project file
TRANSCRIPT
(A Govt. of India Undertaking)
Ministry of Social justice &Empowerment
G.T. Road,Kanpur-208016
SUBMITTED TO:- SUBMITTED BY:-
Mr. A.K. SinghManager(Production)
ALIMCO Kanpur
Md Imran Ali M. Tech (Mechanical Engg)
ISM DHANBAD
ASUMMER TRAINING REPORT
ON“STUDY OF ABOVE AND BELOW KNEE
PROSTHESIS LEG”
CERTIFICATE
Mr. Md Imran Ali student of Mechanical Engineering at Indian School of Mines Dhanbad, has successfully completed his industrial training at Artificial Limbs Manufacturing Corporation of India, G.T. Road Kanpur-208016. During his training period from 2 1 th
May 2013 to 5 th July 2013 , he was found sincere, devoted and dedicated to his work.
We wish him all the best for future.
Mr. A.K. SinghManager(Production)
ALIMCO Kanpur
ACKNOWLEDGEMENT
Before we personally thanks all those who guided us in the successful completion of the research report, we would humbly accept that the time and arena in which I had to trigger our self off foe a win, was mostly aiding and helpful.
The project report has been completed under the guidance of Mr. A. K. Singh(Manager, Production Department) and Mr. S. P. Singh(Design Development) with his coordinated and sincere help, it become possible to prepare the project report.
We express gratitude to our prospective guide Dr. Vinayak Ranjan whose valuable guidance always provide very profitable and made our efforts successful.
Md Imran Ali Student of ISM Dhanbad
CONTENTS
History
Company Profile Quality Policy Objective of Company Achievement of Company Company at a Glance Product Manufactured by Company Orthosis Amputation Prosthesis Fitting the Prosthesis
The preparatory prosthesis Below Knee Prosthesis Fabrication of a Below-Knee Prosthesis SYME Prosthesis Care of The Stump Types of bones of Leg Components of Transfemoral Prosthesis Components of Transtibial Prosthesis The Definitive Above-Knee Prosthesis Above-Knee Prosthesis Fabrication Donning the Sucton Socket Training Knee-Disarticulation Prosthesis Hip-Disarticulation and Hemipelvectomy Prosthesis Maintenance of the Prosthesis Gait Conclusion Suggestions Bibliography
HISTORY OF ALIMCO
The government of India under section 25 of the companies acts. 1956 set up artificial limbs manufacturing corporation of India (ALIMCO) in 1972. Profit is not objective. The company has social objectives. This was proposed to be done by the manufacturing artificial limbs. Components and rehabilitation aids and by promoting encouraging and developing the availability, use supply of distribution of artificial limbs components and rehabilitation aids of high quality to the needy disabled of the country at reasonable cost. The organization started manufacturing disability aids in 1976 and brought about the concept of mass manufacturing of modules limb components to reduce the time of the fabrication of prosthesis and cost of production of all verities of aids and appliances. Its main thrust is on providing better quality aids and appliances to a much larger number of disabled, a ISO 1900:2000 company is the premier and largest manufacturer of disability Aids and appliances in whole of South Asia and manufactured 355 types appliance and aids for Orthopedically , and Visually and Hearing Impaired.
COMPANY PROFILE
ALIMCO set up on 29 November 1972 by the government of India under section 25 of the company’s act 1956 with
objectives to benefiting the disabled person of the country to maximum possible extent.
The stone of ALIMCO was laid down on Sunday: 18 November 1973 by late Prime Minister Mrs. Indira Gandhi. ALIMCO started production in1976. It is largest manufacturing organization of artificial limbs in whole South Asia.
ALIMCO is manufacturing artificial limbs, components and Rehabilitation Aids and promoting encouraging and developing the availability, use supply and distribution of artificial limbs components to needy disable of the country at Reasonable cost.
Profitability is not the motive of the operation corporation and its main thrust is on providing better quality aids and appliances to a much larger number of disable persons.
ALIMCO is spread in a sprawling area of 43 acre; its manufacturing unit and head office are located in Kanpur.
The organization started manufacturing disability aids in 1976 and brought about the concept of mass manufacturing of the modular limb component to reduce the time of fabrication and orthotic and cost of production of all verity of aids and appliances.
OBJECTIVES OF ALIMCO
The main objectives of the Corporation are –
1. To maintain the status of largest manufacturer and supplier of rehabilitation aids in India.
2. To maintain the status of largest ADIP implementing agency through camp activity, headquarters activity, ADIP – SSA activity, special camp activity and limb fitting centers activity.
3. mark and must be durable, modern, sophisticated and scientifically manufactured.
4. To enhance export of quality rehabilitation aids to help disabled persons abroad to achieve self-dependence.
5. To carry out continuous research & development work to improve design of existing aids and develop new assistive aids at affordable prices.
ACHIEVEMENTS OF ALIMCO
Within the country, the Corporation is the premier agency supplying appliances for orthopedically handicapped. It has helped establish 170
Limb Fitting Centers in various parts of the country to ensure proper fitting of aids and appliances. These Limb Fitting Centers provide necessary facilities for fitment of Orthotic and Prosthetic aids to the disabled people.
The Corporation conducts camps in association with various State Govts./Distt. Authorities for fitting and distribution of aids and appliances in rural and semi urban areas of the country.
The Corporation also conducts camps under ADIP-SSA (Sarva Shiksha Abhiyan) Cost Sharing Scheme in association with various State implementing Societies for provision of aids & appliances to children with special Needs of 6-14 years age.
COMPANY AT A GLANCE
Name of Corporation :- ARTIFICIAL LIMBS
MANUFACTURING CORPORATION OF INDIA.
Full address of Corporation :- Artificial Lim Manufacturing Corporation of India G.T. Road
Kanpur -208016, INDIA.
E-mail Address :- [email protected] Website :- www.artlimbs.com Name of Managing Director :- Shri Narayan Rao
Name of Product :- Tricycle , Wheel chair meaning Aids Caliper , Prosthetic Product, Hearing Aids , Folding Cane , Braille Slate etc.
Product Standard :- Confirms to Bureau of IndiaStandard ( BIS ) and ISO 9001:2000
Timing of the Corporation :- 9:00 A.M. – 5:30 P.M.
Turnover of The Company :- 109 Crore
Growth per Year :- 15-20%
Daily Production :- 250 ( Tricycle ) 85 (Wheel Chair) 25 (Walking Stick) 300 (Caliper ) 12 (Braille Slate) etc.
PRODUCT MANUFACTURED BY COMPANY
The Corporation produces 355 different types of quality aids and appliances required by orthopedically, visually & hearing handicapped
persons. ALIMCO has been in the forefront in providing innovative and appropriate solutions to the problems facing the disabled.
The product range includes Orthotic and Prosthetic appliances for Upper & Lower Extremities, Spinal Braces, Cervical Collars, Traction Kits, Rehabilitation Aids like Wheel Chairs, Crutches and Tri Wheelers etc. The Corporation also provides special tools and equipments required for fitment of Orthotic & Prosthetic assemblies by the Limb Fitting Centres.
For visually handicapped, the corporation produces Braille Slate, Folding Cane and Braille Shorthand Machine.
PRODUCTS FOR ORTHOPEDICALLY HANDICAPPED
REHABILITATION AIDS LOWER EXTREMITY ORTHOTICS –
o Ankle Foot Orthosis
o Knee Ankle Foot Orthosis (KAFO) –Small,Medium,Large
o Hip Knee Ankle Foot Orthosis (HKAFO)
o Standard Modular Floor Reaction Outhouses (FRO)
LOWER EXTREMITY PROSTHETICS –o Below Knee (PTB) Prosthesis
o Above Knee Prosthesis (with Silesian Suspension)
o Above Knee Prosthesis (conventional Hip joint & Pelvic
Band )o Hip Disarticulation and Hemipelvectomy Prosthesis
UPPER EXTREMITY PROSTHETICS –o Kit below Elbow
o Kit above Elbow
CERVICAL AND SPINAL BRACES –o Cervical Collar soft
o Cervical Traction Kit
o SOMI Brace
o Brace Milwaukee
MOBILITY AIDS AND WRITING AIDS –o Wheel Chairs non Folding Adult size (airawat)
o Wheel Chairs Standard Folding Adult Size (sathi)
o Wheel Chairs Folding Child Size (mamta)
o Wheel Chairs Folding Adult Size (hans)
o Hand Lever Operated Wheel Chair MK2 (chetak)
o Tricycle (Hamrahi)
o Tricycle (Stuti)
o Tricycle (Sachin)
o Crutches (Axilla)
o Walking Stick
VISUALLY HANDICAPPED –o Folding Cane
o Braille Slate
o Braille Short hand Machine
HEARING AIDS AND STRETCHER –o Pocket Type Hearing Aids
o Folding Stretcher
NEW PRODUCT –o Battery Operated Tricycle
o Electric Hand
o Multi utility Tricycle
LOWER LIMB ORTHOTICS (CALIPERS)
Figure:1
ALIMCO manufactures a large range of components that goes to make a complete Orthotic device for lower limb fitments.
a. Ankle Foot Orthotic (Short Leg Brace) with Limited Motion Ankle Joint or Foot Drop Ankle Joint.
b. Knee Ankle Foot Orthosis (Long Leg Brace) with Limited Motion Ankle Joint or Foot Drop Ankle Joint and Without Knee Joint (for pre-school children) or with Drop Lock Knee Joint for children/adults.
c. Hip Knee Ankle Foot Orthosis (Long Leg Brace With Pelvic Band and Hip Joint) with Limited Motion Ankle Joint or Foot Drop Ankle Joint With it without a Drop Lock Knee Joint and with Drop Lock Hip Joint.
A range of sizes are available in each type of fitment.
ANKLE FOOT ORTHOSIS (SMALL, MEDIUM & LARGE)
Figure :2
Figure :3ANKLE FOOT ORTHOSIS
Product Code No.
Nomenclature
RL 0 Z 01/01 Kit AFO, LM Small (Right)
RL 0 Z 01/02 Kit AFO, LM Small (Left)
RL 0 Z 01/03 Kit AFO, FD Small (Right)
RL 0 Z 01/04 Kit AFO, FD Small (Left)
RL 0 Z 02/01Kit AFO, LM Medium (Right)
RL 0 Z 02/02 Kit AFO, LM Medium (Left)
RL 0 Z 02/03 Kit AFO, FD Medium (Right)
RL 0 Z 02/04 Kit AFO, FD Medium (Left)
RL 0 Z 03/01 Kit AFO, LM Large (Right)
RL 0 Z 03/02 Kit AFO, LM Large (Left)
RL 0 Z 03/03 Kit AFO, FD Large (Right)
KNEE ANKLE FOOT ORTHOSIS EXTRA SMALL (For Pre-school going child)
Figure :4
KNEE ANKLE FOOT ORTHOSIS
Available in One Size only.Product Code No. Nomenclature
RL 0 Z 04/01Kit KAFO, LM Extra Small (Right)
RL 0 Z 04/02 Kit KAFO, LM Extra Small (Left)
RL 0 Z 04/03 Kit KAFO, FD Extra Small (Right)
RL 0 Z 04/04 Kit KAFO, FD Extra Small (Left)
KNEE ANKLE FOOT ORTHOSIS SMALL, MEDIUM & LARGE
(For children beyond 5 years of age and upto
full grown adults) Available in Three Sizes :
Product Code No. Nomenclature
RL 0 Z 05/01 Kit KAFO, LM Small (Right)
RL 0 Z 05/02 Kit KAFO, LM Small (Left)
RL 0 Z 05/03 Kit KAFO, FD Small (Right)
RL 0 Z 05/04 Kit KAFO, FD Small (Left)
RL 0 Z 06/01 Kit KAFO, LM Medium (Right)
RL 0 Z 06/02 Kit KAFO, LM Medium (Left)
RL 0 Z 06/03 Kit KAFO, FD Medium (Right)
RL 0 Z 06/04 Kit KAFO, FD Medium (Left)
RL 0 Z 07/01 Kit KAFO, LM Large (Right)
RL 0 Z 07/02 Kit KAFO, LM Large (Left)
RL 0 Z 07/03 Kit KAFO, FD Large (Right)
RL 0 Z 07/04 Kit KAFO, FD Large (Left)
AMPUTATION
DEFINITION OF AMPUTATION
Amputations are caused by accidents, disease, and congenital disorders. Approximately 74% are due to peripheral vascular disease (poor circulation of the blood) and cancer; 23% are due to accidents, and 3% are due to a problem found at birth.
o The accidents most likely to result in amputation are traffic accidents, followed by farm and industrial accidents.
o Amputations in the case of disease are performed as a lifesaving measure. The diseases that cause the most amputations are peripheral vascular disease (poor circulation of the blood) and cancer.
o A congenital disorder or defect of a limb present at birth is not an amputation, but rather a lack of development of part or all of a limb. A person born with a limb deficiency. usually can be helped by use of an artificial limb.
o Sometimes amputation of part of a deformed limb or other surgery may be desirable before the application of an artificial limb.
o Above-knee (trans-femoral) amputees form the second largest group of amputees.
o Surgeons preserve as much length in thigh amputations as is medically feasible because longer stumps provide better control over the prosthesis. Experienced surgeons avoid leaving unnecessary skin and muscle. Disarticulation at the knee preserves the entire thigh, and, in addition, permits "end-bearing", or the ability of the stump to carry a substantial portion of the body weight over the end.
THE IMMEDIATE POSTSURGICAL PERIOD
o Nearly every amputee feels quite depressed immediately after the
surgery, except possibly those who have suffered intense pain for a period just prior to the amputation.
o This depression is usually replaced early by a will to resume an
active life. o The dressing applied by the surgeon is either "rigid," usually made
of plaster-of-Paris, or "soft," using ordinary cotton bandaging techniques.
o When a rigid dressing is used it is left on for 10 to 14 days during which time most of the healing has taken place. When the soft dressing is used, elastic bandages are used soon after surgery to aid circulation.
o The bandages are removed and reapplied throughout the day. (Instructions for application of elastic bandages are given in the next section)
o Regardless of the type of dressing used, exercises are extremely important to prevent tightening of the muscles, or contractures, which, when present prevent efficient use of a prosthesis.
PROSTHESIS
A prosthesis is a device that is designed to replace, as much as possible, the function or appearance of a missing limb or body part.
It is a device that is designed to support, supplement, or augment the function of an existing limb or body part.
DIFFERENT TYPES OF PROSTHESIS
The continuum of prostheses ranges from mostly passive or cosmetic types on one end to primarily functional types on the other.
Cosmetic prostheses can look extremely natural, but they often are more difficult to keep clean, can be expensive, and usually sacrifice some function for increased cosmetic appearance
THE PREPARATORY PROSTHESIS
Fitting a prosthesis as soon alter surgery as possible helps to combat edema. A preparatory prosthesis is frequently used for several weeks or months until the stump has stabilized before the "permanent" or definitive prosthesis is provided.
The socket of the preparatory prosthesis may be made of either plaster-of-Paris or a plastic material, and is attached to an artificial foot by a lightweight tube or strut, often called a "pylon." When indicated, a suction socket is used. Most pylons are designed so that the alignment of the foot with respect to the socket can' be changed when it is needed.
Although a variety of shoes may be worn with artificial limbs, the patient should consult with the prosthetist before selecting shoes to be used with the prosthesis, because heel height is a major factor in alignment of the artificial leg.
A belt about the waist is usually used to help keep the preparatory prosthesis on the stump properly. At least one prosthetic sock is worn between the socket and stump to provide for ventilation and general comfort.
Most prosthetic socks are woven of virgin lamb's wool, but socks of synthetic yarns are available also. Prosthetic socks are used to prevent skin abrasion and to provide ventilation. They are available in several thicknesses - most commonly 1-ply, 3-ply, 5-ply, and 6-ply.
Additional socks can be used to compensate for stump shrinkage if the amount of shrinkage is not too great. The prosthetist and
Figure: 8
therapist can suggest the sock or socks to be used, but only the patient can determine the proper selection.
Prosthetic socks must be changed daily to reduce the chance of skin irritation or dermatitis.
Prosthetic socks require special care in laundering. Instructions are provided by each manufacturer.
A special woven nylon sock known as a prosthetic sheath is used by many amputees between the skin and regular prosthetic sock to provide additional protection from abrasion.
The sheath also allows perspiration to escape to the prosthetic sock and thus to the atmosphere.
SpecialNote :- Regardless of the functions provided by the most sophisticated mechanical devices, the most important factors in the usefulness of an artificial leg are fitting of the socket and alignment of the various parts with respect to the body and to each other.
Fitting and alignments are difficult procedures that require a great deal of skill on the part of the prosthetist and a great deal of cooperation on the part of the patient.
During fitting and alignment of the first prothesis, it is necessary for the prosthetist to train the amputee in the basic principles of walking.
Fitting affects alignment, alignment affects fitting, and both affect comfort and function. Extensive training is carried out later by the physical therapist.
BELOW KNEE (TRANS-TIBIAL) PROSTHESIS
Figure :-9 BELOW KNEE PROSTHESIS
Most prosthesis for amputation between knee and ankle consist of three major parts:
A socket A shank or Shin A foot
Socket
The most common socket used is some form of Patellar-Tendon-Bearing (PTB) design where all of the weight of the amputee is carried through the stump. The PTB socket totally encloses the stump and usually contains a soft liner to provide a cushioning effect, although many amputees prefer a hard socket because it is considered cooler.
Suspension
The Prosthetic may be held in place in a number of ways:
By a cuff above the knee cap By the shape of the brim of the socket By an elastic sleeve or flexible inner liner attached
mechanically to the prosthesis.
There are other sockets available for transtibial amputees like the Iceross system, which works on the suction socket system. Sockets are manufactured out of Acrylic Resin.
Fabrication of a Below-Knee Prosthesis
Whether the prosthesis is to be crustacean or end skeletal (often called "modular") type, the prosthetist usually begins by wrapping the stump with plaster-of-Paris bandages to obtain a negative mold. A positive model is made by filling the negative mold with a mixture of plaster-of-Paris and water, and allowing it to harden.
After modification of the model to provide the proper characteristics to the finished socket, a plastic socket is formed over it. The first one is usually a test, or check, socket made of a transparent plastic to determine if further modifications are needed.
A new method being used by many prosthetists for obtaining a modified model of the stump involves use of a computer and automatic machinery. Known a CAD/CAM (Computer-Aided-Design/Computer-Aided-Manufacturing), this method permits prosthetists to modify the model more easily since it does not require making and carving an actual plaster model.
The socket is mounted on an adjustable leg for walking trials, and when both the prosthetist and the amputee are satisfied, the limb is ready for the finishing procedures. The exoskeletal shank may be of plastic-covered wood or all plastic. The endoskeletal type uses carved foam rubber over the supporting pylon and the entire prosthesis is encased in a either a latex or fabric stocking.
Steps in the fabrication of a plastic prosthesis for a below-knee (trans-tibial) amputee:
Figure:10
A.A negative mold of the stump is made by wrapping it with a wet plaster-of-Paris bandage.
B.A positive model of the stump is made by filling the cast with a mixture of plaster of Paris and water.
C.After modifications have been made to the model by the prosthetist to make sure that the pressures m the socket will be correct, a test, or check socket, is made by forming a heated sheet of clear plastic over the model.
D.The clear plastic socket is tried on to make sure that it fits properly.
E. A new positive model is made by filling the clear socket with a mixture of plaster of Paris and water.
F. The socket to be used on the definitive prosthesis is formed over the model by using either a mixture of plastic resin and cloth or by forming a heated sheet of plastic over the model.
G.The definitive socket is attached to a pylon that can be adjusted for alignment and walking trials can be made.
H.The finished prosthesis maybe either exoskeletal or endoskeletal.
THE SYME PROSTHESIS
The prosthesis for the patient with Syme's amputation is similar to the below-knee prosthesis except that the socket also serves as the shank. Because of the short space between the end of the stump and the floor, a special type of foot, usually a modification of one of the popular designs, has to be used. Also, because of the shape of the stump, no extra provision for suspension is necessary.
Two types of sockets are in general use: the plastic socket with an expandable liner, and the plastic socket with a medial opening. Both types were designed for easy entry, yet take advantage of the shape of the stump to provide suspension.
Although the end of the stump can take more weight, or load, than in the case of below-knee amputees, it is necessary to shape the upper part of the socket like the PTB so that much of the load can be taken at the knee during walking and standing.
Figure:11
CARE OF THE STUMP
Figure:12
The stump must be washed daily to avoid irritations and infection.
Mild soap and warm water are recommended. The interior of plastic sockets also must be kept clean by washing daily with warm water and a mild soap. Use of detergents should be avoided at all times. Some amputees have found a hair dryer to be useful in drying the stump and preparing the socket for donning.
Prosthetic socks must be applied carefully to avoid wrinkles, and should be replaced daily with newly laundered ones; more often in warm, humid weather. They should be washed in warm water with a mild soap. Manufacturers recommend that socks be rotated on at least a three- or four-day schedule to allow the fibers to retain their original position.
Reductions in the size of the stump can be accommodated by adding one or more prosthetic socks.
Prosthetic socks are woven especially for their intended use and are available in three thicknesses and a variety of sizes.
The thicknesses generally available are designated 3-ply, 5-ply, and 6-ply. With this combination, various thicknesses can be obtained as follows:
One 3-ply = 3 pliesOne 5-ply = 5 pliesTwo 3-ply = 6 plies;One 3-ply + one 5-ply = 8 plies
One 6-ply sock can be used instead of two 3-ply socks.
Some amputees have found that use of a one-ply cotton filler sock provides a satisfactory way to obtain a still finer adjustment in thickness. If the amputee has trouble in obtaining comfort by a combination of prosthetic socks, he should consult his prosthetist immediately.
Frequent adjustments are often required in the first year. When the prosthesis does not feel comfortable during standing and walking, it should be removed and reapplied. If discomfort persists, the prosthetist should be consulted.
Requirements for a patient to wear prosthesis:
The stump must be well formed and round at the distal end. The stump must be well heeled with no open wounds. Good muscle tone. No Swelling. Full movement of hip and knee. Not more than 10kg over weight. Must be able to have good balance and walk on crutches. Stump must be able to carry weight . Must be motivated. Must be able to afford the prosthesis.
There are more transtibial amputees than any other type. Surgeons preserve the knee joint whenever it is practical to do so and will fashion the stump at the lowest practical level. Very short stumps make fitting extremely difficult and very long below knee stumps are prone to circulation problems.
STUMP WRAPPING
Wrapping the stump with elastic bandages has a lot of benefits including:
Eliminates swelling. Waiting for prosthesis. Legs not stable yet Get leg in socket every morning. Leg can’t fit into socket, have an abrasion and not wearing
prosthesis. Stump pain at night.
For the average adult, one or two elastic bandages four inches wide are used. It is important that the bandage is not too tight or too loose. There should be no wrinkles in the bandage and it should be high enough up the leg. There must be no open wounds on the stump while the leg is bandaged.
The stump should be bandaged constantly, but the bandage should be changed every four to six hours. It must never be kept in place for more than 12 hours without re-bandaging. If throbbing should occur the bandage must be removed and re-wrapped. Special elastic Shrinker Socks are available for use instead of elastic bandages, and while not considered by some to be as effective as properly applied bandage, a Shrinker Sock is better than a poorly applied elastic bandage.
Stump Conditioning and Prostheses
Immediately after the amputation the stump will be swollen and it takes a while for this swelling to reduce, usually about a month. To help taper the stump and prevent
swelling from the excessive accumulation of fluid in tissue you will be encouraged to wear an elastic stump shrinker or elastic bandages.
Early walking with a temporary prosthesis enables you to be active, accelerates stump shrinkage, prevents joint stiffness, and helps to reduce phantom limb pain. Using a temporary prosthesis or walking aid, you can start walking exercises between parallel bars and progress to walking with sticks until a permanent prosthesis is made.
The permanent prosthesis will be made to suit your needs and ability, and you will not get more than you need as every extra bit adds additional weight to the leg. The manufacture of a permanent prosthesis will only take place once the stump has shrunk properly. For most patients with a below-the-knee amputation the prosthesis amounts to a socket, pylon and foot with ankle, that is kept in place by a sock that fits over the knee joint.. For above-the-knee amputees there are several knee options available and the socket is secured by a belt which fits around the waist. There are also silicon suspensions that allow the limb to be fitted with out the need for belts.
Complications
Stump pain is a common complaint and is only felt in the stump. You need to differentiated this from phantom limb pain. Mild to severe pain may be felt when the stump is manipulated by medical staff when being examined or when a prosthesis is used. Pain can also be caused by a socket that is not fitting very well, which may be caused by swelling of the stump or a change in body weight. However, the most common causes are nerve
damage or bone formations at the site of the amputation. Nerve ends can be encouraged to settle with well fitting socks, whereas bone formations usually require further surgery.
Phantom limb pain can occur if the patient had a painful condition before amputation, although with good surgery techniques and post operative pain control this can be avoided. Treatments such as simultaneous exercise of both legs, massage of the stump, percussion of the stump with fingers, and ultrasound are effective in reducing or eliminating this condition.
Phantom limb sensation is a painless awareness of the amputated limb, sometimes accompanied by mild tingling. Most amputees experience this sensation, which may last several months or years, but usually disappears without treatment. Frequently, amputees sense only part of the missing limb, often the foot, which is the last phantom sensation to disappear. Some amputees can even describe the position of the foot. Phantom limb sensation is not harmful; however, amputees, without thinking commonly attempt to stand particularly when they wake at night to go to the bathroom.
STUMP SOCKS
Most Prosthetic Socks are woven from virgin wool, but socks of synthetic yarns are also used. They are worn on the stump inside the socket of the prosthesis. Two thicknesses are available in stump socks:
3 Ply; and 5 Ply.
The patient should pull the socks on firmly and evenly so that no wrinkles occur. The seam should not be on any bony areas. Prosthetic Socks must be changed daily to reduce the chance of irritation of the skin and dermatitis.
Socks should be donned in the right sequence to gradually increase the thickness. If the socks thickness goes higher than 15 ply it normally means loss of muscle mass and that a new socket should be constructed.
The socks should be adjusted when necessary, normally when fluid changes occur in the stump. Normally in the following circumstances:
Heat Increased fluid intake Non wrapping of leg at night Letting leg hang down without prosthetic Changes in daily activity.
Add sock if:
Excess weight/ pressure under patella Excess weight/ pressure under amputated Tibia Stump feels loose under pressure.
Subtract a sock if:
The stump is not deep enough in the socket Excess pressure at Tibia head
MAINTENANCE OF THE PROSTHESIS
When a non-articulating foot is used, there is very little maintenance required for the below-knee prosthesis other than keeping it clean inside and out. Articulated feet generally need to be lubricated at regular intervals.
The heel height of the shoe is a very important factor in the alignment of the prosthesis. Therefore, when shoes are changed, it is important that the effective heel height be the same as on the shoes used previously. The effective heel height is obtained by subtracting the thickness of the sole (B) from the apparent heel height (A) as shown below.
For the same reason, the heels of the shoes should be replaced frequently so that wear will not result in alignment changes. Also, a badly worn shoe will increase the wear on a prosthetic foot.
Prostheses should not be worn without shoes. Not only will the temporary misalignment cause excessive stress on the stump and knee joint, but the wear on the foot will result in permanent misalignment.
Most prostheses are water-resistant but few are waterproof. If the foot becomes wet, the shoe should be removed as soon as possible to facilitate drying.
When the amputee has any doubt about the fit, alignment, or condition of the prosthesis or stump, he should consult with his prosthetist immediately.
DEFINITIONS
PREPARATORY PROSTHESIS. An unfinished functional replacement for an amputated limb, fitted and aligned in accordance with sound biomechanical principles, which is worn for a limited period of time to accelerate the rehabilitation process.
Pylon. A rigid member, usually tubular, between the socket or knee unit and the foot to provide support.
Rigid Dressing. A plaster wrap over the stump, usually applied in the operating or recovery room immediately following surgery, for the purpose of controlling edema (swelling) and pain. It is preferable, but not necessary, that the rigid dressing be shaped in accordance with the basic biomechanical principles of socket design.
Early Prosthetic Fitting. A procedure in which a preparatory prosthesis is provided for the amputee immediately after removal of the sutures.
Modular Prosthesis. An artificial limb assembled from components, usually of the endoskeletal type where the supporting member, or pylon, is covered with a soft foam or other light material shaped and finished to resemble the natural limb.
Definitive, or "Permanent", Prosthesis. A replacement for a missing limb or part of a limb which meets accepted
check-out standards for comfort, fit, alignment, function, appearance, and durability,
Check or Test Socket. A temporary socket, often transparent, made over the plaster model to aid in obtaining a proper fit.
Ankle Foot Mechanisms
A variety of artificial foot designs is available, each having its advantages and disadvantages. Feet currently available can be divided into two classes:
Articulated Those with moving joints Non articulated Without moving joints
Articulated feet
Articulated feet require more maintenance and are slightly heavier than most non articulated kind.
Single Axis
The single axis foot (one joint) provides for ankle action that is controlled by two rubber bumpers either of which can be changed to permit more or less motion needed. It is often used to assist in keeping the knee stable.
Multi Axis
The multi-axis foot is often recommended for people who have to walk on uneven surfaces because it allows some motion about
all three axis of the ankle. It is slightly heavier that the other types of feet and is apt to require more maintenance as well.
SACH
Figure:13
The simplest type of non articulated foot is the SACH (Soft Ankle Cushioned Heel) foot. The keel is rigid. Ankle action is provided by the soft rubber heel which compresses under load during the early part of stance phase of walking. The rubber heel wedges are available in three densities: soft, medium and hard.
The Soft Ankle Cushioned heels feet are joint-less and are generally manufactured out of Pedilen Foam. These feet
available on the market are namely the Dynamic and the Dynamic Plus feet.
Flex Foot
The Solid Ankle Flexible Endo-Skeletal foot has the same action as the SACH plus the ability for the sole to conform to slightly irregular surfaces and thus makes it easier for the amputee to walk over uneven terrain. Feet of this type make walking easier because of the flexibility, and are sometimes called flexible keel feet.
Heel Heights
The heel height of the shoe is a very important factor in the alignment of the prosthesis. Therefore, when shoes are changed, it is important that the effective heel height be the same as on the shoes used previously. The effective heel height is obtained by subtracting the thickness of the sole from the apparent heel height. For the same reason, the heels of the shoes should be replaced frequently so that wear will not result in alignment changes. Also, a badly worn shoe will increase the wear on a prosthetic foot. Prosthesis should not be worn without shoes. Not only will the temporary misalignment cause excessive stress on the stump and knee joint, but the wear on the foot will result in permanent misalignment.
BANDAGING TECHNIQUE
Figure:14
Start with the bandage held in place on the inside of the thigh just above the knee and unroll the bandage so that it is laid diagonally down the outer side of the stump while maintaining about two thirds of the maximum stretch of the bandage. Bring the bandage over the inner end of the stump and diagonally up the outer side of the stump.
Bring the bandage under the back of the knee, continue over the upper part of the kneecap and down under the back of the knee.
Bring the bandage diagonally down the back of the stump and around over the stump. Continue up the back of the stump to the starting point on the inside of the thigh and repeat the sequence in a manner so that the entire stump is covered by the time the roll is used up. The end of the bandage is held in place with the special clips that are provided. It is important that the tightest part of the bandage be at the end of the stump.
If your amputation is planned, the various aspects and the rehabilitation program will be explained to you. On the
other hand if your amputation is the result of an accident or sudden trauma you will not get this information until afterwards and you will also find that counseling will be offered to help overcome the psychological effects. The rehabilitation team are usually well organised group with a lot of valuable experience who will discuss with you whether a prosthesis is feasible and what type will be suitable.
Immediately after surgery, measures are taken to prevent secondary disabilities, especially the tightening of the muscle, tendons, ligaments, or skin that could prevent the normal movement of the hip or knee. Exercises for general conditioning, stretching of the hip and knee, and strengthening of all extremities are started as soon as the you are medically stable. Exercises will be set that you can do in bed or in a chair and you will begin standing and balancing exercises with parallel bars as soon as possible.
Generally it has to be recognised that age will play a major part in how much mobility you gain on your new prosthesis and younger people may attain quite high levels. There will be days when your stump is sore or you do not feel so good and a wheelchair will be required instead of your artificial leg.
Unilateral amputation (One limb): Walking requires a 10 to 40% increase in effort after below-the-knee amputation and a 60 to 100% increase after above-the-knee amputation. To compensate, older people generally walk more slowly. As a general rule, you can achieve most of the things that you could have done prior to the amputation with a well-fitting prosthesis and good rehabilitation.
Mobility after a below-the-knee amputation differs greatly from that of an above-the-knee amputation. People who have had a below-the-knee amputation and are fitted with a prosthesis usually become mobile quite quickly. Elderly people who have had an above-the-knee amputation may find that they do not have the energy, flexibility and skills required to deal with an above-the-knee prosthesis and to control the knee joint, and may find a fixed knee easier to use.
Bilateral amputation (Two Limbs): Amputation of both legs is not so common and is usually the result of a trauma. As with unilateral amputation, what can be achieved depends on whether the amputations are above or below the knee. If you have a bilateral below-the-knee amputation with well-fitting prostheses you should be able to walk again without a cane. As a bilateral above-the-knee amputee with prostheses you will probably be able to walk with the support of two canes. Older people with bilateral above-the-knee amputations may not have the necessary energy or strength to walk with prostheses.
Amputees with one below-the-knee and one above-the-knee amputation can generally walk using the one functional knee joint in the same way that a unilateral above-the-knee amputee with a prosthesis would do. Regardless of the level of the amputations, walking distance is generally limited and a wheelchair may be needed, especially outdoors and for long distances.
The Definitive Above-Knee Prosthesis The above-knee prosthesis has four major parts:o socket
o knee system
o Shank
o foot-ankle system.
A variety of sockets, knees, shanks, feet, and ankles are available and can be combined to produce a prosthesis that best meets the needs of each individual amputee.
Description of the components most used are given in the following sections:-
Figure:15
The Socket
Figure:16
The socket is the basis for the connection between the user and the prosthesis. It always provides the means for transferring the weight of the amputee to the ground by way of the rest of the prosthesis.
The shape of the socket is critical to comfort and function. The socket must not restrict circulation, yet it cannot be loose. Most sockets for above-knee prostheses cover the entire stump.
There are several designs available to take maximum advantage of the muscles in the stump of the individual amputee for control of the prosthesis and for transferring the weight of the amputee to the floor.
Most sockets are made of a rigid plastic, but some amputees prefer a flexible socket supported by a rigid frame because comfort during walking and sitting seems to be improved.
For most patients, the prosthesis can be held in place by "suction", or a vacuum, provided by a close fit between stump and socket. This is known as a suction socket.
Nothing is worn between the stump and socket. when circulation is marginal or precarious, a looser fit is provided, a woolen sock is worn over the stump, and the socket is held in place by a "Silesian Bandage".
The Knee System
Figure:17
If the above-knee amputee is to have a normal appearance while walking, the prosthesis must have a knee joint that will not buckle as he rolls over the artificial foot during the stance phase of walking.
The simplest way to achieve this is to use mechanical friction about a bolt that connects the socket (thigh) to the shank. The bolt is located behind the path of the weight of the body to the floor so that it will not buckle when the user is standing straight.
The mechanical friction, which may be a simple adjustable brake, keeps the shank from swinging forward too fast as the user swings the artificial leg through to the next step.
The chief limitation in the single-axis constant friction design is that appearance is normal at only one speed of walking for a given setting of friction, The amputee must be very careful in walking, especially on uneven surfaces, to avoid stumbling.
A great deal of effort has been spent over the Years developing knee systems which overcome the limitations of the single-axis, constant friction knee. Many designers have been successful to some degree, but because of the simplicity of the constant friction design, no new system has totally displaced it.
Weight Actuated Knee Brake:The second level of complexity in knee systems is the use of a weight-actuated brake with constant friction. Two bolts are used at the knee, so that when one pivots about the other when the amputee is standing, the force of the body weight engages a brake that keeps the knee from buckling.
Polycentric Knees :- To provide better control of the above-knee prosthesis during standing and the stance phase of walking than can be provided with a single axis knee, designers have used mechanical linkages between the socket and shank that, in effect provide for a moving center of rotation. Such designs are known as polycentric knees.
Used originally for the knee-disarticulation case, polycentric knees now also used in prostheses for higher levels, especially when stability at heel strike is desirable. The swing
phase control may be either mechanical friction or hydraulic resistance.
The one limitation of the polycentric design is that range of motion about the knee may be restricted to some degree but not enough for it to be objectionable to most users.
Hydraulic Knees:- To allow the amputee to vary his speed of walking, a number of hydraulic devices are available. In the simplest system, the piston is attached to a pivot in the thigh section of the prosthesis behind the knee bolt, and the cylinder is attached to a pivot in the shank. Because of the way oil acts when forced through a small hole the amount of resistance required for a given velocity of walking is provided automatically.
The most complex knee systems of those available are those which control of both swing and stance phase with a single hydraulic cylinder. Braking of the knee is brought about automatically when the knee begins to buckle, without interfering with normal flexion and extension of the knee. The same system permits the velocity of walking to be varied at will. These features are appreciated most by very active amputees.
The prescription for the prosthesis is based on activity level and particular needs of each amputee.
SHANKS
Figure:18
The primary purpose of the shank is to transfer the vertical loads caused by the weight of the amputee to the foot and on to the floor.
Two types are available: Crustacean, or exoskeleton, where the forces are carried through the outside walls of the hollow shank which is shaped like a leg; and endoskeleton, or pylon, where the forces are carried through a central structure, usually a tube and the shape of the leg is provided by a foam covering.
Each design has advantages and disadvantages. The endoskeletal systems offer the most life-like appearance and "feel", but require more care to maintain. The crustacean design is suitable for heavy duty. Most
Figure:19
endoskeletal parts are designed for moderate or light duty, but heavy duty systems are available.
Another advantage of some of the endoskeletal systems is that knee units of greater complexity can be introduced as the amputee becomes more proficient or his functional needs change.
ANKLE-FOOT SYSTEMS
A variety of artificial foot designs is available, each having its advantages and disadvantages.
Feet currently available can be divided into two classes: articulated (those with moving joints), and non-articulated.
Those with moving joints generally require more maintenance and are slightly heavier than most of the non-articulated kind. Articulated feet may have one or more joints.
The single-axis foot (one-joint) provides for ankle action that is controlled by two rubber bumpers either of which can be changed
Figure:19
to permit more or less motion as needed. It is often used to assist in keeping the knee stable.
A multi-axis foot is often recommended for people who have to walk on uneven surfaces because it allows some motion about all three axes of the ankle. It is, of course, slightly heavier than the other types of feet and is apt to require more maintenance as well.
Figure:20
The simplest type of non-articulated foot is the SACH (solid ankle-cushion heel) Foot. The keel is rigid. Ankle action is provided by the soft rubber heel which compresses under load during the early part of the stance phase of walking. The rubber heel wedges are available in three densities: soft, medium, and hard.
The SAFE (solid ankle-flexible-endoskeletal) Foot has the same action as the SACH plus the ability for the sole to conform to slightly irregular surfaces and thus makes it easier for the amputee to walk over uneven terrain. Feet of this type make walking easier because of the flexibility, and are sometimes called "flexible keel" feet.
In recent years, there has been a proliferation of new designs for artificial feet. Most are capable of absorbing energy in a "flexible" keel during the "roll-over" part of the stance phase of walking and springing back immediately to provide push-off, or assistance in getting the toe off of the ground, to start the swing phase of walking. Although the original idea was to provide the active athlete with more function, amputees who are a lot less active have found these designs useful. These designs are often called "dynamic response" feet.
Figure:20
Most of the non-articulated feet are available with toes moulded in to provide a very realistic appearance.
There are available still other ankle-foot systems that incorporate the shank and eliminate the need for a mechanical connection between the foot and shank. The shank-ankle-foot is usually made of a specially developed plastic composite that
Figure:21
responds nicely to the forces created during the stance phase of walking.
These lightweight systems seem to have most of the advantages of more conventional designs, while providing an additional function.
Transverse Rotation Device :- A transverse rotation unit allows some rotation about the long axis of the shank when it is installed in the shank between the ankle and the socket. The idea of providing this function seems to be sound, but the difficulty in designing and manufacturing a unit that is reliable has restricted its acceptance.
FITTING THE PROSTHESIS
In general, the earlier a prosthesis is fitted, the better it is for the amputee. One of the most difficult problems facing the amputee and the treatment team is edema, or swelling of the stump, owing to the accumulation of fluids.
Edema will be present to some extent in all cases, and it makes fitting of the prosthesis difficult, but certain measures can be taken to reduce the amount of edema. The use of a rigid dressing seems to control edema. After the rigid dressing has been removed and when a prosthesis is not being worn, elastic bandages are used to keep edema from developing.
The amputee is taught the proper technique for bandaging and is generally expected 'to do this for himself as shown on the next page.
For the average adult two or three elastic bandages six inches wide are used. During application, the bandages should be stretched to about two-thirds of the limit of the elastic, and the greatest tension should be around the end of the stump.
The stump should be kept bandaged at all times, but the bandage should be changed every four or six hours. It must never be kept in place for more than 12 hours without rebandaging.
If throbbing should occur, the bandage must be removed and rewrapped. Edema occurs rapidly when the stump is left unbandaged so it is very important to replace the bandage without delay.
Special elastic "shrinker" socks are available for use instead of elastic bandages, and while not considered by some to be as effective as a properly applied elastic bandage a shrinker sock is better than a poorly applied elastic bandage.
Whether elastic bandage or shrinker sock is used, it should be removed at least three times daily and the stump should be massaged vigorously for 10-15 minutes.
The bandage or sock must reapplied immediately after the massage.
Figure :22
1. Begin by placing one end of a rolled 6-inch wide elastic bandage on the upper part of the thigh and wrap it around the stump toward the rear.
2. Bring the roll through the legs and over the end of the front of the thigh.
Bring the roll across the back and on across the lower stomach area.
3. Continue to wrap around the thigh, across the back and lower stomach area until the roll is suspended. Attach the end of the roll with the metal clips that are included with the bandage.
4. With a second roll of elastic bandage, begin to wrap the stup from the upper outer surface diagonally toward the lower inner surface.
Figure :23
5. Bring the roll of bandage around the back of the stump and upward diagonally.
6. Bring the roll of bandage behind the uper part of the stump. 7. Continue to wrap the stump in an overlapping fashion until the
entire stump is covered. Fasten the end of the second roll of bandage to the first bandage.
Above-Knee Prosthesis Fabrication
Figure :22
Whether the prosthesis is to be a crustacean or an endoskeletal (often called "modular") type, the prosthetist begins by wrapping the stump with plaster-of-Paris bandages to obtain a negative mold. A positive model is made by filling the negative mold with a mixture of plaster-of-Paris and water, and allowing it to harden.
After modification of the model to provide the proper characteristics
in the finished socket, a plastic socket is formed over it. The first
socket is usually transparent for use as "test" or "check" socket to
determine if further modifications are needed.
A new method being used by some prosthetists for obtaining a
modified model of the stump involves use of a computer and
automatic machinery.
Known as CAD/CAM, (Computer-Aided Design \ Computer-Aided
Manufacturing), this system permits prosthetists to modify the model
more easily since it does not require making and carving an actual
plaster model.
The socket is mounted on an adjustable leg for walking trials, and
when both the prosthetist and the amputee are satisfied, the limb is
ready for the finishing procedures. The crustacean shank may be of
plastic-covered wood or all plastic. The endoskeletal type uses carved
foam rubber over the supporting tube and the entire prosthesis is
encased in a latex or fabric stocking.
Steps in the fabrication of a plastic prosthesis for the trans-femoral
amputee are:-
Figure :24
A negative mold of the stump is made by wrapping it with a wetted plaster-of-Paris bandages.
The cast is filled with a mixture of plaster of Paris and water to make a positive model.
After modifications have been made to the positive model to make sure that the pressure on the stump will be distributed properly, a check, or test, socket is made by forming a heated sheet of a clear plastic over the modified model.
The clear plastic socket is tried on to make sure that it fits properly. A new positive model is made by filling the clear test socket with a
mixture of plaster of Paris and water.
The socket to be used on the definitive prosthesis is formed over the model either by using a mixture of plastic resin and cloth or by forming a heated sheet of plastic over the model. The definitive socket is attached to an adjustable leg for alignment and walking trials.
The finished prosthesis may be either the crustacean or the endoskeleton type.
Donning the Sucton Socket
A number of methods of donning the suction socket have been devised through the years. Each amputee needs to experiment to determine the method that seems easiest for him.
The three most popular methods seem to be use of a nylon stocking or a single layer of tubular stockinet over the stump and removing it through the valve hole as the stump is "pumped" into the socket.
Use of tubular stockinet that has been doubled over the stump and removing the stockinet by pulling the end of the outer layer through the valve hole as the stump is "pumped" into the socket.
Use of an elastic bandage that has been wrapped tightly around the upper half of the stump and then pulled through the valve hole as the stump is "pumped" into the socket.
Various devices have been made available from time to time with the purpose of making the donning of the prosthesis easier, but none seem to have been used widely.
Figure :25
Air bubbles between the socket and stump result in discomfort. The valve is opened as the stump is forced into the socket to expel any air bubbles that may develop and to reestablish suction when it is lost after sitting or for any reason
TRAINING
Extensive training in the use of an above-knee prosthesis is usually necessary if optimum gait and comfort are to be obtained. Early training is provided by the prosthetist during fitting trials.
Physical therapists usually provide the additional training as required. The new prosthesis should be worn initially for short periods and wearing time increased each day depending upon individual situations.
One of the greatest problems in obtaining good performance and maximum comfort is overweight of the amputee, especially the aboveknee.
Fluctuations in body weight are reflected in the stump where changes in volume result in poor fit, discomfort, and consequently poor performance.
A reasonable exercise program and a sensible diet are important factors in the health and well being of every one, but even more so in the case of the amputee.
Slight reduction in size of the stump can be accommodated by adjustments to the socket, but the prosthetist can do little about expanding the size of a socket and almost any increase in size of the stump means a new prosthesis, or, at the least, a new socket.
Knee-Disarticulation Prosthesis
The knee-disarticulation prosthesis is very similar to the above-knee prosthesis, except for the lower part of the socket and the knee mechanism.
Before the introduction of the present day polycentric knee units, sockets for the prosthesis were usually made of leather and metal hinges were used to attach the socket to the shin.
This type of prosthesis is still preferred by a few preferred even though it is bulky and control of the leg during the swing phase is difficult.
However, most prefer one of the polycentric designs where the knee mechanism can be installed within the shin due to its special design.
The major objection to the polycentric units is that the knee protrudes slightly beyond the front of the shank when the amputee is sitting or kneeling.
Leather sockets are held on by a lacing. Plastic sockets usually have a foam liner in the lower part for the bulbous end of the stump to slip by so as to keep the socket in place.
All of the instructions given about use of the above-knee apply equally to the Knee-Disarticulation prosthesis.
Hip-Disarticulation and Hemipelvectomy Prostheses
Most of the components designed for above-knee prostheses are suitable for amputees who have lost function about the hip due to amputation just below the hip joint, at the hip joint (hip-disarticulation), or hemipelvectomy (when half of the pelvis has been removed).
To provide good control of the leg, the artificial hip joint is placed on the front of the socket rather than opposite the anatomical hip joint, an arrangement that provides better control of the prosthesis.
For these prostheses, the socket is either of laminated plastic or a thermoplastic, and the construction is usually modular that is, pylon, or endoskeletal, because this type of construction results in a relatively lightweight prosthesis.
The hemipelvectomy prosthesis presents an added problem to the prosthetist because there is no ichial bone present to aid in weight bearing.
All of the instructions given about use of the above-knee prosthesis apply equally to the hip-disarticulation and hemipelvectomy prostheses.
REHABILITATION
In general the earlier prosthesis is fitted the better it is for the amputee. One of the most trying challenges facing the amputee and the treatment team is Edema (or swelling of the stump) owing to the accumulation of fluids. Edema will be present to some extend in all cases, and it makes fitting of theprosthesis difficult, but certain measures can be taken to reduce the amount of Edema. The use of rigid dressing seems to control edema. After the rigid dressing has been removed and when a prosthesis is not being worn, elastic bandages are used to keep the edema from developing.
EXERCISE
Although the below knee amputees have normal knee function, training in their use is necessary if optimum gait and comfort are to be obtained. Early training is provided by the Prosthetist during fitting trails.
Physical Therapists usually provide the additional training as required. The new prosthesis should be worn initially for short periods and wearing time increased each day depending upon individual situations.
TRAINING
Although the below-knee and Syme's amputee have normal knee function training in their use is necessary if optimum gait and comfort are to be obtained. Early training is provided by the prosthetist during fitting trials.
Physical therapists usually provide the additional training as required. The new prosthesis should be worn initially for short periods and wearing time increased each day depending upon individual situations.
One of the greatest problems in obtaining good performance and maximum comfort is caused by over weight of the amputee. Fluctuations in body weight are reflected in the stump where changes in volume result in poor fit, discomfort, and consequently poor performance. A reasonable exercise program and a sensible diet are important factors in the health and well being of everyone, but even more so in the case of amputees.
Slight reduction in size of the stump can be accommodated by adjustments to the socket, but the prosthetist can do little about expanding the size of a socket and almost any increase in size of the stump means a new prosthesis.
PROSTHETIC HYGIENE
The patient should bathe and wash the stump daily. Preferably in the evening as the irritation might cause swelling and the leg could not fit in the socket. Do not shave the stump as it might cause irritation.
Patient should hand wash the stump socks with warm water and non detergent soap. Lay the socks flat to dry. Do not wash socks in machine or dryer. Wipe out the socket daily with a damp cloth, mild soap or alcohol.
GAIT
A sequence of movements that mimics the human walk cycle is known as gait.
STAGES OF GAIT The general operation of a prosthetic knee - basic lock - unlock
mechanism that corresponds to straightening and bending of a knee.
The two stages of gait walking are the stance phase and the swing phase
The stance phase - where initial contact occurs at the heel and the knee is locked.
swing phase- where the leg is off the ground and swings back to its original configuration before it locks itself to begin the stance phase again.
CONCLUSION
Since 1972 ALIMCO has been Supported / controlled / directed & facilities by central government. The main objective of its installation was to fulfill the fierce requirement of disable person of India as well as rest of the nation , as its NGO Corporation. Therefore, it has to distributed its product as the No Profit and No Loss Point.
The major sources of funds gatherization of ALIMCO is grants provided by the central government as well as state government. Since 1972 to 1990 the sequence of the grant receiving was uncertain in quantity & timing as well. But in the provision of 1990 grant was fixed in quantity & timing also.
So , main emphasis of ALIMCO should be producing more & more product . Every schedule in which it is to be allocated should be well defined & having the clarity of its Goals.
On saying so I would like to finish my Project Report.
SUGGESTIONS
As we know ALIMCO is the largest manufacturer of aids and appliances for PWDs in south Asia, which produce Rehabilitation aids appliances for orthopedically, visually, impaired ALIMCO is growing day to day.
No one are 100% perfect but we should try to be 100% still there are some areas where organization needs improvement.During my research I have gone through the detail of work procedure and working of ALIMCO and based on survey experience
I have come concluded following suggestion for better work and improvement in the existing system.
Manager should motivate the worker by healthy interaction with them for their good work.
Daily work report should be prepared by employees and should be checked by manager.
To make some portion of money from profit and expend it on employee satisfaction and betterment.
Adopted new technologies and machinery. Reduce wastage material. Recruitment of youth employees. Strict control and disciple.
