How do you help patients deal with extreme enviroments or weather conditions?

[With soldiers in Iraq and Afghanistan], the key is to keep it as simple as possible, with few moving parts. We send them with backup supplies: extra foot shells, Spectra socks and suspension sleeves, because those tend to wear out. We also educate them in basic prosthetic alignment more than your normal patient. But we’re still somewhat limited, because there’s not a socket system yet that’s ventilated. There’s a study going on here about the use of Botox to reduce perspiration, but that’s just one treatment modality.
Zach Harvey, CPO
Walter Reed Army Medical Center
Washington, D.C. 

A lot of my patients are farmers and ranchers. They’re working in real extreme conditions, so I always have to consider what the device is going to be used for. I might stay away from College Park or anything multiaxial, because the bushings get full of debris. I find [Ossur’s] modular 3 Flex Foot very durable for farmers, because it has no moving parts.

If it’s really cold, patients will just put on another wool sock or a silicone liner. Really, the big enemy is heat. With sockets, I shy away from silicone because people find it so hot and sweaty. Many of them will use a pelite liner with a wool sock. I prefer silicone, especially for diabetic patients, but some patients I try in it and they can’t do it.

A lot of my patients live two, three, four hundred miles away. So I have to think about what patients can do themselves. One of my patients, if he has a pressure sore, I’ll tell him to cut a hole in the sock. He’ll get me on the phone and I’ll walk him through it.
Brandon Quick, CP
Nebraska Orthotic & Prosthetic Services Inc.
Grand Island, Neb.

I don’t tend to be one who pads my braces a lot, so patients can clean them fairly easily. But perspiration is always an issue. Some patients find Lycra® CoolMax™ a cooler sock to wear.

We’ll drill holes and cut windows to cool things down, but I’d like to ask a plastics engineer for a material that would breathe like leather. That would go a long way toward solving the problem.
Bryan Taylor, CO
Hanger P&O
Fort Walton Beach, Fla.

Probably the best thing we do with patients is educate them. If they get hot, we tell them to take the prosthesis off, wipe it down, cool off a bit, change the sock or the liner, repowder, and put it back on. We also tell them to keep hydrated, since dehydration causes a volume change.

I really can’t say that I’ve seen any advances in this area. We’ve tried drilling holes and using prescription antiperspirant, but patients lose suction and suspension and have skin irritation. The materials are insulators. The Harmony® system is supposed to work better, but it’s not to the point where we’re seeing this is the answer.

About 15 years ago, I was [part of a group] working to get a prosthetic grant. And I said I wanted to see a material that would give the patient a sense of vacuum, but circulate air. Or a gel material that would cool it or keep a certain temperature throughout the day. The people I was working with thought it was a doable thing. But we didn’t get the grant.

The materials are out there, but can we adapt them at this point in the commercial market? Apparently not yet.
Randy Whiteside, CP
Artificial Limb Specialists
Phoenix, Ariz.

Well, we’ve definitely got the cold here. You have some breakage with polypropylene when people go out when it’s 20 below. I think the carbon [prepreg] is going to take care of that, because it’s so much lighter and stronger, but I haven’t used it long enough to see.
Hank Osborne, CO
High Country Orthotics & Prosthetics Inc.
Casper, Wyo.

Some of our patients want to walk on the beach, and sand is going to get into the foot. If it’s an energy-storing foot, we try to give it access. If we try to close it up, sand is going to get in anyway. [Access] lets sand in, but it also lets it out.

With the heat and humidity, a suspension sleeve made out of neoprene or of a perforated fabric breathes a lot easier.

And then the computer-controlled knees have to be protected from rain with plastic shells. Patients can’t just jump in the water.
Jack Pranzarone, CP
Hanger P&O
Fort Walton Beach, Fla.

I had a patient who was a deer hunter who took two heaters with him—one for the toes on his [sound] foot, and one for the toes on his prosthetic foot. He couldn’t explain it, but he told me that when he saw the heater puffing out air on his prosthetic foot, it felt warmer to him.

I think the general discomfort amputees experience is overlooked by all of us. We don’t generally talk to people about that, because they only come in when they have a problem—"This spot is bothering me." They don’t come in and say, "Wearing this leg every day is getting me down."
Tony Fruci, CP
Dan Rowe & Associates
Saint Paul, Minn.

I came to North Dakota from California 16 years ago, and one of the most difficult things up in these northern states is the icy conditions. I don’t think there is a perfect answer, but we try to have a fairly aggressive tread on orthopedic shoes.

With heat, we see a lot of problems with silicone liners, because they’re a perfect environment for different fungi or bacteria. Sometimes [getting rid of the bacteria is] a real battle. We give patients Iceross Clean and Simple pH-balanced soap. Another thing we get is O&P Basics Antimicrobial Sanitizer from Ohio Willow Wood.

I’ll also talk to the manufacturer, because they have tech support and sometimes a product they’ll recommend. One company, Knit-Rite, has a product called the Liner-Liner, which has silver fibers that discourage odor and fungal growth. We’ve had limited success with that.

I don’t think as an industry we’re very diligent about venting things for children. We’re seeing a lot more cranial molding helments, and infants lose 50 percent of their heat through their head. We try to ventilate the helmet without causing too much window edema or petechiae.
Peter Davidson, CPO, RN
Great Plains Rehabilitation Services
Bismarck, N.D.

It’s funny you should ask that—it’s raining here for the first time in a long time. We’ve had 40 consecutive days over 100 degrees. The heat is extreme here, so we don’t use a lot of roll-on suction liners. The heat can’t radiate out of the socket and then perspiration becomes a problem. Sometimes the disadvantages outweigh the advantages.

We are really big proponents of aqua prosthetics—[for instance], a leg that someone would wear on the beach, maybe an older leg that still fits them and that they don’t care if it gets a little saltwater on it. We’d rather have them ruin an old prosthesis and have the experience [of going in the water] as opposed to not doing it.
Gary D. Strobel, CP
Strobel and Associates Prosthetics Inc.
Plano, Texas

Water doesn’t damage plastic or titanium components so much, but sand, grit or any debris that gets inside the prosthetic foot shell or inside the shoe tends to wear away the foot itself and is very abrasive. Those artificial skin protectant covers are usually not adequate.

Another problem is that most prosthetics are finished with a soft foam cover. If the cover gets wet, you can’t get the water out and it can smell. Most patients who want to get into the water use an older prosthesis or a prosthesis specifically designed to get wet.

For snow and ice, [there are] special adapters that slip over the shoe to grip the ice better. Usually the younger, more able-bodied individual can get along fine in snow or ice—it just requires being careful.

The only problem with extreme cold is with an above-the-knee prosthetic where some of the hydraulics are affected by the cold temperature. Most individuals know to put the prosthesis where it’s warmer when taking it off. A couple have gone hiking and put it in the sleeping bag with them at night just to keep the liners or the socket warm.
Stuart Furusho, CPO
FDR Center for Prosthetics & Orthotics
Nashua, N.H.

I don’t think there’s one set protocol that works. If it’s very important for patients to be able to operate in these environments, we need to be on top of the components to ensure the lifespan of what they’re using. We tend to need to see those patients once or twice a year. We rotate the moving parts and clutch locks and make sure that debris or saltwater corrosion is not having a long-term effect.The market for temperature-specific environments is smaller than the market for general components, so designing and engineering and making a system that is environment-specific is challenging. The demand is less than for the standard, everyday component. The hope for many of these components is that they span many activities for the patient.
Ryan Blanck, CPO
Northwest Prosthetic & Orthotic Clinic
Seattle, Wash.

Have a question? If you’d like to suggest a question—or answer—for this column, contact Becky Kesner at bkesner@AOPAnet.org or (571) 431-0815.