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					                                                                                               Volume 5, Issue 1

             2211 Quarry Dr.   Suite E63,   West Lawn, PA   19609   610.678.1200    800.678.0338

“C-Leg” a Case Study
                                                                          Inside This Issue…
Recently, we, at NexStep, had the pleasure of meeting a hero. This
37 year old man had his life changed forever 11 years ago when he          Case Study                         1
stopped to help a stranded motorist with her car. Another vehicle
                                                                           IM ABLE Foundation                 2
smashed into him and pinned his right leg between the two cars. The
next day he woke in the hospital with his right leg amputated below        Prosthetic Functional Levels 3
the knee. Healing was a slow process, as is the case in traumatic am-
putations sometimes, but he was fit with a below the knee (BK) pros-       Case Study, continued              4
thesis, received physical therapy and was successfully ambulating.

Fate stepped in again and the skin graft used to close the amputation site failed, infection ensued and the limb
was removed. The 25 year old now had an above the knee (AK) amputation and the rehabilitation process
began again. His first AK prosthesis fit poorly, was painful to wear and came with a very heavy-duty waist
belt for suspension. He felt like he was in the dark ages. Pretty soon he figured out he could get around faster
and easier using just his axillary crutches. The prosthesis ended up in the closet.

Five and a half years later, there was a guy on ABC’s Extreme Home Makeover wearing an AK prosthesis
with a computerized knee. They mentioned that the company who made the prosthesis was in Ohio. Our
hero called them up and headed to Ohio to get a new prosthesis that was supposed to be the “best available”.
Four days in Ohio and he had his new leg; home he drove only to learn, rather quickly, that the prosthetic
socket was too painful to wear and the leg was too unstable to walk. Physical therapy was tried for a while,
but it just would not work for him. He quit therapy and he quit trying to use the prosthesis. Something must
be wrong with him or something’s not right with his amputation; whatever it was, he figured he was just not a
prosthetic candidate.

Three more years go by; then one day our hero meets an older gentleman at an area coffee shop. The man
starts a conversation by asking why a young fella like himself is not wearing a prosthesis. Half way through
his explanation to the stranger, the guy pulls up his pant leg and shows off his BK prosthesis. The guy says:
“I ride bicycle and everything with mine! You need to see my guy and get a leg that works for you. Socket fit
is everything; my guy is an artist.”
                                                                                              Continues on page 4
          NEXSTEP Prosthetic Newsletter                                                              Page 2

IM ABLE Foundation Kickoff Event

The IM ABLE Foundation held its kickoff event Saturday, November 17th, 2007
in the Designer Building at the VF outlets, Reading, PA. The purpose of the
event was to raise funds for their continued efforts in promoting physical fitness
for individuals with physical disabilities. Their focus is on encouraging children
with disabilities and their families to become physically active, but also to raise
awareness of the able-bodies community to afford them a greater understanding
and respect for what their disabled counterparts face everyday.

Founder and Director, Chris Kaag, created this foundation to “...demonstrate to
individuals with a physical disability that there is a way to become and stay active
despite their physical limitations. Our goal is to help individuals find the physical
fitness modality (e.g. a hand driven bicycle) that will help improve muscle strength
and coordination.” The IM-Able Foundation plans to help families purchase
equipment that best meets their needs.
                              Over 200 people attended the inaugural event, raising over $ 20,000. A good
                              time was had by all, as we participated in wheelchair obstacle course races,
                              wheelchair basketball, football toss and putting on a golf green. Attendees also
                              got to try examples of hand driven bicycles (shown below). Bikes cost $1200-
                              $3000, and Chris teaches people personally how to safely begin this activity.

                              I found out about this organization when a woman called my office looking for
                              somewhere to rent or borrow a hand cycle for her father who was coming to
                              visit. Her father had an above the knee amputation a year ago, and she was
                              hoping to find an outside activity he could enjoy. I had no idea, so I called my
                              bicycle guy, Brad at Technocycle and he referred me to Chris. I gave Chris the
      Chris Kaag 2007
                              information, he made contact, set up a time to meet, loaned the woman’s father
a hand cycle and showed him how to ride. Very cool.
Thanks Chris!

Also worth noting, websites to check out:
For the IMABLE Foundation:
Chris owns and runs a workout facility called Corps Fitness,
see it at: He is a Level 1 CrossFit
instructor and certified group fitness instructor. Check out his
5th Annual “Got the Nerve” Triathlon May 24th. This event
benefits the Myelin Project that supports research on nerve
damage disorders. Details at:

                                                                           Examples of Hand Driven Bicycles
       NEXSTEP Prosthetic Newsletter                                                                Page 3

Prosthetic Functional Levels Explained
There are many factors that must be taken into consideration when deciding what prosthetic components
are used for each individual's prosthesis. The main consideration is the “anticipated functional level”. In
other words, how functional do you expect this individual to become once trained to use their prosthesis.
These prosthetic functional levels are known as “K-Levels” and are broken down as follows:

                  K-0 Does not have the ability or potential to ambulate or transfer safely
                       with or without assistance, and a prosthesis does not enhance
                       their quality of life or mobility.

                  K-1 Has the ability or potential to use a prosthesis for transfers or
                       ambulation on level surfaces at a fixed cadence. Typical of the
                       limited and unlimited household ambulator.

                  K-2 Has the ability or potential for ambulation with the ability to
                       transverse low level environmental barriers such as curbs, stairs
                       or uneven surfaces. Typical of the limited community ambulator.

                  K-3 Has the ability or potential for ambulation with variable cadence.
                       Typical of the community ambulator who has the ability to
                       transverse most environmental barriers and may have vocational,
                       therapeutic, or exercise activity that demands prosthetic
                       utilization beyond simple locomotion

                  K-4 Has the ability or potential for ambulation that exceeds basic
                       ambulation skills, exhibiting high impact, stress or energy levels.
                       Typical of prosthetic demands of the child, active adult or athlete.

Once the rehabilitation team, consisting of the physician, therapist and prosthetist, determine the
anticipated functional level, the prosthetist has specific prosthetic components that are classified for each
level from which to choose. All prosthetic companies, no matter their size, have access to the same
prosthetic componentry available on the market. Each company utilizes the same Medicare coding
system and fee schedule when billing for these components. The difference lies in how much the
prosthetist involves the amputee in the decision making process; how well the prosthetist listens to
individual concerns, how much support and education is provided with the prosthesis and how available
the prosthetist is for follow-up care.
       NEXSTEP Prosthetic Newsletter                                                              Page 4

“C-Leg” a Case Study continued:
A few weeks later our hero is seeing Rick Milen, CPO at NexStep, Inc. for a free consultation. He
arrived using his axillary crutches and carrying his prosthesis which consisted of a black-carbon socket
with flexible inner socket. Suspension was a locking pin system and a 6mm, gel locking liner. The
“C-leg” (microprocessor knee and shin system) and foot appeared brand new. When asked to put his
prosthesis on, he applied the locking liner, easily slide his limb into the socket and stood up. It was
immediately apparent that the socket was extremely too large for his limb. Twenty-one plys of socks was
applied over the liner and tried again. Stability was non-existent, socket design and contours were totally
inappropriate; there was no ischial weight bearing, no ischial containment, no ramus control, no lateral
femoral control, absolutely nothing redeemable about this socket.
A plan was formulated. We would fabricate an appropriately designed and fitting socket; then travel
together to a C-Leg certification course. Prosthetists must be certified by the knees’ manufacturer in order
to provide and program these knees. The first dynamic test socket fitting went very well. We utilized a
hydraulic swing ‘n’stance style knee in the interim. Immediately upon standing and then when he sat, our
hero stated: “Oh, my God, it doesn't hurt anywhere!” A second test fitting was done to fine tune the socket
shape and optimize his stability and control of the limb. When we were both satisfied, the definitive socket
was fabricated and fit. We set up a few sessions of physical therapy prior to our trip to Florida for the
C-Leg course; then we were off.
Right before lunch on day one of the course, it was time to replace the loaner knee with his microprocessor
knee-shin system and begin programming it. Literally, within the first five minutes, he was ambulating
across the room using only one crutch, and 10 minutes later he was moving down stairs and a ramp step-
over-step using one railing. This was huge! He was telling his story to everyone; he could not believe the
difference a well designed and fitting socket made. After a full day of class and walking, he removed his
prosthesis to find not one area of concern. There was no rubbing, pinching or pain anywhere. Day two of
the course we learned more about the functions of this incredible microprocessor knee and finished
programming it.
It is only two weeks after returning from the course that this article is being written, and our hero is
continuing his out-patient physical therapy to learn proper body mechanics used with an AK prosthesis and
un-learn many bad habits that have developed thanks to years on axillary crutches. The prosthesis is worn
all day, almost everyday and as Spring moves in, our hero is working with OVR (occupational-vocational
rehabilitation) to find work in his field of electric contracting or begin training for another career.
     Moral of the story: Without a comfortable and properly designed socket, it doesn’t matter what
                    technology is involved, you will not be able to use your prosthesis.

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