Ivan Long CP[E] Does It Again!

I made some presentations on stance control orthoses at the most recent meeting of the Midwest Chapter of the Academy, in Milwaukee, Wisconsin, - because this was the major themes of this program. Folks from Becker and Bock also participated, and helped us all get up to speed on the current state of the art in this exciting new realm of orthotic practice. But, all our lectures and workshops on "what's newly available" paled by comparison to a simple demonstration by a white-haired retired prosthetist who walked on his own molded leather KAFO to show us "what's possible".

Many readers will already be familiar with the name "Ivan Long", but for those who are not, Mr. Long is one of the most creative and caring practitioners the world has ever known. He was certainly one of the most deserving recipients of the Academy's Distinguished Practitioner Award in recent memory.

In addition to being a gifted prosthetist, Mr. Long has always "done it his way", tenaciously pursuing what he felt were promising new approaches that might better meet the patient's needs that the current state of the art. One of his best-known contributions has been originating the socket design concept that is now termed "Ischial Containment". When I was a rank novice and student prosthetist in the 1970s, Gunter Gehl CP told our graduating class at Northwestern University, "Ivan Long has written an article about a new type of socket that you should all be aware of, because if Ivan says it is a better way, then it is."

Ironically, the photo showing the inner contours of his new socket was inadvertently printed in Prosthetics and Orthotics incorrectly. It was rotated 90 degrees prior to printing because the wider antero-posterior dimension "looked wrong" as submitted and was presumed to be the mediolateral dimension! The resulting confusion delayed widespread understanding of Ivan's watershed work, which wasn't really recognized until John Sabolich re-interpreted it some years later and coined the now-defunct acronym "CAT-CAM".

However, the test of time has now confirmed that Ivan Long's contribution was truly to take us "beyond the Quadrilateral", and his insights and methods have changed the way we think about and create transfermoral sockets worldwide. Some years ago, Ivan left his practice and began a well-earned retirement. Most people would be content at that point to enjoy the fruits of their labor, content to have changed the face of prosthetic practice irrevocably. But, doing "the sensible thing" has never been Ivan's way!

Microprocessor-controlled hydraulic KAFO with yielding stance control

In addition to being a gifted clinician, Ivan Long is also a polio survivor, and he has worn a molded leather and steel KAFO with a locked knee for many decades. This device allowed him to work full-time as a prosthetist despite having a totally flail leg. The recent spate of interest in stance control orthoses piqued his interest, and he began musing about whether it would be possible to adapt existing prosthetic knees to work with his own KAFO.

Of course, Ivan was among the first wave of practitioners to take the training to become a C-Leg Qualified practitioner; he is as up to date with making the proper adjustments to an electronic knee as he was with fine tuning the Polycadence of yesteryear. His experience fitting Carol Harper's C-Leg, and observing how graceful and secure her gait became with this technology, started the wheels turning in his mind.

Since he is also a master craftsman, Ivan decided to modify his own KAFO by welding on some extensions that would permit him to temporarily attach a C-Leg knee-shin set-up on the lateral side of his brace.

Using himself as the test subject, Ivan then systematically changed the numerous adjustments offered by the C-Leg until he found the best settings for his pattern of paralysis and gait. This jury-rigged system functioned very well and he wore it for quite some time to "feel" how it functioned.

Of course, it also took a great deal of commitment and effort to change the way he walked after all those decades, but Ivan gradually acclimated to having a free knee and concluded that this was a promising concept. When the packed room of CPOs saw the video demonstrating the marked improvement in Ivan's gait, the room hushed and then erupted in a buzz of comments, questions, and excitement. Ivan has graciously provided a clip for downloading that shows his gait with his "C-Leg KAFO" experiment.

Hydraulically actuated KAFO with yielding stance control

Following the success of his first experiment, Ivan concluded that he received no benefit from the elegant swing phase control the C-Leg offered because his flail hip musculature restricted his cadence to a very slow and steady pace. So, he decided to see what a Mauch SNS knee could add to his KAFO. So, he welded slightly different attachments to his KAFO, attached a Mauch unit, and started the second round of self-experimentation.

At the Midwest Chapter meeting, Ivan demonstrated this result by simply rolling up his pants leg. Once again, the room was abuzz with excitement. You can download a video clip of this KAFO to see for yourself.

I spoke with Ivan just prior to press time, and he informed me that he continues to use the SNS-KAFO on a daily basis as his sole brace. Because his thigh is quite atrophied, he has welded on yet another set of brackets, and now mounts the cylinder lateral to the thigh, when it fits better under his trousers.

After some months of practice on level surfaces and irregular surfaces, Ivan is now tackling steeper terrain. He has provided two video clips showing how he descends stairs, step-over-step, using the current experimental KAFO. The first illustrates the rotary instability that occurs when the hip musculature is paralyzed, as in Ivan's case. In the second clip, he has added a modified Silesian belt to his KAFO to control rotation - although it is not visible under his clothing.

Ivan is firmly convinced that yielding stance control is a feasible approach to adding stability to a KAFO, and his single-subject experiment demonstrates that it is at least possible for selected patients to gradually adapt to this new type of orthotic control, although it may be necessary to modify the KAFO in various ways once the locked knee components are deleted. He is interested in fostering more widespread investigation of this possibility, and can be contacted via email at artl1195@aol.com .

Based on our collective experience with prosthetic knees mechanisms, I consider it quite likely that yielding stance control will prove to be clinically superior to locking against flexion [which is the current state of the art in stance control orthoses]. Of course, it is a real engineering challenge to create an orthotic joint that is light enough, sleek enough, and durable enough to offer this function. But, Ivan Long has once again "pushed the envelope" and demonstrated the direction our thinking and clinical practice should evolve.

Reader Comments: Read all user comments Laminated Orthotics What is the deal with laminating AFOs and KAFOs. I work with Children, and occasionally one breaks a device. We have done hundreds of the typical coploy AFO, KAFO and semirigid foot orthotics. We have a new guy working here and he loves lam... read more - greg   10/11/2005 Re: Laminated Orthotics The short answer, Greg, is that laminated structures can be more precisely controlled than thermoplastic ones and can also be made far more rigid, either selectively or globally. When those are important clinical criteria, then lamination ... read more - John Michael   10/12/2005 Trans-Tibial Sockets Dear folks in the US, What do you think about one of my websites? http://home.t-online.de/home/markusthonius/bufa-sockets.html I don't know, how much this philosophy is known in the US? Regards from Germany, Markus Thonius - Thonius Markus   9/29/2002 about KAFO+ C-leg stance and swing control of postpolio cases joints instability by a prosthetic joint is a good idea, but demands for a special design and features like as: low-weight, durability, and spe. small-size. it seems with new-born joints having ... read more - alireza vasefnia   9/24/2002 Re: about KAFO+ C-leg Ivan's point was to generate just the sort of speculation that you have offered, and you are correct in commenting that a stance control orthosis must be more than just a prosthetic joint grafted onto a KAFO. Ivan just wanted to investigat... read more - John Michael   9/24/2002 Liners de Silicón para pacientes diabéticos? Ciudad de México 9 de Septiembre, 2002. Estimado John Michael, C. P. O. FAAOP: recibimos un correo de Quito, Ecuador con las siguientes preguntas: ¿Que tipo de forros (liners) son recomendables para pacientes diabéticos? Algunos pacient... read more - Alberto E. Castillo Moreno O.P.   9/9/2002 Re: Liners de Silicón para pacientes diabéticos? Thanks for forwarding this inquiry. I don't think we have any evidence that one brand of liner is superior to another for diabetic patients: they have all been generally but not universally successful. Hygeine is important so both liner a... read more - John Michael   9/10/2002 Re: Re: Liners de Silicón para pacientes diabéticos? Ciudad de Mexico 11 de Septiembre, 2002. Estimado John Michael C. P. O., FAAOP: gracias por su acertada respuesta y la enviaremos al colega Marco Muñóz técnico en prótesis de la Fundación Hermano Miguel en Quito, Ecuador. Aprovechamos ... read more - Alberto E. Castillo Moreno O.P.   9/11/2002 Re: Re: Re: Liners de Silicón para pacientes diabéticos? You are welcome to post my comments on any professional forum where they may be helpful. It is always difficult to respond intelligently when there is no opportunity to examine the individual patient, but I try to limit my answers to the g... read more - John Michael   9/12/2002 Diferencias en la Alineacion de Protesis Transfemorales. Ciudad de Mexico 13 de Septiembre, 2002. Estimado John Michael, C. P. O. FAAOP: nuevamente solicitamos su ayuda profesional. Un colega de Buenos Aires, Argentina esta elaborando su Tesis para graduarse como Licenciado en Ortesis y Protes... read more - Alberto E. Castillo Moreno O.P.   9/13/2002 Re: Diferencias en la Alineacion de Protesis Transfemorales. Clinicians worldwide have been trying to pinpoint the differences between US and German static alignment. To the best of my knowledge, there is no one reference that concisely compares and contrasts these theories. So, I'd recommend a sea... read more - John Michael   9/14/2002 Congreso Interbor 2002 Valladolid España. Ciudad de Mexico 18 de Septiembre, 2002. Estimado John Michael, C. P. O. FAAOP: muchas gracias por su respuesta con relacion a las diferencias en la alineación estática americana y europea. Esta información ha sido enviada a Buenos Aires, ... read more - Alberto E. Castillo Moreno O.P.   9/19/2002 Re: Congreso Interbor 2002 Valladolid España. The Secretariat of INTERBOR can be reached at l.fischer@ueapme.kmonet.be; he can probably provide details on the meeting in Spain. The Spanish Federation of Orthotists and Prosthetists web site is at http://www.fedop.org/index.htm but I di... read more - John Michael   9/20/2002