responses, claudication pain and elevated vacuum

responses, claudication pain and elevated vacuum

Lane Ferrin

10/9/2018

Here are the responses to my search for experiences with elevated
vacuum to reduce claudication pain.

The only case I am aware of where claudication was eliminated was a
very determined individual who attended the local VA prosthetic clinic
(another facility provided his prostheses). He developed claudication
in both lower extremities a few years post surgery for unilateral
trans-tibial level. He was overweight and had type 2 diabetes. Over the
years he became very frustrated with his physical deterioration, so he
adopted a vegan diet, He quickly lost about 40 - 50 pounds, and
eventually he was able to eliminate his meds and was walking 10+ miles
per day.

I had a case (almost exactly) like this years ago and vacuum did not
help. For my patient the only thing that worked was a thick keasy cone
liner in the socket with tsb socket.

One beautifully therapeutic quality of lower limb prosthetics is the
potential in venous pressure gradients, or sequentially increasing and
and decreasing outside pressure on the residuum. In theory, anything
that you might be able to due structurally or mechanically to enhance
or increase this gradient coefficient might indeed mitigate to some
degree peremptory pain due to vascular inadequacy. It is interesting to
note that this condition seems to be more prevalent as people age.

Can your client rest standing up on the sound and perhaps less affected
leg with reduced claudication in the residuum? If so, perhaps
unloading the residuum altogether (ischial weight bearing, etc.) might
prove to be a viable approach.

I have seen it help but the socket can’t be overly tight. Use the
vacuum more for the control. Also use a flexible and frame and cut the
trim of frame as low as possible to still have control. I have also
seen the gradual increase in vacuum help. I have seen some not
tolerate high vacuum at first especially if the socket is tight already
and doesn’t allow the muscles to expand. I have no scientific proof,
but I believe it can help. I make my suction sockets pretty much the
same as vacuum sockets in trans-tibials, so no problem applying vacuum
as it must have total contact with either. I tend to use non- covered
custom urethane and usually custom and those liners are usually thicker
to give more protection to a bony limb and absorb a lot of pressure
instead of the limb tissue and this allows a more lose fit without risk
of harm to the soft tissue and bony anatomy. I tend to use limblogic to
be able to adjust with greater ease the vacuum levels. If you fit the
socket too tight and you have vacuum as high as possible, I have seen
the claudication pain be worsened. I always encourage the patient to
push themselves to go to the point of claudication pain and then go
just a little further each time and have seen the Patients be able to
improve how far they can go before the claudication onset.

Very anecdotal but, I would be glad to discuss further to help. I have
fit many vacuum sockets and the claudication pain is difficult to deal
with no matter what socket design we offer, but I have seen gradual
improvement in most cases with this approach.

Thanks for the post. I am not familiar with any published evidence. I
can only offer anecdotal experience with a case that was eerily
similar. We tried elevated vacuum with the same thought as you, but
unfortunately it did not work. That may have been my ability though to
get it to work successfully because the reasoning/rationale to me
sounds very good.

Ultimately for my patient we were only able to get him successfully
ambulatory more than a minute by utilizing a design that went proximal
to his ischium so that the patient carried his weight through his
ischium (laminated thigh piece with ischial seat kind of quad socket
like with external hinges crossing the knee). The patient then used his
limb muscles to flex/extend the knee but bore weight through proximal
as it was his body weight being carried through his residual limb that
was too much pressure in his limb for his arteries to effectively
refill capillaries in his residual limb. We had 2 of us that tried to
fit the BK before we moved to the design with proximal weight bearing.
Once he had that style, he put the leg on and could any activity all
day non stop, he was excited to send me pictures of himself snowblowing
his driveway the week after he got it noting no pain.

Similar case.
68 y/o 5'3 150 lb male who worked all his life on his feet doing
electrical maintenance. VERY active working outside his job doing
welding work & roofing repairs. On ladders all of the time. Underwent
a BKA d/t severe PVD. Non-diabetic, severe COPD from life time of
smoking.

Began symptoms of intermittent claudication about 2yrs after beginning
his prosthetic use. Was no longer working outside of his handyman
jobs, but still up/down ladders & on his feet all day for welding jobs,
roofing, etc. Not a guy to sit until his 12-14hr day was done. We
tried everything. He could Not tolerate elevated vacuum of even the
smallest amt. Not even the lock-valve combo. He loved his 6mm gel
locking liner & lock suspn the best. His limb Never showed signs of
excessive pressures of socket issues. He could be on his feet,
standing or moving, for about an hour at 1st. A 5min seated rest & his
pain dissipated & he could get another hr. This scenario gradually
swapped to where he was only getting about 5-10mins on his feet before
he had to sit for 30-60mins before relief. Understandably, very
frustrating for him. Around this time I noted his residual limb had
less color & was cool on palpation. Within a month of his pain setting
in at 5mins his limb was actually cold to the touch. Even coming
straight out of his socket, it was cold...like touching a cadaver's
leg. Finally convinced him to go see his vascular doc. An AKA was
recommended. This guy refused to go AKA & lived another 1.5yrs with
this pain, was on oxygen & still working on projects throughout his
days. Developed a wound on his limb after a particular active weekend
of roofing work. He worked with that wound for another yr & he was
even being seen by a wound care clinic!? Not sure what the thought
process was there b/c they were told by vascular that there was no
blood there!
Died with a BKA. I was told it was the COPD.

Moral of the story...if it can't be revascularized to at least the
minimal amt of pain from intermittent claudication, amputate & move on!
  His life was absolute misery & frustration the last 2yrs

Lane, evidence is a loaded term when it comes to EV. With our small
numbers when talking about EV with px users the best that we can say is
that, studies suggest... We think we know many things that are not
necessarily true. I have had reps say that they have studies that
show regenerative results in the circulatory system of diabetic limbs.
If that is true, then would it not be fair to assume that some hyper
situation would occur if an otherwise healthy limb? I think it is fair
to assume that we do not actually know what it is we think we know when
it come to exactly what is going on inside these EV environments. We do
know that if you make a bad socket that EV will exploit that situation
and make it obvious soon with horrible results. So EV does force us to
make a better fitting socket. In your specific situation I have found
that patients like you are describing hate the tight - snug feeling of
these systems. A more conventional approach may yield better results.
We can not prosthetise away conditions like IC, adhesion, and crappy
plain old bad amputation technique. Good luck my man.

I had success with a patient like this. Vacuum has to be above 17mmhg
to get benefits.Studies showed a 300 to 350% increase in circulation

Guy wears leg all day now and it is his dominant side. Back to work even.

Has to be the right patient to manage high vacuum. This guy runs over 20mmhg.



This encrypted email is in compliance with the Breach Notification
Requirements under Section 13402 of Title X111 (Health Information
Technology for Economic and Clinical Health Act) of the American
Recovery and Reinvestment Act of 2009.



CONFIDENTIALITY NOTICE: This e-mail message and any attachments are for
the sole use of the intended recipient(s) and may contain proprietary,
confidential, trade secret or privileged information. Any unauthorized
review, use, disclosure or distribution is prohibited and may be a
violation of law. If you are not the intended recipient or a person
responsible for delivering this message to an intended recipient,
please contact the sender by reply e-mail and destroy all copies of the
original message.
--
Lane Ferrin
<Email Address Redacted>

                          ********************
To unsubscribe, send a message to: <Email Address Redacted> with
the words UNSUB OANDP-L in the body of the
message.

If you have a problem unsubscribing,or have other
questions, send e-mail to the moderator
Paul E. Prusakowski,CPO at <Email Address Redacted>

OANDP-L is a forum for the discussion of topics
related to Orthotics and Prosthetics.

Public commercial postings are forbidden. Responses to inquiries
should not be sent to the entire oandp-l list. Professional credentials
or affiliations should be used in all communications.