Modern prosthetic sockets and liners are made from impermeable materials that act as insulators and create a hostile environment around the residuum. Temperature and humidity can directly influence not only the mechanical behaviour of the interface (e.g. sweat acting as a lubricant), but also the health of the skin and soft tissue of the residual limb.
The problem of excessive residual limb sweating has a real effect on the quality of life of amputees60,61, with up to seven out of ten amputees are adversely affected60,62. Another study found that 66% of amputees reported that the amount they sweat really affects their daily activities63. Contrast this with 2.9% of the general population who are medically diagnosed as suffering from excessive sweating64, also known as hyperhidrosis, and the size of the problem becomes clear.
There are many factors that contribute to this issue. It is known that trans-tibial amputees use proportionally more energy than able-bodied people during the course of their daily activities. For unilateral trans-tibial amputees, the increased effort can range from 10 to 40%, while for bilateral trans-tibial amputees, it is more likely to be closer to a 40% increase65. As with any increase in energy consumption, this leads to an increase in body temperature. The body’s natural cooling response is sweat production.
The rate of heat transfer between an object and the surrounding environment is proportional to the surface area of the object. After a below-knee amputation, a person’s surface area has been reduced by 10-15%66. Consequently, the rate at which they can cool down is reduced. For individuals with limb loss the problem of overheating is more acute.
Localised sweating on the residual limb is particularly common due to the popularity of prosthetic liners made from cushioning materials, such as TPE gel, polyurethane or silicones. Unfortunately, while effective at reducing interface stress, these impermeable67 liners with poor thermal conductivity68,69 can add to the overheating problem. Sweat remains on the skin surface, unable to evaporate70. They also create a closed micro-climate that is moist, warm and nutrient-rich – an ideal breeding ground for bacteria. With the sweat unable to transport away, skin problems, such as dermatitis, are likely to occur70,71. This can be particularly problematic for the vulnerable residual limbs of older, vascular amputees. With limited mobility already, any residuum pain or problem may further restrict prosthesis use, resulting in social isolation and reduced independence.
Excessive sweating effectively lubricates the ‘extra joint’ at the socket interface, which can lead to pistoning, decreasing ground clearance and making a trip or fall more likely to occur. In order to compensate, an amputee may walk with gait abnormalities, making the overall gait pattern less energy efficient, further compounding the problem of overheating.
Many different approaches have been experimented with to reduce residual limb sweating. Antiperspirant sprays are available, along with more drastic solutions such as Botulinum Toxin injections, electrical stimulation and even surgical intervention72. These methods often involve ongoing treatment, they can be very costly, and may have side effects. Additionally, there is no guarantee of success. One approach that has been developed is the use of perforated prosthetic liners, which allow moisture and trapped air to move away from the skin. This keeps the residual limb dry. Research has shown the benefit this can have to skin health73.
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