Prosthetic Interfaces Survey

Prosthetic Interfaces Survey

Todd J. Sleeman

Dear Clinician,
  As part of my residency project, I am conducting a survey on the use of
gel/silicone/urethane interfaces for skin protection and/or suspension.
Please take a moment to fill out the attached survey and return. Final
results will be available on the web at < <URL Redacted>> in late
June, or you may request to have a summary of the results faxed to you.

Enter your responses in the [ ] areas. It looks best in a monospaced
font like Courier, with your mail-window wide open. If you prefer, e-mail me
your fax # and I will fax a copy to your office. I haven't attached it as a
file because of the variety of file types, and I'm aware of the concern
regarding viruses. For those outside the U.S., I can e-mail a file, just
specify the program you're using or the file-type you prefer.

  In addition to this survey, I am conducting a survey of patients who have
either used a gel/silicone/urethane interface with unsatisfactory results or
have used two or more different types of gel/silicone/urethane interfaces.
If you have patients who fit this criteria and would be willing to
participate, please include your address and how many surveys you require,
and I will mail self addressed stamped surveys for you to distribute. Part
of this survey should be filled out by the clinician, and part by the patient.

Also, I would be happy to fax/mail a patient survey to any
trans-tibial/below-knee amputees on this list.

Thank you,


Todd J. Sleeman, Resident Prosthetist
Newington O & P Systems, Hartford, CT

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Start Survey
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                        Trans-Tibial Prosthetic Interfaces Survey
                                (NCOPE Residency Research Project)

                                        Please return by May 10, 1999

                                                * * * *
* *
Note: Percentages provided below can be estimates, and should be for the
trans-tibial population only.
Information should be for the individual clinician, not the whole facility.
Please forward this survey to other clinicians within your facility.

***Practitioner Information***
Name (optional): [ ]
Facility (optional): [ ]
State: [ ] Country: [ ]
Prosthetic program you attended: [ ]
Year Graduated: [ ]
Years of clinical experience: [ ]

***Interface Selection***
In this section, please provide percentages for the primary reason you
provide an interface, broken down by patient type. Note that for each
patient type, the four columns should add up to 100%.
***Examples:
**None-No gel/silicone/urethane type interface is provided (i.e.-pelite, hard
socket, leather, etc.)
**Suspension-An Iceross (or equivalent) is provided primarily for suspension
purposes
**Protection-A TEC liner or Silosheath (or equivalent) is provided primarily
for protection
**Suspension & Protection-A TEC Profile or Alpha Liner (or equivalent) with
pin is provided to suspend prosthesis and protect skin

                        Patient Type None Suspension
Protection Susp. & Protection
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Functional K1 [ ] [ ] [ ]
                [ ] =100%
Level K2 [ ] [ ] [ ]
                [ ] =100%
                                K3 [ ] [ ]
        [ ] [ ] =100%
                                K4 [ ] [ ]
        [ ] [ ] =100%
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Reason PVD [ ] [ ]
[ ] [ ] =100%
  for Trauma [ ] [ ] [ ]
                [ ] =100%
Amputation Other [ ] [ ] [ ]
        [ ] =100%
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Please list your top three interface choices (please be specific as possible,
including thickness, shape, etc.) when you are using the interface primarily
for:
*Suspension Only*
1. [ ]
2. [ ]
3. [ ]
*Protection only*
1. [ ]
2. [ ]
3. [ ]
*Suspension and Protection*
1. [ ]
2. [ ]
3. [ ]




Feel free to provide any additional comments you may have regarding your use
of interfaces.

Thank you for participating in this survey. Results will be available in
late June online at: www.biome.com/survey
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End of Survey
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