1
|
Klotz R, Emile G, Daviet JC, De Sèze M, Godet J, Urbinelli R, Krasny-Pacini A. Daily socket comfort in transtibial amputee with a vacuum-assisted suspension system: study protocol of a randomized, multicenter, double-blind multiple N-of-1 trial. BMC Sports Sci Med Rehabil 2023; 15:85. [PMID: 37452356 PMCID: PMC10347726 DOI: 10.1186/s13102-023-00694-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 06/25/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND The main aim of this paper is to present the feasibility of rigorously designed multiple N-of-1 design in prosthetics research. While research of adequate power and high quality is often lacking in rehabilitation, N-of-1 trials can offer a feasible alternative to randomized controlled group trials, both increasing design power at group level and allowing a rigorous, statistically confirmed evaluation of effectiveness at a single patient level. The paper presents a multiple N-of-1 trial protocol, which aim is to evaluate the effectiveness of Unity, a prosthetic add-on suspension system for amputees, on patient-reported comfort during daily activities (main outcome measure), prosthesis wearing time, perception of limb-prosthesis fitting and stump volume and functional walking parameters. METHODS Multicenter, randomized, prospective, double-blind multiple N-of-1 trial using an introduction/withdrawal design alternating Unity connected/disconnected phases of randomized length on twenty patients with unilateral transtibial amputation. The primary outcome measure is the Prosthetic Socket Comfort Score (SCS), a validated measure of comfort, administered daily by an phone app designed for the study. Secondary outcomes measures will be collected during the 50 days period of the N-of-1 trial: (1) by the same app, daily for patient-reported limb-prosthesis fitting, stump volume variation, and daily wearing time of the prosthesis; (2) by a pedometer for the number of steps per day; (3) by blind assessors in the rehabilitation center during adjustment visits for functional walking parameter (L-Test, 6-minute walk test), and by the patient for the QUEST, and ABC-S. Effectiveness of the Unity system regarding SCS and daily secondary outcome measures will be tested by randomization test. The secondary outcome measures assessed during visits in the rehabilitation center will be analyzed by Non Overlap of All pairs. An estimate of the effect on the amputee population will be generated by aggregating each individual clinical trial (N-of-1 trial) by Hierarchical Bayesian methods. DISCUSSION This study protocol was designed to answer the question "which device is best for THIS patient" and to conclude at a group level on the effectiveness of a new devic, using a Multiple N-of-1 trial, which is promising but underused in prosthetics research so far. TRIAL REGISTRATION N° ID-RCB 2020-A01309-30 Clintrial.gov : NCT04804150 - Retrospectively registered March 20th 2021.
Collapse
Affiliation(s)
- Rémi Klotz
- La Tour de Gassies Centre for Physical Medicine and Rehabilitation, UGECAM, Rue de la Tour de Gassies, Bruges, 33523, France
| | - Guilhem Emile
- Department of Physical and Rehabilitation Medicine, Centre Hospitalier d'Arcachon, Avenue Jean Hameau, 33260, La Teste de Buch, France
| | - Jean-Christophe Daviet
- Department of Physical and Rehabilitation Medicine, Limoges University, Jean Rebeyrol Hospital, Avenue du Buisson, 87170, Limoges, France
| | - Mathieu De Sèze
- Physical and Rehabilitation Medicine Unit, Bordeaux University Hospital, University of Bordeaux, EA4136, Bordeaux, France
| | - Julien Godet
- Clinical Research Methods Group, Laboratory of Bioimaging and Pathologies, UMR CNRS 7021, University Hospitals of Strasbourg, Illkirch, Strasbourg, France
| | | | - Agata Krasny-Pacini
- Department of Physical and Rehabilitation Medicine, UF 4372, CHU de Strasbourg, Institut Universitaire de Réadaptation Clémenceau, 45 Boulevard Clémenceau, Strasbourg, 67000, France
- Department of Psychiatry, Hôpital civil, INSERM 1114, Strasbourg University Hospital, Strasbourg, France
| |
Collapse
|
2
|
Safari R. Lower limb prosthetic interfaces: Clinical and technological advancement and potential future direction. Prosthet Orthot Int 2020; 44:384-401. [PMID: 33164655 DOI: 10.1177/0309364620969226] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The human-prosthesis interface is one of the most complicated challenges facing the field of prosthetics, despite substantive investments in research and development by researchers and clinicians around the world. The journal of the International Society for Prosthetics and Orthotics, Prosthetics and Orthotics International, has contributed substantively to the growing body of knowledge on this topic. In celebrating the 50th anniversary of the International Society for Prosthetics and Orthotics, this narrative review aims to explore how human-prosthesis interfaces have changed over the last five decades; how research has contributed to an understanding of interface mechanics; how clinical practice has been informed as a result; and what might be potential future directions. Studies reporting on comparison, design, manufacturing and evaluation of lower limb prosthetic sockets, and osseointegration were considered. This review demonstrates that, over the last 50 years, clinical research has improved our understanding of socket designs and their effects; however, high-quality research is still needed. In particular, there have been advances in the development of volume and thermal control mechanisms with a few designs having the potential for clinical application. Similarly, advances in sensing technology, soft tissue quantification techniques, computing technology, and additive manufacturing are moving towards enabling automated, data-driven manufacturing of sockets. In people who are unable to use a prosthetic socket, osseointegration provides a functional solution not available 50 years ago. Furthermore, osseointegration has the potential to facilitate neuromuscular integration. Despite these advances, further improvement in mechanical features of implants, and infection control and prevention are needed.
Collapse
Affiliation(s)
- Reza Safari
- Health and Social Care Research Centre, University of Derby, Derby, UK
| |
Collapse
|
3
|
Quinlan J, Yohay J, Subramanian V, Poziembo B, Fatone S. Using mechanical testing to assess the effect of lower-limb prosthetic socket texturing on longitudinal suspension. PLoS One 2020; 15:e0237841. [PMID: 32813733 PMCID: PMC7437898 DOI: 10.1371/journal.pone.0237841] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 07/27/2020] [Indexed: 11/18/2022] Open
Abstract
To function effectively, a lower limb prosthetic socket must remain securely coupled to the residual limb during walking, running and other activities of daily living; this coupling is referred to as suspension. When this coupling is insufficient longitudinal pistoning of the socket relative to the residual limb occurs. Increasing friction of the socket/liner interface may improve socket suspension and textured sockets may be fabricated relatively easily with 3D printing. The aim of this study was to investigate longitudinal displacement of sockets with different types of textures under two suspension conditions: passive suction and active vacuum. In order to do this, we developed a mock residual limb and mechanical testing protocol. Prosthetic sockets, 14 textured sockets and an Original Squirt-Shape (OSS) Socket, were fabricated from polypropylene copolymer using the Squirt-Shape™ 3D Printer and compared to a smooth socket thermoformed from polypropylene copolymer. Sockets were mounted onto a dual durometer mock residual limb and subjected to four levels of distraction forces (100 N, 250 N, 500 N and 650 N) using a hydraulic material testing system. There was a statistically significant three-way interaction between suspension, force level and texture (p < 0.0005). Longitudinal displacements between textured and reference sockets, for all force levels and both suspension conditions, were significantly different (p < 0.0005). Using these newly developed mechanical testing protocols, it was demonstrated that texturing of polypropylene copolymer sockets fabricated using Squirt-Shape significantly decreased longitudinal displacements compared to a smooth socket. However, none of the novel textured sockets significantly reduced longitudinal displacement compared to the OSS socket under passive suction suspension.
Collapse
Affiliation(s)
- Julia Quinlan
- Department of Physical Medicine and Rehabilitation, Northwestern University Prosthetics-Orthotics Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Jessica Yohay
- Department of Physical Medicine and Rehabilitation, Northwestern University Prosthetics-Orthotics Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Vasanth Subramanian
- Department of Physical Medicine and Rehabilitation, Northwestern University Prosthetics-Orthotics Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| | - Brad Poziembo
- Prosthetic Design Inc, Dayton, Ohio, United States of America
| | - Stefania Fatone
- Department of Physical Medicine and Rehabilitation, Northwestern University Prosthetics-Orthotics Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
- * E-mail:
| |
Collapse
|
4
|
Youngblood RT, Brzostowski JT, Hafner BJ, Czerniecki JM, Allyn KJ, Foster RL, Sanders JE. Effectiveness of elevated vacuum and suction prosthetic suspension systems in managing daily residual limb fluid volume change in people with transtibial amputation. Prosthet Orthot Int 2020; 44:155-163. [PMID: 32186238 PMCID: PMC7443051 DOI: 10.1177/0309364620909044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Previous studies investigating limb volume change with elevated vacuum have shown inconsistent results and have been limited by out-of-socket volume measurements and short, single-activity protocols. OBJECTIVES To evaluate the effectiveness of elevated vacuum for managing limb fluid volume compared to suction suspension with an in-socket measurement modality during many hours of activity. STUDY DESIGN Fixed-order crossover design with a standardized out-of-laboratory activity protocol. METHODS Transtibial electronic elevated vacuum users participated in two sessions. Elevated vacuum was used during the first session, and suction suspension in the second. Participants completed a 5.5-h protocol consisting of multiple intervals of activity. In-socket residual limb fluid volume was continuously measured using a custom portable bioimpedance analyzer. RESULTS A total of 12 individuals participated. Overall rate of fluid volume change was not significantly different, though the rate of posterior fluid volume change during Cycle 3 was significantly lower with elevated vacuum. Although individual results varied, 11 participants experienced lower overall rates of fluid volume loss in at least one limb region using elevated vacuum. CONCLUSION Elevated vacuum may be more effective as a volume management strategy after accumulation of activity. Individual variation suggests the potential to optimize the limb fluid volume benefits of elevated vacuum by reducing socket vacuum pressure for some users. CLINICAL RELEVANCE A better understanding of how elevated vacuum (EV) affects residual limb fluid volume will allow prosthetists to make more informed clinical decisions regarding accommodation strategies designed to improve daily socket fit.
Collapse
Affiliation(s)
| | | | - Brian J Hafner
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Joseph M Czerniecki
- VA Center for Limb Loss and Mobility, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Katheryn J Allyn
- Department of Bioengineering, University of Washington, Seattle, WA, USA
| | | | - Joan E Sanders
- Department of Bioengineering, University of Washington, Seattle, WA, USA
| |
Collapse
|
5
|
Schoepp KR, Schofield JS, Home D, Dawson MR, Lou E, Keri M, Marasco PD, Hebert JS. Real time monitoring of transtibial elevated vacuum prostheses: A case series on socket air pressure. PLoS One 2018; 13:e0202716. [PMID: 30346953 PMCID: PMC6197629 DOI: 10.1371/journal.pone.0202716] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/09/2018] [Indexed: 12/03/2022] Open
Abstract
Prosthetic elevated vacuum is a suspension method used to reduce daily volume changes of the residual limb. Evaluation of the effectiveness of these systems is limited due to a lack of correlation to actual socket air pressure, particularly during unconstrained movements. This may explain some of the variability in functional outcomes reported in the literature. Our objective was to develop a light-weight portable socket measurement system to quantify internal socket air pressure, temperature, and acceleration; and to present preliminary results from implementation with three transtibial prosthesis users with mechanical elevated vacuum pumps. Participants completed five functional tasks with and without the vacuum pumps actively connected, including the 2-Minute Walk test, 5-Times Sit-to-Stand test, 4-Square Step test, L-Test, and Figure-8 test. Results demonstrated different gait profiles and pressure ranges for each user. Two of the participants demonstrated substantially lower air pressure (higher vacuum) over time while the pump was active compared to inactive. The minimum air pressure measured for all participants was -34.6 ± 7.7 kPa. One participant did not show substantial changes in pressure over time for either pump condition. Functional task performance was not significantly different between pump conditions. Correlation with accelerometer readings indicated peak positive pressures occurred just following initial contact of the foot in early stance, and the most negative pressures (highest vacuum) were observed throughout swing. This study has demonstrated the use of a portable data logging tool that may serve the clinical and research communities to quantify the operation of elevated vacuum systems, and better understand the variability of mechanical pump operation and overall system performance.
Collapse
Affiliation(s)
- Katherine R. Schoepp
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Jonathon S. Schofield
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland, Ohio, United States of America
| | - David Home
- Prosthetics and Orthotics Department, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada
| | - Michael R. Dawson
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Edmond Lou
- Department of Electrical & Computer Engineering, Faculty of Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - McNiel Keri
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Paul D. Marasco
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland, Ohio, United States of America
- Advanced Platform Technology Center of Excellence, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio, United States of America
| | - Jacqueline S. Hebert
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- * E-mail:
| |
Collapse
|
6
|
Gholizadeh H, Lemaire ED, Eshraghi A. The evidence-base for elevated vacuum in lower limb prosthetics: Literature review and professional feedback. Clin Biomech (Bristol, Avon) 2016; 37:108-116. [PMID: 27423025 DOI: 10.1016/j.clinbiomech.2016.06.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 06/17/2016] [Accepted: 06/21/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND An optimal suspension system can improve comfort and quality of life in people with limb loss. To guide practice on prosthetic vacuum suspension systems, assessment of the current evidence and professional opinion are required. METHODS PubMed, Web of Science, and Google Scholar databases were explored to find related articles. Search terms were amputees, artificial limb, prosthetic suspension, prosthetic liner, vacuum, and prosthesis. The results were refined by vacuum socket or vacuum assisted suspension or sub-atmospheric suspension. Study design, research instrument, sample size, and outcome measures were reviewed. An online questionnaire was also designed and distributed worldwide among professionals and prosthetists (www.ispoint.org, OANDP-L, LinkedIn, personal email). FINDINGS 26 articles were published from 2001 to March 2016. The number of participants averaged 7 (SD=4) for transtibial and 6 (SD=6) for transfemoral amputees. Most studies evaluated the short-term effects of vacuum systems by measuring stump volume changes, gait parameters, pistoning, interface pressures, satisfaction, balance, and wound healing. 155 professionals replied to the questionnaire and supported results from the literature. Elevated vacuum systems may have some advantages over the other suspension systems, but may not be appropriate for all people with limb loss. INTERPRETATION Elevated vacuum suspension could improve comfort and quality of life for people with limb loss. However, future investigations with larger sample sizes are needed to provide strong statistical conclusions and to evaluate long-term effects of these systems.
Collapse
Affiliation(s)
- H Gholizadeh
- Ottawa Hospital Research Institute, Centre for Rehabilitation Research and Development, Ottawa, Canada; Department of Biomedical Engineering, Faculty of Engineering, University of Malaya, Kuala Lumpur, Malaysia.
| | - E D Lemaire
- Ottawa Hospital Research Institute, Centre for Rehabilitation Research and Development, Ottawa, Canada; Faculty of Medicine, University of Ottawa, Canada.
| | - A Eshraghi
- Bloorview Research Institute, Holland Bloorview Kid's Rehabilitation Hospital, Toronto, Canada.
| |
Collapse
|