Design of Adjustable Frame-Type Prosthetic Socket for Lower Limb

ObjectivesProsthetic socket is the contact interface between the stump and the prosthesis, and also the interface component that transmits forces from the stump to the prosthesis distal. The current prosthetic socket fit is a major factor affecting rehabilitation, especially with the stump volume fluctuations. The main goal of this article is to design an adjustable frame-type prosthetic socket with constant force to adapt to the stump volume fluctuations.Materials and methodsIn this paper, an adjustable frame-type prosthetic socket with constant force is designed. The constant force device is designed based on the superelasticity of the shape memory alloy for maintaining constant stump-socket interface stress and automatically adapting to certain volume fluctuations. The constant force extrusion performance of this prosthetic socket was verified and optimized by finite element analysis.ResultsThe results suggest that the constant force unit may maintain constant interface stress. According to the optimization results, the shape memory alloy dimensional parameters could be selected according to different requirements.ConclusionThe adjustable frame-type prosthetic socket allows the user to adjust the socket volume through the cable system and has a large heat dissipation area. The constant force unit maintains constant interface stress and automatically adapts to stump volume fluctuations.     

Altered kinetic strategy for the control of swing limb elevation over obstacles in unilateral below-knee amputee gait.

Our goal was to document the kinetic strategies for obstacle avoidance in below-knee amputees. Kinematic data were collected as unilateral below-knee traumatic amputees stepped over obstacles of various heights in the walking path. Inverse dynamics were employed to calculate power profiles and work during the limb-elevation and limb-lowering phases. Limb elevation was achieved by employing a different strategy of intra-limb interaction for elevation of the prosthetic limb than for the sound limb, which was similar to that seen in healthy adult non-amputees. As obstacle height increased, prosthetic side knee flexion was increased by modulating the work done at the hip, and not the knee, as seen on the sound side. Although the strength of the muscles about the residual knee was preserved, the range of motion of that knee had previously been found to be somewhat limited. Perhaps more importantly, potential instability of the interface between the stump and the prosthetic socket, and associated discomfort at the stump could explain the altered limb-elevation strategy. Interestingly, the limb-lowering strategy seen in the sound limb and in non-amputees already features modulation of rotational and translational work at the hip, so an alternate strategy was not required. Thus, following a major insult to the sensory and neuromuscular system, the CNS is able to update the internal model of the locomotor apparatus as the individual uses the new limb in a variety of movements, and modify control strategies as appropriate.     

Regeneration potency of mouse limbs

Mammalians have a low potency for limb regeneration compared to that of amphibians. One explanation for the low potency is the deficiency of cells for regenerating amputated limbs in mammals. Amphibians can form a blastema with dedifferentiated cells, but mammals have few such cells. In this paper, we report limb formation, especially bone/cartilage formation in amputated limbs, because bone/cartilage formation is a basic step in limb pattern regeneration. After the amputation of limbs of a neonatal mouse, hypertrophy of the stump bone was observed at the amputation site, which was preceded by cell proliferation and cartilage formation. However, no new elements of bone/cartilage were formed. Thus, we grafted limb buds of mouse embryo into amputated limbs of neonatal mice. When the intact limb bud of a transgenic green fluorescent protein (GFP) mouse was grafted to the limb stump after amputation at the digit joint level, the grafted limb bud grew and differentiated into bone, cartilage and soft tissues, and it formed a segmented pattern that was constituted by bone and cartilage. The skeletal pattern was more complicated when limb buds at advanced stages were used. To examine if the grafted limb bud autonomously develops a limb or interacts with stump tissue to form a limb, the limb bud was dissociated into single cells and reaggregated before grafting. The reaggregated limb bud cells formed similar digit-like bone/cartilage structures. The reaggregated grafts also formed segmented cartilage. When the reaggregates of bone marrow mesenchymal cells were grafted into the stump, these cells formed cartilage, as do limb bud cells. Finally, to examine the potency of new bone formation in the stump tissue without exogenously supplied cells, we grafted gelatin gel containing BMP-7. BMP induced formation of several new bone elements, which was preceded by cartilage formation. The results suggest that the environmental tissues of the stump allow the formation of cartilage and bone at least partially, and that limb formation will be possible by supplying competent cells endogenously or exogenously in the future.     

Method for the design and analysis of a non-linear anisotropic lower limb prosthetic socket

A simplified computer-based structural analysis procedure has been developed for evaluating the stresses in a lower limb prosthetic socket when subjected to external loads. This technique has been tested by studying a simple linear axisymmetric shell subjected to uniform loads. It was found that the stress and strain distributions obtained are close to those determined by a finite element technique. The method that has been proposed involves an incremental procedure, which can be used to analyse the behaviour of a prosthetic socket of irregular shape made from non-linear anisotropic materials. By employing the proposed procedure to study an example, in which a simplified lower limb prosthetic socket is subject to internal pressure and frictional forces, the effects of the material non-linearity have been found to be significant.     

Comfort level discussion for prosthetic sockets with different fabricating processing conditions

Background

In the past, manufacture of prosthetic socket by using traditional handmade method not only consumed research time but also required a special assembly approach. Recently, reverse engineering and rapid prototype technology have grown up explosively, and thus, provide a choice to fabricate prosthetic socket.

Methods

Application 3D computer aided design and manufacturing (computer-aided design/computer-aided engineering) tools approach the surface shape stump data is digitized and can be easily modified and reused. Collocation investigates gait parameters of prosthetic socket, and interface stress between stump and socket with different processing conditions. Meanwhile, questionnaire was utilized to survey satisfaction rating scale, comfort level, of subjects using this kind of artificial device.

Results

The main outcome of current research including gait parameters, stress interface and satisfaction rating scale those would be an informative reference for further studies in design and manufacture as well as clinical applications of prosthetic sockets.

Conclusions

This study found that, regardless of the method used for socket fabrication, most stress was concentrated in tibia end pressure-relief area. This caused discomfort in the area of tibia end to the participant wearing prosthesis. This discomfort was most evident in case when the prosthetic socket was fabricated using RE and RP.

     

Computer-aided design and manufacture of an above-knee amputee socket

This paper describes the initial test results obtained from a newly developed computer-aided socket design (CASD) and manufacturing (CASM) process for above-knee amputees. Anthropometric measures taken from an amputee provided input information to a CASD system. Using these measurements, data from a reference shape library stored in the computer were selected and modified to create a unique socket shape reflecting the particular characteristics of the amputation stump. The resultant shape was produced as a ‘primitive’ test socket by a CASM process. Numerical shape data were then transferred to a CNC milling machine to construct a negative cast, from which the primitive socket was produced by a vacuum-forming procedure. The resultant primitive socket shape was fitted and the amputee was able to load the socket without discomfort. Some shape discrepancies were identified and the shape data were modified interactively by the CASD system to create a final socket shape. The final socket shape was manufactured and worn by the amputee during a 35 min walking trial. Subjective evaluation was that the socket provided comfort and control comparable with that of the conventional socket, and proved to be acceptable to the amputee. This was followed by a 2-month home trial which was also successful. The CASD socket shapes were compared numerically in area, shape and volume with data taken from the original socket worn by the amputee, a new socket made by conventional methods and a topographic model of the amputation stump. The final CASD socket shape compared favourably with that of a socket manufactured by conventional methods. Results indicated that by the use of the CASD/CASM process, it was possible to produce an above-knee prosthetic socket which provided comfort and control for the amputee.     

Internal mechanical conditions in the soft tissues of a residual limb of a trans-tibial amputee

Most trans-tibial amputation (TTA) patients use a prosthesis to retain upright mobility capabilities. Unfortunately, interaction between the residual limb and the prosthetic socket causes elevated internal strains and stresses in the muscle and fat tissues in the residual limb, which may lead to deep tissue injury (DTI) and other complications. Presently, there is paucity of information on the mechanical conditions in the TTA residual limb during load-bearing. Accordingly, our aim was to characterize the mechanical conditions in the muscle flap of the residual limb of a TTA patient after donning the prosthetic socket and during load-bearing. Knowledge of internal mechanical conditions in the muscle flap can be used to identify the risk for DTI and improve the fitting of the prosthesis. We used a patient-specific modelling approach which involved an MRI scan, interface pressure measurements between the residual limb and the socket of the prosthesis and three-dimensional non-linear large-deformation finite-element (FE) modelling to quantify internal soft tissue strains and stresses in a female TTA patient during static load-bearing. Movement of the truncated tibia and fibula during load-bearing was measured by means of MRI and used as displacement boundary conditions for the FE model. Subsequently, we calculated the internal strains, strain energy density (SED) and stresses in the muscle flap under the truncated bones. Internal strains under the tibia peaked at 85%, 129% and 106% for compression, tension and shear strains, respectively. Internal strains under the fibula peaked at substantially lower values, that is, 19%, 22% and 19% for compression, tension and shear strains, respectively. Strain energy density peaked at the tibial end (104kJ/m(3)). The von Mises stresses peaked at 215kPa around the distal end of the tibia. Stresses under the fibula were at least one order of magnitude lower than the stresses under the tibia. We surmise that our present patient-specific modelling method is an important tool in understanding the etiology of DTI in the residual limbs of TTA patients.     

Pressure variation in the below-knee, patellar tendon bearing suction socket prosthesis

The function of a below-knee suction socket in establishing and maintaining negative pressures in the limb-socket cavity for suspension during swing phase is examined. An hypothesis of function. pertinent factors. and variables are established in the development of a model used as a basis of experimental investigation of such a prosthesis in ten tests of nine subjects. Model predictions indicate that carity suction necessary for static suspension may vary from −3 to −52 mm Hg depending upon the shape and dimensions of limb stump and on the coefficient of friction between limb and interface material. Experimental data reveals that cavity suction is increased by calf muscle contraction to a level of −200 mm Hg. The cyclic pumping action in walking increases it further to about −350 mm Hg. It is shown that leakage time exceeds wwing phase period if adequate sealing is established by limb socket normal pressures at calf level.     

Load transfer mechanics between trans-tibial prosthetic socket and residual limb--dynamic effects

The effects of inertial loads on the interface stresses between trans-tibial residual limb and prosthetic socket were investigated. The motion of the limb and prosthesis was monitored using a Vicon motion analysis system and the ground reaction force was measured by a force platform. Equivalent loads at the knee joint during walking were calculated in two cases with and without consideration of the material inertia. A 3D nonlinear finite element (FE) model based on the actual geometry of residual limb, internal bones and socket liner was developed to study the mechanical interaction between socket and residual limb during walking. To simulate the friction/slip boundary conditions between the skin and liner, automated surface-to-surface contact was used. The prediction results indicated that interface pressure and shear stress had the similar double-peaked waveform shape in stance phase. The average difference in interface stresses between the two cases with and without consideration of inertial forces was 8.4% in stance phase and 20.1% in swing phase. The maximum difference during stance phase is up to 19%. This suggests that it is preferable to consider the material inertia effect in a fully dynamic FE model.     

Supernumerary limgs in amphibians: experimental production in Notophthalmus viridescens and a new interpretation of their formation.

The formation of supernumerary limbs was studied in the adult newt, Notophthalmus viridescens. Forelimb blastemas at the stages of medium bud and early digits were either transplanted to the contralateral forelimb with their dorsal-ventral axis opposed to that of the limb stump, or removed, rotated through 180°, and replaced on the same limb stump with both dorsal-ventral and anterior-posterior axes opposed to those of the stump, or as a control, removed, and replaced in normal orientation. Supernumerary limbs were produced in both experimental series, but not in the controls.Following contralateral transplantation, supernumerary limbs arose close to the graft junction at the two positions where dorsal limb tissue was in contact with ventral limb tissue. Both dorsal and ventral supernumerary limbs were of the same handedness as the limb stump and they were mirror-images of the regenerate developing directly from the transplanted blastema. Following 180° rotation, supernumerary limbs arose close to the graft junction at those positions where anterior-ventral and posterior-dorsal limb tissues were in contact. The supernumerary limb which arose in the posterior-dorsal position with respect to the limb stump was a mirror-image of the transplant, and was therefore of opposite handedness to both transplant and stump. The supernumerary limb which arose in the anterior-ventral position was of the same handedness as both transplant and stump. A new model of pattern regulation in epimorphic fields which can account for these results and which has retrospective value in the interpretation of earlier experiments on developing limbs is discussed.     

Salvage of amputation stumps by secondary reconstruction utilizing microsurgical free-tissue transfer

During a 2-year period, 15 lower and upper extremity amputees were treated by microsurgical free-tissue transfer in an effort to salvage their amputation stumps. Salvage of length and restoration of contour to aid in prosthetic rehabilitation were the two main indications for reconstruction. Included in the 15 transfers were 3 scapular free flaps, 11 latissimus dorsi musculocutaneous flaps, and 1 groin flap. Thirteen of the patients in this group were refitted with prostheses following reconstruction and did well with no pain or skin breakdown of the resurfaced stumps. The follow-up period on these patients averaged 16 months. One patient, in whom the flap succeeded, underwent stump soft-tissue revision and myodesis. One patient, in whom the flap failed, continued to develop recurrent ulceration in his stump. This clinical experience followed an extensive laboratory study of 12 above-knee amputation patients using noninvasive Doppler ultrasound measurements to determine weight-loading and interface-pressure distribution between the stump and the socket of the prostheses and their relation to stump length and circumference.     

Effect of alignment changes on socket reaction moments during gait in transfemoral and knee-disarticulation prostheses: Case series

The alignment of a lower-limb prosthesis is critical to the successful prosthetic fitting and utilization by the wearer. Loads generated by the socket applied to the residual limb while walking are thought to be different in transfemoral and knee-disarticulation prostheses. The aim of this case series was to compare the socket reaction moments between transfemoral and knee-disarticulation prostheses and to investigate the effect of alignment changes on them. Two amputees, one with a transfemoral prosthesis and another with a knee-disarticulation prosthesis, participated in this study. A Smart Pyramid™ was used to measure socket reaction moments while walking under 9 selected alignment conditions; including nominally aligned, angle malalignments of 6° (flexion, extension, abduction and adduction) and translation malalignments of 15 mm (anterior, posterior, medial and lateral) of the socket relative to the foot. This study found that the pattern of the socket reaction moments was similar between transfemoral and knee-disarticulation prostheses. An extension moment in the sagittal plane and a varus moment in the coronal plane were dominant during stance under the nominally aligned condition. This study also demonstrated that alignment changes might have consistent effects on the socket reaction moments in transfemoral and knee-disarticulation prostheses. Extension and posterior translation of the socket resulted in increases in an extension moment, while abduction and lateral translation of the socket resulted in increases in a varus moment. The socket reaction moments may potentially serve as useful biomechanical parameters to evaluate alignment in transfemoral and knee-disarticulation prostheses.     

Evidence for polarizing zone in the limb buds of Xenopus laevis

To test for the presence of polarizing mesoderm in an amphibian, Xenopus laevis hindlimb bud tips were rotated 180° on the proximodistal axis and returned to the stump. Supernumerary outgrowths were induced in the preaxial stump and preaxial tip tissues, and the most postaxial digit always formed next to the grafted postaxial tissue. The occurrence of polarized supernumerary outgrowths indicated that the posterior limb border contained a polarizing zone. When the limb tip was cut at varying known lengths from the body wall, rotated, and grafted to the limb stump, the incidence of twinning along the proximodistal axis permitted insight into the distribution of the polarizing zone along the posterior border. The location of polarizing tissues was found to be similar to that in the chick wing bud at comparable stages. To confirm the posterior border stump influence on the rotated preaxial limb tip tissues, 180° tip rotations were made at the proximodistal level with the highest incidence of twinning. In these cases, the adjacent stump posterior border tissues (polarizing zone) were removed, leaving a substantial amount of the deeper postaxial stump tissue, however. The frequency of twinning from tip tissues was greatly reduced in these larvae compared to those with rotated limb tips on intact stumps. Cytological examination of supernumerary outgrowths resulting from grafts of two-nucleolate tips onto one-nucleolate stumps confirmed the preaxial source of the supernumerary outgrowths.     

A new method to quantify liner deformation within a prosthetic socket for below knee amputees

Many amputees who wear a leg prosthesis develop significant skin wounds on their residual limb. The exact cause of these wounds is unclear as little work has studied the interface between the prosthetic device and user. Our research objective was to develop a quantitative method for assessing displacement patterns of the gel liner during walking for patients with transtibial amputation. Using a reflective marker system and a custom clear socket, evaluations were conducted with a clear transparent test socket mounted over a plaster limb model and a deformable limb model. Distances between markers placed on the limb were measured with a digital caliper and then compared with data from the motion capture system. Additionally, the rigid plaster set-up was moved in the capture volume to simulate walking and evaluate if inter-marker distances changed in comparison to static data. Dynamic displacement trials were then collected to measure changes in inter-marker distance due to vertical elongation of the gel liner. Static and dynamic inter-marker distances within day and across days confirmed the ability to accurately capture displacements using this new approach. These results encourage this novel method to be applied to a sample of amputee patients during walking to assess displacements and the distribution of the liner deformation within the socket. The ability to capture changes in deformation of the gel liner will provide new data that will enable clinicians and researchers to improve design and fit of the prosthesis so the incidence of pressure ulcers can be reduced.     

Local dynamic stability of amputees wearing a torsion adapter compared to a rigid adapter during straight-line and turning gait

Lower limb amputees have decreased balance during daily ambulation compared to nonamputees. An optimally compliant torsion adapter, which enables transverse plane rotation at the socket–pylon junction may reduce limb asymmetries and improve comfort leading to increased confidence and stability during gait. The purpose of this study was to determine if the presence of a torsion adapter affects amputee sensitivity to local perturbations (local dynamic stability) during straight-line walking and during a turning task. Ten unilateral transtibial amputees were fit with a torsion and rigid adapter in random order and blinded to the condition. After a 3-week acclimation period, kinematic data were collected while subjects walked in a straight-line on a treadmill and around a 1-m radius circular path at constant speed. Maximum finite-time Lyapunov exponents (λ), an estimator of local dynamic stability, were calculated for the amputee’s sagittal plane hip, knee and ankle angles for each condition. The prosthetic limb λ was greater during a turn compared to straight-line walking, suggesting amputees are less stable while turning. There were no statistically significant differences found in λ between adapters during both walking conditions, suggesting the torsion adapter had no effect on amputee stability; however, high inter-subject variability due to the examined population and turning task may have masked a small decrease in prosthetic limb hip and knee stability for the torsion adapter during straight-line gait. Therefore, the torsion adapter’s added degree of freedom may have a small adverse effect on prosthetic limb stability during straight-line walking and no effect on turning.     

Systemic cell cycle activation is induced following complex tissue injury in axolotl

Activation of progenitor cells is crucial to promote tissue repair following injury in adult animals. In the context of successful limb regeneration following amputation, progenitor cells residing within the stump must re-enter the cell cycle to promote regrowth of the missing limb. We demonstrate that in axolotls, amputation is sufficient to induce cell-cycle activation in both the amputated limb and the intact, uninjured contralateral limb. Activated cells were found throughout all major tissue populations of the intact contralateral limb, with internal cellular populations (bone and soft tissue) the most affected. Further, activated cells were additionally found within the heart, liver, and spinal cord, suggesting that amputation induces a common global activation signal throughout the body. Among two other injury models, limb crush and skin excisional wound, only limb crush injuries were capable of inducing cellular responses in contralateral uninjured limbs but did not achieve activation levels seen following limb loss. We found this systemic activation response to injury is independent of formation of a wound epidermis over the amputation plane, suggesting that injury-induced signals alone can promote cellular activation. In mammals, mTOR signaling has been shown to promote activation of quiescent cells following injury, and we confirmed a subset of activated contralateral cells is positive for mTOR signaling within axolotl limbs. These findings suggest that conservation of an early systemic response to injury exists between mammals and axolotls, and propose that a distinguishing feature in species capable of full regeneration is converting this initial activation into sustained and productive growth at the site of regeneration.     

Lens formation from cornea implanted into amputated hindlimbs of Xenopus laevis larvae requires innervation or proliferating cell populations in the stump

The capacity of amputated early and late limbs of larval Xenopus laevis to promote lens-forming transformations of corneal implants in the absence of a limb regeneration blastema has been tested by implanting outer cornea fragments from donor larvae at stage 48 (according to Nieuwkoop and Faber 1956), into limb stumps of larvae at stage 52 and 57. Blastema formation has been prevented either by covering the amputation surface with the skin or by reconnecting the amputated part to the limb stump. Results show that stage 52 non-regenerating limbs could promote lens formation from corneal implants not only when innervated but also when denervated. A similar result was observed in stage 57 limbs where blastema formation was prevented by reconnecting the amputated part to the stump. In this case, relevant tissue dedifferentiation was observed in the boundary region between the stump and the autografted part of the limb. However, stage 57 limbs, where blastema formation was prevented by covering the amputation surface with skin, could promote lens formation from the outer cornea only when innervated. In this case, no relevant dedifferentiation of the stump tissues was observed. These results indicate that blastema formation is not a prerequisite for lens-forming transformations of corneal fragments implanted into amputated hindlimbs of larval X. laevis and that lens formation can be promoted by factors delivered by the nerve fibres or produced by populations of undifferentiated or dedifferentiated limb cells.     

Temporal distribution of 5BrdU-labelled cells suggests that most injured tissues contribute proliferating cells for the regeneration of the tail and limb in lizard

After tail and limb amputation in lizard, injection of 5BrdU for 6 days produces immunolabelled cells in most tissues of tail and limb stumps. After further 8 and 16 days, and 14 and 22 days of regeneration, numerous 5BrdU-labelled cells are detected in regenerating tail and limb, derived from most stump tissues. In tail blastema cone at 14 days, sparse-labelled cells remain in proximal dermis, muscles, cartilaginous tube and external layers of wound epidermis but are numerous in the blastema. In apical regions at 22 days of regeneration, labelled mesenchymal cells are sparse, while the apical wound epidermis contains numerous labelled cells in suprabasal and external layers, indicating cell accumulation from more proximal epidermis. Cell proliferation dilutes the label, and keratinocytes take 8 days to migrate into corneous layers. In healing limbs, labelled cells remain sparse from 14 to 22 days of regeneration in wound epidermis and repairing tissues and little labelling dilution occurs indicating low cell proliferation for local tissue repair but not distal growth. Labelled cells are present in epidermis, intermuscle and peri-nerve connectives, bone periosteum, cartilaginous callus and sparse fibroblasts, leading to the formation of a scarring outgrowth. Resident stem cells and dedifferentiation occur when stump tissues are damaged.     

The effects of rotation and positional change of stump tissues upon morphogenesis of the regenerating axolotl limb.

Rotation of a skin cuff 180° around the proximodistal axis of the upper arm in the axolotl results in the formation of multiple regenerates in about 80° of cases after amputation of the limb through the rotated skin. Rotation of the dermis or the flexor and extensor muscles folowed by amputation produced similar percentages of multiple regenerates. Rotated bone produced no abnormalities, and rotated stump epidermis was minimally effective in stimulating multiple regeneration. A thin strip of normally oriented skin interposed between a rotated skin cuff and the amputation surface blocks the morphogenetic effect of the rotated stump skin whereas removal of the normal skin between a rotated proximal skin cuff and the amputation surface allows the formation of a low percentage of multiple regenerates. Gross rotation of stump tissue components can be broken down into axial rotation per se and positional dislocation. Experiments conducted upon skin and muscle have shown that positional dislocation along the anteroposterior axis rather than axial rotation is the manipulation that leads to the formation of multiple regenerates. The first morphological indication of multiple regeneration is the appearance of a triaxial apical ridge on the blastema. Subsequently, digits form along the apical ridges.     

Effect of prosthetic alignment changes on socket reaction moment impulse during walking in transtibial amputees

The alignment of a lower limb prosthesis affects the way load is transferred to the residual limb through the socket, and this load is critically important for the comfort and function of the prosthesis. Both magnitude and duration of the moment are important factors that may affect the residual limb health. Moment impulse is a well-accepted measurement that incorporates both factors via moment–time integrals. The aim of this study was to investigate the effect of alignment changes on the socket reaction moment impulse in transtibial prostheses. Ten amputees with transtibial prostheses participated in this study. The socket reaction moment impulse was measured at a self-selected walking speed using a Smart Pyramid™ in 25 alignment conditions, including a nominal alignment (clinically aligned by a prosthetist), as well as angle malalignments of 2°, 4° and 6° (abduction, adduction, extension and flexion) and translation malalignments of 5 mm, 10 mm and 15 mm (lateral, medial, anterior and posterior). The socket reaction moment impulse of the nominal alignment was compared for each condition. The relationship between the alignment and the socket reaction moment impulse was clearly observed in the coronal angle, coronal translation and sagittal translation alignment changes. However, this relationship was not evident in the sagittal angle alignment changes. The results of this study suggested that the socket reaction moment impulse could potentially serve as a valuable parameter to assist the alignment tuning process for transtibial prostheses. Further study is needed to investigate the influence of the socket reaction moment impulse on the residual limb health.