program, than with total rest. Appropriate stabilization of proximal segments
should be done to avoid substitution. The affected muscles must be strengthened progressively
by resisted exercises, which are specific for the group to which the muscles belong.

Progressive Resisted Exercise

For strengthening not only overload is important, but it must be progressively increased
as the individual adapts to the training and increases in strength. This approach is known as
Progressive resisted exercise. This term was coined by DeLorme. DeLorme and McQueen based
their progressive resistance program on the concept of 10 RM, i.e. the maximum load which can
be lifted ten times (Figs 3.12 and 3.13).

Isotonic Exercise

Isotonic exercise consists of dynamic movement with a constant weight through a range
as the muscle shortens or lengthens. Many gymnasiums use machines and free weights based on
this concept. It is recommended to gradually build up to the 10 repetition maximum in
progressive percentages of the 10 RM (i.e., 40%, 50%, and so on till 100%). A repetition
maximum (RM) is the maximum amount of weight lifted correctly for one repetition. When the
RM is reached, muscle fibers are fully recruited and the muscle is working at high intensity.
Most physiotherapy centers gradually build up to or work down from the RM as an effective
method of resistance training.

Figure 3.12: Free and active resisted [strengthening exercises]

Figure 3.13: Wall climbing—active range of movement for the shoulder

Isotonic Resistance Equipment

Resistance

The resistance is increased by:

 Increasing the poundage of the resistance

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  Increasing the leverage of the resistance.

 Free weights: These are graduated weights that are hand held or applied to the upper or
lower extremity and include dumbbells and sand bags

 Elastic resistance devices: Elastic resistance materials and surgical tubing such as Thera-
bands, Bull worker and exercise tubing are available in several grades or thicknesses.

 Pulley systems: Free standing or wall mounted pulley systems (with weightsor springs)
provide either fixed or variable resistance and can be used forupper and lower extremity
and trunk strengthening (Fig. 3.14)

Figure 3.14: Pulley exercises

 Variable-resistance equipment: Designed to provide variable resistance throughout the

range of motion as a muscle contracts concentrically and eccentrically.

 Exercise bicycle: The stationary exercise bicycle is used to increase lower extremity
strength and endurance. Some exercise cycles provide resistance to both the upper and
lower extremities.

 Other resistance devices that are often available in a gymnasium, are Minels apparatus,
wrist exerciser, FEPS Flexion-extension-pronation-supination, grip exerciser, stepping
machine and sliding seats, to name a few

Isokinetic Exercise

Isokinetic exercise is performed using special equipment that only permits movement at a
preset angular velocity. The muscle shortens or lengthens through a range at a constant angular
velocity. This is dictated by the machine moves at the same rate no matter how much force is
applied to it. However, the load or force exerted may be variable. This causes maximum tension
at all angles. Motivation of the person performing the exercises must be very high because he has
to recruit all his muscle fibers. Another is that strength gained at one particular velocity may not
transfer to other velocities.

Precautions while doing Strenuous Exercises

Valsalva maneuver:

It is the expiratory effort against closed glottis. This increases the intra-abdominal and intra
- thoracic pressure which in turn decreases the venous flow to the heart. This leads to a
temporary drop in blood pressure and increase in heart rate. Valsalva maneuver is commonly
seen in isometric and heavy resistance training like weight lifting. Care should be given to avoid
the effects of Valsalva maneuver when framing these training programs for patients with
cardiovascular problems, cerebrovascular accidents, myocardial infarction, herniation, unhealed

63
incisional scar, or those who belong to the geriatric age group.

Local or general fatigue:

Persons may get fatigued due to decrease in blood glucose, K+ ions, oxygen in blood and
advanced age. Persons with multiple sclerosis may function well in the early morning, and their
strength deteriorates due to fatigue as the day passes on, while in early evening their strength
improves. Persons with cardiopulmonary disease may fatigue more rapidly and require longer
periods for recovery after exercise. So training for such conditions would require low intensity
strengthening with rest intervals to avoid tiring the muscles.

Osteoporosis:

It is common in neuromuscular disease, inflammatory joint diseases, post-menopausal

period, and due to sedentary lifestyle. Resistance during exercise should be added gradually with
care, especially for aged persons.

Inflammation:

When a muscle or a joint is acutely inflamed, strengthening is too stressful and is

therefore contra indicated.

MOBILIZATION EXERCISES

Mobilization is defined as a passive movement performed in such a manner or speed that

the patient can stop the movement at his will. It is a method of restoring or maintaining joint
movement.

General Principles

 The patient should be positioned such that he feels comfortable and relaxed.

 Techniques of relaxation can be used if necessary

 Warming of the tissues using massage/heating modalities can be done prior to mobilization.

 The joint to be mobilized is placed in the least painful position.

 The bone proximal to the joint is fixed manually or mechanically with straps or belts.

 The treatment force should be applied close to the joint.

 Progression of the technique depends on how the joint reacts to mobilization.

 Dosage is decided in terms of the grade, speed and duration of treatment

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Indications

Pain and associated muscle spasm:

The technique can reduce muscle spasm directly by stimulating type III joint receptors
which can inhibit the activity of the motor neurons of the nearby muscles. Small amplitude
oscillatory and distraction movements used in the pain free range stimulate types I and I
mechanoreceptors located in the joint capsule, ligaments and fat pads in the joints. This also
inhibits pain at the spinal level through the pain gate mechanism

Restriction of joint ROM

Due to capsular tightness, meniscus displacement, ligamentous tightness or adhesion

formation within the articular structures. Most of these can result due to prolonged
immobilization. When connective tissue is immobilized there is desiccation (reduction in water)
and depletion of glycosaminoglycans while the total collagen remains the same. This reduces the
space and leads to formation of cross-links between collagen fibers, leading to tightness. It is
better to use joint play stretching techniques to mechanically distract the contracted tissue.

Progressive limitation of joint ROM , e.g. as in rheumatoid arthritis. Mobilization helps to

maintain the functional ROM required for daily activities.

Contraindications

1. Hyper mobility of joints

2. Joint effusion
3. Infection of joints
4. Recent fracture involving articular surfaces
5. Neoplasm
6. Acute inflammatory conditions of the joint
7. Hemarthrosis (Hemophilia)

Effects of Joint Motion

Movement of the joints is beneficial to the patient as it stimulates activity by increasing
circulation of synovial fluid, and maintains extensibility and tensile strength of the articular and
peri-articular tissue. It also gives sensations on speed, direction, and tone relating to the joint.
Other benefits are:

 Pain relief - through pain gate mechanism

 Improving tissue nutrition by increasing cellular diffusion rates and tissue fluid transport

 Kick starting the healing process by helping in scar tissue formation and myofibroblast
formation

 Placebo effect of the human touch and satisfaction to the patient

65
  Improving quality of life by maintaining/restoring the ADL’s as in Rheumatoid arthritis.

Grades of Mobilization

The grade refers to the amplitude of movement and the range in which the movement is
performed. Different systems of grading have been devised and used in mobilization. The most
common ones in practice are those of Maitlandand Cyriax.

Maitlands concept or technique:

This is a method to treat pain and stiffness due to mechanical reasons by applying skillful
oscillatory movements to the vertebral joints. The techniques try to restore movements between
joints like spin, glide and roll. They are graded according to their amplitude.
Grade I: A small amplitude movement performed at the beginning of the range within
the resistance free part of the range

Grade II: A large amplitude movement performed within the resistance free part of the
range.

Grade III: A large amplitude movement performed into resistance or up to the limit of
resistance.

Grade IV: A small amplitude movement performed into resistance or up to the limit of
resistance.

Grade V: A high velocity, short amplitude, thrust often near or at the limit of abnormal
movement (at a speed outside patient’s control).

Selection of Dosage

Dosage depends on the patient’s condition. In cases where the pain is experienced before
tissue resistance, mobilizing the joint can induce pain relief and in cases where pain is
experienced after tissue limitation, the effect desired is increase in ROM. Here the dosage in
Grades III, IV and V can be given at- 2-3 cycles/sec for a duration of 2 to 5 minutes. This is
different from manipulation, which is a passive movement done with greater force when the
patient is under anesthesia. Obviously the type of motion occurring between bony participants
within a joint is influenced by the shape of joint circumference, the type of joint, the freedom of
movement permitted, and accessory movements.

Techniques
1. Passive angular stretching
2. Joint glide stretching
3. Compression
4. Traction.

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Cyriax Techniques
Cyriax was a physician who made medical diagnosis of musculoskeletal disorders
localizing the “lesion” to a particular anatomical structure. The concept of referred pain which
meant that the location of the pain was not always the exact location of the lesion was adapted by
his method of examination. Later it included selective tissue tension to localize the lesion
precisely. The treatment of the soft tissue lesions consisted of manipulation, massage, traction
and injection.

ENDURANCE EXERCISES

Endurance exercises are any activity that challenges the cardio-respiratory function and increases
heart rate and breathing for an extended period of time. Examples of endurance exercises are:

Moderate: Examples of moderate exercise are bicycling, or cycling on a stationary cycle, and
walking briskly on a level surface for three to five km.For housewives who may not be able to
take time off for their exercises, mopping or scrubbing the floor itself is a good exercise. In our
country several ADL’s like working out in the fields or at home without gadgets would construe
moderate exercise.

Vigorous: Climbing flights of stairs, brisk cycling up gradients, playing tennis(singles)

swimming, hiking or jogging.

Therapeutic endurance exercise may be recommended for persons with Duchennes muscular
dystrophy. Duration of exercise and its intensity should be based on each individual’s tolerance
to exercise, and spontaneous walking speed. The physical medicine specialist and physical
therapist design an exercise program that won’t aggravate the problem or cause muscle damage.
The patient is advised to walk as much as he can, use a stationary bicycle or elliptical trainer in
moderation to work a number of muscles groups at the same time or go swimming. Sometimes
light weights can be included. It is better to increase repetitions than weights.

Suspension Therapy Sling suspension therapy is a form of physical therapy where joint
movement and tissue stretches are achieved through pendular movements in a suspension frame
fixed on to a bed. Motion may be assisted, neutral or resisted. Weights are added to the slings,
which are all suspended through hooks and pulleys to the overhead meshed frame. Correct
placement of the suspension point above is important to get a good range of movement and also
strengthen the muscles. Suspension can be used for all parts of the body.

Factors used in suspension therapy:

 Positioning of patient
 Size and shape of slings
 Fixing methods
 Supports above

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 Control of ROM

68
Hydrotherapy:
The uniqueness of water lies mainly in its buoyancy, which relieves stress on weight
bearing joints and permits movement to take place with reduced gravitational forces. The other
properties of water that are used in pool rehabilitation are hydrostatic pressure, surface tension,
and hydrodynamics. The upward buoyancy exerts on an immersed body reduces the weight on
the recovering muscles and joints in chronic arthritis.
Buoyancy varies according to depth; the deeper it is, the lesser is the weight in comparison to
land-weight.

Hydrostatic pressure, which is the pressure exerted equally in all directions by the fluid on the
surface of an immersed body in the water is used in management of edema.

Force is necessary to overcome the viscosity of the water, or its surface tension. This property of
hydrodynamics can be used by progressively increasing resistance during strength training
programs. Swimmers have extremely well developed Latissimus dorsi due to this property. In
sports rehabilitation, the athletes are motivated to move their limbs or swim faster through water,
by which more muscle fibres are recruited and strength increases.

The use of the Bad Ragaz technique in the rehabilitation of a child with spasticity, where
proprioceptive neuromuscular facilitation is used, utilizes tubes or rings are used to support it in
the water. Incorporation flotation devices to either assist or resist movements adds variety and
interest to the treatment. The therapist provides the source of manual stability as well as
resistance to a functional pattern of movement, typically by pushing or pulling against a
movement that the child is making. Stability and resistance are promoted with the patient
suspended at the surface. Like PNF techniques on land, this enhances muscle activity to recruit
the inactive muscle into the functional movement pattern.

The benefits of using an exercise pool are:

a. the relief of pain and muscle spasm,

b. the maintenance or increase in range of motion of joints,

c. the strengthening of weak muscles and an increase in their tolerance to exercise,

d. the re-education of paralyzed muscles,

e. the improvement of circulation,

f. the encouragement of functional activities, and

g. the maintenance and improvement of balance, co-ordination and posture.

69
Some of the conditions which benefit from hydrotherapy

1. Cerebral palsy and stroke

2. Arthritis

3. Poliomyelitis

MASSAGE TECHNIQUES (FIG. 3.15)

The massage techniques are:

 Stroking
 Effleurage
 Kneading
 Hacking
 Rolling
 Friction

Stroking

It is usually performed with the fingers or finger tips. The operator’s hands are relaxed and
passed over the patient’s skin in a rhythmic manner with pressure on the finger tips
producing a sedative effect.

Effleurage:

It is performed by the palmar surface of the hands with moderate pressure and speed from
distal to proximal in the direction of venous and lymphatic drainage and ending into the
major lymphatic glands of the body. It produces an increase in venous and lymphatic
drainage and also soothing effect, and is used in cases of gross lymph edema.

70
 Figure 3.15: Vacuum therapy—Mechanical form of massage
(For color version see Plate 1)

Kneading:

Here the fingers are used for moulding the part by alternate compression and release in a
circular manner, mainly performed for the soft tissues such as muscles. Occasionally thumb
kneading may also be applied for irregular areas such as eyebrows. It increases blood
circulation to the tissues.

Hacking:

It is performed by the ulnar borders of ring and little fingers with alternate pronation and
supination of the relaxed hand and the wrist slightly in extension. It produces a sensory
stimulation to the tissues treated as inmuscle re-education.

Rolling:

Here both the hands are moved gently with constant pressure generally on the lower
back. Lifting and releasing of the part occurs which helps in stretching of soft tissue
adhesions and skin, apart from release of tension and improvement of blood supply.

Friction:

These are similar to kneading but are applied to the joints. These are done with the finger
tips and thumb and range from superficial to deep frictions. Friction may be performed in
circular manner with considerable pressure on the fingers and thumb.

71
 UNIT IV
PRINCIPLES IN MANAGEMENT OF COMMUNICATION

Topics:
Impairment-introduction to communication, Aphasia, Types of aphasia, Treatment of
aphasic patient, Augmentative communication-general form of communication, types of visual
aids, Hearing aids, Types of conventional hearing aid, Writing aids.

Introduction
Verbal communication, or the ability to convey information and ideas from one person to
another through use of speech, sets us apart from every other species on Earth. Without any
formal training, children who develop typically with no medical, cognitive, or perceptual
problems can learn to speak by simply attending to the signs and signals that surround them in
the home setting. Through the social environment in which they are raised, children learn to
“crack the code” and acquire a native language for the expression of thoughts and ideas, using
arbitrary linguistic symbols while abiding by the rules that govern how these symbols are
combined. Through speech they express their thoughts, using a finely tuned coordination of the
neuromuscular complex. This complex involves four separate subsystems for speaking:
respiration, phonation, resonance, and articulation.
Each of these systems involves specifi c motor activities that result in the production of
speech sounds that can then be interpreted by the speakers of the language to represent different
concepts. The major function of all this coordinated effort is communication, which involves
both a speaker and a listener in a mutually negotiated interchange of information in a
sociolinguistic context.
Deficits in communication may be determined to be either speech or language problems
or both, and must be differentially diagnosed.
Cerebral localization
In terms of cortical function, the role that the different lobes play in the control of
different activities is well documented. The frontal lobe, the largest part of the cortex, is
primarily responsible for voluntary motor function or muscle movement, which includes
volitional movements of the head, neck, trunk, and four extremities as well as verbal speech
production.
The parietal lobe is primarily responsible for sensory function or the interpretation of
sensory information that it receives from the environment through the sense organs of the body.
Among other things, this includes the sense of touch as it relates to the articulation of sounds in
the oral cavity.
The temporal lobe is mostly responsible for hearing and long-term memory storage.
When information is heard through our ears, data get transmitted to the temporal lobe for
perception and interpretation, or the attachment of meaning. The auditory data that people
receive may include words that contain meaning, or sounds with inherent meaning attached (e.g.,
sirens or car alarms).

72
 Finally, the occipital lobe is responsible for the interpretation of visual information.
When our eyes see, the visual data are sent to the occipital lobe where it is perceived in the form
of a picture. Visual data or symbols may come in a variety of different forms, such as printed
words (e.g., “Do Not Enter”); colors that have meaning (e.g., a red light to imply “stop”); or
even stick figures (e.g., caricature in skirt to represent “ladies room”).

The cerebellum (“small cerebrum”) is considered the most recent evolutionary

development in human neurology. This part of the brain is responsible for balance and
coordination. In terms of the oral movements involved in speech production, a person would not
be able to perform rapid and repetitive transitioning of the tongue, jaw, and soft palate without it.

The cerebellum also helps individuals to judge the distance, speed, and power of a
voluntary muscle movement, which helps to maintain the correct amount of muscle tone needed
for the synergistic coordination of breathing, voicing, resonating, and articulating involved in
speech production. Finally, the brain stem serves as a connecting pathway between the brain
above and the spinal cord below.
Speech and language problems

When patients suffer from some sort of brain damage, it may leave them with the
inability to either formulate words (a language problem) or verbally produce them (a speech
problem). These inabilities need to be differentiated. Language disorders include aphasia, a
disorder in which patients may suffer either in the ability to encode a message (deciding how or
what to say before they produce any verbal speech) or in decoding the message heard (perceiving
the signal through the auditory channel and attaching meaning).

However, with speech disorders that result from brain injury, the problems in
communication may be more motorically rather than cognitively based in terms of how patients
actually perform certain muscle movements to produce the speech sounds needed in a message.
Such speech disorders are classified as dysarthria, a term for a collection of motor speech
disorders due to an impairment originating in the central or peripheral nervous systems.

Aphasia

Aphasia is one of the most common problems of communication confronted by a patient

in an acute care setting. This disorder of language is caused by brain injury that results in a range
of symptoms. In some patients, all aspects of language comprehension (the ability to perceive or
understand) and production (the ability to express thoughts or ideas) may be impaired. In others,
fewer aspects of comprehension and/or production may be lost or affected. The most common
cause of aphasia is a cerebrovascular accident (CVA).

Types of aphasia:
Broca’s aphasia
This type of aphasia is considered a nonfl uent language disorder in that the person who
73
suffers from it is unable to speak in a fl owing or connected way. The patient with this type of
aphasia has sustained some degree of injury to the third frontal convolution of the left, or
language-dominant, hemisphere, or Broca’s area. The speech of these patients is
characteristically “choppy,” with many occurrences of the patient not being able to remember the
words he or she is trying to say.

Wernicke’s aphasia

Wernicke’s aphasia results from injury to the posterior portion of the superior temporal
gyrus in the left, or language-dominant, hemisphere, or Wernicke’s area. This type of aphasia is
considered a fl uent aphasia in which the patient is capable of speaking in a connected or fl uent
manner. However, the spontaneous speech of these patients is also spliced with jargon or
nonsense utterances, referred to as paraphasias. Most Wernicke aphasics are unaware of the
speech errors they commit in connected speech and may act surprised that people do not
understand them when they speak. They may feel paranoid, homicidal, suicidal, and depressed,
and may at times be confused with psychiatric patients. Wernicke’s aphasia has also been
referred to as word deafness, syntactic aphasia, or central aphasia.

Anomic aphasia

This variety of fl uent aphasia may be caused by lesions in different regions of the brain,
including the angular gyrus, the second temporal gyrus, or at the juncture of the temperoparietal
lobes. With this type of language disorder, a patient is typically unable to produce the names of
things whereas most other language functions besides naming are relatively intact (e.g., such
patients exhibit good auditory comprehension ability).

Conduction aphasia

This type of fluent aphasia results from damage done to the arcuate fasciculus, or bundle
of neurons that connect both Broca’s and Wernicke’s areas within the same hemisphere. It is also
linked to lesions located deep in the supramarginal gyrus of the parietal lobe. Speech is usually fl
uent but with frequent paraphasias noted. Overall, the patient’s comprehension is considered
good, though verbal imitation is quite poor.

Conduction aphasia is similar to Wernicke’s aphasia with one main exception:

conduction aphasics have relatively good auditory comprehension.

Global aphasia

Considered a nonfl uent type of language disorder, global aphasia is marked by severe
deficits in both comprehension and production of language. The brain damage is usually severe,
with lesions in the frontal, temporal, and parietal lobes, and with damage extending to
subcortical regions of the brain as well. Both Broca’s and Wernicke’s areas of the brain may be
involved. Such patients often require assistance to speak, in the form of augmentative
communication devices.

74
Treatment of aphasic patient

Psychological factors are particularly relevant in rehabilitation, as they can impede a

patient’s acceptance of goals, their progress toward those goals, and, ultimately, their outcome.
In addition, brain injury and stroke give rise to cognitive, behavioral, and emotional sequelae that
can have a profound effect on the patient’s rehabilitation and functioning. These are also
arguably the most distressing symptoms for the family, the most difficult to treat, and the least
understood in the rehabilitation setting.

Psychologists, and neuropsychologists in particular, are therefore an essential part of the

rehabilitation team. They can help the patient (as well as the patient’s family) understand their
condition, manage emotions, and cope with stressors and pain. They also inform the team and
contribute to goal setting and discharge planning. Neuropsychologists have specialized training
in brain–behavior relationships, and can perform cognitive evaluations in addition to treatment.

Emotional and behavioral problems

Patients in a rehabilitation setting can exhibit emotional and behavioral difficulties as

reactions to the injury or operation that brought them to rehabilitation in the fi rst place and/or as
a result of the experience of hospitalization, including loss of independence, separation from
loved ones, and frustration over wanting to go home. Patients often have many practical concerns
and anxieties about their functioning, such as who is paying the bills while they’re hospitalized,
when they can return to work, and whether they will need continued help at home. Pain, which is
common in this population, can induce or exacerbate emotional symptoms.

In addition, patients with brain injury must cope with cognitive and physical limitations
and the very real possibility that their lives will not to return to the way they were. Emotional
and behavioral sequelae can also be the direct result of underlying neurological impairment. For
example, patients with left frontal strokes or those localized to subcortical areas of the brain can
experience an “organic depression.”

Alternatively, damage to frontal areas may also result in behavioral disturbances such as
disinhibition, impulsivity, abulia (lack of initiation), and emotional lability.

Some common emotional problems include the following:

• Depression, often with feelings of sadness, hopelessness, worthlessness, irritability, and

disturbed sleep, appetite, and activity
• Anxiety, including obsessive thinking, fears, and worry; low self confidence
• Post traumatic stress disorder (PTSD), with hypervigilance and reliving of the trauma
• Adjustment disorder
• Denial (to be differentiated from organic unawareness of defi cit, or anosognosia, which
may result from right hemisphere dysfunction)
75
 A psychologist or psychiatrist, preferably one familiar with emotional and behavioral
manifestations following brain injury, should evaluate the patient to determine the correct
diagnosis. Management and treatment may include psychotherapeutics, medication, and/or
environmental modifcation. Mood disorders are often over diagnosed in the brain-injured
population, as physical symptoms thought to be from depression may be secondary to the brain
injury itself.
The neuropsychological evaluation

A neuropsychological evaluation is a comprehensive assessment of cognitive, behavioral,

and emotional and personality functions. This involves a clinical interview, behavioral
observations, and a wide variety of standardized tests (primarily paper–pencil tests), most of
which are done sitting at a table or at bedside in a hospital. Evaluations can vary from less than 1
hour to 6–8 hours of face-to-face contact, depending on the information sought (and the patient’s
stamina).

Neuropsychological evaluations are tailored to the individual patient and frequently done
as an outpatient (after acute hospitalization). An estimate of the patient’s premorbid functioning
is part of the evaluation.

A neuropsychological evaluation can help with diagnosis, guidance of treatment, tracking

of treatment progress, establishment of a baseline (as in prior to brain surgery), and assessment
of psychological factors impacting rehabilitation. It can also be used for disability, return to work
or school, driving, or legal purposes.

An evaluation can assess orientation, awareness, attention, memory and learning,

language, perceptual and visuospatial functions, planning, problem solving, multitasking,
intelligence, academic skills, and motor skills. Some of the tests measure consistency of effort or
attempts to deceive (malingering). Among the more commonly used tests are the Mini Mental
Status Examination, Minnesota Multiphasic Personality Inventory (MMPI), Wechsler Adult
Intelligence Scale, and many others. The battery of tests chosen should be individualized.

Other commonly used tests are listed in Table 1, including tests for the evaluation of
memory, attention, and executive functioning, as well as mood and personality. The evaluation
of language diffi culties is covered in Communication disorders (p. 396).This list is by no means
exhaustive (see Lezak et al., 2004; Strauss et al., 2006).

Table 1 Examples of neuropsychological tests by domain

Commonly, questions arise as to whether and when a patient may return to work or to
driving. As these are extremely complex tasks, requiring numerous cognitive skills, the
assessment of readiness for these functions requires evaluation of various cognitive areas
underlying these abilities. Predictors of driving ability include evaluation of vision, hearing,
reaction time, processing speed, attention, concentration, visuospatial skills, judgment, ability to

76
multitask, memory, and motor control. A road test or driver training is frequently necessary.
Similar assessments need to be made for return to work (which should be job specific). Studies
have shown that the best time to attempt return to work following a brain injury is 6–18 months
post-injury. Returning to work too quickly can result in failure, which may inhibit further
attempts. Ideally, if the patient can return to their previous employer with ongoing supervision
and support, outcomes appear better.

In sum, no one test or test battery can accurately predict how a person who has sustained
a brain injury will drive or function in everyday settings or vocational settings. Predictions are
made on the basis of multiple tests that closely match the skill subsets required to perform the
task(s). The closer that testing can simulate the demands required, the more accurate the
predictions will be.

Interventions and treatment

Psychotherapy
In an acute setting, psychotherapy is likely to be of short duration, supportive in nature,
and more problem-focused in orientation. Cognitivebehavioral techniques appear to be effi
cacious. Psychotherapy with brain-injured patients may also involve a degree of awareness
orientation, with a careful and titrated explanation of their injury and resultant deficits.
Support groups, family therapy, stress management, and relaxation skills all may play a
role in treating brain-injured patients.

Cognitive remediation

Treatment of cognitive and behavioral sequelae of brain injury is known as cognitive

remediation. Cognitive remediation achieves functional change by reinforcing, strengthening, or
restoring previously learned patterns of behavior and establishing new patterns of cognitive
activity or compensatory mechanisms for impaired neurological systems. When performed by
neuropsychologists, this is based on theories of cognitive psychology, learning, and
neuropsychology and is approached systematically to provide an empirical measure of change.

With regard to compensation, a neuropsychologist should be able to make suggestions for

structuring the environment and the patient’s support system to compensate for the brain injury.
External prostheses (i.e., planners, calendars, recording devices, timers, pagers, etc.) and internal
cueing strategies (i.e., developing mnemonics or an internal checklist) are also taught and their
use is reinforced.

Education plays a large part in cognitive remediation. Patients often benefit from being
told their diagnosis, resultant disabilities, and prognosis. Some elementary review of the parts of
the brain and where theirs has been affected can go a long way toward relieving uncertainty and
anxiety, and reassuring patients that they are not “going crazy.” Patients with poor awareness can
also benefit from a consistent review of their areas of strengths and weaknesses, as well as
orientation training (date, time, names, etc.). Cognitive remediation can occur individually and/or
in group settings.
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INTRODUCTION

Alternative and augmentative communication (AAC) is an endeavor with a goal to

optimize the communication of individuals with significant communication disorders (ASHA,
2004). For individuals who have complex communication needs, the process of achieving
communication success may be perceived as an insurmountable challenge by their families and
those providing clinical services. However, students of rehabilitation engineering and
professional rehabilitation engineers on AAC teams can contribute to the success of such
endeavors. Individuals who rely on AAC are attending school, graduating from college, and
participating in theworkforce, because of rehabilitation technology and services.

The basic elements of a comprehensive AAC assessment and the role of rehabilitation
engineers in making decisions about AAC technology are critical to achieving success. The
significance of language issues and AAC language representation methods must be understood
prior to evaluating solutions, emphasizing the need for AAC technology to support the
spontaneous generation of language in order to optimize communication function and
participation. Only by understanding language issues can rehabilitation engineering professionals
appreciate the technology, device features, and human factors issues associated with AAC
interventions.

AAC:

Alternative and augmentative communication (AAC) refers to any communication

approach that supplements or replaces natural speech and/or writing that may be impaired. AAC
services and interventions can be considered to be interactions between components of the
International Classification of Functioning (ICF) model (WHO, 2001) for improved function and
participation in activities. Communication may occur within all components of the ICF model,
requiring application of the principles of rehabilitation engineering to maximize outcomes.
Effective communication is desired for participation at work and school or for leisure and
entertainment.
Alternative and augmentative communication (AAC) interventions can be classified by
the methods used to transmit messages. Methods are classified as unaided or aided (Lloyd et al.,
1997). Unaided symbols do not require an external device or apparatus. Nothing other than an
individual’s body parts are needed to transmit a message, such as using one’s hands to gesture.
Aided symbols, on the other hand, require some kind of an external device. Aided AAC
technology can be further classified into low-, light-, and high-performance technologies. High-
performance technology solutions can then be identified as nondedicated or dedicatedAAC
systems. Nondedicated technology generally refers to computers that are running an AAC
software solution, but the primary application of the technology is computer-based. Conversely,
dedicated AAC devices have been designed and evaluated specifically for communication, but
frequently have secondary features that provide computer or environmental control functions.
The range of aided technology increases as availability of power, voice output, electronics, and
computer chips become part of the system. Table 2 shows the basic AAC classification
78
taxonomy.

AAC USES
Individuals who use or need AAC make up a diverse group of all ages and
socioeconomic, ethnic, and racial backgrounds. In addition, a variety of acquired and congenital
disabilities exist, which can contribute to a person’s inability to speak and maintain functional,
independent communication throughout their lifetime. Acquired neurological disorders that may
contribute to the need for AAC include amyotrophic lateral sclerosis (ALS), Parkinson’s disease,
aphasia, or traumatic brain injury.
Congenital disorders that may contribute to the need for AAC include cerebral palsy,
Down’s syndrome, autism, Angelman syndrome, and other developmental disabilities.
Approximately 2 million, or 8 to 12 individuals per 1000 (0.8 to 01.2%), in the general
population of the US can benefit from AAC (Beukelman and Ansel, 1995). Blackstone (1990)
summarized results from several studies, which suggested that, at the end of the last century, 0.2
to 0.6% of the total school-age population worldwide had severe communication disorders.

Table: 2 AAC Unaided and Aided Ranges of Technology Used as AAC Intervention

DEFINITIONS OF VISUAL ACUITY

Traditionally, visual acuity is expressed as a Snellen fraction such as 20/200, meaning
the ability to identify at 20 ft a letter that a “normal” viewer can identify at 200 ft. Thus, it is a
measure of angular spatial resolution, and visual scientists often express it as a “LogMAR”
number, that is, the logarithm (to the base 10) of the minimum angle of resolution in minutes of
arc. Conveniently, 20/20 represents a resolution of about 1’, or a LogMAR of 0, and 20/200
represents a LogMAR of 1.0. Most people can achieve 20/15 acuity (LogMAR 0.12) with best
optical correction.
NATURE OF DIFFERENT VISUAL IMPAIRMENTS
Different “blinding diseases,” accidents, wounds, or ocular pathologies give rise to
widely differing forms of functional visual impairments, most of which are not measurable
simply as a loss of acuity or resolution. For example, cataracts and other ocular media do
degrade acuity but also cause an even bigger loss in the contrast of the image on the retina,
known as contrast sensitivity. Scattering of light in the ocular media causes an even more severe
reduction in contrast in the presence of glare. Agerelated maculopathy (ARM), the most common
cause of statutory blindness in the United States, causes loss of resolution and ultimately blind
spots (“scotomas”) in the center of the visual field, accompanied by a reduction in contrast
sensitivity and inability to adapt rapidly to different light levels. Advanced glaucoma and
retinopathy of prematurity (ROP) cause a degradation of the peripheral field. Diabetes can cause
losses in seemingly random parts of the visual field. Color blindness affects about 8% of the
male population and can affect tasks such as interpretation of computer graphics, although it is
not considered disabling.
IMPACT ON TASK PERFORMANCE
Naturally, these different functional deficits have widely differing impacts on th
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performance of different visual tasks. Standard acuity testing only evaluates one’s ability to read
very-high-contrast letters in very good lighting a situation that does not correspond to most real-
world viewing conditions. Most eye diseases degrade performance even more under nonideal
viewing conditions; hence, effective impairment Aids for People Who Are Blind or is often far
greater than that suggested by an individual’s acuity score. Only in recent years has there been
greater appreciation of these increased deficits in real-world conditions. Because of this complex
interplay between the dimensions of visual deficits, the viewing conditions, the varying visual
demands of different tasks, and the impact of an individual’s visual impairment on performance
of a particular task can be hard to predict. In general, there is increasing evidence that in many
cases, visual task performance is more closely related to variables such as contrast sensitivity
than to resolution or acuity. For these reasons, in rehabilitation practice, the provision of optimal
lighting and contrast, and the elimination of glare, are just as important as providing adequate
magnification.

DISABILITY RATING SCALES AND THE INTERNATIONAL CLASSIFICATION OF

FUNCTION (ICF)
Because of the difficulty of characterizing the interaction between the many dimensions
of visual function, real-world abilities, and task performance, eligibility for disability benefits
has historically been based on the simplest medical measures of visual impairment, namely
visual acuity and visual field extent. ICD-9-CM (1978) (the official U.S. clinical classification of
diseases) introduced a gradual scale of mild/moderate/severe/profound/total vision loss to replace
the old black-and-white dichotomy of legally sighted vs. legally blind. The 5th edition (2001) of
the AMA Guides to the Evaluation of Permanent Impairment added a numerical scale to this,
with 20/20 rated as 100 points, 20/200 as 50 and 20/2000 as 0 (similar calculations factor in
losses of visual field). Although any such scale is somewhat arbitrary, a recent study (Fuhr et al.,
2003) showed that this scale, developed mostly by Colenbrander (Colenbrander, 1977),
correlated better than other scales with self-reported quality of life.
In a recent report on disability determination for individuals who are visually impaired,
the National Research Council (NRC, 2002) took a similar approach, emphasizing the continuity
of function from normally sighted to totally blind. It recommended the use of a very similar scale
to that outlined here, using the visual acuity rating (VAR), which can be calculated as follows:
VAR = 100−50 LogMAR (NRC, 2002). This also gives the current 20/200 “statutory blindness”
level a score of 50%.
The aforementioned scales adhere to what has been called the “medical model of
disability.” In recent years, another framework for classifying functional deficits has emerged in
the form of the International Classification of Functioning (ICF) of the WHO. This classification
adheres to the “social model of disability,” based on the difficulties people experience in their
participation in societal activities. To fully describe a disability, both aspects are needed, because
the difficulties a person experiences result from the interaction between individual abilities and
societal demands.
For example, the AMA scale measures visual acuity and relies on the fact that visual
reading ability is related to visual acuity. The ICF lists “reading” and includes visual reading as
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well as Braille reading, because both contribute to literacy, which in turn contributes to
participation. This emphasis on ability, function, and participation is an increasing trend in
rehabilitation theory and terminology.

BLIND MOBILITY AIDS

The task of safe, independent travel through the environment is challenging with little or
no visual input. A family of mobility aids has been developed to detect nearby objects and
obstacles. For example, the Mowat Sensor, a handheld ultrasonic device, uses a vibratory code to
warn of the presence and range of an object in its beam. The Sonic Pathfinder is a head-worn
device with ultrasonic beams controlled by a microcomputer. The Nurion Industries Laser Cane
uses laser beams to detect objects, and incorporates the ability to warn of drop-offs. Taking a
different approach is the family of wide-bandwidth frequency-modulated sonars developed by
Kay, beginning with the Sonic Torch. These are sometimes termed environmental sensors, due to
their ability to provide information about the nature of the surface being sensed in addition to its
distance and direction. The ultrasonic swept FM transmissions are multiplied by the received
signals to produce an audible difference signal whose pitch is proportional to range and whose
timbre indicates the nature of the target. Variants have included the head-worn Sonicguide, in
which two wide-beam receivers are splayed apart so that the interaural amplitude difference of
the received signal gives a directional cue. The Trisensor or KASPA system combined a narrow
central beam superimposed on the wide peripheral beams to mimic the manner in which central
and peripheral signals are processed in the visual system. The current version of this technology
is the BAT “K” sonar cane, which is a single-channel narrow-beam version of this sonar system
that can be handheld or clipped to a long cane.

ORIENTATION AND NAVIGATION AIDS

Beyond the difficulties of steering a safe path through the immediate environment, the
broader aspect of the travel problem is variously known as navigation, “orientation,” or “way
finding.” Navigational difficulties are considerable without access to the usual cues (such as
signs and landmarks) used by sighted persons. Technology to address this aspect of the travel
problem has a shorter history, and devices in this category have only recently entered
commercial production.

REMOTELY READABLE INFRARED SIGNAGE

The infrared Talking Signs® system was developed as an environmental labeling system
to allow blind travelers to locate and identify landmarks, signs, and facilities of interest in the
environment. It uses coded infrared transmitters as labels, and the user’s handheld receiver
converts the transmissions into speech. The infrared beam pattern provides control of range and
coverage, and the directional nature of infrared light allows the user to accurately locate each
sign. Since this concept was prototyped in 1979, a number of alternative systems have been
proposed. An infrared system (“Pathfinder,” modeled on Talking Signs) was evaluated in a
London subway station. Similar approaches have been taken in the European OPEN (Orientation
by Personal Electronic Navigation) project, the SEAL Pilot-Light system, the Tele- Sensory

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Marco system, the RNIB Infra InfraVoice, and the AudioSigns infrared orientation system.
Systems using speech labels triggered by a user carried device include the REACT system
(1987) and The Open University device (1991). Verbal Landmark® demonstrated a radio-based
system in 1993 (see evaluation by Bentzen and Mitchell, 1995) in which a portable receiver
detects messages transmitted from an electromagnetic loop. Numerous proposals have been
made to use Radio Frequency Identification (RFID) tags for this function, but as with other
radio-based systems they lack directional information. While these and other proposals have
come and gone, the original Talking Signs system has been in continuous production and
spreading steadily. It has also spawned many variants including incorporation into bus arrival
announcing systems, and museum tour guide systems with different messages for different
audiences (children, sighted adults, blind persons, etc.). Transmitters now incorporate a digital
code that identifies their position, and future versions will use this information to access
(possibly via the Internet) information of interest in the vicinity, such as nearby restaurant
locations and menus, train time tables, etc.

GPS TECHNOLOGY
GPS technology can be of some assistance in orienting blind persons to open outdoor
environments. Loomis et al. (1994, 2001) have systematically studied this possibility combined
with externalized sounds for locating environmental features. Another version was developed by
Arkenstone, Inc., using a notebook computer packaged with the GPS and synthetic speech in a
backpack. A commercial version of this approach, GPS-Talk, is now available through the
Sendero Group LLC. Another example now available is the Trekker from Pulse Data. The
European consortium project named MoBIC (Mobility of Blind and Elderly People Interacting
with Computers) (1994 to 1996) proposed using GPS technology and a protocol, based upon
ISO’s Open Systems Interconnection architecture (1978), to interface other technologies that
could be used for orientation and navigation. The MoBIC Project and Brabyn et al. (2002) found
that the accuracy of GPS is severely degraded on the sidewalks in city areas next to multistory
buildings, and needs to be supplemented by other forms of information. One possibility is dead-
reckoning systems using inertial navigation sensors.

COMPUTER VISION
“Computer vision” technology, mentioned under general-purpose solutions, is now
being explored for several specific tasks encountered in travel. The concept is to use portable
computing power to analyze images from a digital camera and extract features of interest, such
as street signs, intersection crossing signals, etc., and convey this information to the traveler via
synthetic speech and/or enhanced image presentations. The development of this technology
involves not only difficult problems in algorithm design to find and extract the desired
information from images but also a variety of human factors problems including capturing usable
images and effective information presentation without causing sensory overload. As of this
writing, prototype systems have been developed with head-mounted cameras and with
computing power supplied by a notebook computer carried in a backpack.

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AUDIBLE PEDESTRIAN SIGNALS
For the specific problem of street crossing safety, at least 11 accessible traffic signal
systems are available to cities. Most provide a simple auditory signal when the“Walk” signal is
on. Some indicate other information such as the position of the crossing light activation control
by an auditory beeper or ticking sound. However, these systems are implemented only in a few
locations in relatively few cities. In some areas they are turned off at night (arguably when they
are most needed) to avoid disturbing local residents.

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Introduction:
Approximately 90% of hearing impairments in adults are sensorineural in nature (Yueh
et al., 2003). Sensorineural hearing loss is, in most cases, not treatable by medication or surgery.
Recently, developments in the area of inner-ear hair cell regeneration have shown promise for
possibly restoring auditory function. More specifically, research has suggested that mammalian
cochlear hair cells can be stimulated to regenerate via mitosis or transdifferentiation. Mitosis is a
process in the cell cycle that facilitates cell division. Trans differentiation is the process in which
one cell type changes its phenotype to become another, with or without mitosis. Both processes
are native to the inner ear of nonmammalian species, such as birds. Interestingly, the mammalian
vestibular, or balance, sensory epithelia may also induce both processes. However, the
mammalian cochlear, or auditory, sensory epithelium is limited in both. Current research is
focused on using gene therapy or stem cells to stimulate mitosis or transdifferentiation in the
damaged cochlear sensory epithelium. Success with this type of hearing-loss treatment is
certainly far in the future.
Currently, the majority of persons with hearing loss find hearing aids and/or HAT to be
the only means available to maximize their communication participation. The technologies
available to address this challenge range from surgically implanted devices to body-worn remote
microphone technologies

SURGICALLY IMPLANTED DEVICES:

Recently, a variety of surgically implanted devices have become available for hearing
rehabilitation. It is useful to categorize these devices according to the degree of hearing loss for
which they are intended. Middle-ear implants (MEIs) and bone anchored hearing aids (BAHAs)
are for those individuals with a useful amount of residual hearing. Cochlear implants are
designed for those with severe to profound hearingloss
MEIs are an adapted hearing aid design in that the receiver of the hearing aid is
implanted in the middle-ear space as a mechanical transducer on the ossicular chain (the three
bones in the middle ear that convert acoustic energy in to mechanicalenergy). MEI’s basic design
consists of both external and internal parts. Externally, the user would wear a device that looks
very much like a behind-the-ear hearing aid. This device houses the microphone, the digital
processing circuit, and the battery. The external device is coupled to the internal device by a
magnetic button that is worn on the head, which transmits the signal through to the internal
magnetic receiver. A wire then transfers the auditory signal to the transducer attached to the
ossicular chain
The MEI provides amplification through the direct enhancement of the middle-ear
mechanical vibration. TheMEI has several advantagesoverconventional hearing aids in that
acoustic feedback may be reduced and the occlusion effect (resulting from the hearing aid
earmold plugging the ear) is diminished. However, it is a surgical procedure, therefore
introducing more risks to the patient.
Currently researchers are developing a completely implantable MEI so that the
microphone of the aid could be embedded in either the canal wall or tympanic membrane.
BAHAs are designed for those individuals with conductive hearing loss Avibrotactile device is
attached to atitanium base that has been surgically implanted in the temporal bone behind the ear.
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Transduction of sound is highly efficient because the vibrating transducer is directly connected
to the skull, where the sense organ of the inner ear is located. The use of BAHAs has shown
reduced levels of disability and handicap, and significant patient benefit and satisfaction
Cochlear Implants (CIs) are devices that provide direct electrical stimulation to the
auditory nerve. The electrical stimuli result in an auditory sensation. The components worn
include the microphone, speech processor, and a magnetic coil that transmits auditory signals to
the internal components. The internal components include a magnetic receiver and a multiband
electrode that is fed through the shellshaped turns of the cochlea in the inner ear. The algorithms
of CI’s signal processing strategies are designed to extract the salient features of speech such as
frequency, temporal, and intensity cues and deliver these parameters to the electrode array. The
electrode array then electrically stimulates the residual auditory neurons, transating

NONSURGICAL HEARING AIDS

Hearing aids are personal amplification devices that improve hearing function through
the use of an amplifier circuit. Hearing aids increase the audibility of the acoustic energy
entering its microphone. The major advantage of hearing aid use is that audibility is increased in
a variety of listening situations. Another advantage of hearing aids is that numerous electronic
modifications to the signal processing circuitry can be made. The incoming signal waveform can
be divided into numerous bands (up to 32) for frequency shaping and intensity compression.
Hearing aid dispensers are able to manipulate the frequency/gain response of the amplified signal
via a personal computer to meet the needs of the patient. Although there are many benefits to
hearing aids, a major limitation is that the hearing aid is not able to alter the user’s environment
or to amplify only the wanted signal. Hearing aids come in a variety of sizes and styles (Figure
15.1). Although they may all look different, they contain the same basic components. Sound
energy enters the microphone port of the hearing aid and is initially converted to an electrical
signal. This signal is amplified via either an analog or a digital circuit. The amplified signal is
then delivered to the receiver. Sound exits the hearing aid and is directed to the eardrum via
tubing in the shell of a “custom” instrument or the ear mold in a “behind-the-ear” instrument.
One optional component is called a telecoil. A hearing aid with a telecoil takes advantage of the
stray magnetic field that normally emanates from the receiver in a telephone handset. By placing
an induction coil inside the hearing aid, direct transmission of the telephone signal is
accomplished, eliminating the need to pass the signal through the hearing aid microphone.
Advantages of the telecoil include avoidance of the ambient noise surrounding the listener and
elimination of acoustic feedback problems associated with telephone placement near the hearing
aid
Another advantage of the telecoil is its ability to couple with assistive listening
technology, thus allowing the hearing aid user to directly receive the signal from a remote
microphone system in the hearing aid (Figure 4. 1). Alternatively, some hearing aids have direct
audio input capability. This feature allows for the direct connection of an auxiliary input signal to
electrical contacts on the hearing aid. Audio signals from either a remote microphone system or
other audio sources (CD player, telephone, or television) can be delivered directly to the hearing
in this way

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 Fig 4.1: Ear-level hearing aid types. Shown from left to right are a behind-the ear
hearing aid and custom earmold; in-the-ear hearing aid; in-the-canal hearing aid; and
completely-in-the-canal hearing aid.

There are two main types of conventional hearing aids:

 In-The-Ear hearing aids, and

 Behind-The-Ear hearing aids

These two types of conventional hearing aids can be further subdivided. Details are below:
In-The-Ear Hearing Aids

In-The-Ear (ITE) hearing aids house electronics within a custom-made acrylic shell that fills the
entire bowl shape of the ear and part of the ear canal. They are typically the most powerful of the
in-the-ear hearing aids and are able to fit many beneficial techonologies in them because of their
larger size.

In-The-Canal (ITC) hearing aids house electronics within a custom-made acrylic shell that fills
approximately half of the bowl shape of the ear and part of the ear canal. Recent advancements
and technology miniturisation have meant that an ITC can usually match the power and
technology of the larger ITE.

Completely-In-Canal (CIC) hearing aids house electronics within a custom-made shell that fills
only the ear canal. Cosmetically the hearing aids are very good and can only be seen if looking
closely at the ear. However, because there is a focus on miniturisation for these hearing aids,
they often need to extend far into the ear canal to fit all of the components in, which can be
uncomfortable for some people. Furthermore, CIC’s are unable to fit some device features that
are commonly seen in standard size hearing aids, such as a directional microphone and telecoil.

Invisible-In-Canal (IIC) hearing aids are similar to CIC hearing aids. A custom made shell
houses the electronics of the hearing aid, however it is seated very deeply in the ear canal so that
it cannot be seen, even if looking directly at the ear. IIC hearing aids often have air vents in them
to allow for more natural hearing and comfort. They are not suitable for people with poor sight or
manual dexterity because of their very small size.

Lyric hearing aids are also invisible and are disposable hearing aids that are designed to last up
to 4 months of continuous use. After this time they are thrown away and replaced. These hearing
aids are usually bought by way of a yearly subscription and are non-surgically placed deep into
the ear canal by a hearing professional. The benefit of these hearing aids is that they do not have
to be handled by the client at all.

Behind-The-Ear Hearing Aids

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Behind-the-Ear (BTE) hearing aids house electronics within a standard size casing that sits at
the top of the ear where the ear meets the head. Standard size BTE hearing aids are often very
robust and are capable of housing many different hearing aid features. These hearing aids are
often quite comfortable and less prone to whistling than their ITE counterparts. Standard BTE
hearing aids may require a custom made earmold to be made to couple the sound from the
hearing device into the ear.

Open-Fit BTE hearing aids house electronics within a standard or small size casing that sits at
the top of the ear. Open-Fit BTE hearing aids are often just as robust as standard BTE hearing
aids with the same features and benefits. As the name would suggest, slim-tube hearing aids have
thinner tubing leading from the hearing device into the ear, making them more cosmetically
appealing.

Receiver-In-Canal BTE hearing aids house most electronics within a small size casing that sits
at the tops of the ear however the receiver (or speaker) of the hearing aid sits in the ear canal
portion of the hearing device. The receiver and the rest of the hearing device are connected via a
thin wire cable that sits within a slim-tube. Having the receiver in the ear canal portion of the
device allows the rest of the hearing device to be significantly smaller than a standard or open-fit
hearing aid. RIC hearing aids may have slightly increased sound smoothness and clarity when
compared to standard or open-fit BTE’s, however they may also be more prone to breakdown.

TECHNOLOGY FOR READING, WRITING, AND GRAPHICS ACCESS

BRAILLE

Braille is a code in which each character is represented by an arrangement of six raised

dots arranged in two columns of three side by side, with an interdot spacing of slightly less than
0.1 in. (2.5 mm). Presence or absence of particular dots identifies the character. Advanced
readers use “contractions,” in which one character may represent several letters. While
individuals who become blind at a young age pick up Braille easily, those who lose vision as
adults often find it difficult to learn or they have reduced motivation.

After a period in the late 20th century, when its use was considered superfluous many,
Braille has undergone a revival as appreciation of its importance as a mean of literacy has
spread. Technology for producing Braille has also improved steadily in its sophistication,
availability, and affordability. A manual slate and stylus is still commonly used for making the
dots in paper for small Braille notes, but electronic note takers with six-key Braille keyboards are
becoming common. For output, these usually include a 20-character display of mechanical
Braille dots that are raised and lowered electronically to form a line of Braille characters.

Personal Braille embossers, equivalent to printers for sighted persons, are becoming more
attainable. Other means of producing Braille from computer outputs include heat-sensitive
capsule or swell paper, which can be printed with Braille or other tactile dot patterns on a regular
ink printer and then run through an infrared heating machine. The black dots absorb more heat
than the lighter surround, and so the paper swells under the dots, producing Braille. The
technology for producing this type of output is inexpensive, but the paper itself is expensive if
large quantities are required. Irrespective of the method of Braille production from computer
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output, software is needed to produce the Braille code. Companies such as Duxbury systems
supply software packages to translate regular text (in the form of ASCII code, PDF files, and
other computer formats) into Braille and format it for printing.

BOOKS ON TAPE AND DIGITAL FORMATS

Talking books have long been a mainstay of reading material for blind persons. Along
history of special tape and vinyl disk formats and players for this purpose has included special
indexing codes for finding chapters and sections rapidly. Organizations such as the American
Printing House for the Blind produce books and magazines on tape. Digital Talking Books are
now available to accomplish the same ends, using the new “Daisy” standard developed by an
international consortium. These are designed to benefit not only blind persons but anyone who
has trouble reading normal print for any reason such as a learning disability or inability to hold a
book. They offer improved quality and navigation features over the older talking books, and can
be produced on any available digital media including CD and DVD. Special players are
available, but these can also be played on computers using suitable software. Increasing amounts
of reading material are becoming available in this format from such organizations as the
American Printing House, Bookshare.org, and the Library of Congress National Library Service.

BRAILLE NOTE TAKERS

Over the past 10 to 15 years, numerous Braille Note takers have evolved, serving much
of the purpose of a notebook computer. They commonly use a Braille keyboard, which is
convenient as it is smaller than a conventional keyboard, requiring only six keys (one for each
dot in the Braille cell) and a space bar. (Often eight keys are provided to accommodate the eight-
dot computer Braille code). Output is via a refreshable Braille display, usually of about 20 cells.
These small computers (most will fit in a large pocket) can be interfaced to a variety of
peripherals and perform other functions such as a calculator, calendar, etc. Most use proprietary
word processing software. The pioneer in this fieldwas the Blazie Engineering “Braille ‘n
Speak,” nowproduced by Freedom Scientific.

OPTICAL-TO-TACTILE AND OPTICAL-TO-AUDITORY CONVERSIONS

An early reading aid for blind persons was the “Stereotoner,” which a user could scan
across a line of print to convert it into a combination of tones. A more widely used device, the
Optacon, developed by John Linville and James Bliss, uses a handheld camera that the user scans
across a line of print to produce a tactile image on a 144-pin array of vibrating piezoelectric pins
placed under a finger of the other (stationary) hand. With some training and practice, a blind user
could read any type of print including handwriting—an ability still not available on automated
reading machines. Proficient users could reach up to 80 words per minute. Production ceased in
1996. A few years later, a new device called the Video TIM, from German manufacturer
ABTIM, emerged with a 256-pin (nonvibrating) 4 × 4 cm2 display.

READING MACHINES

Early research on reading machines for blind persons (designed to “read” print and
convert it into the spoken word) produced technologies (document scanners and synthetic
speech) that have subsequently become commonplace in the general consumer market.

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Accordingly, most stand-alone reading machines have been replaced by software packages
designed for use with personal computers and scanners. However, stand-alone reading machines
still exist, such as the Galileo and the Portset Reader, which are more portable than PC-based
systems. The problem of reading handwriting has still not been cracked, and current machines
are still nowhere near the capability of a sighted reader (still used by most blind persons for
intelligent analysis and scanning over documents), but they have come a long way since the early
days and are eminently capable of dealing with straightforward text-reading tasks.

ACCESS TO GRAPHICS AND MAPS

Access to graphical, pictorial, and map information is very problematic for blind persons.
Tactile maps, graphs, and pictures can be made by a variety of manual methods producing raised
line drawings on various materials, but these are laborious. The result is that few graphical
educational materials are available to blind children, and so they do not become well exposed to
tactile spatial representations.

GRAPHICS ACCESS AND PRODUCTION

In recent years, increased efforts have been exerted to make the production of graphics
from computer Braille embossers more feasible. There are numerous problems involved:
generating a perceptible tactile equivalent of a visual picture, and drawing or map is not
straightforward, because the density of information needs to be much lower and the tactile sense
operates different from that of vision. One recent development in this field is the advent of the
View Plus “Tiger” embosser, which can emboss dots of variable heights as well as closer
together than standard Braille dot spacing. The “holy grail” of graphics access for blind persons
is the full-page volatile Braille/graphics tablet, with an array of dots that can be raised or lowered
using computer control. Many efforts have been devoted to this problem, but the technological
problems are formidable and to date the largest arrays available are the Dotview units of 30×40
dots. Present volatile Braille and tactile graphics displays use piezoelectric or electromagnetic
technology, and current research efforts are devoted to harnessing other technologies such as
smart polymers, electrorheological fluids, and micromachining.

Meanwhile, other methods of graphics access have become available, including touch
tablet technology in combination with speech output, allowing a user to trace out spatial
information and receive spoken feedback. However, raised overlays for touch pads usually have
to be specially produced for each diagram or picture being explored. Examples include the
Nomad, Concept Keyboard, and Tag Pad. The “Vertouch,” a computer mouse with two small
tactile arrays on it, had software available for tactile games and exploration of computer screen
information. Force feedback is another technology that can be used for tactile and haptic
exploration. Examples include a force-feedback mouse and the PHANTOM system for
exploration of virtual three dimensional objects. For displaying graphs, SKDATA Tools makes
graphical output from MATLAB accessible through auditory and Braille outputs.

MAPS
Traditionally, street maps suitable for pedestrian navigation have been extremely scarce
due to the difficulty and expense of making them. For some areas, such as the Washington, D.C.,
Metro, tactile maps are available as a general guide to the system. Even these, however, cannot
include the level of detail of a printed street map. Auditory maps and travel directions can be a

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substitute, and are available, for example, using the Atlas Strider system. Another approach
combines a touch tablet with a tactile map or graphic overlay, interfaced to a computer to
produce a talking map. Examples include the Talking Tactile Tablet from Touch Graphics and
the Nomad system by Quantum Technology. Advances in computer, Internet, and Braille
embossing technologies are about to revolutionize tactile map production. For example, the
TMAP project will make it possible for a blind user to access aWeb site on which he/she can
specify any address or set of cross streets of which a street map is desired. The computer system
will then generate a street map centered on that address for download and printing on the user’s
own Braille embosser. If the user does not have one, the map can be sent to a Braille embossing
service for production and then mailed to the user.

LOW-VISION READING PROBLEMS AND SOLUTIONS

Reading difficulties in low vision depend heavily on the type of visual impairment. In the
most common type, due to age-related maculopathy, the resolution of the central vision is
reduced drastically, and training is often given to help the individual use the remaining (lower-
resolution) areas of the surrounding retina for reading (known as “eccentric viewing”).
Considerable magnification is often needed. Large print, where available, is a partial solution to
this problem. Some periodicals and books are produced in large print (for example, by the
American Printing House for the Blind). Often neglected is the fact that providing proper
lighting can make an enormous difference in the ability to read. A good, bright, glare-free light,
coming from over the reader’s shoulder, can often compensate for minor visual impairments
without any magnification requirements.

The traditional low-vision reading aid is an optical magnifier. These come in many
forms, most commonly handheld or mounted on stands. The practical degree of magnification
obtainable with these is modest, about two to four times, but is often enough to make a
difference. For people with limited dexterity, stand magnifiers can make positioning of the
magnifier relative to the page easier, with the page staying in focus. Both types can have internal
illumination to ensure adequate lighting on the reading material (which has a major effect for
most low-vision readers). To gain higher magnifications, high-powered reading lenses (e.g., 10
or 20 dpt) on spectacle frames are sometimes used. Special short-range telescopes mounted on
spectacle frames can be designed to preserve normal reading distance while providing the
desired degree of magnification.

Higher magnifications still are possible with CCTV, or closed circuit television,
magnifiers, usually consisting of a camera and CRT monitor mounted on a stand with a table
underneath upon which the reading material is placed. The viewing table is commonly mounted
on sliders or rollers so that the material can be moved easily for scanning. All systems allow
adjustment of magnification and contrast (including contrast reversal to produce white print on a
black background, thus reducing glare), and most also enable the user to choose the background
color. When text or graphical images are magnified, the viewer can only see a small portion of
the overall page or picture, often making interpretation more difficult. The ability to see an
overall view on one part of the screen and the magnified view on another part may provide an
advantage in this respect, and many CCTV systems provide a split-screen feature.

In recent years, much smaller versions of these CCTV magnifiers have become available
using solid state cameras and displays. There are now several handheld, pocket-sized electronic
magnifiers (such as the Pocket Reader, Quicklook, PICO, and Pulse Data Pocketviewer) that can

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simply be placed on the page surface to magnify it by 5 to 7 times. These devices conveniently
enable the user to look at details and price labels in shops, sign credit card payments, read
restaurant menus, theatre programs, and timetables, check lottery results, check television and
radio programs, browse through magazines, and read books while traveling. Another variant is
the head-mounted camera and display combination described earlier and in the following section;
this concept can be used for a variety of reading and writing tasks.

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 UNIT V
ORTHOTIC & PROSTHETIC DEVICES

Topics:
General orthotics, Classification of orthotics-functional & regional, General principles of Orthosis,
Calipers- FO, AFO, KAFO, HKAFO.
Prosthetic devices: Hand and arm replacement, Body powered prosthetics, Myoelectric controlled
prosthetics and Externally powered limb prosthetics.

INTRODUCTION

The intent of this chapter is to provide a general overview of the principles, design,
fabrication, and function of spinal, lower extremity, and upper extremity orthoses. It is
acknowledged that entire books and atlases have been dedicated to this subject. Orthotics is
considered an art and skill, requiring creativity and knowledge in anatomy, physiology,
biomechanics, pathology, and healing. Evolving into a competent clinician, who is comfortable
with designing and fabricating orthoses to meet the unique needs of each individual client,
requires practice of these skills and knowledge.
The word orthosis derives from the Greek orthos, meaning “to straighten.” An
orthosis is an orthopedic device that provides functional stability to a joint or prevents,
corrects, or compensates for a deformity or weakness. Typically, this is accomplished
through external bracing (although the term brace is somewhat deprecated because of
institutionalized stereotypes and implications of static fixation), whereas orthoses also
provide dynamic joint control. An orthosis can be as simple as an off-the-shelf, prefabricated
shoe insert that one could purchase at a pharmacy or department store, or something more
complex, such as a reciprocating gait orthosis usually consisting of custom-molded plastic
solid ankle and thigh shells connected via bilateral uprights with locking knee joints, dual
cables for controlling alternating gait, and gas-filled struts or springs to aid in knee and hip
flexion.
The term splint is synonymous with orthosis and is commonly referred to in the
literature, especially with regard to upper extremity orthoses.

CLASSIFICATION

Standard nomenclature for orthoses varies, depending on the type, i.e., upper
extremity vs. spinal vs. lower extremity. Names for orthoses originate from the joint or joints
they encompass (e.g., wrist orthosis), the function provided (e.g., reciprocating gait orthosis),
condition treated (e.g., tennis elbow splint), appearance (e.g., airplane splint and halo brace),
or person who designed it or place where it was designed (e.g., Milwaukee brace and Jewett
orthosis). In addition, organizations such as the American Society of Hand Therapists
(ASHT) and International Standards Organization (ISO) have developed standard
nomenclature for orthoses. The current method of naming an orthosis is by creating of an
acronym from the English words for the joints that the orthosis crosses, in sequence from
proximal to distal. The letter “O” is appended to signify orthosis. For instance, an orthosis
that covers the foot and attaches to the leg to compensate for weakened ankle dorsiflexors
(drop foot) would be called an ankle–foot orthosis, or AFO. Often, additional letters are
added, describing the device, such as AFO–SA (solid ankle) or AFO–PLS (posterior leaf
spring).
FUNCTION

Orthoses are classified as static or dynamic. Static orthoses are designed to prevent or
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limit motion and have no moveable parts. Dynamic orthoses are designed to facilitate
movement and have one or more movable parts. The three general functions of orthoses are
categorized as (1) immobilizing, (2) restrictive, and (3) mobilizing. Immobilizing and
restrictive orthoses, both provide static support. Immobilizing orthoses prevent any
movement in the joints involved, whereas restrictive orthoses limit movement in a specific
aspect of joint range of motion.
The static support helps to reduce stress and maintain joint alignment; prevent
deformities and soft tissue contractures; scar reduction; provide rest to reduce inflammation
and pain; positioning to facilitate proper healing; and protection against further injury.
Mobilization or dynamic orthoses are designed to increase range of motion (stretch
soft tissue contractures) and assist muscle weakness or spasticity to improve function. These
orthoses are also used for exercise to improve the range of motion and strength.

PRINCIPLES

1. THREE-POINT PRESSURE SYSTEM

Orthoses act to restrict joint motion via a three-point pressure system.
Although other pressure systems exist, this is the most basic one. The terminology
three-point force is also used to describe this system; however, pressure is preferred as
it reminds us that it is an applied force distributed over an area. The three-point
pressure system generally consists of a principal force acting at or near the affected
joint, opposed by two forces, one proximal and the other distal to the joint, to stabilize
the joint.
2 LEVERAGE
Leverage goes hand in hand with the three-point pressure system. Leverage is
the mechanical advantage of a force applied at a distance from a fulcrum. The
moment of this force causes the body to tend to rotate about the fulcrum. The larger
the perpendicular distance of the force to the fulcrum, the greater the moment
generated. To stabilize the joint, the moments from all applied forces (including
gravity and inertia) must sum to zero. By increasing the lever arm length, the force
necessary to stabilize the joint can be reduced, thus increasing comfort.
3 GROUND REACTION FORCE
The ground reaction force, or force generated by the floor on the patient due to
gravity and body accelerations, is also important in controlling joint motion. The
ground reaction force can be utilized to stabilize a joint more proximal to the orthosis.
When the foot contacts the ground during gait, it produces a moment about each of
the joints of the lower extremity. Depending on the line of action of the force, the

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 moment could be in flexion, extension, or through the joint center, causing no
moment. A heel cutoff on a shoe can compensate for weak quadriceps muscles by
shifting the contact point forward and the direction of the ground reaction force closer
to the knee center, thus reducing the flexion moment about the knee. Alternatively, an
AFO–SA with an anterior band provides a posteriorly directed force at the tibia that
limits knee flexion by resisting forward motion of the tibia.
4 AXIAL FORCES
Axial force is a force directed along the long axis of the bone. Reduction of
axial forces in lower limb fractures is typically via crutches or in unweighting AFOs
that unload the ankle or foot by transferring the weight through the orthoses.
5 PRESSURE
In general, it is beneficial to distribute the forces the orthosis applies to the
body over a large area. This minimizes the stress on soft tissue. An AFO with a
custom-molded plastic calf shell would be more comfortable than a leather–metal
AFO; however, this would be contraindicated in cases of edema and dermatitis or hot
climates.
6 SHEAR STRESS
It is important to minimize shear stress at the interface of the patient and
orthosis. Shear stress is typically caused by tangential forces applied to the load-
bearing surface of the body. These shear forces can cause motion between the
underlying skin, muscle, and fascia and the orthosis. The deformation may restrict
blood and lymph flow, causing ulcers and tissue damage. Shear stresses can be
reduced by optimal design, proper fit and alignment of the orthosis, and use of
slippery elastic padding at the patient–orthoses interface.
7 CREEP
Creep is the time-dependent strain, or change in shape, of a material due to
exposure to stresses and loading. This creep occurs in a matter of seconds or weeks,
depending on the stiffness and viscoelastic properties of the material. Creep occurs in
both muscles and soft tissues bearing load due to the orthosis, and is critical in the
design and fit of orthoses.

LOWER EXTREMITY ORTHOSES

1 FOOT ORTHOSES (FOs)

Foot orthoses (FOs) are the most common type of lower limb orthosis. FOs are
used to realign the foot, change the distribution of pressure in the foot, and reduce
pain. In addition, they can correct for problems at more proximal joints (e.g., leg
length discrepancy, weak quadriceps, and osteoarthritis of the knee). An FO can
consist of an insert that fits inside the shoe, an internal shoe modification, an external
modification to the heel or sole of the shoe, or combinations of the previous (Figure
5.1). Shoes may be considered FOs when prescribed for therapeutic reasons. A shoe
with an enlarged toe box can be used to relieve pressure on claw, hammer toes, and
bunions. Inserts inside the shoe are used to reduce pressure on load-bearing areas.
Internal shoe modifications can provide the same benefits as inserts but cannot be
transferred to another shoe. An important anatomical consideration in the use of foot
orthoses is the goal of keeping the subtalar joint in a neutral position. The subtalar
joint is the joint between the calcaneus and talus. It allows for the motions of
inversion and eversion as well as supination and pronation at the ankle. Abnormalities
in the alignment of this joint can limit proper functioning of the foot, including gait
abnormalities, and lead to pain and degeneration in all joints of the lower limb.
Maintaining neutral subtalar joint alignment is the primary goal of FOs.

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 FIG 5.1: Metal AFO. (Courtesy of De LaTorre Orthotics and Prosthetics, Inc.)

Common Indications for Foot Orthoses

Degeneration of the joints within the foot, or osteoarthritis (OA) of the foot,
can lead to pain and difficulty with ambulation. By limiting motion at these joints, as well as
limiting the amount of stress placed on specific joints, FOs can be used in the treatment of
this condition. The University of California Biomechanics Laboratory (UCBL) orthosis is a
device that can be inserted into a shoe to prevent excessive pronation. It is a custom-molded
polypropylene plastic device molded to the shape and size of the patient’s foot. It has a flat
surface that contacts the bottom of the hind foot and prevents motion at the joints of the hind
foot. Devices to treat midfoot OA can be as simple as a standard shoe with a very stiff sole.
Steel shanks can be customized to fit inside a patient’s shoes to limit midfoot motion in the
sagittal plane. Finally, rocker-bottom shoes limit bending at the midfoot during ambulation
by providing a transition from heel strike to push-off that does not require motion at the
midfoot.
In OA of the knee, even though the site of pathology is at the knee, orthotic treatment
can be accomplished with FOs. In typical knee OA, the medial knee joint is more
significantly affected. When the medial knee joint decreases in size, the knee tends to deform
such that the lower leg and foot are medially displaced (a condition known as genu varum, or
“bowlegged”). A lateral heel wedge can be used to compensate for this condition and keep
the leg in a normal alignment, thereby alleviating pain and preventing further degeneration.
Plantar fasciitis is a condition of very small tears in the fibers of the plantar fascia at
its site of insertion on the bottom of the calcaneus. This creates inflammation at this site,
which results in heel pain. The condition can be caused by excessive mechanical forces
placed on the plantar fascia, for example, in an excessively pronated foot, tight Achilles
tendon, or high arches. This condition can be treated with an orthotic device that distributes
the weight to minimize pressure on the painful area. A device as simple as a heel pad (or heel
wedge) can be used for this purpose. The UCBL orthosis can be used to maintain neutrality at
the subtalar joint if excessive pronation is the underlying cause. An elevated arch support
may be useful to decrease stress on the longitudinal arch of the foot, and therefore decrease
stress on the plantar fascia.
Pes planus is a term used to describe a flat foot, or a foot with a reduced longitudinal
arch. This condition is most frequently identified by excessive pronation, or “inrolling” of the
foot, where the medial side of foot is too close to the ground. This deformity is most
commonly caused by dysfunction of the posterior tibialis tendon, which plays an important
role in the dynamic support of the longitudinal arch. When the tendon is weakened or
ruptured, pes planus occurs. Correction of this deformity can be accomplished with an
upward force on the medial side of the calcaneus. In order to provide the necessary forces, the
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distal part of the orthosis should extend beyond the metatarsophalangeal joints so that the
lever arm is of sufficient length. In order to prevent further complications and adequately
treat this condition, the subtalar joint must be in a neutral position when the foot is in the
orthosis. Off-the-shelf shoe inserts are available for these purposes. In addition, a UCBL
orthosis is a custom made device that can provide the necessary forces.

2. ANKLE–FOOT ORTHOSES
AFOs contain a component that crosses the ankle joint. Their primary function is to
control the amount of dorsiflexion and plantarflexion that the ankle can move through.
However, all AFOs have a component that connects to the foot, and can therefore be useful in
controlling movement at the subtalar joint as well as providing medial–lateral ankle support.
As with FOs, AFOs can be useful not only in conditions that affect the foot and ankle but in
conditions of more proximal joints as well. For example, an AFO can be useful in the
treatment of quadriceps weakness, a condition of instability at the knee.
Unlike FOs, AFOs cross a joint and have attachments both above and below the joint.
Therefore, more components are required and the device as a whole is somewhat more
complex. It is useful in the discussion of AFOs to divide them into two broad categories:
metal and plastic. Metal AFOs have largely been replaced by plastic AFOs. However, a
discussion of metal AFOs is important because many of the components are the same as
those used in plastic AFOs, and the principles that guide the design and prescription are the
same in both groups.
FIG 5.2 :Plastic AFO solid ankle. (Courtesy of De LaTorre Orthotics and Prosthetics,Inc.)

The metal AFO is made up of at least four components: (1) the calf band, which
attaches the device to the leg, (2) the metal uprights, (3) the ankle joint, and (4) the attachment
to the shoe (Figure 5 .1). The calf band is made of metal only in its posterior half. The
anterior half is a Velcro band. The function is to attach the AFO to the leg and to prevent
posterior movement of leg relative to the ankle. The metal uprights connect the calf band to
the ankle joint and shoe attachment, and can provide some medial–lateral support. The ankle
joint is made up of several components that will be discussed further in the following text.
The attachment to the shoe may be a solid or a split stirrup. A solid stirrup is permanently
attached to the shoe, whereas a split stirrup (or calipers) allows the uprights to be removed
from the sole plate that attaches to the bottom of the shoe.
Plastic AFOs have virtually replaced metal AFOs in clinical use. AFOs made from
plastic are less expensive, more cosmetic, lighter, and provide better foot support when
compared to metal AFOs. Cosmesis is improved because the plastic AFO can be worn inside
the patient’s shoes. They can be prefabricated (off-the-shelf) or custom molded to the specific
dimensions of the patients and the specifications of the physician. Plastic AFOs can be
divided into two categories: solid or hinged. Asolid AFO is made from a single piece of
plastic, and it has no extra ankle component (Figure 3). Even though there is no ankle joint,
some motion is allowed at the ankle due to the inherent flexibility of the material. The angle
between the foot and the leg will be determined by the clinical needs of the patient. For
example, in a patient with dorsiflexion weakness, the angle should be set to 90
to allow for toe clearance during ambulation. A hinged or articulated plastic AFO has two
plastic components connected by a metal ankle joint. They are used when some ankle motion
is wanted, and complete restriction of movement is not necessary. The metal ankle
joints are identical to those used in metal AFOs, and have the same components and
functions.
The stability of the ankle joint in a plastic AFO is determined by three factors.
(1) The trim line, which describes the line of the most anterior extension of the part of
the AFO that is posterior to the ankle (the posterior leaf); if the trim line is moved

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 anteriorly, the ankle becomes more stable;
(2) The thickness of the plastic; a thicker plastic will provide more stability; and
(3) corrugations in the posterior leaf, whose presence makes the ankle more stable.

Common Indications for AFOs

An equinovarus deformity is frequently seen in the lower limbs of children with
cerebral palsy (CP). An equinovarus deformity describes a foot that is inverted, plantar
flexed, and adducted. In CP, this is usually due to spasticity in the calf muscles.An AFO can
be used to prevent or treat these deformities, which can make ambulation more feasible in
patients affected. A posterior rod in the ankle joint would be useful in this case to prevent
dorsiflexion.
Foot drop, or weakness of ankle dorsiflexors, is a condition frequently caused by an
injury to the peroneal nerve. Depending on the severity of the weakness, this condition can
lead to gait abnormalities including foot drop (failure to clear the toes during the swing phase
of gait) and foot slap (failure to control the speed with which the foot returns to the ground
after heel strike). An AFO can be used to substitute for the weak muscles and return the
patient to a normal gait pattern. The thickness of the posterior leaf can be varied to give the
desired amount of resistance to plantar flexion as well as the amount of passive dorsiflexion.
If an ankle joint is used, a posterior channel spring can substitute for dorsiflexors that have no
strength at all. when a joint is affected by OA, limiting the movement of that joint can help
treat the pain associated with OA. In ankle osteoarthritis,
AFOs can be used to limit the motion at the ankle joints. In this case, the AFO should
be custom molded to the patient’s size and shape and should provide a great deal of ankle
stability to limit the motion of the ankle. Simply by providing a well-fit AFO that effectively
limits ankle motion during ambulation, a patient with significant ankle OA can have dramatic
reductions in pain. Knee instability can be a tremendous barrier to ambulation. In particular,
quadriceps weakness due to a spinal cord injury can be devastating in terms of prognosis for
Ambulation. However, AFOs can help to overcome these barriers. When the quadriceps are
weak, there is nothing to prevent “knee buckling,” which would occur during the stance
phase of gait any time there was flexion at the knee. This can be overcome by using an AFO
to create a knee extension moment during stance phase. By limiting the amount of
dorsiflexion that can occur (e.g., with an anterior channel pin), a knee extension moment can
be created. This is because during stance phase, dorsiflexion creates a knee flexion moment
and plantarflexion creates a knee extension moment.This can be visualized if one imagines a
foot flat on the ground during the stance phase of gait. If the ankle is dorsiflexed, the tibia
moves forward in space. In order to prevent the whole body from moving forward and falling
over, the knee must flex to restore balance. Thus, dorsiflexion has created a knee flexion
moment. In the case of quadriceps weakness, the aim is to prevent knee flexion, and therefore
prevent “knee buckling.” Therefore, by limiting the amount of dorsiflexion that can occur, the
knee is made more stable, and the prognosis for ambulation has increased.

LOWER EXTREMITY ORTHOSES

KNEE ORTHOSES
A knee orthosis (KO) is an external device that crosses the knee in order to provide
support, correct deformity, or prevent injury to the knee itself. Because the knee is the only
joint involved, their use is limited to conditions that affect only the knee. Although they are
used for a wide variety of applications, the use of KOs is a subject of some controversy.
Although there are a few indications for KOS that are well supported by scientific evidence,
the amount of knee orthoses prescribed far outnumbers those for which there is consensus
regarding their utility. It is widely accepted that KOs are useful patients with genu

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recurvatum (hyperextension of the knee). By applying the three-point system of orthosis
design, a Swedish knee cage can keep the knee from hyperextending (Figure 5.3). One brace is
placed posterior to the knee joint at the level of the knee. The other two bands are placed
anterior to the knee joint, one above and one below the level of the knee.With the use of a
knee joint that allows full knee flexion while limiting extension beyond neutral, the patient
can be protected from genu recurvatum.
In contrast to the Swedish knee cage, KOs can be used in patients with knee OA.
Typically, in knee OA, the medial compartment of the knee joint is the most severely
affected, and therefore has lost the most joint space. There is an asymmetry within the knee
where the lateral joint space is larger than the medial joint space. This results in a valgus
deformity at the knee (the foot is displaced laterally compared with a normal leg). By
applying three-point systems in a different plane, this deformity can be corrected with a knee
orthosis. This orthosis would have one strap on the lateral side of the leg at the level of the
knee. The other two straps would be on the medial side of the leg, one above and one below
the level of the knee. This system allows the pressure on the medial compartment of the knee
joint to be minimized.

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 FIG : 5.3 Swedish knee cage. (Courtesy of De LaTorre Orthotics and Prosthetics, Inc.)

Many providers and patients have advocated the use of KOs for prophylaxis against
knee injury or in the rehabilitation from a knee injury. These braces are often prescribed to be
worn during athletic activity. Despite their widespread use, there is little scientific evidence
to support their efficacy, and the use of these devices is controversial. In some cases, the
devices may be detrimental to the patient by increasing the amount of energy required for
walking or running, or by providing the wearer with a false sense of security.
Regardless of the indication for its use, a KO must have some form of knee joint. A
knee joint may be either single axis or polycentric. A single-axis knee joint rotates about a
single axis, whereas a polycentric knee joint has an axis of rotation that varies with the
position of the knee. Even though the polycentric knee joint more closely resembles the
rotation of a human knee joint, it has not been found to improve ambulation.With few
exceptions, the polycentric knee joint is limited to applications involving sports KOs.
A single-axis knee joint may be placed in line with the natural knee joint or may be
offset in the anterior–posterior plane. A knee joint that is offset posteriorly can help stabilize
the knee. If the knee is offset posteriorly, the ground reaction force that is applied to the
lower limb from the ground will be directed in front of the knee. This will have the effect of
promoting knee extension. By promoting knee extension, knee buckling can be prevented,
thus making the knee more stable.
A knee lock is a component of an orthotic knee joint that locks the knee in a given
position. For example, some patients may require full knee extension for safe ambulation. In
this case, a knee lockwould be used to keep the knee in a fully extended position during
ambulation. For the patient to sit down and perform other activities, the knee lock would need
to be released. Two examples of knee locks help illustrate their use. A drop-ring lock is used
to keep the knee fully extended during ambulation. When the patient is seated, the ring is
freely mobile and is around the thigh component of the knee joint. When a patient rises to a
standing position, gravity causes the ring to descend to the position where the thigh
component and the leg component overlap. The ring surrounds both components and prevents
any relative motion between them, therefore preventing any flexion of the knee. When the

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patient wishes to flex the knee, they can manually lift the ring, thus freeing the joint for
flexion.
A ratchet lock has a different mechanism that prevents knee flexion. When the patient
is seated, the lock is disengaged. When the patient begins to extend the knee (for example, to
stand up), the ratchet catches at various intervals between full flexion and full extension.
Each time the lock catches, it prevents knee flexion beyond the point where the catch is set.
Therefore, if a patient is unable to fully support himself/herself while rising from a seated
position, the knee will flex only to the point of the most recent catch and prevent the knee
from buckling, thus stopping the patient from falling back to the seated position.

KNEE–ANKLE–FOOT ORTHOSES
Knee–ankle–foot orthoses (KAFOs) differ from KOs in that they cross the ankle joint
and contain a component that contacts the foot (Figure5.4). The knee joints available for
KAFOs are no different from those used in KOs, just as the ankle components are identical to
those used in AFOs. The only difference being that, in a KAFO, all components are present
in the same device. KAFOs are generally used in patients with severe knee extensor and
hamstring weakness, knee instability, and spasticity of hamstring muscles, most commonly in
patients with paraplegia due to spinal cord injury. Many patients with paraplegia are able to
achieve ambulation with bilateral KAFOs used in combination with walkers or crutches.
Therefore, it is crucial that users have good upper body and trunk control to be considered
candidates for the use of KAFOs. Because of the weight and bulk of these devices,
ambulation with KAFOs requires a great deal of energy expenditure and is rather inefficient.
As a result, most patients with paraplegia who are able to ambulate with KAFOs will still rely
on a wheelchair as their primary means of ambulation.

FIG : 5.4 KAFO metal. (Courtesy of De LaTorre Orthotics and Prosthetics, Inc.)

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HIP– KNEE – ANKLE – FOOT ORTHOSES AND RECIPROCATING GAIT
ORTHOSES
Hip–knee–ankle–foot orthoses (HKAFOs) are very similar to KAFOs, but contain a
component that attaches to the patient’s trunk. The most common type of HKAFO is a
reciprocating gait orthosis (RGO). An RGO is a bilateral HKAFO with both limbs connected.
It is composed of a series of cables and pulleys. The purpose of the equipment is to provide
for unilateral hip flexion simultaneously with contralateral hip extension. When a patient
wearing a RGO lifts one limb off the ground, the cables and pulleys provide hip flexion of
that limb, thereby advancing the limb, or accomplishing a step. Next, the other limb is lifted
from the ground, and that limb is advanced to complete one full stride. RGOs are used in
conjunction with upper limb crutches to assist in ambulation for patients who may otherwise
not be able to ambulate. Much like KAFOs, RGOs are typically used in paraplegic patients.
RGOs are usually prescribed to children aged 3 to 6 years. Similar to ambulation with
KAFOs, ambulation with RGOs is slow, inefficient, and energy consuming. Almost all
patients will choose to use a wheelchair as a primary means of ambulation, but RGOs can
provide an excellent resource for exercise and may allow the patient to experience the world
“at eye level.”

2.2 INTRODUCTION
In the developing world, trauma is the leading cause of amputation in 80% of cases,
often due to inadequately treated fractures (Esquenazi, 2004). In the US, 57,000 new
amputations are seen per year (Edmond and James, 1990; Esquenazi, 2004). Of these, 68%
are acquired from disease, mainly lower limb vascular complications of diabetes, whereas
30% are acquired from trauma. Table 1.1 lists the incidence of amputations by anatomical
level, Up to 3% of limb losses are congenital, or present at birth, and often have unclear
etiology (Edmond and James, 1990). However, several genetic syndromes and congenital
exposures are known to include skeletal deficiencies. As of 1990, the incidence of congenital
skeletal deficiencies involving the upper limbwas 1.58 per 10,000 births, almost double that
of congenital lower limb deficiencies (Edmond and James, 1990). When upper limb
amputations are acquired, it is usually due to trauma on th dominant arm of young males, and
less often to cancer, tumors, or diabetic complications.
According to the National Limb Loss Information Center, as of 1996, nearly 1.3
million American live with major limb loss (Amputee Coalition of America [ACA], 2006).
Most lower limb amputations occur in individuals 65 years of age or older, who typically
have dysvascular disease (ACA, 2006). Trauma is the second most common cause of lower
limb amputations and most often occurs in young males.

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 FIG: 5.5 Bones of the upper and lower extremities

SOCKETS AND LINERS

Socket design will depend on residual limb length, muscle strength, and joint stability.
The socket is the firm shell that encases the residual limb and contains the interface between
the prosthesis and the residual limb. Hard and soft socket designs are commonly used
(Millstein et al., 1986). Hard and soft sockets may have a single or double-wall design. In the
double-wall design, the first, i.e., inner, lamination creates the socket’s interface, and the
second lamination provides an attachment for the rest of the components of the prosthesis.
Single-wall design incorporates the interface and the attachment area for components in one
lamination. Sockets may also contain a flexible plastic inner liner. Sockets can be split such
that two separate shells are used, one above the elbow joint and the other below. They can
also partially encase the joint, as in Muenster or Northwestern University sockets.

102
 Sometimes, the socket or inner flexible liner is a direct interface with the limb.
However, other liners can provide another interface and a suspension mechanism for the
prosthesis. Cushion liners are made from gel materials with varying thickness and are mainly
designed to increase comfort (Figure 5.6 ). Locking liners use lanyards or shuttle pin
mechanisms along with a soft silicon liner not only to cushion but also to suspend the
prosthesis. Occasionally, layers of socks are used between a locking or cushion liner and the
socket, especially if volume has been lost in the residual limb.
SUSPENSION
The suspension system secures the prosthesis to the residual limb despite the weight
of the prosthesis and the forces associated with its use. Three types of suspension are used,
with harnesses being the most commonly used system (Datta et al., 2004). A

FIG: 5.6 Iceross Seal-in Liner with a hypobaric sealing membrane in conjunction with
an air-expulsion valve (from Ossur, www.ossur.com/template110.asp?pageID=15230).

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FIG-5.7 arm prosthesis attachment system

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 FIG 5.8 Body-powered transradial prosthesis.

figure 5.7 is the most commonly used harness. One loop of the figure 5.7 harness goes
underneath the axilla on the unaffected side. The strap then crosses over the upper back and
loops over the shoulder. The anterior portion connects to either the socket in transhumeral
limb loss or to a Y-strap and triceps pad in a transradial amputation. These straps provide
most of the suspension force. The posterior portion of the strap attaches to a control cable,
which is affixed to the elbow in a transhumeral amputation or to an axilla loop in a transradial
amputation, as well as to the terminal device (Figure 5.7).
Another type of harness is a shoulder saddle with chest strap (Figure 5.8). This is used
when the figure-8 strap causes discomfort or when heavy lifting is expected. The chest strap
loops around the chest wall on the unaffected side and connects to a leather or plastic saddle
that sits on the opposite shoulder. The saddle is then connected to the prosthesis using a
posterior and anterior strap that anchors in a fashion similar to the figure5.7strap.
Self-suspension is used when the socket design is sufficient to secure the prosthesis to
the residual limb. This type of suspension is typically used in wrist disarticulations or short
transradial amputations. Muenster and Northwestern University sockets are self-suspending.
Suction suspension can be used in two ways. First, a total-contact socket with a one-
way air valve can be donned by using a lubricant or a pull-sock. The valve creates a negative
pressure inside the socket to secure the prosthesis. Second, the prosthesis can be suspended
by connecting to a silicon sleeve that rolls onto the residual limb and locks via a pin or
lanyard mechanism. Skin friction is also an important consideration in this suspension
mechanism.

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 A less commonly recognized form of suspension is the aforementioned osseous
integration procedure (Figure5.8 ). A titanium bone implant directly attaches to the
prosthesis, eliminating the need for a socket. Being a relatively new attachment system, the
ramifications of long-term use are unknown

CONTROL SYSTEMS
In upper limb prostheses, two types of control systems currently exist: body-powered
control and myoelectric control. Body-powered control relies on the effectiveness of the
harness to capture body movements to control the terminal device or elbow joint
(Rehabilitation Medicine, 1998). To open a transradial terminal device such as a simple hook
device, 2.5 in. of body movement is required. Specific movements are used to control upper
limb prostheses. Scapular abduction and shoulder flexion typically operate the terminal
device or flex the elbow when it is unlocked, while shoulder depression with shoulder
extension and abduction lock and unlock the elbow (see Figure 5.7 & 5.8 (Esquenazi and Meier,
1996). When movements activate a single component of the prosthesis, typically the terminal
device, the cable is called a single-control cable, or a Bowden cable. When movements
activate two components, typically elbow flexion and the terminal device, the cable is called
a dual-control cable.
Myoelectric control uses the electrical activity of muscles to control the actions of the
prosthesis. Muscle electricity, which is recorded by electromyography (EMG), is produced by
the activation of particular muscle groups. In this control system, the EMG signals are
recorded by electrodes in the socket that come into contact with the residual limb of the user
and get amplified and transmitted for activation and operation of the prosthetic system. The
use of this control system has been effectively implemented as the control mechanism of
transradial prostheses. Myoelectric controls may provide stronger grasp forces and more fine
movements, with less energy expenditure than the traditional cable-controlled prosthesis
system (Datta et al., 1989). This can be used to operate the elbow, wrist, and terminal device.

Long-term acceptance of prostheses depends on a number of factors, including

cosmesis, ability to perform ADLs without a prosthesis, chronic pain, and weight of the
prosthesis. When individuals with amputations begin to perform ADLs without the use of
prosthesis or use their preserved limb only, they typically find prostheses cumbersome and
are less receptive to fitting. Generally, lower limb prostheses are accepted more commonly
than upper limb prostheses. For rates of rejection of various upper extremity prostheses, see
Table 2. Prostheses are usually fitted within 30 days of surgery to promote acceptance by the
amputee (Malone et al., 1984). In several large studies (Millstein et al., 1986 Crandall and
Tomhave, 2002; Wright et al., 1995) that followed-up subjects to 49 years, 38% of
individuals with unilateral upper limb amputations reject their prostheses, whereas all
individuals with bilateral amputations continued to use their prostheses.
The abandonment or change rate of lower limb prostheses is approximately 15%
within 1 to 5 year of discharge from a rehabilitation program (Gauthier-Gagnon et al., 1998).
No rejection statistics by type of lower limb prostheses are available. Of those who did use
their lower limb prostheses, approximately 64% used their prostheses for outdoor mobility
and 53% used them for ADLs in their homes (Gauthier-Gagnon et al., 1998).

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INTERNATIONAL STANDARDS
To eliminate technical barriers to trade and establish a consensus of technical
cohesion, the International Standards Organization (ISO) is a legal association that facilitates
the exchange of goods and services. Two groups of ISO standards have been adopted for
prosthetic devices. One ISO standard provides a system of nomenclature and related
terminology to allow all parties involved in lower limb and upper limb prosthetic and orthotic
treatments to apply a standard terminology (Millstein et al., 1986; Crandalland Tomhave,
2002; Wright et al., 1995). The second outlines a system of test methods for the verification
of essential requirements on prosthetic and orthotic devices related to the safety of the users.
The American Board for Certification in Orthotics and Prosthetics (http://www.abcop.org/)
and the International Society for Prosthetics and Orthotics (http://www.ispo.ws/) are good
sources for finding the ISO standards.

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