The Desire to Achieve

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A little creative adaptation can go a long way toward helping recreational enthusiasts pursue their passions.

The tattoo on this high-definition cosmetic cover adds the finishing touch to restore this patient's lost limb.
The tattoo on this high-definition cosmetic cover adds the finishing touch to restore this patient's lost limb.

Recreational activities are vital to our sense of well-being. A person who experiences limb loss might find these activities especially meaningful and fulfilling as confidence builders for everyday life. Whether learning a new skill or adapting methods of doing a past skill, prosthetic design can make a difference in that person's performance. For most amputees, adapting to an activity using their everyday prosthesis is the simplest solution, but for the serious athlete a recreational prosthetic device may be necessary.

During the course of my work at Walter Reed Army Medical Center (WRAMC), Washington DC, a number of challenges have come my way. Finding creative solutions and building devices that don't exist commercially has been interesting and fun. Our team of prosthetists has built everything from customized gel undergarments (Medical Center Orthotics & Prosthetics, Silver Spring, Maryland) and upper-extremity rock climbing terminal devices (Advanced Arm Dynamics Inc., Redondo Beach, California), to silicone restorations with high-definition tattoos (Alternative Prosthetics Services Inc., Fairfield, Connecticut). Not only have these devices allowed our patients with amputations to begin or resume the recreational activities they love, the devices have provided an outlet for these people to express their personalities and interests.

Skating In-line

For Gunnery Sergeant Angel Barcenas, uphill in-line skating used to be a great way to train for triathlons. After losing both legs below the knee in Iraq and months of rehabilitation at WRAMC, he returned home to California. Barcenas wanted to resume in-line skating. "He tried on his rollerblades and wiped out on the garage floor," laughed his brother, George. Barcenas asked me if I could build skates for him that were lightweight and that would prevent him from immediately falling, so his brother wouldn't laugh at him.

It took some time to optimize the alignment and select the proper bumpers for the ankle. Knee braces provide Barcenas mediolateral (M-L) support as he pushes to the side. Brio™ ankles by Endolite North America, Centerville, Ohio, allow adjustability for slopes. In-line skating is now an option for Barcenas as he continues his athletic training. It is a great aerobic exercise that doesn't pound on his residual limbs the way running would.

Gunnery Sergeant Angel Barcenas demonstrates his athletic talent on custom-built in-line skates.
Gunnery Sergeant Angel Barcenas demonstrates his athletic talent on custom-built in-line skates.

I got the idea for directly attaching in-line skates to a prosthesis from Peter Reidl, CPO, at Streifeneder Group, Emmering, Germany, who fit Martin Karmann, Streifeneder's technical director and a semi-professional in-line skater. Their design incorporates the ankle unit of a Venture Foot® by College Park Industries, Fraser, Michigan.

Barcenas drew a crowd of observers as he skated down the prosthetics hallway at WRAMC, and it wasn't long before more people became interested. I received requests for customized in-line skates from two more bilateral patients and one unilateral patient. I even had a request for an ice hockey leg for Sergeant First Class (retired) Joe Bowser, a unilateral transtibial amputee. Bowser is an avid hockey player and wanted to take his game to the next level. In fact, he recently made the U.S. amputee hockey team. I fabricated his ice hockey skates similar to the rollerblades but found that the rocker skates he uses added another dimension. We're currently working on balancing ankle motion with the curvature of the blade to provide adequate stability and maneuverability on the ice. Using mold-making techniques with silicone, a protective cover for the pylon and ankle unit was fabricated to protect the device (and other players) from impact.

The Mother of Invention

Sergeant (retired) Brian Doyne tests his vacuum socket with a custom climbing device on the rock wall at Walter Reed Army Medical Center.
Sergeant (retired) Brian Doyne tests his vacuum socket with a custom climbing device on the rock wall at Walter Reed Army Medical Center.

Sometimes, amputees come up with their own solutions. Rock climbing was a big part of Sergeant First Class Jake Keesler's life prior to his limb loss. During an adaptive climbing trip, I had the opportunity to climb with Keesler, a bilateral knee disarticulation/transtibial amplutee. He realized right away some of the limitations of his prosthetic feet. We turned Keesler's feet backward for the duration of the outing, which slightly improved his ability to grip the wall, but upon returning to WRAMC, he was so excited to climb again that he immediately started drawing up ideas for rock climbing feet. Keesler and I worked on a prototype of a rock climbing foot that locks with weight and unlocks when picked up. Depending on the upcoming terrain, the device can be spun to the desired foot-hold pattern so that climbing techniques such as smearing or edging can be performed without slipping.

Cycling (and Carving) Up a Storm

Biking legs have been popular as well, and it was amputee athlete Scott Rigsby who introduced me to his biking setup. The relatively inexpensive Senator™ Foot can be ordered from Freedom Innovations Inc., Irvine, California, without a heel. A bike clip is then mounted to the toe. I fit amputee triathlete Major David Rozelle with this device, and for the first time he was able to stand and pedal without coming unclipped. Since then, several more avid cyclists have requested these devices.

The XT9© knee by Symbiotechs USA LLC, Amity, Oregon, produced by transfemoral amputee Jarem Frye, has helped simulate quadriceps function in transfemoral amputees, allowing a more athletic stance for skiers and snowboarders. The mountain bike shock in the knee absorbs shock and is adjustable in position and resistance. I work with a bilateral knee disarticulation/transfemoral amputee who is into four-wheeling and uses the XT9s to stand up while he's riding.

Snowboarders also find the knee useful, especially for making heel-side turns. Other knees either lock out or yield and are not conducive to the requirements of snowboarding. Ski instructors at the recent DS/USA Ski Spectacular in Breckenridge, Colorado, commented that the recent technology has allowed more amputees to use their prostheses for skiing or riding. This year, there were two bilateral transtibial/transfemoral amputee participants who picked up snowboarding, which the instructors said was the first time this had happened in their instructing experience.

Some simple devices can make the difference on the ski slopes. Snowboarders are required to take their back foot out of the binding at the lift in order to skate along the lift line. A device called the Swivler fits under the front binding and proved helpful for an amputee who has trouble skating at the lift. The binding can be rotated forward by pulling up on the leash, making it much easier to skate for those wearing a prosthesis. Another device called Walk-EZ Revolution is helpful for skiers. This collapsible rocker-bottom sole can be attached to ski boots and even fits Freedom Innovation's ski foot. Walking on snow with Walk-EZ is much easier for those wearing a prosthesis.

Making a Splash

The key to designing water prostheses is to really define what activities a person intends to do, whether it be swimming, SCUBA diving, wakeboarding, boating, jet skiing, fly-fishing, or just bumming around the beach wearing a flip-flop that still flips. One transfemoral amputee from WRAMC went back to active duty with the Naval Explosive Ordinance Disposal. In order to dive around mines, the prosthesis could not have any ferrous metals or the mine might detonate. It was a challenge to find components and materials, including set screws, that fit this requirement.

Sit-ups Without the Letdown

The 'flexion'assist helps Staff Sergeant Alex Shaw do sit-ups.
The 'flexion'assist helps Staff Sergeant Alex Shaw do sit-ups.

For amputees going back to active duty, there are some set physical requirements. One of these is to do a certain number of sit-ups. For Staff Sergeant Alex Shaw, limited knee flexion on his transtibial amputated limb prevented him from getting his foot back far enough to use proper form. I took apart a Freedom Runway Foot and mounted the ankle to the bottom of a socket. After showing the design to Freedom Innovations, a robust unit was created and shipped out. Now with the push of a button, Shaw is able to get more flexion out of his limb. This helps him with driving as well as sitting in a chair.

Solid designs are paramount to safety and durability. Sports and extreme activities are dangerous, and knowing that, it should be expected that occasionally parts will break. If anyone can attest to that fact, it's Sergeant Max Ramsey, a transfemoral amputee who is part of the Screaming Eagles Demonstration Parachute team. John Warren, CP, who works with Ramsey, first fastened an adjustable strap from Ramsey's socket to the shin of the prosthesis to limit knee flexion to 90 degrees during free fall. Ramsey later found the strap unnecessary as he re-learned to control his movements in the air. Occasionally with a hard landing, he shares the impact with his hydraulic unit, which fails as a result. Warren has replaced a number of units and is on the lookout for a better system. Still, it's better to have a mechanical knee fail than have a sound-side injury.

At WRAMC, if there is a limitation to using a sport or recreational device, all attempts will be made to accommodate the prosthesis or piece of sporting equipment to make that activity possible. I'm currently working on directly attaching prosthetic feet to a snowboard and a prosthesis for an amputee who is determined to climb Mt. Everest.

Enabling patients to participate in activities not otherwise possible due to the limitations of their prosthesis is incredibly rewarding. The human spirit is capable of surpassing incredible obstacles, and a patient's ambition to achieve is enough to inspire a similar ambition in his prosthetist to create these specialized devices. 

Zach Harvey, CPO, is the lead prosthetist at Walter Reed Army Medical Center, Washington DC.

The views expressed in this article are those of the author and do not reflect the official policy of the U.S. Department of the Army, U.S. Department of Defense, or the U.S. Government.

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