Donald G. Shurr’s research while affiliated with Atlanta Prosthetics & Orthotics, Inc. and other places

Össur Kristinsson first developed the Icelandic roll-on silicone socket (ICEROSS) in the mid 1980s. This type of socket interface was quickly popularized in the prosthetic community and has become the standard of treatment for transtibial amputees. Multiple manufacturers of roll-on liners, of various materials, now exist. These companies claim that liners offer superior comfort, suspension, and relief of dermatological problems compared with previous prosthetic options. A review of relevant literature reveals studies that are limited by the lack of diagnoses made by dermatologists (Cluitman et al., Prosthet Orthot Int. 1994;18:78-83; Lake and Supan, J Prosth Orthot. 1997;9:97-106; and Hachisuka et al., Arch Phys Med Rehabil. 2001;82:1286-1289) and a failure to identify the frequency of these problems (Levy, Prosthet Orthot Int. 1980;4:37-44 and Dudek, et al. Arch Phys Med Rehabil. 2005;86:659-663). The purpose of this cross-sectional study is to determine the prevalence of dermatological problems in transtibial amputee subjects who use a roll-on liner with their prosthesis. A questionnaire determined demographic information, skin type, hygiene and prosthetic habits, comorbidities, and reported skin problems. All participants were offered a free examination by the dermatologist to verify medical history and document current skin problems. A χ2, trend, and rank-sum test were used. Results indicated that 90.9% of subjects reported a history of skin problems, whereas 78% presented with a problem during the exam with the dermatologist. Specific correlations between habits and reported skin problems are also reported in this article. However, a direct correlation between amputee habits and skin problems is not clear. Because of high gasoline prices in rural Iowa, few participated in the skin exam. In this study, a greater number of transtibial amputees using roll-on liners had dermatological problems than previously reported.

To investigate the physiologic differences during multispeed treadmill walking and physical activity profiles for the Otto Bock C-Walk foot (C-Walk), Flex-Foot, and solid ankle cushion heel (SACH) foot in people with transtibial amputation. A repeated-measures design with 3 prostheses. Research laboratory. Eight men with unilateral transtibial amputation. Not applicable. Physiologic responses (energy expenditure, gait efficiency, exercise intensity, rating of perceived exertion [RPE]) during multispeed treadmill walking (53.64, 67.05, 80.46, 93.87, 107.28 m/min) test were analyzed with 2-way repeated-measures analysis of variance (ANOVA). One-way ANOVA was employed to analyze foot-type differences for self-selected walking velocity (SSWV), and steps per day (daily activity). Analysis of covariance was used to analyze foot-type differences with SSWV as the covariable for the physiologic measurements. The C-Walk had a trend of improved physiologic responses compared with the SACH; however, no foot-type differences were statistically significant. Compared with the C-Walk and SACH, the Flex-Foot showed no significant differences in energy expenditure and gait efficiency, but significantly lower percentage of age-predicted maximum heart rate and RPE values. The energy storing-releasing feet appeared to have certain trends of improved gait performance compared with the SACH; however, not many objective foot-type differences were significantly noted. Further studies with a larger sample size are suggested.

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Patients with diabetes are often prescribed foot orthoses to help prevent foot ulcer formation. Orthotics are used to redistribute normal and shear stress. Shear stresses are not easily measurable and considered to be responsible for skin breakdown. Local elevation of skin temperature has been implicated as an early sign of impending ulceration especially in regions of high shear stress. The purpose of this study was to measure the effects of commonly prescribed insole materials on local changes in plantar foot temperature during normal gait. Six commonly used foot orthosis materials were tested using the Thermo Trace infrared thermometer to measure foot temperature. Ten healthy adult volunteers without any history of diabetes or abnormal sensation participated in the study. During each trial the subject walked on a treadmill with the test material in the dominant foot's shoe, for six minutes at a speed of four miles per hour and rested for six minutes between trials. Four locations on the foot (hallux, first and fifth metatarsal heads, and heel) and the contralateral bicep temperatures were measured at 0, 1, 3, 5 minutes during the rest period. The order of material and skin location testing was randomized. Significant differences were found between baseline temperatures and foot temperatures for all materials. However, no differences were found between materials for any location on the foot. Previous studies have attempted to characterize materials based on laboratory and clinical testing, while other studies have attempted to characterize the effect of pressure on skin temperature. However, no study has previously attempted to characterize foot orthosis materials based on foot temperatures. This study compared foot temperatures of healthy adults based on the material tested. Although this study was unable to distinguish between materials based on foot temperatures, it was able to show a rise in foot temperature with any material used. This study demonstrates a need to a larger study on a population with diabetes.

To determine the effect of 3 prosthetic mass conditions on selected physiologic responses during multiple speed treadmill walking in persons with transtibial amputation. A repeated-measures design for 3 prosthetic mass conditions and 5 walking speeds. University research laboratory. Eight ambulatory men with unilateral traumatic transtibial amputation. The 3 prosthetic mass conditions were 60%, 80%, and 100% of the estimated intact limb below-knee mass. The multiple-speed treadmill walking test (4min at each speed: 54, 67, 80, 94, 107m/min) was performed on an instrumented treadmill according to randomly assigned mass conditions. Oxygen consumption, gait efficiency, relative exercise intensity (percentage of age-predicted maximal heart rate), and stride frequency. Prosthetic mass did not significantly alter oxygen consumption or gait efficiency (P>.05). From the 60% to the 100% prosthetic mass conditions, relative exercise intensity significantly increased and stride frequency significantly decreased (P<.05). A heavier prosthesis (up to 100% of estimated intact limb below-knee mass) did not significantly increase the energy costs of walking for the 5 speeds examined. Further study of gait symmetry with the use of a heavier prosthesis is warranted.

To date, there have been no longitudinal studies comparing walking at different levels of amputation. The objective of this study was to compare the self-selected walking velocity (SSWV) and selected physiologic variables during walking between a Syme and a later transtibial level of amputation for a single subject. Additional comparison was made between the SACH foot prosthesis and a dynamic response foot prosthesis. A 35-year-old male with a traumatic Syme amputation later underwent elective transtibial amputation. SSWV and multiple speed treadmill walking tests (53.64, 67.05, 80.46, 93.87 and 107.28 m/min) were evaluated under three conditions (Syme prosthesis with SACH foot, transtibial prosthesis with SACH foot, and transtibial prosthesis with Flex-Foot). Walking with transtibial prosthesis showed minimal differences in oxygen consumption (0 - 5% reduction), heart rate response (0 - 1% reduction), or gait efficiency (0 - 5% improvement) across all speeds when compared with Syme prosthesis (both with SACH foot). However, the SSWV was 6 - 8% faster for the transtibial SACH foot. Walking with transtibial Flex-Foot required less cardiovascular demand than with transtibial SACH foot at higher speeds. In this case report, it seemed that transtibial amputation did not have adverse effects on selected physiological responses at a variety of walking speeds when compared to Syme amputation, and that the use of a dynamic response foot enhanced his gait performance. Further experimental studies involving more subjects with traumatic Syme and transtibial amputations are required to better understand the effect of these two levels of amputation on energy cost of walking.

Lin-Chan S-J, Nielsen DH, Yack HJ, Hsu M-J, Shurr DG. The effects of added prosthetic mass on physiologic responses and stride frequency during multiple speeds of walking in persons with transtibial amputation. Arch Phys Med Rehabil 2003;84:1865–71.

The level of physical activity may be a potential correlate of accommodation to amputee walking. The purpose of this study was to compare the energy cost, gait efficiency, and relative exercise intensity of physically active persons with transtibial amputation during walking with the solid ankle cushioned heel (SACH) foot, the Flex-Foot (FF), and the Re-Flex Vertical Shock Pylon (VSP) prosthesis versus persons with nonpathological gait. Subjects were healthy, physically active males, including five subjects with unilateral transtibial amputation and 18 control subjects with nonpathological gait. A repeated-measures design involving multiple-speed treadmill walking (53.64, 67.05, 80.46, 93.87, and 107.28 m/min) was used. Between-group analyses involved separate repeated-measures analysis of variance according to foot type with a priori pairwise contrasts at each test speed. Betweengroup SACH and FF analyses showed nonsignificant differences in energy cost and gait efficiency for 53.64, 67.05, and 80.46 m/min, but significantly increased energy cost and decreased gait efficiency for 93.87 and 107.28 m/min. Between-group Re-Flex VSP analyses indicated nonsignificant differences for all test speeds. The relative exercise intensity of subjects with transtibial amputation for all foot types was significantly higher than that for controls across all walking speeds. Physically active individuals with transtibial amputation may have enhanced adaptability optimizing gait performance regardless of foot type at both slower and higher walking velocities with the Re-Flex VSP. (C) 2000 American Academy of Orthotists & Prosthetists

A 3-factor (foot type, speed, and mode of ambulation) repeated-measures experimental design was used. To compare the differences in energy expenditure, gait efficiency, and relative exercise intensity in persons with transtibial amputations with various prostheses. There is a need for improved prosthetic designs to accommodate physically active persons with lower-extremity amputations. We used progressive speeds of treadmill walking (53.64, 67.05, 80.46, 93.87, and 107.28 m/min) and running (120.69, 134.1, and 147.51 m/min) with 3 different types of prostheses: the Solid Ankle Cushion Heel (SACH) foot, the Flex-Foot (FF), and the Re-Flex Vertical Shock Pylon (VSP) prosthesis. Five physically active men with unilateral transtibial amputations served as subjects (aged 31.6 +/- 4.28 years). The following statistically significant differences (improvements) between the Re-Flex VSP versus the FF and the SACH foot were found. Energy cost: walking (5%), running (11%); gait efficiency: walking (6%), running (9%); relative exercise intensity: walking (4%), running (5%). However, we found no significant differences between the FF and the SACH. The Re-Flex VSP appears to have a positive effect on energy cost, efficiency, and relative exercise intensity compared with the other prosthetic foot types during walking and running.