O&P Pioneer: Ivan Long, CP(E) Horse Trainer Turned Prosthetist
Recognized as a legendary pioneer, Ivan Long, CP(E) began his distinguished career in the orthotics and prosthetics field in a saddle shop. The leatherwork he did as a horse trainer led to an interest in orthotics manufacturing. An interest heightened, perhaps, by a personal desire for a better gait, since a polio affliction at the age of two resulted in a weak left leg and a first-hand appreciation of the challenges and benefits of the field.
During the 1950s, Long developed braces and orthotics in Minneapolis, Minnesota, then moved to Denver, Colorado, in 1957 to begin prosthetic work. He traveled across the country during this time, taking every available course in the field at the University of California-Los Angeles (UCLA), New York University (NYU) and Northwestern University, Chicago, Illinois.
Then, in 1974, Long made a discovery that led to his best-known contribution, a revolutionary socket design. While working with transfemoral amputees who were Vietnam veterans at Fitzsimmons Army Hospital near Denver, Long requested a full-length X-ray of a prosthetic patient standing in his prosthesis. What he saw was something completely unexpected. He found that the femur in the quadrilateral socket, the socket most widely used at the time, was at nearly 20 degrees of abduction. He proceeded to X-ray 100 amputees fitted with the quadrilateral socket from hip to floor. His findings were astonishing: 94 of those patients presented with abducted femurs. "I began taking X-rays of patients standing in prostheses, and that was the turning point of my life," Long remembers. He published his findings in the December 1975 issue of Orthotics and Prosthetics, and since that time, his career has focused on remedying the problem of femoral abduction in transfemoral amputees.
Long discovered that current socket design offered little support for the amputated femur. Unsupported, the femur is abducted by the gluteus medius muscle, one of 12 muscles unaffected by transfemoral amputation. The gluteus medius and gluteus maximus muscles' normal function is to adduct the femur when walking. Therefore, Long found that an improper socket resulted in healthy muscles working opposite of what they should do. "When the femur of the amputated limb is pointed away (abducted) from the midline of the body, it has the same effect on the gluteus medius as paralysis." Long explained in a 2004 issue of inMotion magazine, "When this muscle is functioning properly, it helps support the upper body, and the head moves forward without shifting to the side when an individual walks. Without gluteus medius support, however, the entire upper body moves over to the side for balance." This causes the amputee to walk with a wide base and a "lurch" to the amputated side.
Long's lifelong goal has been to help amputees improve their gait. "It's a tremendous feeling when you can change the way a person walks and take away that lurch to the side." To this end, Long developed what he termed the Normal Shape, Normal Alignment (NSNA) method. The first step was to design a socket that would support the femur in place and reduce the abduction problem. "In order to support the femur," Long explained, "it is necessary to narrow the M-L dimension of the socket."
Ischial Containment Socket
Long noted that in the quadrilateral socket, the ischial tuberosity rested on the posterior wall of the socket, which allowed the patient's socket to move laterally during weight bearing. His solution was to create a socket that contained the ischial tuberosity, now known as the ischial containment socket.
"Ischial containment alone is not the complete answer," Long stresses. "There definitely needs to be proper alignment to go with it, and that is where Long's Line comes in." Long's Line is a straight line starting at the center of the hip joint, passing down through the distal femur, through the center of the heel of the prosthetic foot. To this day, one of Long's greatest disappointments has been that, though the ischial containment socket is widely used, the crucial alignment process is often ignored. In his opinion, the best way to achieve the proper alignment is by X-raying the patient in his/her prosthesis. His hope is clearly stated on the back of his "Above Knee Prosthetic Consultant" business card: "Wish for the day when a prescription for an above-knee prosthesis will be accompanied with an X-ray of the pelvis and both femurs. The X-ray would show the ability of the amputee to adduct the amputated femur to a normal angle. Another X-ray would be taken of the amputee standing in the finished prosthesis to demonstrate normal adduction."
After his article in inMotion magazine was published, Long received e-mails from amputees around the country asking if he could help them "walk better." He corresponds with both the patient and their prosthetists in an effort to assist with proper alignment. Is it possible for this sort of "long-distance" patient care to occur? In fact, one of Long's career highlights occurred when he demonstrated the incredible fitting of a prosthesis to a patient he had never met. Long presented the prosthesis he had created in advance from the measurements and cast of the residual limb mailed to him by a transfemoral amputee at the 1985 American Orthotic & Prosthetic Association (AOPA) meeting in Pittsburgh, Pennsylvania. He successfully fit the patient with the new limb in front of 140 prosthetists, and the amputee incredibly walked better than he had since his amputation, declaring that for the first time he was free from the pain of his distal femur pressing against the wall of the socket.
Because actually seeing an amputee's gait change in this way is worth a thousand words, Long videotaped his patients walking down a hallway with their "old" prosthetic limb and then with a new one Long fitted using the NSNA method. Patient after patient appeared on the tape, and the results were all the same: the side-to-side motion, lurching to the amputated side, and discomfort were all remedied by the new limb. One patient remarked, "Wow, that feels better!"
Honored for Work
In 1991, the American Academy of Orthotists and Prosthetists
(the Academy) honored Long's work with transfemoral amputees by
awarding him the Distinguished Practitioner Award. "I was quite
excited to be the first prosthetist to receive the award," Long
said. Students and colleagues alike respect him. "Mr. Long is a
shining example of the best of the O&P pioneers," commented
John Michael, CPO, FAAOP, who began his career in 1976. "He never
lost his patient focus. He mastered the state-of-the-art of his
era, then he had the courage and insight to violate the "norms" to
take state-of-the- art to another level." Michael continued, "When
I was a student prosthetist in the 1970s, Gunter Gehl, CP, told our
graduating class at Northwestern University that Ivan Long had
written an article about a new type of socket. He said we should
all read it because if Ivan says it's better, then it is." This
year, Long was honored with a Lifetime Achievement Award at the
Hanger Orthopedic Group Education Fair in Reno, Nevada. Yet, Long
said, "The greatest reward comes from helping people walk straight.
That's what keeps me going to this day."
Sherry Metzger, MS, is a freelance writer with degrees in anatomy and neurobiology. She is based in Westminster, Colorado, and may be reached at firstname.lastname@example.org