131Bulletin of Prosthetics Research, BPR 10-34 (Vol . 17 No . 2) Fall 1980

VA Rehabilitation Engineering Center (VAREC)252 Seventh Avenue, New York, N .Y . 10001Anthony Stmron M .S .M.E ., DirectorEdward Peizer, Ph .D., Deputy Director

Beginning with the first issue of the Bulletin of Prosthetics Research in theSpring of 1964, the VA Prosthetics Center (VAPC), now the VA RehabilitationEngineering Center (VAREC) a , has presented descriptions of its programsand projontn, for the purpose of disseminating information on new devicesand technology available to the handicapped veteran . Although funded inpart by VA Research and Development funds until very recently, the VAPCprograms were always oriented toward the most crying needs of the dis-abled veteran for treatment service . The Center was in large part engagedin finding the immediate solution to these needs.

The Center's long-time role inevaluation of rehabilitation devicesaimed at improving the quality ofpatient care and the efficiency ofservice delivery is well-known . Wewill continue all of these missionsas the VA Rehabilitation Engineer-ing Center . But it should be appar-ent from past and current effortsthat although the major programsare service delivery and evaluationof devices for the handicapped insupport of treatment programs, theCenter also has certain unique ca-pabilities in research.

Most of the Center's workthroughout those years when it wasin part funded with VA Researchand Development dollars was fo-cused on development . In lateryears, to help fill a real world-wideneed, the Center undertook an in-creasing role in evaluation and intesting . The broadening of the Cen-ter's scope recently mandated byVA Central Office calls for an evenwider service-delivery capabilitywith a more direct impact on the re-habilitation efforts of the VA De-partment of Medicine and Surgery,nationwide.

VAREC will report its work in anew publication on a quarterly ba-sis . The audience of this new pub-lication will be mainly those whoare on the "front !in*^ of patientoare, service delivery, and counsel-ing . Indeed it is expected to becomeone of the VA'a major channels forinformation about new products andprocesses being developed byman-ufaoturem' other rehabilitation cen-

a The VAPC became VAREC on July 1,1980 .

ters, research !aborutohon, privateinventors, and others . The newVAREC publication will periodicallypresent descriptions of the Center'sdevelopment, evaluation, and test-ing programs, as well as its service-delivery programs.

Within the broad spectrum of ne'habi!itudon ' the center's work willremain concentrated in the bandmost closely associated with treat-ment programs . Its commitment tohigh quality service delivery meansthat the center must always be onthe forefront of technology, thusunderlining the importance of itsmajor role in the evaluation of theproducts of technology . During theprocess of evaluation, criteria forprescription, training, and use be-come apparent . Gaps in the tech-nology are also noted, new needs indesign and development becomeknown . Moreover, with VAREC en-gineers directly involved in the careof the severely handicapped to solveor alleviate their individuol prob-lems, general needs become moreprecisely defined . Indicated devel-opment projects can then bounder-taken with vigor.

In contrast, the research activitiesof the Center are related to studiesor development of devices or eya-temavvhioh will have not an imme-diate impact but, rather, a long-termpotential . The Center staff will oon-tinuato publish progress reports onthese, periodically, in the Bulletin ofProsthetics Research.

As part of the Center's broadenedscope and new status, it will be-come more closely identified withthe modival capabilities within theVA Medical Center in New York City,

with New York University College ofMedicine, and the Polytechnic Insti-tute of New York . From these rela-tionships, other research projectsare expected to be generated.

Beginning with this issue of theBulletin, the VAREC (formerly VAPC)report will be presented in a newformat. Presented here is a brief re-port on research currently beingconducted in the oentor, and se-lected final reports on evaluationprojects previously the subject ofProgress Reports in the Bulletin ofProsthetics Research.

Anthony Staros, M .S .M.E.DirectorEdward Peizer, Ph .D.Deputy Director

Research

In recent years, reports on the op-erations of the Center have not pre-sented material specifically desig-nated as "research ." The results ofboth in-house and contractual workdealing with design and nwvvtech-nology were reported as "develop-ments," ranging from relativelysimple items to highly complexelectromechanical innovations.Many of those projects involved sci-entific efforts of sufficient rigor andnovelty to be considered research.For that reason, and in response tochanges in our mission and to thehigher technological level of ourwork, we now wish to identify cer-tain projects as research efforts eventhough they remain goal-oriented.

To conduct research studies inseveral areas of great need, we haveestablished the Tissue Stress Labo-ratory and the Motion Control Lab-oratory . The mission of the formeris very broad, encompassing stud-ies on the response of all kinds oftissue to all kinds of stress. The Mo-tion Control Laboratory is chargedwith re-establishing, or substitutingfor, lost oontrol of motion of thelimbs. The following are descrip-tions of some current research inthose laboratories.

A. Pressure Sores

Work in this area consists of clar-ifying the etiology of pressure soresas the euoential first step in devel-oping effective preventive, amelio-

132VAREC PROGRESS REPORT

FIGURE 1.Instrumented wheelchair seat simultaneously measures local skin arteriolar blood flow as well as pressure and shear . Remotereading device is located to gather data in the vicinity of the ivohial tuberosity. (Some information on the sensor, the disk-shapeddevice shown taped to the hard transparent-plastic seat of the wheelchair, appeared in : Bull Prosth Res BPR 10-29 . Spring 1e78 'pp . 160-161).

ouive, and perhaps eventually ther-apeutic measures.

1. Etiology—The sitting charac-teristics of geriatric hoopital pa-tients have been examined in termsof pressure, shear, and skin arter-iolar blood-flow in the area of theischium (Fig. 1) . The blood vesselsof geriatric patients occlude at lowersitting pressures (in two cases, aslow as 20 mmHg) and may developthree times the average shear valueseen in young healthy males. Thedesign goals of oonvandonal pas-sive seat-cushions appear insuffi-ciently stringent in the light of ourresults . FO- r example, we questionthe desirability of 40-mmHg contactpreeaure, or even 32 mmHg' forlong-term sitting of geriatric pa-tientsb .

A paper dealing in detail with thesubject is being prepared.

2. Prevention—The concept of aseat that is arranged to supply anoscillating or alternating pressureto prevent pressure sores is roughly

Kosiak, M ., "Etiology ofDeoubhva U!-oa,a^ ' Arco pxvox4ou nohobx42 :10-2S '1961 .

26 years old . While a number ofmechanically practical versions ofthis idea have been produced, todate no significant o!inioul suc-cesses seem to have been achieved.To some extent, this lack of successmay reflect inadequate design in'formahon ' and reliance on intuitivechoices of seat-oscillation ampli-tude and frequency.

We are designing a dynamic seatcontaining motorized cammedshafts arranged to produce a trav-eling wave under the ischial area.Amplitude and frequency are the in-put parameters ; output will consistof skin arteriolar blood volume andflow-rate, and shear values.

Instrumentation capable of func-tioning while placed between amoving cushion and a portion ofsoft tissue is currently in develop-ment . c Testing will seek to deter-mine appropriate seat motion, am-plitude, and frequency required to

lee, BY and Bennett, L : Seat Cushionsfor the Paralyzed . Bull Pros Res BPR 10-29\ pp . 160-161 . Spring 1978 . Also 10-30 (pg . 258) ; 10-31 (pg . 118) ; 10-32 (pp.405—406) ; and 10-33 (pg . 225) .

ensure adequate skin blood-flownear the ischium.

B.Nqicrmorcu!adon

A second related area deals withmore general phenomena related tothe microcirculation of the skin anddeeper tissue of the lower limbs.Changes in blood-flow in the limbsresulting from electrostimulationhave been infrequently reportedover the last century . In the pastfew years, the ready availability ofstimulating devices (transcutaneouse!eotrioal nerve stimulators) has ac-celerated efforts in this area . Recentreports indicate that roughly two-thirds of those patients with occlu-sive vascular disease of the lowerlimbs experience a 25 percent ormore increase in blood-flow afterextended electrostimulation treat-ment . d Relief of symptoms is re-ported as most effective for thosepatients with vasospastic disorders,

d Canosa, F, and 6o-y1e, E . "VascularPost Transcutaneous

Electrical Stimulation of Spinal Cordand Nerve Roots" Proc . 6th Inter Sympem Comm! Human Extrem, Belgrade .

133Bulletin of prosthetics Research, BPR 10~4 (Vol . 17mu2) Fall 1980

varicose ulcers and intermittentclaudication.

The reasons for increased blood-flow in an a!uotrioul field are un-clear. The limitations of the proce-dures are unknown . The thresholdvalue of blood-flow, i .e ., the !evelbelow which augmentation will notsucceed, is unknown although theliterature suggests that such athreshold exists.

In a major effort to clarify thesematters, VAREC has joined forceswith the Rehabilitation Medicine de-partment at the Bronx, N .Y . VAMedical Center . We are currentlyassembling instrumentation andpreparing protocols for thosestudies.

C. Prosthetic Myoelectric Hook

This work is intended to improvethe funotionol performance of up-per-limb amputees by means of amyoelectric hook which is inter-changeable with the VA myoelectrichand. The system is attached at thewrist by means of a quick-connectdevice, permitting the amputee touse one socket for both units.

The hook makes use of a high-performance permanent-magnetmotor, a unidirectional force lock,tv/oetagoaof^Eve!oid^gaaring ' andmodified removable (interchangea-ble) hook fingers . The batteries con-sist of six 450-mAh Nicad cells, lo-cated in the wrist housing with themy000ntrol electronics . The hookfeatures proportional control and thesame feature of energy savings dur-ing motor ota!l that was originallydeveloped for the VA switch-hand.Protection from feedback stimula-tion is also provided.

The engineering performance-goals are : fast response of less than50 ms tau (r) ; fast speed of 25 cm/s; large opening range of 15 cmmaximum ; high pinch-force of 5 to7 kg maximum (49 to 68 .6N) ; 800cycles per battery charge ; largeproportional control range of at leastone decade ; and provision for po-sition and force feedback . The pro-totype hook provides many of thedesired characteristics, but our goalsrelated to proportional control,weight, and efficiency have not beenfully achieved .

D. Paraplegic Ambulation

This seven-step research programis intended to explore a number ofavailable phyoio!ogioal and techno-logical means to enable paraplegicsto walk. The first step will be to de-velop a self-contained, externallypowered orthotic support systemthat can provide enough energy toenable a paraplegic to ambulate atan acceptable fatigue level . The userwill control this servosystem withslide potentiometers in the hand-grips of a pair of Canadian crutches.The angular position of the hip rel-ative to the torso will be controlledby the user's thumb on the slide.Putting the user in the system asthe control "intelligence" will sim-plify the !ogioal interface, at this re-search stage.

An Evaluation Committee to guidethe program is composed of a phys-iologist (who also serves as its co-ordinator), a health science special-ist, a rehabilitation engineer, aproothmtiot'orthotint ' and a secre-tary . The Committee screens andchannels all incoming projects ear-marked for evaluation, sets priori-ties, reviews protocols and reportedresults, maintains data, and moni-tors project status.

Evaluation projects may be con-ducted within the center, or at otherVA or contract fani!itioo, or both.They are mu!hdiauip!inary, requir-ing the services of engineers,prosthetists-orthotists, therapists,and physicians . Medical support forthe program is provided by VA-REC's Chief of the Special ClinicTeam, and staff of participating VAyNodioe! Centers ; paramediool sup-port is provided by the physiologistand health science specialist andtheir staffs ; engineering support isprovided by a VAREC rehabilitationengineer and his staff stationed atVA Medical Center, Castle Point,New York. Prosthetic-orthotic sup-port is provided by the Chief of VA-

Two approaches to the moohani-oal requirements will be studied . Thefirst employs hydraulic actuators,with their advantage of high forceand small size . The second is a high-performance electromechanical oyo-temvvich permanent-magnet motor,clutch, brake assembly, and a ballscrew—with the potmndal for highlevels of efficiency and control.

Both systems are intended to pro-vide the energy and stability forlimited !ovol walking . This is con-ceived as the first step (of five) to-ward independent ambulation. Atstep four we anticipate having aclinically uoeful devic*, one with ex-ternal muscle-stimulation and ex-ternal feedback elements, active vo-litional control, and the ability toabsorb mechanical energy or force.

REC\ePronthaboo{}rthodonService.The functional relationship betweenthe Evaluation Program and each ofthe other VAREC services is mu-tually supportive . Other servicesconduct tests, specialized analyses,and small-scale in-house evalua-tions of devices or techniques, asrequested by the Evaluation Com-mittee.

Following are final reports ofVA'REC evaluation projects between 1July 1979 and 1 July 1980 . Whereappropriate, historical reviews arealso presented.

Stand Aid.

The Stand Aid" (Fig . 2) designedby Ken Haibeck of South Falls, SouthDakota, and manufactured and dis-tributed by Main-Trainer Corp ..Shelton, Iowa, is a portable stand-ing frame designed to support ahandicapped individual in thestanding position . The adult StandAid 900 consists of a 30-in by 50-inby 27-in metul frame that weighs

aBriefly described in Bull Prosth Res BPR

10-30. Fall 1878 ' page 133. Must . pp.135-136.

VAREC Evaluation ProgramThe purpose of this program is to evaluate rehabilitation engineering de-

vices, procedures, and systems . Activities may range from the most basicm*uhonical bench-testing, through engineering and bioengineering evalua-tion of a concept and its implementation, to broad-scale, multicenter clinicalotudieoinappnopriateenvironmontoondpopu!adono ' vvithottontiontosub-jective factors, training requirements, etc .

134

VAREC PROGRESS REPORT

FIGURE 2.

Stand Aid portable standing frame supporting handicapped occupant in standing po-sition. Cutouts in floor plate admit front wheels of wheelchair for closer approach,to place occupant's knees against knee-support pads.

approximately 85 lb . The metal sidegrab bars are hinged to the frontsupport bar, to permit folding whenthe device is transported or stored.The contoured knee support, whichis padded, can be removed or ad-justed easily for various leg lengths.The trunk support is also paddedand attaches at various heights.Five-inch rubber casters allow safeand controlled mobility while an at-tendant is moving the Stand , Aidwith occupant.

The foot platform has properlyspaced foot locations, with adjusta-ble heel stabilizers .

The brakes are located on thefront frame ; when forced down, theylift the front casters slightly off thefloor.

There are three other modelsavailable : 1 . Little Tots 30-in W1ode!803 (35 in through 45 in child'sheight) ; 2 . Mini Jr. 40-in Model 902(45 through 55 in child's height) ; 3.Adults Jr . 48-in Model 901 (5 ftthrough 5 ft 10 in—small adult'sheight).

Optional equipment includes aclear plastic worktable, 25 in by 22in, enclosed in a mmtal frame andpadded on the area that supports

the occupant . A very important op-tion is the power lift to operate thelift bar . Two 12-V d .c . motors andgear assemblies and a 12-V re-chargeable battery are provided . Astandard canvas sling is attached tothe hooks located on the })ft bar:the lift bar slowly raises and lowersthe occupant when he engages thepower lift's rocker switch which isattached to the frame.

Utilization—The Stand Aid can beused either independently or withanoistonoe, when using the powerlift . The canvas sling should beplaced in the wheelchair before sit-ting, particularly for those who needassistance . The user approaches theframe from the open end, position-ing the wheelchair within the frameso that the knees are against thepadded knee-support and position-ing the feet on the foot platform.Next, the rocker switch is depressedto lower the lifting bar so that thecanvas sling can be attached to thehooks on each side of lift bar . Bydepressing the upper part of therocker switch, the user is then ablq ,to attain a fu!l standing position.When the lower part of the rockerswitch is depressed, the user is low-ered into the wheelchair.

A paraplegic needs the power liftto stand alone since he cannot in-depondant!yattauhthebuttooknup'port even if he can achieve thestanding position alone . (At leasttwo strong attendants are neededto stand a quadriplegic in the StandAid without the power lift .) There-fore, the power lift is highly rec-ommended.

Initial Evaluation—On August 16,1978, Mr . E. Kleinwolterink demon-strated the Stand Aid to VAPC staff.The demonstration was videotaped.The device then underwent labora-tory tests . The unit was then placedin the Corrective Therapy Clinic atthe VA Medical Center, Castle Point,N .Y, for o!ininal trials for a periodof 4 weeks ; next, it was tested inthe homes of oevoral disabled vet-eranofor a period of 6 weeks.

!nitial recommendations for im-proving utility of the Stand Aidwere:

1 . A power lift for raising theuser ;

135

Bulletinof Prosthetics Research, BPR 10-34 (Vol . 17 No . 2) Fall 1980

enough to stall the motors : morethan 18 repetitions were obtainedbefore the battery ran down if an in-terval of a few minutes was allowedbetween cycles.

User Trials—Evaluations by veter-ans in VAREC Laboratory and vet-eran homes.

a. A4O'year-o!d male (with an un-confirmed diagnosis of multiplesclerosis) with normal function ofthe upper limbs used one unit . Hehad sensation and movement in thelower limbs but was unable to standand remain standing without kneesupport . He also experienced spas-ticity at times. He weighed 140 lbend was 6 ft tall.

His initial use of the original StandAid produced no problems in get-ting from wheelchair to standingposition, due to a thin body struc-ture and good upper limbs. How-ever, he was unable to strap him-self in across the trunk with thepadded support . At that point it wasobvious that some type of lift assistwas needed ; without it he could notuse the Stand Aid independently.

b. A 50-year-old paraplegic whoweighed 181 lb . and was 5 ft .8 in,ta!l tried the Stand Aid before andafter the power lift kit and nylonharness strap were added . He hadbeen unable to pull himself up to astanding position without help froman attendant, but was able to standindependently with the power lift.(Once he was up and strapped in,the nylon trunk harness dug intothe soft tissue in the gluteal area . Itwas again recommended that themanufacturer replace the nylon har-ness with a full canvas sling .)

After the fu!l canvas sling wasadded, the same veteran tested theunit at home for 6 weeks. He wasable to stand approximately 2 hoursper day, 4to0days uweek . In com-paring the device to other standingdevices he had tried previously, hefound it to be more useful becausehe could read, oat ' or talk on thetelephone while getting his stand-ing exercise . The only disadvantagewas an inability to move independ-ently from one place to anotherwhile standing. He stated that it wasan excellent device and he wouldlike to purchase one.

FIGURE 3.Stand Aid portable standing frame equipped with power lift and canvas sling . Slingis meant to be placed on wheelchair seat before occupant sits in chair . Independentuse of the Stand Aid is then possible for some handicapped individuals . Note controlbox with mnko,owiu`h, and the pair of electric motors with m *coanioal linear acti-vators which raise or lower the lifting bars and attached sling . A patient using theStand Aid independently will be supported by the sling while standing and can usethe rocker switch to lower the sling (and himself) back into the wheelchair seat.Power is supplied by a sealed lead-acid battery, not shown here.

2. A full canvas sling (Fig . 3) in-stead of the nylon harness;

3. An improved method for con-necting the charger to the battery.The above recommendations wereadopted by the manufacturer andthe device was again laboratory andclinically evaluated . The resultswere:

Laboratory Tests—The power cellwas a 12-volt, 5 .0 Ah, sealed !oad-

acid battery produced by Gates En-ergy Products . The battery chargerproduced a 12 V d .c ., 500-mA out-put ; it uses a Standard 120-V 60-Hza.c . power source and consumes 8watts. The system drew 12 ampereswhen lowering the buttock pad withno occupant : the system drew 25amperes when raising and 12 am-peres when lowering a 220'!b oc-cupant . Thesystem vvaocycled con-tinuously und! the voltage dropped

136

VAREC PROGRESS REPORT

c. Another veteran tried the StandAid in the laboratory for 40 min 'with intervals of standing for 10 minand sitting for 5 min . (He had pre-viously been using a Stand Alone athome.) The Stand Aid's motorizedlift and its table top were the fea-tures he most preferred . After sev-eral uaeo, the nylon trunk harnessshowed signs of cutting into the0!uteol area. He said that the con-trol switch could bemade more ac-cessible totheuuorifhookadonthoframe with an extension cord in-stead of being screwed to the frame.Another suggestion was to includean adjustable back-plate for theheels, and a set of straps to holdthe foot across the top, for spasticindividuals . The final suggestionwas to provide a completely pad-ded lift bar . He liked the device verymuch and stated he would like tohave one—with these modifica-tions .

d. Another veteran, age 40, withmultiple sclerosis, reported after 10weeks with the Stand Aid that heused the devioe2 hours per day, 7days a week. He had previously usedother standing devices (parallel bars,a Castor Standing Frame, a LEVOStandup Wheelchair, etc .) . He likedthe power lift on the Stand Aid be-cause he was unable to stand upsafely on his own without knee andtrunk supports. He said that whilethe Stand Aid was very useful tohim, he would like to see a propul-sion motor added to give the usermobility while standing.

When the Stand Aid was retrievedfrom that veteran after the evalua-tion period, it was operating im-properly due to low energy in thebattery. A checkout revealed thatthe charger was malfunctioning.This was reported to the manufao-turur ' who later sent a replacement.

e. Another veteran, age 22, withtraumatic encephalopathy and righthemiparesis due to head injury, hadbeen using one of the original StandAids without the power lift . He wasfunctionally strong enough to stand,but due to ataxia he needed an at-tendant to attach the trunk support.When he was not using the StandAid for standing, the veteran's fatherallowed him to walk behind it whilepushing it under the father's super-

vision . The father felt that this wasan excellent device for standing ex-ercises and hoped it would aid inimproving his son's walking ability.The father liked the folding featureespecially because when folded, thedevice fit into the car trunk.Recommendations—The Stand Aidwith canvas sling trunk-support andpower lift was recommended forapproval for veteran beneficiaries(o!inical trials had proved the StandAid could not be used independ-ently without power). It was alsorecommended that an instructionmanual be supplied with each unit.Other (optional) recommendationswere for a motorized base for mo-bility in a work area, and a manuoloverride or release to allow the oc-cupant to lower himself if the liftmechanism failed.

Apor Safety Shower and TubGuards.

These devices (Fig. 4), manufac-tured by Apor Industries, Inc ., Au-rora, Ohio, replace standard built-inshower or tub filler-spouts . Temper-ature controls regulate water flowby reacting to increases in watertemperature . This can be a critical

requirement for persons with ab-sent or decreased sensation.

Description—Both devices usesealed thermostatic valves thatsense changes in temperature . Thevalves are encapsulated in chrome-plated, molded acrylonitrile-buta-dene-styrene plastic filler spouts . bOperating temperature is 110 deg F(43 deg C) ; normal bathing temper-ature 102 deg F(38dagC}to 104deg F (40 deg C) . When water tem-perature exceeds 110 deg F, waterflow automatically reduces to lessthan one half gallon (1 .80 liters) perminute . Hot water must then beturned off and cold water left onun-ti! full flow (cold) is reestablished,in approximately 15 to 20 seconds.The water temperature is then read-justed for nnrmal bathing . The unitscome in two models : Model CP-1and CP-2 are the standard models,and K8odo! V'CP-1 and V-CP-2 arethe "theft-proof" models which em-ploy a recessed Allen screw that isused to apply pressure on the waterpipe to prevent easy removal.

Clinical Evaluation —Shower Guardswere installed and tested in the

b Nvndonedin auUProath Rws8Pn 10-30,Fall 1978, page 147. !Dust. pg . 148.

FIGURE 4.Apor Safety Shower and Tub Guards replace standard built-in tub-filler spouts (left)or shower fixtures .

137Bulletin of Prosthetics Research, BPR 10-34 (Vol . 17 No . 2) Fall 1980

shower room of the Activities ofDaily Living (ADL) Training Roomand in the shower room on WardD-1 at the VA Medical Center, CastlePoint, New York. Three weeks fol-lowing these supervised clinicaltrials, a Shower Guard unit was in-stalled in the home of a disabledveteran in the Castle Point area, andseveral Shower and Tub Guardswere sent to the Acting Coordinatorof the Home Based Home Care(HBHC) program at the Albany, NewYork, VA Medical Center, and to theAids Technician at the Center for In-dependent Living, Berkeley, Califor-nia .

The Spinal Cord Injury Servicestaff at the Castle Point VAMC re-ported the Shower Guard to be ben-eficial to patients who bathe inde-pendently, and suggested that allshowers in the hospital be equippedwith the device, for safety. The headnurse stated : "Our water tempera-ture does fluctuate and burns are areal probability in patients with lostor diminished temperature-sensa-tion . This device eliminates thatprobability . Patients would alsobenefit from such a device in theirshowers at home."

The therapist in the ADL TrainingRoom at Castle Point felt it wouldbe an advantage to have both a TubGuard and Shower Guard if theycould be fitted without modifica-tions. The Shower Guard was in-stalled in the ADL Training Room,with a hand-held shower attachedfor the convenience of some of thedisabled veterans training in thatarea.

The installer said that it was easyto install the Shower Guards, but heovertightened the Allen screw onthe first unit and thus caused a crackin the plastic housing . The crackedunit was replaced and the units arenow functioning well.

A Shower Guard was installed inthe house of a disabled veteran bya staff technician of the VAREC lab-oratory at Castle Point . On his initialvisit to the veteran's home, thetechnician noted that an extensionpipe would be necessary before theShower Guard would fit . He wasable to obtain a 0 .5-in by 2 .5-in(1 .27-cm by 6 .35-cm) nipple fromthe plumbing shop to complete the

installation of the Shower Guard.Also, a hand-held shower was at-tached to the Shower Guard for theconvenience of the veteran.

The hand-held shower unit camewith a "water-saver" washer thatlimits water flow. When the hot andcold water valves were fully opened,only a moderate amount of watercame out, causing back pressure onthe Shower Guard and initiating aleak around the seam . The water-saver washer was removed and theleak was eliminated . This occur-rence was reported to the manufac-turer who later sent us a Dole FlowControl, Model PCG 3.0 GPM (whichwas never used), manufactured byEaton Controls Products, CarolStream, Illinois. Apor Industries rec-ommends that this water saver beused with its Shower Guard if aproblem occurs with the flow of thewater.

The Apor Shower and Tub Guardswere evaluated at the Center for In-dependent Living, Berkeley, Califor-nia, by subjects with spinal-cord-in-jury disabilities, arthritis, multiplesclerosis, and post-polio quadriple-gia.

Results—Five Shower Guards andtwo Tub Guards were installed, witha total of 59 user-months . All de-vices functioned properly after in-stallation and during followup test-ing. Although the devices operatedfrequently only during original tem-perature adjustment, there were twooccasions of flow reduction whenthe user was actually in the shower:those two users reported that seri-ous scalds might otherwise have re-sulted . All users claimed a greaterfeeling of security in their bathing,and one arthritic user who had beentaking baths rather than showersfor 15 years because of fear ofscalding, now took showers confi-dently.

Consultations with two plumbingcompanies pointed up a problem,however . Both expressed concernthat flow reduction would cause hotwater back-pressure to the extentthat, if the flow were not readjustedquickly, hot water might enter thetoilet system through the cold waterinlet and crack the fixture . Althoughthis seemed unlikely, both compa-

nies stated it was a possiblity.The Shower and Tub Guards are

relatively easy to install ; they havestandard half-inch threads and re-quire only a simple hand tool . Theyare chrome-plated and so do notclash visually with other bath fix-tures . All in all, these devices seemto be extremely cost-effective andin some cases might mean a greatdifference in bathing comfort, inde-pendence, and sometimes safety.

Conclusion—The Apor Shower andTub Guards have proven to be ef-fective devices in controlling theflow of water to a bathing area byreacting to increases in temperatureof the water-supply system . theyhave eliminated any dangers of abather with lost or diminished tem-perature sensation being scalded.

Clinical evaluation of the devicesshowed that they provide safetyagainst scalding during bathing, andthat they are useful in both hospitaland home . The evaluation of theTub Guard was limited because itlacked a diverter for tub/showercombination fixtures, but mostbathrooms have modern tubs withcombination tub and shower . TheTub Guard functions identically tothe Shower Guard and should beused when it can be properly in-stalled.

Recommendation—The Apor SafetyShower and Tub Guards can be pre-scribed when medically indicated aspart of a treatment program for aveteran beneficiary . It was furtherrecommended that the manufac-turer include a statement about useof the Dole Flow Control, Model PCG3 .0 GPM, and how and where topurchase it . The manufacturer wasalso asked to add a warning againstover-tightening the Allen screw onthe vandal-proof model, in the in-stallation instructions.

Porta Care Sink.

The Porta Care Sink c , a product ofthe Sinkette Corporation, Garden-ville, Pennsylvania is a portable sinkused to shampoo and wash the hair

°Briefly described in Bull Prosth Res BPR10-30, Fall 1978, pg . 145, with illustra-tion in use on pg 146 .

138

VAREC PROGRESS REPORT

bidUri ,iii. 5.,orta Care Sink is a portable sink ucud to shampoo and wash the hair nfa bedriddenor wheelchair-confined person . In use it is self-contained, once freshwater reservoirhas been filled and disposable plastic bag has been placed in wastewater sink.

of individuals confined to bed orwheelchair and unable to use bath-room facilities (Fig . 5).

The Porta Sink is made of light-weight molded plastic (polystyrene)in the shape of a small sink, withthe following attachments (Fig . 6):a plastic yoke that goes around theneck to prevent water from flowingon the user, a reservoir with four

peg s to hold a plastic disposablebag for collecting the soiled water(about 2 gal), a shoulder-board at-tachment for use when sitting in awheelchair, a hose with a sprayhead, a Power-Pak (12-V dry-cellbattery), a 12-V d .c . submersiblepump, and a water chamber thatholds about 2 gal of water . Overallthe device is 10 in wide by 16 .5 indeep by 12 in high, and it weighs20 lb.

Utilization—In use, the Porta CareSink is brought to the disabled per-son's bed or wheelchair, and a dis-posable sanitary bag is attached tothe four pegs in the reservoir . Toshampoo the head of a person in awheelchair, the shoulder board is

attached to the sinkette at the properheight of the sinkette relative to thefold in the back of the neck . Toshampoo a person in bed, a pillowis placed beneath the shoulder sothat the neck is free from obstruc-tion and is approximately 5 inchesoff the bed . The sinkette is posi-tioned behind and beneath the head,and the yoke is attached by gentlybending and engaging it in thegrooves of the shoulder board . Thewater chamber is filled with Oto 8quarts of water and the Power-Pakis placed directly into the nearchamber of the unit . The Power-Pakis turned on and the spray head isused to wet the user's head . Whileshampooing the user's hair, thePower-Pak is turned off to save bat-tery energy and aid motor life.

Upon completion of the shampoo,the yoke and Power-Pak are re-moved and the hair is towel-driedand wrapped in a towel . The dis-posable pouch is removed and dis-carded and the sinkette is removed.The user's hair is now ready forblow drying or styling.

The manufacturer contends thatthe Porte Care unit is easily adapt-

able to use for neurosurgery prep-arations, decubitus care, perineumcare, as an ADL device, and foremergency room use.

In May, 1977' the Sinkette Corp.loaned one Porta Care unit toVAREC for evaluation . The unitunderwent laboratory tests to deter-mine its safety and operation. Theproject monitor demonstrated theunit to the nursing staff on SpinalCord Injury Wards at the VA K8edi-oa! Center, Castle Point, New York.The unit was left on the wards to betested on as many different patientsas possible in the wheelchair and inbed. A second unit was purchasedby VAREC for evaluation in thehomes of severely physically dis-abled veterans.

Laboratory TestsInventory and specification

checks : all attachments were sup-plied and were operadonal on re-ceipt of the unit . The manufac-turer's brochures were supplied withdiagrams, operating instructions andsuggested usage.

Power requirements : the 12-V dry-oo!l battery was adequate for oper-ating the unit.

Clinical and Home EvauationIn the hospital : the Porta Care Sink

was used on a 44-year-old veteranwith a parLial myelopathy, trau-matic left-leg amputation, and os-teomyelitis . He was functionally ableto wash his own hair in a standardbathroom ; however, while he wasconfined to bed, the nursing stafftried the Porta Care Sink . He said hewas very pleased and comfortablewith the unit's operation and wantedto try it again . The nurse said it wasan excellent device . Its portabilityand simplicity was of great value ingrooming bedridden or wheelchair-confined patients.

A 45-year-old veteran with Gui!-!ian-BenA Syndrome was at onetime functioning on the level of acomplete quadriplegic . During thetime he was tested with the PortaCare Sink he had begun to showfunodonal use of all four limbs . Heasked to try this device because hespeculated that he would need it ifhe had a relapse . After having theunit used on him oncm, he observed

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Bulletin of Prosthetics Research, BPR 10-34 (Vol . 17 No . 2) Fall 1980

FIGURE 6.Porta Care Sink and associated accessories . Reservoir at right in photo shows freshwater chamber (filled) in rear and emptyvvavmw,ate, sink lined with disposable plastic bag.

that the head-and-neck slot was in-adequate because it produced un-due discomfort in both the neck andupper back . Overall, he thought theconcept was good but somethingshould be done to better supportthe head and neck . It was suggestedthat he use a pillow for support inthe future.

In the home : the family of a vet-eran who had severe joint contrac-tures, limited use of upper limbs,and paralysis of the lower limbsfrom neuromyelopathy and Parkin-sonism, also used the Porte CareSink . He reported that the sink hadworked well but he had experienceddiscomfort in the neck area due to

a lack of proper support and pad-ding . Folded wash towels placedbeneath the neck and shoulder pro-vided the necessary support andcomfort . Prior to using the PortaCare Sink, the family had used aface pan and pitcher of water, whichproved inconvenient and untidy . ThePorta Care Sink represented adme-aave/ for the family and an easiermeans of hygienic care for the pa-tient.

Two malfunctions occurred dur-ing the evaluations. After the first,the VAREC technician first checkedthe battery and wiring but could notisolate any problem . The batteryholder, which was glued on with aop*oiol waterproof g!um, was then

removed to gain access to the mo-tor. One strand of hair was foundwrapped tightly around the motorshaft, preventing it from rotating.Once it was removed, the unit wasoperational again . That piece of hairwas probably sucked in from theclean water chamber . The secondtime the unit malfunctioned, it hadto be sent back to the manufacturer.It was repaired, waterproofed andreturned to VAREC.

A C4-5 quadriplegic had his hairwashed three times a week usingthe Porta Care Sink . Prior to usingit, his hair had been washed once amonth . He reported that approxi-mately 10 minutes is required tocompletely wash his hair . Most im-

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VAREC PROGRESS REPORT

portant, the unit could be used al-most anywhere because of its sizeand portability . Also, once water isadded, it is completely oa!foon-tained.

This same veteran also reportedthat the hose was too short to ade-quately spray the entire hood, thewater spray was not forcefulenough, and the battery needed tobe rep!aced^t000ften^<onnemvory2 months) . He suggested a re-chargeable battery instead of the12-Vdrycell . (The first time the 12-V battery was replaced, two 6-Vbatteries had to be wired togetherbecause the required 12-V dry-cellbattery was not readily available atlocal stores.)

Conclusions and Recommendations—The Porta Care Sink is usefulin the care of veteran beneficiarieswho cannot wash their own hair.There are, however, several modifi-cations which would improve theovem!l quality of the unit : conver-sion to a rechargeable battery sys-tem to eliminate the periodic needto purchase the hard-to-find and ex-pensive 12-V dry-cell battery; addi-tion of an adapter to connect tworeadily available 6-V dry-uo!l butter-imo, and provision of slightly longerhose to allow the user to rinse allparts of the patient's head withoutmoving him.

Winsford FeederThe Winsford Feederd, originally

called the Morewood Spoon Lifter(Fig . 7) was developed by Mr . Wil-liam H . Morewood and is distrib-uted by Winsford Products, Inc .,Pennington, New Jersey. it is asemiautomatic feeding device thatallows quadriplegics to feed them-selves independently, using onlyhead motion, when food is alreadyon the plate and they are properlypositioned . The original MorewoodSpoon Lifter was submitted to thisCenter for evaluation in March 1974.Following clinical evaluation of theoriginol device at Castle Point, NewYork, a list of recommended modi-fications was sent to the manufac-turer to be incorporated in theSpoon Lifter.

dDescribed briefly in Bull Prosth R*oBPR10-28, pp. 126-127 .

In 1975, VAPC purchased 12 mod-ified Spoon Lifters ; 11 of them weredistributed to Veterans Administra-tion Spinal Cord Injury Centers foro!inioal evaluation ; one was re-tained by VAPC.

Description—The Spoon Lifter con-sisted of a square polypropylenebase approximately 12 in by 12 inwith four 1-in steel legs attached atthe corners beneath the base . Theswitch control was connected to thebase on the upper-left corner, andthe switch rod, which required adownward touch, had to be in-stalled by the attendant before eachmeal . The motor, which operatedfrom standard 110-V a .c . house uu prent. was connected to the base atthe lower-right corner. A metal ex-tension arm from the motor, withan adjustable steel clamp attachedto a steel disc at the end, held al-most any size of eating utensil . Thearm moved between the two posi-tions in one continuous motion oncethe switch control had activated themotor. At the lower left corner, therewas a stainless steel glass-holderwith a stainless steel receptacle fora otravv--it oou!d ho!d a otondard10-in plastic straw at the sameheight as the spoon when the spoonwas lifted to its highest level.

The other component of theMorewood Spoon Lifter was an ad-justable plastic headband with astainless steel piece connected to itthat went around the front of theuser's head. The stainless steel bandhad a steel receptacle attached to itin the front, which was used to holda 14-in non-adjustable vinyl-cov-ered metal rod with a "pusher" orshovel at its end.

The modified Morewood SpoonLifter, designated the WinsfordFeeder, utilizes an 18-in by 14 .5'inpolypropylene base with a 3-inch-deep curve cut out across the endnearest the user so that he can bepositioned nearer the plate . Bm-noaththo base, at each corner, thestationary legs were replaced witha receptacle designed to hold eachof the four sets of legs of differentlengths that range in size from 1 into 5 in . The switch uuntro!, con-nected to the base at the upper leftcorner, was enclosed, and the switch

rod no longer requires installationeach time the device is operated.No changes were made in the head-band, but the rod receptacle at-tached to the front of the stainlesssteel piece was changed from steelto plastic, to reduce the chance ofelectrical conductance that couldshock the user . The pushing rodwas designed for continuously ad-justable length, to prevent pushingthe head-piece off and to enable itto be set to any position on theplate by merely a tilting or turningof the user's head without movingthe shoulders . The glass-holder andstraw receptacle were not altered inany way for the Winsford Feedermodel.

In June 1976, the feeder was fur-ther modified by removing thestainless steel disc at the end of thelifting arm and replacing it with aDelrin disc . In July 1876, the stain-less atoel spoon clamp was re-placed by a plastic spoon clamp.Both changes were initiated to im-prove the device's insulation toavoid creating an electrical path be-tween the user and the mechanism.The motor on the Winsford Feederuomoo 110'Va .o . energy source ac-tivated by a oingle-po!a, single-throw N1ioroevvitoh, via a switch rodthat moves to the side and is heldin position for a brief moment toactivate the cam in the spoon drive.

Clinical Evaluation—Evaluation wasconducted at the following VeteransAdministration Medical Centers:Castle Point, New York ; Cleveland,Ohio ; East Orange, New Jersey;Hines, Illinois ; Long Beach, Califor-nia ; Miami, Florida ; Palo Alto, Cali-fornia ; Richmond, Virginia ; Tampa,Florida ; West Roxbury, Massachu-setts; and Wood, Wisconsin.

The purpose of the evaluationproject was to determine the safety,utility, and efficacy of the deviceand to ascertain the accuracy of themanufacturer's claim that only headmotion was needed for a quadri-plegic to independently feed him-self.

The user of the Winsford Feederrequires assistance before he canindependently feed himself . Thehelper must cut such foods as meator spaghetti into pieces that can be

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Bulletin of Prosthetics Research, BPR 10-34 (Vol . 17 No . 2) Fall 1980

FIGURE 7.The Winsford Feeder is a semiautomatic feeding device for quadriplegics, basedupon the Morewood Spoon Lifter shown here.

picked up with a spoon, must setthe plate of food on the base of thefeeder, must place the spoon in theclamp and place the headband withits attached "shovel" on the user.The attendant should then run thespoon to the upper end of its traveland position the user so that, withthe user sitting comfortably, hismouth and the spoon will be at thesame height . The subject shouldthen use the pusher to hold theswitch rod in position for a briefmoment to activate the extensionarm, which moves the spoon to thelower position . Once the spoon is inthe lower position, the attendantshould adjust the spoon so that thebowl of the spoon just clears theplate and the tip of the spoontouches the plate . Once this processis completed and the attendant hasmade all adjustments necessary, theuser shovels or pushes the food intothe spoon with head motions . An-other touch on the switch rod withthe pusher (holding it in positionbriefly) causes the spoon to lift inone continuous motion to its high-est level, where it stops and allowsthe subject to eat . This process isfollowed until the subject has corn-

pleted his meal . The attendant re-moves the headband when the sub-ject hoafininhnd eating.

Most users have been able to op-erate the Winsford Feeder inde-pendently, once the plate of foodwas placed on the base of the de-vice and the headband was at-tached to their heads . However, veryfew subjects were interested in useof the device because they wouldrather be fed by someone else thanexpend the time and energy neededto do it themselves.

Evaluation reports on the Wins-ford Feeder received from six VASCI Centers : (Castle Point, LongBeach, Miami, Palo Alto, Richmond,and Wood) reported on 16quadriplegics, of level C-5 andabove, who tested the device atthose centers . The test trials rangedall the way from only one attemptto repeated daily use in the homeenvironment . Highlights of the re-ports follow.

a . (Castle Point) : The staff re-ported that the attitude of most in-dividuals who saw the originalspoon-lifter was negative toward"gadgets"—they preferred to have

someone else feed them . However,one quadriplegic (C-4) was able tofeed himon(fa complete moal byuo-ing the device . This subject re-quested permission to take the de-vice home and arrangements weremade for him to do so . He contin-ued to use it at home for almost 3years. He found it necessary to putReston foam under the front of theheadband to relieve pressureagainst his forehead and help keepthe band from slipping.

The initial suggestions of the staffat that center were incorporated inthe modified feeder, and that sub-ject's spoon-lifter was modified.

The staff also reported that aoub-jon1 required good trunk balance touse the feeder, and that the motorwould stall if food stuck to thespoon bottom.

b . (Long Beach) : The WinsfordFeeder was evaluated in a clinicalsetting with five quadriplegics, C-5level and above. One subject tookthe device home for a week trialafter learning how to use it ; hecould use it only if he was up andin a wheelchair . A second subjectinterested in using the device couldonly assume a sitting position up to90 deg and had a tracheotomy tubethat interfered with the cervical neckmotion necessary to activate thedevice . The fourth subject was ableto use the Winsford Feeder in theo!inical setting ; and the fifth indi-vidual, who also used the deviceseveral times in the clinic, was ableto use it well and with consistency;he also wanted to use it at home.

Staff members at this facility ob-served the following : (i) the devicefailed to operate properly with stickyfoods such as baked beans andmashed potatoes, (ii) the subjectneeded good range of motion of thecervical neck to use the deviceproperly, and (iii) newly injuredsubjects were more receptive totrying the device than those withold injuries.

Staff and subjects at the LongBeach facility recommended the fol-lowing:

1. Lengthen the switch lever andspoon.

2. Adapt the legs with a spring-loading

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VAREC PROGRESS REPORT

sitioning the device.3. Reduce the speed of the lifting

arm .4. Try a "scoop-shaped" spoon

which might be more advanta-geous.

5. Adapt the device for batterypower for use away from the home,and even outdoors.

c. (Miami) : Staff members re-ported that the Winsford Feederworked well, and that subjects wereable to use it, but that its use provedto be too strenuous for certain sub-jects and required too much train-ing . They further noted that sub-jects should have good trunkbalance, should not be too spastic,and should have good neckstrength, control and coordination.Finally, they reported that the sub-jects rejected the headband be-cause of "appearance ."

d. (Palo Alto) : The staff at this SCICenter evaluated the WinsfordFeeder with four quadriplegic sub-jects (C-5) ; they requested threemore feeders because all subjectswere able to use the device.

e . (Richmond) : The WinsfordFeeder was evaluated with fourquadriplegic subjects (C-5) in theclinic ; the subjects were able to usethe device . However, the staff wasunable to find a subject who wouldaccept the device and use it morethan once, because most of theirsubjects had developed a dislike for"gadgets ." Staff suggestions in-cluded:

1. The pusher rod should betelescopic rather than coming invariable lengths.

2. The grip of the spoon clampshould hold more securely.

3. The switch rod should consistof adjustable lengths.

4. The headpiece should be pad-ded.

f . (Wood) : The Winsford Feederwas used successfully by a subjectwho could operate the controlswitch and load the spoon with hishands but could not lift his hands tohis mouth . Other subjects at thiscenter rejected the head device .

Conclusions and Recommenda-tions—Recommendations for im-provement in the design of the"modified spoon lifter" reportedfrom the various field stations in-clude:

1. A more comfortable headband,which can maintain its position dur-ing "shovelling" and chewing, issuggested;

2. The holding grip of the spoon-clamp should be more secure;

3. The legs should be made ad-

justable (instead of supplying legsof various size) for greater conven-ience when one unit is used by sev-eral persons;

4. A longer and/or adjustableswitch rod is needed;

5. A slower and/or an adjustablespoon speed is needed;

6. Adaptation for battery power,for use away from home and out-doors, would be useful.

The Winsford Feeder in its pres-ent form was found to be useful by

FIGURE 8.Recent version of the Winsford Feeder reflects comments and evaluations from pa-tients and clinicians : the headband and its antenna-like pusher have been eliminated.Ball-tipped switch arm now conveys minimal patient head motion to switch, and boththe "pushing" and the spoon motion are powered . Smooth, seamless housing con-ceals working parts, replacing the former box-like metal housings which gave astrong visual suggestion of machinery, the laboratory, and industrial gadgetryto some patients.

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Bulletin of Prosthetics Research, BPR 10-34 (Vol . 17 No. 2) Fall 1980

a small number of the veterans whoevaluated it . In its present configu-ration, it was most useful to thenewly injured and those with rela-tively mobile cervical spines. Forthese reasons, we can recommendthat the device be made available toveteran beneficiaries on prescrip-tions that recognize its limitations.It is further recommended that themanufacturer be urged to improvethe utility of the device in accord-ance with the six recommendationscited above, to make it useful to aneven larger number of people.

For a recent view of the WinsfordFeeder see Figure 8 .