Harmony® Vacuum System

Reimbursement Reference Guide

©2013 Otto Bock HealthCare LP . 13012534_1 • 1/13
Harmony Vacuum System
Reimbursement Reference Guide
Effective January 1, 2015
Harmony Vacuum System
Elevated vacuum suspension has been commercially
available in the U.S. since 1999 when Total Environmental
Control (TEC) introduced the Vacuum Assisted Socket
System (VASS). Today, the VASS is manufactured by
Ottobock and marketed as the Harmony® Vacuum System.
Harmony Coding1
The Healthcare Common Procedure Coding System
(HCPCS) for prosthetics is an add-on code system. Primary
codes for vacuum pumps were issued in 2003. Since then,
additional features have been added to our pumps.
Depending on which model is ordered, functions, such as
shock absorption, torsion, or rotation may be provided in
addition to vacuum, which are described by add-on codes.
The following HCPCS1 codes are applicable to
Harmony Products:
4R144 Harmony P2: L5781 (vacuum pump), L5984*
(axial rotation), L5988 (vertical shock pylon)
4R147 Harmony P3: L5781 (vacuum pump), L5984*
(axial rotation), L5988 (vertical shock pylon)
4R150 Harmony HD: L5782 (vacuum pump heavy duty),
L5984* (axial rotation), L5988 (vertical shock pylon)
4R152 Harmony E2: L5781 (vacuum pump)
1C62 Triton Harmony: L5781 (vacuum pump), L5986*
(multi-axial rotation), L5987** (shank foot system)
3R60=VC: L5781 (vacuum pump), L5814** (polycentric
knee), L5845 (stance flexion), L5848** (stance extension
damping), L5930*** (high activity knee frame)
* Medicare covers for K2 and higher; ** Medicare covers for K3 and
higher; ***Medicare covers for K4 only
Other items that may be coded on a claim related to
Harmony® (not all inclusive):
- Total Surface Weight Bearing (TSWB) Socket and
additional materials/features added to the socket
(various codes)
- Flexible Inner Socket – L5645, L5651
- Cushion Socket – L5646
- Supracondylar Suspension - L5670
- Test Sockets, L5618 – L5628
- Custom Socket Inserts (liners), L5681 or L5683
(initial insert), L5679 (additional insert)
- Prefabricated Socket Inserts (liners) L5679
- Sheaths L8400, L8410
- Sealing Sleeves L5685
- Socks L8420 , L8430, L8470, L8480
Harmony® Certification Training
Ottobock lists Harmony® Trained Practitioners on its
website. These practitioners have taken a 3.0 CEU on-line
course and passed the exam.
FDA Status
Under FDA’s regulations, the Harmony® Vacuum System is
a Class I medical device and exempt from the premarket
notification [510(k)] requirements. Given the low risk of
Class I medical devices, FDA determined that General
Controls are sufficient to provide reasonable assurance of
the device’s safety and effectiveness; therefore, safety and
effectiveness research is not required for this device.
Harmony has met all the General Control requirements
which include Establishment Registration (21CFR 807),
Medical Device Listing(21 CFR part 807), Quality System
Regulation (21CFR part820), Labeling (21CFR part 801),
and Medical Device Reporting(21 CFR Part 803). The
Harmony Vacuum System is listed under External Limb
Prosthetic Component; Listing Number E253231.
Harmony® Warranty
Otto Bock HealthCare (Otto Bock) warrants all of its
products, to the original purchaser, to be free from defects
in materials and workmanship. The Limited Warranty for
the Harmony® is 24 months. For additional information on
the Harmony® System Warranty, see Harmony®
Instructions for Use (IFU).
------------------------------------------------------------------------
1
The product/device “Supplier” (defined as an O&P
practitioner, O&P patient care facility, or DME supplier)
assumes full responsibility for accurate billing of Ottobock
products. It is the Supplier’s responsibility to determine
medical necessity; ensure coverage criteria is met; and
submit appropriate HCPCS codes, modifiers, and charges
for services/products delivered. It is also recommended that
Supplier’s contact insurance payer(s) for coding and
coverage guidance prior to submitting claims. Ottobock
Coding Suggestions and Reimbursement Guides are based
on reasonable judgment and are not recommended to
replace the Supplier’s judgment. These recommendations
may be subject to revision based on additional information
or alphanumeric system changes.
1
The Harmony® Vacuum System
Features and Benefits
Volume Control
Compared to a standard transtibial
prosthetic socket, the Harmony® System’s
elevated vacuum pulls more oxygenated
fluids into the residual limb during swing
phase and pushes less fluids out during
weight bearing. The result is less than 1%
volume loss during the course of the
day.1,2 As a result, the socket fit is more
consistent and may eliminate the need for
the user to remove the prosthesis multiple
times/day while attempting to manage
volume changes with socks and/or spots.
Reduced Forces
In standard sockets daily volume
fluctuations inherently cause an
inconsistent fit for many amputees not
under vacuum and can lead to pressure
points on the limb.2,3 Controlling volume
under vacuum may reduce these forces
and-promote better limb health.2
Proprioception
The Harmony® System’s elevated vacuum
leads to heightened proprioception which
increases the awareness a user has of her
or his leg during walking. As a result,
users may experience increased balance,
stability and control over the prosthesis.2
Ottobock
800.328.4058
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Reduced Moisture Build-up
The Harmony® System pulls air from the
sealed socket creating an even pressure
total contact environment reducing the
likelihood of sweating. The Harmony
system can also be configured for direct
evacuation of moisture from the socket
system thus greatly reducing moisture
buildup.
Shock Absorber and Torsion Adapter
The Harmony® System mechanical pump
has an integrated, adjustable shock
absorber and torsion adapter, which work
together to increase walking comfort and
relieve strain on joints and spine. These
features may also contribute to a more
natural gait pattern.4
1
Ottobock Healthcare. Harmony Spec Sheet.
http://ottobockus.com/cps/rde/xbcr/ob_us_en/04
020441.7BHarmonySpecSheet.pdf.
2
Board WJ, Street GM, Caspers CA.
Comparison of trans-tibial amputee suction and
vacuum socket conditions. Prosthet Orthot Int.
2001, 25, 202-209.
3
Beil TL, Street GM, Covey SJ. Interface
pressures during ambulation using suction and
vacuum-assisted prosthetic sockets. J Rehabil
Res Dev. 2002;39(6):693-700.
4
Ottobock Healthcare. Harmony® P2 and HD.
http://ottobockus.com/cps/rde/xchg/ob_us_en/hs.
xsl/16873.html.
2
Ottobock
800.328.4058
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Clinical Research Summary
The Benefits of Vacuum
Compared to Other
Suspension Methods
Elevated vacuum suspension systems
manage limb volume fluctuation, a problem
that people with limb loss are challenged
with. Over time and on a daily basis, these
volume changes can affect how the socket
fits. When the limb volume increases, the
socket becomes tighter, exerting pressure,
restricting blood flow, and allowing for
accumulated cell waste. When limb volume
decreases, the socket is loose-fitting often
causing pressure to bony prominences,
which may result in pain and/or injury to the
limb.1
Vacuum Compared to Pin
Suspension
Ferraro (2011) conducted an outcomes study
(n=13) comparing pin suspension to
electronic vacuum suspension. All subjects
used each suspension system for at least 30
days. 2 A validated measurement tool called
the Activity-specific Balance Confidence
(ABC) scale was used to evaluate the subject’s
confidence when performing certain
activities (n=16) with regard to balance.
Subjects taking the survey rated their
confidence in performing each activity on a
scale from 0 (no confidence) to 100
(completely confident). 3 A score below 67
indicates a risk for falling.4
Ottobock
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Results: Four surveys were excluded from
the final analysis; (survey not complete,
subject did not use both suspension systems,
vacuum system was not electronic, and
incorrect amputation level). The ABC scores
for the remaining 9 surveys were Vacuum
Suspension (80±10) and Pin Suspension
(65±20), resulting in a confidence level of
95% (p=0.0359) in favor of vacuum.
Subjects (n=13) were also surveyed on a
variety of related problems experienced with
suspension systems. Results for pistoning,
blisters, volume change, difficulty knee
bending, redness, falls, and walking time, all
favored vacuum suspension over pin
suspension; however the results were not
significant, possibly due to small sample
size.1
An earlier study by Beil5 (2004) compared pin
suspension to suction suspension (n=9) by
measuring impulse and peak pressures in the
socket during ambulation. Results: During
stance phase there was no difference between
the two suspension methods (p=0.076);
however, during swing phase, differences
were significant (positive pressure impulses
p=0.008, average positive pressure p-0.004,
distal negative impulse p=0.053 and peak
pressure p=0.026) demonstrating that pin
suspension exerts an occlusive pressure on
the proximal tissues of the residual limb,
while at the same time generating
considerable suction at the distal end of the
socket, and that these pressures are likely
causing both the persistent and the day-to-
day skin issues witnessed with pin
suspension users.
4
The Benefits of Vacuum Compared to
Other Suspension Methods (cont.)
Vacuum compared to Suction
Suspension
Board6 (2001) conducted a randomized trial
comparing suction suspension to vacuum-
assisted suspension; evaluating changes in
volume, tibia and liner pistoning, and stance
phase and step length symmetry. Volume:
Residual limb volume (n=10) was measured
prior to and after a 30 minute treadmill walk,
and a significant increase of 3.7% or 30 ml
(p=0.007) was found when using vacuum as
compared to a significant decrease of 6.5% or
52 ml when using suction. Pistoning:
Pistoning of the tibia and liner (n=11) were
measured using X-ray and extraction force
and a significant decrease (p=0.000) in both
tibia and liner pistoning was found in favor of
the vacuum system. Symmetry: Gait
symmetry (n=10) was assessed with video
and found significant improvements in both
stance phase symmetry (p=0.037) and step
length symmetry (p=0.000). Conclusion:
The authors concluded that while suction
suspension fits well, it also causes volume
loss due to the pressure that it exerts, which
in turn worsens the fit, subjecting the skin to
higher stresses and “shear forces” with
potential for ulcers. Vacuum suspension,
such as the Harmony®, retains correct fit,
averts volume loss, and lessons pistoning in
the socket; maintaining skin integrity,
symmetry, and comfort.
Beil7 (2002) also compared vacuum
suspension to suction suspension (using total
surface weight-bearing sockets) by measuring
Ottobock
800.328.4058
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impulse and peak pressures during
ambulation (n=9). Results: Findings were
favorable for vacuum, both during stance
phase (impulse p=0.00, peak p=0.003) and
during swing phase (impulse p=0.000,
average p=0.000, and peak 0.001). It is
believed that lower pressures seen during
stance when using the vacuum-assisted
socket force less fluid out and greater
negative pressures seen during swing
increases the amount of fluid drawn into the
limb, thereby preventing volume loss.
1
Sanders JE, Harrison DS, Myers TR, Allyn KJ.
Effects of elevated vacuum on in-socket residual limb
fluid volume: Case study results using bioimpedance
analysis. JRRD. 2011;48(10):1231-1248
2
Ferraro C. Outcomes study of transtibial amputees
using elevated vacuum suspension in comparison
with pin suspension. Journal of Prosthetics and
Orthotics. 2011;23(2):78-81
3
Powell LE, Myers AM. The activities-specific
balance confidence (ABC) scale. J Gerontol Med Sci
1995;50A:M28–M34.
4
Lajoie, Y. and Gallagher, S. P. (2004). Predicting
falls within the elderly community: comparison of
postural sway, reaction time, the Berg balance scale
and the Activities-specific Balance Confidence
(ABC) scale for comparing fallers and non-fallers.
Archives of Gerontology and Geriatrics 38(1):11-26
5
Beil TL, Street GM. Comparison of interface
pressures with pin and suction suspension systems.
JRRD. 2004;41(6A): 821-828
6
Board WJ, Street GM, Caspers C A comparison of
trans-tibial amputee suction and vacuum socket
conditions. Prosthet Orthot Int 2001; 25:202-209
7
Beil TL, Street GM, Covey SJ. Interface pressures
during ambulation using suction and vacuum-
assisted prosthetic sockets. J Rehabil Res Dev.
2002;39(6):693-700
5
Clinical Research Summary
The Harmony®: Early Fitting of
Transtibial Amputees with
Unhealed Residual Limb
Wounds
According to the most recent update by the Amputee
Coalition (2012), close to two-million persons with
limb loss reside in the United States, and of those,
54% of their amputations were a result of vascular
disease.1,2 Furthermore, in 2009, hospitals reported
costs related to limb loss as being greater than 8.3
billion dollars.1,3
When there is Presence of Unhealed
Wounds
Until recently, standard practice was to delay the
prosthetic fitting until the residual limb was in good
condition and could withstand the forces generated
by the prosthesis. In his research, VanVelzen (2005)
found that ideally, the surgical wound from the
amputation must be healed, the stump matured and
conically shaped, and there should be no remaining
edema when the prosthesis is fit.4,5,6
Persons with transtibial limb loss have (4X) greater
likelihood of successful prosthetic use than persons
with higher-level amputations.6 However, they are
also more likely to experience skin complications on
the residual limb.7, 8 Presence of ulcers or unhealed
surgical wounds may delay prosthetic rehabilitation
and increase the need for medical treatment . 6,9
As a result, it has been suggested that there are
benefits to accelerating the initiation of
rehabilitation after amputation surgery.10,11 One
way that this may be achieved when there are
wound-healing issues is by early fitting with a
vacuum-assisted socket system (VASS), such as
the Harmony® Vacuum System.
Ottobock
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Early Fitting with Prompt Ambulation Using
the Harmony® Vacuum System
A randomized controlled trial recently published by
Traballesi, et al,7 evaluated fitting of the Harmony®
System on subjects with open ulcers/wounds (n=10)
compared to fitting a standard suction socket (n=10)
after wounds were healed to 1cm2 (control group).
Subjects were limited community ambulators (MFCL-
2) or full community ambulators (MFCL-3), average
age 61.3±13.2, with recent admission to the
rehabilitation hospital after transtibial amputation
due to dysvascular cause.
A twelve-week rehabilitation program was initiated
for all subjects and additional follow-up conducted
at weeks 28 and 36. First Steps: Harmony® users
took their first step at 16±8.6 days, while the control
group took their first step at 58.6±24.7 days
(p=0.012). Independent Walking: At week 12 all
Harmony® users were independent walkers, while
only 5 in the control group were independent
(p=0.001). Prosthetic Use: At 2-months the
Harmony® group used their prostheses 62 hours/wk.
(mean), while the control group used theirs 12
hours/wk. (p=0.003). At 6 months, prosthetic use
was 80 hours/wk. for the Harmony® group compared
to 59 hours/wk. for the control group; however,
results were no longer significant (p=0.191).
Locomotor Capability Index (LCI): At week 12
the median LCI score for the Harmony® group was 42
(maximum score possible) versus 21 for the control
Group (p=0.002). Drop-outs: Three subjects
dropped out of the control group (one each at 4
weeks, 6 weeks, and 16 weeks) and one dropped out
of the Harmony® group at 20 weeks. Wound
Healing and Pain: Considering the difference in
prosthetic use between the two groups, one would
expect the Harmony® users to experience increased
6
The Harmony®: Early Fitting of
Transtibial Amputees with Unhealed
Residual Limb Wounds (cont.)
pain and possibly less healing. However, wound-
healing and pain perception scores were not
statistically significant between the groups.
Conclusion: The authors concluded that that early
use of the Harmony® in the presence of open
ulcers/wounds did not impede healing, nor did it
increase pain.
When Compared to Amputees without
Ulcer/Wound Healing Failure
An earlier study by Brunelli,12 conducted at the same
rehabilitation facility, reported on 24 transtibial
amputees; 7 subjects with ulcer/wound healing
failure fit with the Harmony® and 17 subjects with no
ulcer/wound healing failure fitted with a standard
PTB socket (PTB Group). Locomotor Capability
Index (LCI): Subjects were measured using LCI to
determine prosthetic use. At nine months, the
Harmony® group scored 36±6.7 on the LCI compared
to the PTB group which scored 28±4.2. Pain
Perception: Subjects were measured using the
Visual Analog Scale (VAS) for pain perception. VAS
scores were favorable for the Harmony® group both
at 1 month (6.3±2.2 compared to 7.5±2.5) and at 9
months (4.6±1.3 compared to7±1.8). Conclusion:
The authors concluded that patients fit with the
Harmony® were compliant in its use, and their
ulcers/wounds improved during the study.
Large Wound Case Study
Traballesi4 also reported on a 60 year-old,
dysvacular, transtibial amputee with a 43.5cm2
category IV wound on his residual limb.
Measurements included the LCI for prosthetic use,
the Barthel Index (BI) for functional independence,
and digital photos of the wound for healing. The
subject wore the Harmony® 8 hours per day for 4
months and participated in outpatient gait therapy.
Ottobock
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Results: Despite having such a large open wound,
when tested using the Harmony®, the subject’s LCI
score was 41 and BI was 85. Additionally, after 3-4
hours of continuous ambulation and standing
activities, VAS (pain) score was 0. At the end of 4
months, the wound area was reduced to 28cm2,
which equated to a 34% reduction in wound area.
1
Amputee Coalition. Limb loss statistics.
http://limblossawareness.org/about-llam/limb-loss-
statistics/index.php.
2
Ziegler‐Graham K, MacKenzie EJ, Ephraim PL, et al.
Estimating the prevalence of limb loss in the United States:
2005 to 2050. Arch Phys Med Rehabil. 2008;89(3):422‐429.
3
HCUP Nationwide Inpatient Sample (NIS). Healthcare Cost
and Utilization Project (HCUP). Rockville, MD: AHRQ; 2009.
4
Traballesi M, Averna T, Delussu AS, Brunelli S. Trans-tibial
prosthesization in large area of residual limb wound: Is it
possible? A case report. Disability and Rehabilitation: Assistive
Technology. 2009;4(5):373–375.
5
Van Velzen AD, Nederhand MJ, Emmelot CH, Ijzerman MJ.
Early treatment of trans-tibial amputees: Retrospective analysis
of early fitting and elastic bandaging. Prosthet Orthot Int
2005;29:3 –12.
6
Gauthier-Gagnon C, Grise MC, Potvin D. Predisposing
factors related to prosthetic use by people with a transtibial
and transfemoral amputation. JPO. 1998;10(4):99-109; Waters
RL, Mulroy S. The energy expenditure of amputee gait. Gait
and Posture. 1999:9(3):207-231; Bowker JH, Michael JW
(ed):In: Atlas of limb prosthetics: Surgical, prosthetic and
rehabilitation principles. St. Louis: Mosby Year Book,
1992;381-387.
7
Trabalessi M, Delussu AS, Fusco A, et al. Residual limb
wounds or ulcers heal in transtibial amputees using an active
suction socket system. A randomized controlled study. Eur J
Phys Rehabil Med 2012:48:1-2
8
Dudek NL, Marks MV, Marshll SC, Chardon JP.
Dermatologic conditions associated with use of lower extremity
prosthesis. Arch Phys Med Rehabil. 2005:86:659-663
9
Meulenbelt HE, Geertzen JH, Jonkman MF, Dijkstra PU.
Determinants of skin problems of the stump in lower-limb
amputees. Arch Phys Med Rehabil. 2009:90:74-81
10
Munin et al. Predictive factors for successful early prosthetic
ambulation among lower-limb amputees. J Rehabil Res Dev.
2001:38;4
11
White SA, Thompson MM, Zickerman AM, et al. Lower limb
amputation and grade of surgeon. Br J Surg 1997; 84(4): 509-
11.
12
Brunelli S, Averna T, Delusso AS, Traballesi M. Vacuum
assisted socket system in trans-tibial amputees: Clinical report.
Orthopädie-Technik Quarterly, English edition. 2009; II:2-4
7
Vacuum Studies Bibliography
Reverse Chronological Order

1. Samitier BC, Guirao L, Costea M, Camós JM, Pleguezuelos E. Hospital de Mataró,

Barcelona, Spain. The benefits of using a vacuum-assisted socket system to improve
balance and gait in elderly transtibial amputees. Prosthet Orthot Int. 2014 Sep 26. pii:
0309364614546927. [Epub ahead of print]
http://www.ncbi.nlm.nih.gov/pubmed/25261489

2. Kahle JT, Orriola JJ, Johnston W, Highsmith MJ. The effects of vacuum-assisted
suspension on residual limb physiology, wound healing, and function: A systematic
review. Technol Innov. 2014; 1(15): 333-341.
http://www.ingentaconnect.com/content/cog/ti/2014/00000015/00000004/art00009

3. Kahle JT, Highsmith MJ. Transfemoral interfaces with vacuum assisted suspension
comparison of skeletal kinematics, pressure and preference: Ischial containment versus
brimless. J Rehabil, Res, Dev. 2013; 50(9): 1241-1252.
http://www.rehab.research.va.gov/jour/2013/509/jrrd-2012-01-0003.html

4. Kahle JT, Highsmith MJ. Transfemoral sockets with vacuum-assisted suspension

comparison of hip kinematics, socket position, contact pressure, and preference: Ischial
containment versus brimless. J Rehabil Res Dev. 2013; 50(9):1241–52.
http://dx.doi.org/10.1682/JRRD.2013.01.0003

5. Hoskins RD, Sutton EE, Kinor D, Schaeffer JM, Fatone S. Using vacuum-assisted
suspension to manage residual limb wounds in persons with Transtibial amputation: A
case series. POI. 2013;05 DOI:10.1177/0309364613487547
http://www.researchgate.net/publication/236920322_Using_vacuum-
assisted_suspension_to_manage_residual_limb_wounds_in_persons_with_transtibial_a
mputation_A_case_series

6. Traballesi M, Delussu AS, Fusco A, et al. Residual limb wounds or ulcers heal in
transtibial amputees using an active suction socket system. A randomized controlled
study. Eur J Phys Rehab Med 2012;48:1-2.
http://www.ncbi.nlm.nih.gov/pubmed/22641248

7. Ferraro C. Outcomes study of transtibial amputees using elevated vacuum suspension in

comparison with pin suspension. JPO 2011;23(2):78-81.
http://journals.lww.com/jpojournal/Abstract/2011/04000/Outcomes_Study_of_Transtib
ial_Amputees_Using.7.aspx
Ottobock
800.328.4058
http://professionals.ottobockus.com 8
Vacuum Studies Bibliography
Reverse Chronological Order

8. Gerschutz MJ, Denune JA, Colvin JM, and Schober G. Elevated vacuum suspension
influence on lower limb amputee’s residual limb volume at different vacuum pressure
settings. JPO 2010;22(4):252-256.
http://courses.washington.edu/rehab427/Fall%202010/Student%20Papers%20for%20
Review/Phil%20-%20Gerschutz%20(2010).pdf

9. Gerschutz MJ, Haynes ML, Colvin JM, Nixon D, Denune JA, and Schober G. A vacuum
suspension measurement tool for use in prosthetic research and clinical outcomes:
Validation and analysis of vacuum pressure in a prosthetic socket. JPO 2010;22(3): 172-
176.
http://journals.lww.com/jpojournal/Fulltext/2010/07000/A_Vacuum_Suspension_Meas
urement_Tool_for_Use_in.8.aspx?WT.mc_id=HPxADx20100319xMP

10. Traballesi M, Averna T, Delussu AS, et al. Trans-tibial prosthesization in large area of
residual limb wound: is it possible? A case report. Disabil Rehabil Assist Technol
2009;4:373–375.
http://www.hsantalucia.it/ric/attivita2009/AutoPlay/Docs/I%20pagine%20pubblicazio
ni/295-Trans-tibial%20prosthesization.pdf

11. Brunelli S, Averna T, Delusso S, et al. Vacuum assisted socket system in trans-tibial
amputees: Clinical report. The Orthopadie Technik, 2009;2:2-8. http://www.ot-
forum.de/verlag_ot/otquarterly/e30554/infoboxContent30555/OT_Quarterly_2_09_72_
dpi_ger.pdf

12. Fairley M. ‘Hanging Tight’: elevated vacuum suspension systems step forward. The O&P
Edge, March 2008. http://www.oandp.com/articles/2008-03_03.asp

13. Street G. Vacuum suspension and its effects on the limb. The Orthopadie Technik,
2006;4:1–4 http://www.ottobockus.com/cps/rde/xbcr/ob_us_en/Street-
0661_OT_GB.pdf

14. Beil TL, Street GM. Comparison of interface pressures with pin and suction suspension
systems. J Rehabil Res Dev 2004;41:821–828.
http://www.rehab.research.va.gov/jour/04/41/6/pdf/Beil.pdf

Ottobock
800.328.4058
http://professionals.ottobockus.com 9
Vacuum Studies Bibliography
Reverse Chronological Order

15. Goswami J, Lynn R, Street G, Harlander M: Walking in a vacuum-assisted socket shifts the
stump fluid balance Prosthet Orthot Int 2003;27(2):107-113
http://www.ottobockus.com/cps/rde/xbcr/ob_us_en/harmony_article_1.pdf

16. Beil TL, Street GM, Covey SJ. Interface pressures during ambulation using suction and
vacuum-assisted prosthetic sockets. J Rehabil Res Dev 2002;39(6):693-700.
http://www.rehab.research.va.gov/jour/02/39/6/pdf/Beil.pdf

17. Board WJ, Street GM, Caspers C A comparison of trans-tibial amputee suction and vacuum
socket conditions. Prosthet Orthot Int 2001;25:202-209
http://www.ottobockus.com/cps/rde/xbcr/ob_us_en/harmony_article_3.pdf

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