Ampnation Magazine - Volume 1 Issue 6 2019

AMPNATION

MAGAZINE MAGAZINE

VOLUME 1 ISSUE 6 DECEMBER 2019

THE PARA SPARTANS CHAMPIONS

10

Contents 23

Stump for Advocacy and Empowerment

Q&A What to Expect When Facing Amputation

25

Health & Fitness Gratitude

28

The Para Spartan Champions Still Making History

2

AMPNATION

GREETINGS AMPNATION!

As we approach the holidays your mind is probably on family, food and friends. And if you are one of the brave souls, travel. With all of this going on it is easy to forget something that is very important around this time of year which could affect your wallet. Weather a new or current amputee this information is very important to life as it may cause a delay in you getting prosthetic care.

When Does Your Medicare Deductible Reset?

Your Medicare deductible resets on January 1 of each year.

The Medicare deductible is based on each calendar year, meaning that it lasts from January 1-December 31, and then it resets for the new year.

If you’re signing up for Medicare for the first time, and your coverage starts sometime during the middle or later-part of the year, your deductible will still reset on January 1.

This year, the Medicare Part A deductible is $1,408, and the Medicare Part B deductible is $198.

So, if you’re on Medicare, you would need to meet these deductibles before Medicare starts covering your medical bills.

If you are in the process of getting any DME, Durable medical equipment (DME) coverage could be affected by this if you don’t get it authorized before the cut off date.

Prosthetics, if you are working with a company make sure you have a discussion with them about getting everything in before it’s too late. Make sure whatever you are trying to get has been covered and will not be affected this reset.

A Publication For Amputees

Ampnation Magazine publishes unbiased journalism that seeks to “empower and inform” amputees and those affected by limb loss. The magazine’s audience is primarily amputees and their families and is provided free electronically (digital) to anyone who subscribes subscribe@ ampnationmagazine.com and there is a hard copy available for purchase ass well. Each issue covers health, well-being, better outcomes of amputees living and thriving, O&P News, Vascular News, Tech and products & services.

INSIDE THIS ISSUE 5 Better Outcomes Empathetic Listening

6 Correspondence

Headline News - How soda impacts diabetes risk

8 Vascular & Ortho News

When to Treat Type 2 Diabetes as a Vascular Disease

16 O&P News

Grad student helps make prosthetic sockets out of recycled plastic

19 TECH News

Apps that help you

Now, if you find yourself on the bad end of this situation there is some hope. There is a way to avoid paying Medicare deductibles, which is to have a Medicare Supplement – also called a Medigap plan.

There are 11 total Medicare Supplement plans, and each one varies in terms of price and benefits.

The 3 most popular plans are Plan F, Plan G, and Plan N, because they provide the most coverage.

You can read more about Medicare Supplement Plans F, G, and N by here: https://www.medicareallies.com/senior-insurance-blog/how-to-compare-popular-medigap-plans-f-gand-n.

However, many of the Medicare Supplement plans help pay for your Medicare deductibles.

Editor’s Message Sean Harrison contact@ampnationmagazine.com

Feature Contacts

Better Outcomes - Editor@ampnationmagazine.com Correspondence - Editor@ampnationmagazine.com Vascular & Orthopedic - Editor@ampnationmagazine.com Prosthetic & Orthotic - Editor@ampnationmagazine.com Q&A - Editor@ampnationmagazine.com If would like be involved with Amp Nation Magazine please send inquires to: Contact@ampnationmagazine.com 3

Better Outcomes Empathetic Listening Improve the Patient Experience

by Honoring the First Golden Moments to Understand Patient Needs and Values AMA Hub

As healthcare providers one of the most important things we do is listen.

Are you doing it right? Does it really matter? How we listen can improve our practice and the quality of care we provide to our patients.

Empathy begins with “engaged curiosity about another’s particular emotional perspective.”1 Empathetic listening builds on the concept of being attentive in an effort to gain a better understanding of another person’s experiences. Empathy is also described as the capacity to put one’s self in another’s shoes to feel what that person is going through and share their emotions; the recognition and validation of a patient’s fear, anxiety, pain, and worry; and the ability to understand patients’ feelings to facilitate more accurate diagnoses and more caring treatment.

condition, patients often arrive for the visit with emotions such as anxiety, fear, and apprehension. By connecting with empathy, you can help to dissuade those fears and convey that you and your care team are listening to their concerns.

The feeling of being understood by another person is intrinsically therapeutic. It bridges the isolation of illness and helps to restore the sense of connectedness that patients need to feel whole.

The foundation of empathetic communication is based on accurately understanding the patient’s feelings and effectively communicating that understanding back to the patient so the patient feels understood.3

Empathetic listening can be used in emotionally charged situations. You might try it with a patient who is experiencing grief related to an illness or with a co-worker who is having a work-related conflict. As you practice empathetic listening, use body language to show that you are actively listening. You can do this by sitting next to or near the speaker, leaning in their direction, and maintaining eye contact. Make sure your arms are not crossed, as this can signal to the speaker that you are closed off and not really listening. It is also helpful Empathetic listening fosters the not to focus solely on a computer keyconnection between the patient and physician and can effectively alleviate board or screen with your back to the patient. As patients tell their story, pedifficult conversations. Patients who riodically echo or summarize to further feel understood are often more open demonstrate that you heard what they and responsive to their physician’s advice. In return, physicians may have had to say. an improved sense of professional satIn a clinical situation, the first few isfaction and joy in work. minutes of the encounter are precious.

During the initial patient visit, you may There are 5 STEPS to Listening With feel pressured to dive into the various Empathy: 1. Connect with Empathy by Honoring clinical tasks that need to be completed.

However, if you leap into these tasks the First “Golden Moments.” without listening to the patient, you may 2. Listen for Underlying Feelings, miss critical information. Take the time Needs, or Values. to honor the first “golden moments” of 3. Remain Present When You Are the visit by setting aside distractions Listening.

4. Look for Cues That the Patient Has such as charts, computers, phones, alarms, and pagers. Giving the patient Finished Speaking. your full attention at the start of the visit 5. Reflect on Your Experience. prevents important issues from surfacing at the end, and will allow you to better Step 1 Connect with Empathy by understand the patient’s concerns or Honoring the First “Golden Mosymptoms. ments.

Step 2 Listen for Underlying Feelings, Needs, or Values.

Sometimes feelings may be right on the surface, but at other times they can be hidden. Patients often mention emotional situations, and then wait for a practitioner’s cue that it is okay to continue. As the patient explains the situation, watch for feelings hidden in body language, facial expressions, or other non-verbal cues. As your interaction continues, take your own emotional temperature and note your own internal feelings like anxiety, sadness, or frustration. Use the patient’s non-verbal cues to assess if this is an opportunity to switch from medical questioning to empathetic listening. To switch to empathetic listening, allow for a brief pause in the conversation, soften your tone of voice, and ask a question that is directly related to your interest in the patient’s feelings. This strategy invites the patients to express their concerns, and allows you to address the patient’s unique needs.

We all have common needs, but different ways of acting in response to these needs. When we focus on needs and values, we can identify ways in which we are the same. During empathetic listening, keep focused on the patient’s underlying need, rather than communication style or behavior. You may not know what the need is at first—be open to hearing the need.

There might be situations where you may not be able to identify the feeling that the patient is experiencing. In those circumstances, it is important to emphasize that you are interested in hearing about the patient’s experiences. Expressing interest invites more expansive conversation, and increases the probability that the patient will reveal underlying feelings.

Step 3 Remain Present When You Are Listening.

Give patients an opportunity to express their feelings to completion, without interruption. Their feelings and values will surface if they are given ample time to express themselves in While the first few minutes of a visit are Expressing empathy is a key ingredient a welcoming environment. Focus on important, you should continue to be to enhancing the patient experience.

In fact, 65% of patient satisfaction has fully attentive throughout the interaction moments when the patient seems to been attributed to physician empa- to ensure that you capture any concerns display the most energy around a topic 4 (e.g., more rapid speech, change in that may be revealed later in the visit. thy.2 Regardless of their medical

Amputee Comprehensive Training (ACT) Warriors Camp The UCSF ACT Program hosts an annual amputee basketball and mobility clinic. Led by the Warriors Basketball Academy and the AMP1 Basketball Team, the clinic teaches fundamentals of the game in a supportive team environment. The clinic is designed to focus on skill development and mobility for those affected by limb loss while encouraging a healthy and active lifestyle. Participants of all activity levels and experience are encouraged to attend.

Saturday, February 22, 2020 10-11:30am NEW THIS YEAR: The clinic will be held at the new Warriors Basketball Facility (former practice facility for the Golden State Warriors) in downtown Oakland. Be among the first to play on their newly renovated courts! The address is 1011 Broadway, Oakland CA 94607

Registration Required Please register by contacting Erin.Simon@ucsf.edu The AMP1 Basketball Team is comprised of amputee athletes who connected while seeking opportunities to play competitive stand-up basketball. AMP1 demonstrates that all you need is courage, motivation, and heart to follow your dreams.

The mission of the UCSF Amputee Comprehensive Training (ACT) Program is to assist those affected by limb loss in maximizing their physical and functional mobility. We support a community of individuals motivated to engage in activities they enjoyed prior to amputation and recover a healthy and active lifestyle.

For more information on our program and monthly clinics, please email act@ucsf.edu.

5

Correspondence

News, Opinion & Information

The Medical Minute: Cramps in the recommend that you walk more to help research from 2017 Trusted Source. legs could indicate peripheral artery the condition because that encourages your body to form other vessels around According to a study published in disease The Medical Minute by Penn State

the blockage.”

2010, the risk of developing diabetes is 26 percent higher for people who consume one or more sugary drinks every day.

Medications that help modify risk factors such as high blood pressure, cholesterol and insulin levels have shown to be helpful, but the condition can’t be Even switching to artificially sweetreversed once it begins. ened or ‘diet’ soda containing sugar alternatives may not reduce the risk “Whatever blockages have occurred will of diabetes. While research on these Initially, the body may form smaller not go away unless they are stented or has reached more varied conclusions, blood vessels around the blocked ones bypassed,” Aziz said. “But risk-factor this 2018 investigation Trusted Source to reroute some blood. modification can slow the progression of suggests that artificially sweetened the disease.” beverage consumption cannot be ruled Once the condition advances, those who out as a risk factor for diabetes. experience it can develop severe leg In cases where walking doesn’t improve cramps when they walk a lot, but that the situation, 70 to 80% of patients Insulin resistance is central to the the pain disappears when they sit and can be helped with minimally invasive development of type 2 diabetes. It the demand for nutrients and oxygen procedures that involve injecting dye occurs when the cells become used to decreases. into the vessels and placing balloons an excess of sugar in the bloodstream or stents in the vessels to help with and do not absorb glucose as effective“Pain with physical exertion is a clascirculation. ly, responding less to insulin. Insulin is sic, hallmark sign,” said Dr. Faisal Aziz, the hormone that unlocks cells, allows chief of vascular surgery at Penn State He said more serious cases may need a glucose to enter.

Health Milton S. Hershey Medical Censurgical bypass where blood is rerouted ter. “When it gets really bad, it can form from the damaged vessel to a good one This 2016 study Trusted Source found wounds on the legs that do not heal or nearby. that sugar-sweetened beverages cause blackening of the foot or toes.” contribute to the progression of insulin “It’s like building a bridge across a body resistance and prediabetes, the stage Risk factors for the disease include age of water though, so there are times we before full diabetes. and gender. Men, and all people age 65 can’t even do that,” he said. “We need a and older, are most likely to develop good piece of land on both sides.”

Some studies, controversially, found the condition. People who have heart no association between added sugars disease are also predisposed to it. and diabetes, such as this review from How soda impacts diabetes risk 2016 Trusted Source.

Sweetened sodas are hugely popular Most of the other risk factors – smokthroughout the United States.

Research ing, high blood pressure, high cholesHowever, the study authors list their suggests that drinking too much soda has terol and uncontrolled diabetes – can conflicts of interest at the end of the be modified with education, medication strong links to diabetes. article, advising funding from an array Source: Medical News Today and/or lifestyle changes. of food and drink manufacturers who Peripheral artery disease develops silently, narrowing blood vessels for decades until the supply of nutrients and oxygen falls low enough to cause cramps and leg pain.

Aziz said many of his older patients with the condition grew up during a time when the hazards of smoking and inhalation of secondhand smoke were not well known.

In the U.S., an estimated 9.4 percent of the population has diabetes. It is the seventh leading cause of mortality in the country.

While type 1 diabetes is not preventable, an individual can take steps to “The body is very forgiving, so we keep reduce the more common type 2 by abusing it,” he said. “But in this case, moderating sugar intake. prevention is better than a cure.”

Aziz said anyone who has some of the risk factors, along with pain in their legs, should discuss the possibility of the disease with their primary care physician.

In this article, we examine the effects of soda on diabetes risk and how cutting it out can help prevent the development of the common and life-threatening disease.

Soda and diabetes “If you aren’t exercising or walking Soda can also reduce the ability of enough, you won’t even know you have people who already have diabetes to it until it has silently progressed,” 6 control blood glucose, according to this he said. “Most physicians will also

add vast amounts of sugar to products, including The Coca Cola Company and PepsiCo, bringing into question the reliability of the evidence.

How do sweetened drinks lead to diabetes?

Drinking too many sweetened drinks means that the body stores excess energy in the form of fat, so, drinking too much soda can play a part in the development of overweight and obesity.

Research has shown that being overweight or obese is a risk factor for type 2 diabetes and other conditions.

A review of relevant studies, compiled in 2015, confirmed the relationship between diabetes and beverages sweetened with sugar despite the exact bio-

logical mechanisms remaining unclear.

One study, published by The American Journal of Clinical Nutrition in 2010, investigated relationships between the diet and health of 91,249 female nurses over 8 years. They found a link between a diet with a high glycemic index (GI), or quickly digested foods and drinks that cause a spike in blood sugar, and type 2 diabetes.

The risk for diabetes was high even after taking into account other known risks and dietary factors involved in diabetes. In fact, the diabetes risk associated with a high energy intake was greater than that of consuming unhealthy fats.

accounted for, the high soda drinkers still had a higher risk for type 2 diabetes.

The authors of the report speculated how sugar-sweetened drinks could potentially cause type 2 diabetes, but, as with other researchers, could offer no firm conclusions. Their study could not prove a direct causal link between soda and diabetes risk, just a correlation between the two.

The authors did, however, suggest that the link could be due to “an effect on weight gain,” as well as the “glycemic effects” of sugar-sweetened drinks “inducing rapid spikes in glucose and insulin and causing insulin resistance.”

The authors explained the following process through which high sugar intake could lead to diabetes:

Is diet soda healthier?

Artificially sweetened sodas are controversial.

•

While some studies, such as these findings from 2016Trusted Source, found that sugar-sweetened beverages increased the risk of diabetes whereas diet soda did not.

•

•

Higher blood glucose concentrations from a high load of quick-digesting carbs mean more demand for insulin.

Higher demand for insulin in the long-term wears out the pancreas.

This can result in glucose intolerance from the cells.

High-GI diets may, therefore, directly increase insulin resistance.

Some people see diet, low-sugar, or alternatively sweetened soda as a less damaging option.

Another study followed the soda consumption habits of thousands of people and compared those who developed diabetes with those who did not. They did The review also supports the suggestion find a link between artificially sweetened drinks and diabetes. that high sugar intake adds to obesity by increasing the total energy conHowever, further analysis showed that sumed. those with higher diet soda intake were more likely to already have, or be at In other words, as sugary beverages higher risk for, diabetes. The effect also add to the overall daily intake of calories, the increase in calories likely leads disappeared from the analysis when their higher BMI was taken into acto an increase in weight. count.

The paper also investigated the idea of Not all researchers are convinced by sugar-sweetened drinks more directly causing type 2 diabetes. They conclud- diet soda, though. One reviewer Trusted Source, writing in 2013, said “frequent ed that research in this area had not yet been able to rule out other factors, consumption of high-intensity sweeteners” might have an effect opposite to such as obesity, and that further rethat desired. It may lead to metabolic search is needed. issues that can contribute to heart disA case-cohort study from 2013 investi- ease, type 2 diabetes, and high blood pressure. gating the relationship between sugar-sweetened drinks and diabetes compared data about the soda consumption A potentially harmful effect of artificially sweetened beverages on glycemic habits of 11,684 people with type 2 diabetes to those of 15,374 people who control for people who already have diabetes is that the artificial sweetendid not have diabetes. ers are roughly 200 times sweeter than sugar Trusted Source. This extra sweetThe team found that people who conness then tricks the brain into reducing sumed one or more sugar-sweetened blood glucose levels, running the risk of drinks every day had a higher risk for hypoglycemia. diabetes than those who drank less than one a month. Even when energy intake and body mass index (BMI) were The author, Susan Swithers, writAs soda has an extremely high GI, it may well contribute to this process.

ing while at the Ingestive Behavior Research Center of Purdue University, West Lafayette, IN, concluded: Current findings suggest that caution about the overall sweetening of the diet is warranted, regardless of whether the sweetener provides energy directly or not.”

Overall, moderation is key. Too much of any food or drink is likely to have adverse health effects, especially if it contains high levels of sugar.

7

Vascular& Ortho When to Treat Type 2 Diabetes as a Vascular Disease

-- Medical group association president argues for rapid shift toward multi-faceted drugs John W. Kennedy MD/Medpage Today

Cardiovascular disease (CVD) is a leading cause of morbidity and mortality among patients with type 2 diabetes mellitus (T2DM). About one third of people with T2DM also have CVD. Not only are these patients up to eight times more likely to suffer a heart attack and nearly seven times more likely to suffer a stroke, two out of every three diabetes patients die from CV complications.

Thankfully, this unique population of patients now has new cause for optimism.

The American Diabetes Association (ADA) recently announced an update to its Standard of Care Guidelines for medical co-management of T2DM and established atherosclerotic cardiovascular disease or chronic kidney disease (CKD). For the large numbers of patients who fail to achieve adequate diabetes control as measured by hemoglobin A1c% (HbA1c) -- despite their best efforts at comprehensive lifestyle change management through diet and exercise -- two newer classes of medications, GLP-1 analogues and SGLT-2 inhibitors, are now recommended as a second-line medical therapy.

It is important to pause and emphasize the importance of this recommended change in standard diabetes practice.

Previously, the standard of care was for physicians and patients to consider a variety of options for second-line therapy for patients with persistently uncontrolled T2DM and CVD or CKD who failed to achieve target glucose levels despite lifestyle intervention and metformin treatment. This led to a standard practice in which agents associated with a significant risk of hypoglycemia would be chosen -- a source of concern for many patients with advanced diabetes complications.

New evidence and specialty society guidelines are disrupting this predominantly glycemic-centric approach as providers and patients are now being asked to think of diabetes also as a vas8 cular disease and to preferentially

select proven second-line classes of diabetes therapies that target preservation of heart, brain, and kidney function in patients with comorbid T2D, CVD, and/ or CKD.

surprised to learn that even among high-performing health systems, initial measurements showed that less than 5% of patients who qualified were being prescribed these therapies.

While the recommendation of GLP-1 analogues and SGLT-2 inhibitors by the ADA was based upon a thorough review of the literature and landmark studies, clinicians may not widely adopt these lifesaving guidelines and therapies for their patients for years to come.

After a year-long process of shared learning and operationalizing systematic changes in care pathways, the highest performing systems within this cohort achieved more than threefold improvements in evidence-based prescribing of SGLT-2 or GLP-1 therapy among qualified patients within 1 Unfortunately, even in the information year. These outcomes were possible in age, lifesaving knowledge travels slowly part because of the coordinated, pathrough the legacy healthcare system. tient-centered, team-based approach Crossing the Quality Chasm, the semthat AMGA members embrace. inal 2001 report from the Institute of Medicine, pointed out this lengthy gap Encouraged by these outcomes, I between discovery and application in remain optimistic that, through the medicine, noting that “scientific knowl- collective efforts of our AMGA member edge about best care is not applied sys- organizations, we can accelerate the tematically or expeditiously to clinical delivery of proven therapies to qualipractice. It now takes an average of 17 fied patients in a timely and effective years for new knowledge generated by manner. It’s the right course of action randomized, controlled trials to be infor patients, for health systems, and corporated into practice, and even then, for the health of the U.S. application is highly uneven.”

John W. Kennedy, MD, is president of We are seeing this lag time today. Dethe AMGA Foundation and chief medspite the research evidence and recom- ical officer of AMGA. He previously mendations by specialty medical sociserved as division director of endocrieties, the vast majority of patients with nology at Geisinger Health System in T2DM and CVD, chronic heart failure, Danville, Pennsylvania, where he led or CKD are not being prescribed the the clinical, education, research, and GLP-1 or SGLT-2 classes of medications, quality program development and exand if they are, many are not regularly pansion for the health system. compliant in taking them.

AMGA is a nonprofit trade association The good news is that the FDA recently representing hundreds of multispeapproved the first-ever GLP-1 analog cialty medical groups and integrated pill. Hopefully this new delivery method systems of care. More than 175,000 will lessen patient medication compliphysicians practice in AMGA member ance challenges associated with self-in- organizations, delivering care to one in jections. three Americans.

At AMGA, our members have collectively set a course to accelerate the evidence-based treatment of patients with T2DM. Through the AMGA Foundation’s signature national campaign, Together2Goal, over 150 AMGA member integrated delivery systems and medical groups have joined to share data and collectively work to improve outcomes in more than 2 million adult patients with T2DM nationwide.

Within that campaign, a cohort of 12 AMGA members specifically focused on improving care for patients with comorbid T2DM and CVD. Many were

Fast Five Quiz: Coronary Artery Atherosclerosis Do you know key aspects related to coronary artery atherosclerosis, as well as best practices for management? Test yourself on the basics of this condition with this short quiz.

The answers are provided after the quiz at the bottom of the page.

Which of the following is most accurate regarding risk factors associated with coronary artery atherosclerosis and related conditions?

1. Risk factors for cardiovascular disease (CVD) that are more common or typically more significant in men than in women include psychosocial factors and autoimmune diseases (eg, lupus, rheumatoid arthritis) 2. Risk factors for cardiovascular disease (CVD) that are more common or typically more significant in men than in women include psychosocial factors and autoimmune diseases (eg, lupus, rheumatoid arthritis) 3. Coronary heart disease risk assessment in asymptomatic patients should be measured using MRI for detection of vascular plaque or coronary CT angiography.

4. Risk for CAD is increased in individuals with heart disease in the father or a brother before age 55 years and in the mother or a sister before age 65 years.

Which of the following is most accurate regarding the presentation and physical examination of patients with coronary artery atherosclerosis?

1. High or low blood pressure may be noted in patients with atherosclerosis, and hypotension often reflects hemodynamic compromise.

2. Impairment of arterial flow occurs once 20% of the lumen diameter is obstructed, resulting in symptoms of inadequate blood supply to the target organ.

3. An S3 gallop is a common early finding in patients with atherosclerosis, whereas the presence of an S4 gallop indicates reduced left ventricular function.

4. Stable angina pectoris may be associated with pain at rest.

Which of the following is accurate, according to the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease?

1. Patients aged 20-39 years should undergo measurement of traditional risk factors annually to identify major concerns.

2. Coronary artery calcium (CAC) measurement should be routinely used as a screening test.

3. Low-dose aspirin should be administered on a routine basis for the primary prevention of atherosclerotic CVD in adults older than 70 years.

4. Statins are recommended in patients younger than 19 years with familial hypercholesterolemia.

Which of the following is accurate regarding imaging studies in patients with coronary artery atherosclerosis and related conditions?

1. For the diagnosis of obstructive CAD, technetium-99m (99mTc)-based single-photon emission CT (SPECT) is superior to rubidium-82 (82Rb) PET. 2. Doppler velocity probe is used to measure absolute velocity and volumetric flow, rather than changes in flow velocity, in patients with CAD. 3. Coronary angiography remains the criterion standard for detecting significant flow-limiting stenoses that may be revascularized through percutaneous or surgical intervention.

4. Electron-beam CT (EBCT) is contraindicated in symptomatic patients with suspected obstructive CAD. Which of the following is most accurate, according to 2019 European Society of Cardiology (ESC) guidelines for patients with chronic coronary syndromes?

1. Nitrates are recommended in patients with hypertrophic obstructive cardiomyopathy.

2. When oral anticoagulation is initiated in patients with chronic coronary syndrome and atrial fibrillation (AF) who is eligible for a non-vitamin K antagonist oral anticoagulant (NOAC), a NOAC is preferred to a vitamin K antagonist (VKA).

3. Combination therapy with a statin and ezetimibe is contraindicated.

4. Angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARB) are preferred over beta-blockers and/or calcium-channel blockers for angina/ischemia relief in patients with chronic coronary syndromes.

Answers: 1-4, 2-1, 3-4, 4-3, 5-2 Source: Medscape.com 9

Stump For

Advocacy and Empowerment We’re In Your Corner

Financial Coverage

• The patient’s history

Sources: Medicare and Ottobock

• The current condition of the patient which also includes the current states of the residual limb with the nature of other medical problems that might be there and

What you need to know about paying for your device.

MEDICARE FOR AMPUTEES For amputee financial assistance, Medicare is one of the first resources patients use to receive financial relief.

Medicare provides the largest financial resource for prosthetic care across the US, which is provided to patients under Medicare’s durable medical equipment, prosthetic and orthotics also known as DMEPOS benefits.

What kinds of prosthetic devices does Medicare cover?

There are three main parts of Medicare insurance services plan from which Part B of the Medicare plan helps in covering prosthetic and orthotic devices. These include the following prosthetic devices and supplies relating to amputee patients:

• The desired level to move around.

What amount is covered and what are the requirements?

But if you plan to choose the third option of Medicare plan that is the Medicare Part C Advantage plan than that would help in covering up all the other original Medicare parts both included in Part A and Part B. While at the same time providing some extra services to it as well.

As for Medicare Part B it pays up to 80% of the approved amount made by Medicare which covers both orthotics and prosthetics.

There are different types of add-on codes that help in describing the different options in the feet, ankles, knees and any other form of technology which combines with the base code to help in properly describing the total services that the patient would receive as well as what might be covered in his or her Medicare plan. While the patients classification levels include: Level 1: if the patient does not have the patient does not have the ability to move around safely with or without the proper assistance Level 2: have the ability to move around with low level barriers such as curbs, or any other uneven surfaces Level 3: those who require prosthetic use which is beyond simple walking Level 4: who has the ability to use prosthetics which is beyond the basic walking skills such as a child, an active adult or an athlete?

But it should be kept in mind that in order for all parts of Medicare plan to 1. Artificial limbs and eyes provide its coverage, there are two What happens if Medicare doesn’t main requirements that should be met: cover all my medical expenses?

2. Breast prostheses (suitable for For patients who have undergone finanbreast cancer patients) 1. It should prescribe by a proper cial assistance through Medicare and licensed doctor or physician and that have found that their costs are still high 3. Braces for the legs, arms, neck and Medicare approves that it is extremely or they are still unable to get coverback important and necessary. age for specific prosthetic devices and supplies, there are a few other amputee 4. Supplies and devices such as surgi- 2. The services should be provided by financial assistance options available. cal bras for patients following a masthose healthcare workers who are par- One of these includes conducting an tectomy. ticipating in Medicare. on-line fundraiser to help cover the costs directly. Unlike other financial 5. Orthopedic shoes (only if they are a Once the plan has been approved all assistance options, fundraising on-line necessary required part of the Medithe accessories for prosthetics are also offers individuals to quickly raise funds care covered orthotic leg braces.) all covered in these plans which are es- directly from family, friends and other sential for effective use for the artificial loved ones. We also have a resource 6. Cochlear implants or surgically imlimb. guide here to help patients looking for planted prosthetic devices more financial assistance resources.

Understanding the medical billing 7. Ostomy supplies such as colostosystem Advocating For You my bags, ostomy pouches, barriers, It is important for patients and their Whether it’s a new or upgraded prosaccessories loved ones to familiarize themselves thesis, orthosis, wheelchair, or other with the unique medical billing system mobility assistive device, learning to 8. Urinary catheter supplies that is used under Medicare. This will advocate for yourself is very important. help you properly apply for reductions Here is some information that can help What does Medicare check when and financial assistance in a timely you move through the insurance or reviewing my application for finan- manner. While a current method of bill- reimbursement process. cial assistance? ing for Medicare for prosthetic services In order to get approval of amputee is known as the “L-Code”. This is a very Check out these 5 tips for advocating financial assistance through Medicare, unique form of medical billing system in for yourself to get the device you need. there are set requirements and rules which a base code helps in identifying that are required to be met. The criand a descriptive language helps in ex- 1. Be organize teria that help in considering a patient plaining the main approach that needs Keep a file. Any payer or insurance will for these Medicare plans include: to be taken. want documented information about 10

your disability, medical treatment,

income, living expenses, dependents, employment, and more. If you keep everything organized, it will prevent delays and make sure your information is complete.

to pay. If you are not insured, talk to 1. Restate the reason why the claim your health care team. Other sources of was denied. funding may be available. If you receive 2. Quote their policy and why you a denial from your insurer, don’t give up disagree (if applicable).

– make an appeal.

3. Include a bulleted list detailing the attached documentation.

2. Work closely with your health Get informed about: 4. Lead them down the path to the care team • Services your insurer will pay for proof of why you think the claim Whether it’s your physician, your prosand will not pay for should be paid. thetist, your orthotist, your therapist • Amounts you will owe • Follow the instructions provided – your health care team is critical in • Referral procedures with your Explanation of Benefits helping procure payment for your first – • Payments for out-of-network ser(EOB). and future –devices. vices 1. You must submit each appeal with• Who to contact if you have a disin the stated time-frame.

Most funding sources (public or pripute about coverage 2. Generally, you will be allowed 1-2 vate insurance companies, government • Procedures for settling disputes appeals with the insurance comfunders, etc.) will require documenabout coverage pany and then depending on your tation (an exam, notes from a visit, • If there’s a time limit on appealing plan, an external appeal may be an a physical) that justifies the “medical a plan’s decision option. necessity” of the device before funds 3. If you don’t receive instructions, are released to you.

4. Be persistent and don’t give up contact your insurance provider as If your request for payment is denied, soon as possible to avoid missing For prosthetics, the documentation make an appeal. deadlines. must show your current level of function or activity as well as your expected Homework for you Even if you are the one who must or potential level, once you have the If you did not receive a copy of the de- make the appeal, your health care device. It can also describe how the nial letter, request a written copy of the team is still a great resource for you, device will help in your employment or reason for denying the claim. This can since they have had experience with increase your independence. be done by contacting your insurance the appeals process. provider’s customer service depart[If you’re a lower-limb amputee, watch ment. Review the letter and ask “Why 5. Stay informed about what works to learn why your activity level can de- specifically was the claim denied?” best for you termine the device you receive] If you were denied for missing docIf you are newly disabled … umentation, ask “What was missing?”

For orthotics, the documentation must Work with your health care team to get If you need to upgrade from old or describe your functional limitations and the documentation needed. outdated devices … a history and prognosis of the weak or If your submission was denied bedeformed (injured or diseased) body cause the device was “not medically If your disability or ability level has part. necessary/experimental,” ask the insur- changed … er/payer to define those terms. TogethFor mobility assistive devices, mobility er with your health care team, gather If you hear about new technology that limitations of mobility-related activities the documentation or clinical studies might increase your function or indeof daily living (MRADL) should be docu- needed to counter the denial. pendence … mented. Some policies may also require Ask your insurance company for a a home assessment, a face-to-face copy of their medical coverage policy. … talk with your health care team visit with your treating physician, and Ask what documentation you will (therapist, physician, practitioner) to documentation of past mobility assistive need to send them in order to receive a understand the features you need in devices. favorable decision. an assistive device. Continue to stay If the insurer’s customer service in contact with them even after you Based on your health care team’s eval- cannot provide answers for you, ask if receive your first device. Your team uation, your physician will give you a they have a patient advocate/advocacy will help you get the most out of your prescription for what you need. Be sure department that can help you assistive device as you have more exto keep the name of the make, model, perience with it. Sometimes you may and manufacturer in your file.

The appeal process think the device “isn’t working” but it Many times your physician or practimay simply need an adjustment.

3. Take time to understand your tioner or other health care provider will insurance plan or payment options be the one writing the appeal (someContact your team if your needs Ask your insurer for a copy of the plan’s times they may require permission from change or to ask about new technoloSummary Plan Description (sometimes you) but there are times when only you gy. called Summary of Benefits). Review (the beneficiary) has authorization to it closely. You should also check your appeal. If you are the one making the deductible and maximum out-of-pockappeal, here is what you will need to et, allowed amount covered for assisdo: tive devices, and if there are annual or lifetime caps. If there are sections you • Request copies of your medical don’t understand, contact your health records (from your prosthetists, plan and ask questions. The Summary physicians, therapists, rehabilitation Plan Description tells you what services facility, hospital, home health, etc.) your plan will pay for, what it will not to support your case.

11 pay for and the amounts you will need • Prepare a cover letter.

V& O

Care of the Elderly Patient With Lower Extremity Amputation

Department of Family Medicine, Brown University School of Medicine Providence; and the Department of Gerontology, Memorial Hospital of Rhode Island, Pawtucket. J Am Board Fam Med. 2000;13(1)

of older adults living with LEA has increased because of the aging of the US population and the increasing incidence of peripheral vascular disease with age.

A literature review was performed using the key words “lower extremity amputation,” “aged” and “rehabilitation.” In addition, I drew upon personal experience and that of local experts.

Diabetics have a 15-fold higher risk for LEA. Risk factors for amputation among diabetic patients include older age, male sex, certain racial and ethnic groups, poor glycemic control, diabetes of longer duration, and poor preventive health care. The risk for amputation in diabetics has declined in the last few years, probably as a result of improved diabetic control, changes in patient lifestyle, and the increased use of limb salvage vascular surgery. Structured diabetes management programs have shown an overall reduction in subsequent LEA rate. One program, implemented in a primary care setting, showed a 48% reduction in LEA during a 3-year period. Structured diabetes management programs systematically implement comprehensive diabetes care according to practice guidelines.

The elderly patient with a lower extremity amputation (LEA) remains relatively common in most family medicine practices. LEA can be categorized into three major types: partial foot, transtibial amputation, and transfemoral amputation. Family physicians have not been well trained to provide care to these patients.

Appropriate medical, surgical, and rehabilitative care can have a positive effect on the functional outcome for an elderly patient with a lower extremity amputation. The family physician can be instrumental in preparing the patient and family for surgery, providing psychological support, preventing and treating complications, managing comorbid illness, and assisting in rehabilitation. In addition, the family physician is primarily responsible for the daily care needs of these patients.

Despite improvements in medical and surgical limb salvage techniques, lower extremity amputation (LEA) remains a relatively common procedure. In 1993, 1,546,000 people in the United States were living with some form of major limb amputation. Of the 127,000 limb amputation procedures done in acutecare, nonfederal hospitals that year, 98,000 involved the lower extremity. The direct medical cost for a single LEA procedure is approximately $46,900. [3] Lower Extremity Amputation LEA is disproportionately a problem of older men; 75% of patients who undergo LEA are male. The incidence of LEA increases after age 55 years.

Although the average age of a lower extremity amputee patient is 51 to 69 years, from 1910 to 1979, the agerelated incidence of LEA increased fourfold for persons older than 80 years.

Despite medical and surgical advances in the treatment of the dysvascular limb, the overall incidence of LEA did not begin to decrease until the 1980s.

12 [8,9] Still, the absolute number

The morbidity and mortality related to LEA remains considerable. Operative mortality rates range from 5% to 17% and postoperative (within 30 days) death rates vary from 2% to 23%.

[6,9] Worsened mortality figures are associated with a higher amputation level and diabetes.[6,8,9] Age older than 80 years is also associated with decreased survival after amputation.

The mean survival for a LEA patient is 2 to 5 years. The most frequent cause of death is cardiovascular disease. The incidence of ipsilateral re-amputation ranges from 8% to 22%, but might be decreasing as a result of improved surgical techniques and more appropriate initial choice of amputation level. The contralateral LEA rate within 4 years is 26% to 44%.[6,9] Most bilateral amputee patients have diabetes.

Pathogenesis Among older adults, vascular insufficiency, often with concomitant diabetes, accounts for approximately 75% of LEAs. Twenty percent of LEAs are done as a result of traumatic limb damage.[2] Traumatic amputee patients tend to be younger and healthier than vascular amputee patients.

Benign or malignant tumors are responsible for the remaining 5% of amputations among older patients.

Types of Amputation

LEA can be categorized into three major types, partial foot, transtibial amputation, and transfemoral amputation.

Transmetatarsel and more distal foot amputations usually cause minor functional problems. Midfoot amputation procedures are not universally accepted because of the potential for equinus deformity, residual limb ulceration, and problems with prosthesis fitting.

There are functional benefits, however, gained from retaining the calcaneus and preserving ankle motion. Ankle and hindfoot procedures are similarly controversial, except for a Syme amputation (disarticulation of the foot).

[13] Transtibial amputations are usually done at the junction of the upper and middle third of the tibia. For higher levels of transtibial amputation, it is usually better to preserve the knee joint, even if the remaining limb is short. The knee joint is very important for functional gait and dramatically decreases the energy expenditure of ambulation. As the level of LEA is higher, there is a progressive loss of proprioception and balance, leading to a less efficient and less functional gait.

Preserving the knee is especially important for elderly amputee patients, because they will more often have comorbid disease that might limit their exercise potential or adversely affect their baseline gait.[6] In general, transfemoral amputation with residual limb must be at least 4 to 6 inches in length from the groin to fit a prosthesis, but success is also dependent on adequate soft-tissue volume. The number of transfemoral amputations has declined since the 1980s.[9] This decline is probably due to improved surgical techniques, as well as better preoperative assessment of vascular status that more accurately determines the level of tissue viability.[6] The study contains a summary of the changes in the energy demands (kilocalorie per meter) of ambulation with various amputation levels. These increased energy demands can preclude ambulation for a small subpopulation of amputee patients or limit ambulation distance for a greater number of patients. Most LEA patients compensate for the higher energy demands of ambulation by walking more slowly,

so that their energy expenditure is not increased. Because of the extreme energy demands (.200% more than normal bipedal ambulation), only young, healthy, motivated bilateral transfemoral amputation patients have a high success rate for independent ambulation. For patients with concomitant comorbid disease, especially cardiac problems, the increased arm activity required for self-propelling a wheelchair can be stressful to the heart.

setting.

The medical, surgical, and rehabilitation care of the elderly amputee patient is complex because of the normal physiologic changes of aging, the common occurrence of comorbid disease, and the likelihood that the contralateral extremity is vascularly compromised. Decreases in muscle strength, bone density, and maximum oxygen consumption with aging, as well as the increased susceptibility of elderly patients to deconditioning Rehabilitation Potential and other medical problems with even short periods of immobility, can lead to To estimate preoperative rehabilitation a more complicated postoperative and potential, it is important to establish rehabilitative course. Four percent to the goals of the amputation procedure, 29% of elderly amputee patients have estimate the functional prognosis, and had a stroke either before or subseselect an appropriate site for rehabiliquent to their amputation. In addition, tation. Depending on rehabilitation po- approximately 40% of elderly amputee tential, the goal of LEA can vary from patients have arthritis, and 20% to patient comfort only to restoration of 30% have some impairment in hearan independent lifestyle. ing or vision. Fifteen percent to 20% have overt heart disease, but many To estimate rehabilitation potential, more have underlying asymptomatic the family physician should assess the coronary disease that might first come patient’s overall medical condition, to medical attention during the rehaprognosis, cardiopulmonary reserve, bilitation phase of recovery when the cognitive and functional status, muscle elderly patient has progressed to a strength, and the mobility of adjacent more physically taxing level of exerjoints. Although being older than 80 cise. More than 5% of elderly amputee years is associated with poorer rehabil- patients also have cognitive dysfuncitation outcomes, in general, comorbid tion that could increase the chance of illness, general health status, and level postoperative delirium. Overall, elderly of amputation are more important patients are more likely to develop than age in determining the outcome postoperative medical problems (eg, of rehabilitation. congestive heart failure, stroke) that affect ultimate recovery.

Barriers to successful rehabilitation include cognitive dysfunction that is Stages of Care severe enough to preclude training, severe neurologic impairment, irreduc- The stages of care for an LEA patient ible knee or hip contracture, or comor- are outlined in the study. The family bid disease (eg, congestive heart failphysician should be involved in almost ure, angina, or chronic lung disease) all these stages of care and will have that greatly impairs exercise tolerance. the primary role providing ongoing Patients with impaired cognition have care to these patients. lower levels of functional improvement after rehabilitation, but might still be An elderly patient with an imperiled able to achieve major functional imlimb often has other chronic medical provements that are maintained with problems that make the risk of surtime and that increase the chance for gical complications relatively high. a home discharge. A relative contraAs a result, the decision to first offer indication to gait training is vascular time-consuming, possibly unsuccesscompromise of the contralateral exful, limb salvage surgery becomes tremity, which might worsen secondary very complex. Overall, vascular bypass to its increased weight-bearing load surgery seems to reduce the incidence postoperatively. Some experts, howof subsequent lower extremity ampuever, consider threatened gangrene of tation, but a failed vascular procedure the contralateral limb an urgent indica- does predict a need for a higher level tion for prosthetic training because of of subsequent amputation. After the the increased risk of contralateral limb decision for amputation is made, the loss.[11,14] No single comorbid illness surgeon must make an assessment of will universally contraindicate a trial the appropriate surgical level that will of rehabilitation. Any amputee patient insure tissue viability while addressing who has recently walked or has the functional concerns. The challenge in potential to walk should be given an initial choice of amputation level is to opportunity for rehabilitation in some weigh the potential need for a sur-

gical revision against the functional benefit of a lower amputation level that preserves the knee. Clinical limb assessment, noninvasive tests (eg, ankle-brachial Doppler index or segmental lower extremity pressures) and lower extremityphy can be informative. An ankle-brachial Doppler index ratio of greater than 0.5 is associated with a greater than 90% success rate for healing a transtibial amputation.

A ratio of less than 0.35 is associated with a poor prognosis for healing a toe amputation. Diabetic patients can have a spuriously high ankle-brachial pressure index despite considerable large- and small-vessel disease.[21] A popliteal artery segmental occlusion pressure of greater than 50 mm Hg is associated with successful healing of a transtibial amputation. Despite the above tests, the final decision on amputation level can be made at surgery, where the amount of blood flow to tissues can be observed.

The family physician should play a major role in all other aspects of preoperative care. Control of comorbid medical illnesses preoperatively will decrease subsequent mortality figures. Preoperative psychologic support is one of the most important roles for the family physician. A patient’s reaction to an anticipated limb amputation is related to age, sex, type of amputation planned, expectation of the success of rehabilitation, and the patient’s perception of the functional value of the lost limb. Body image concerns might be less important for elderly amputee patients.

In addition, the patient’s premorbid personality and coping skills, previous losses, the amount and quality of social support, occupational and vocational demands, as well as the type and degree of comorbid illness, are important. The supportive counseling initiated by the family physician in the preoperative period should be continued throughout the patient’s operative, rehabilitative, and chronic care.

13

V& O

Care of the Elderly Patient With Lower Extremity Amputation

Preoperative physical therapy is helpful to prevent joint contracture and improve balance and muscle strength in the remaining limb. Full range of motion of the more proximal joints of the affected limb is especially important to maximize postoperative mobility. A preventive care plan for the remaining limb should be established because it will usually be at risk for ulceration and amputation also.

the patient’s nutritional status and treating comorbid medical conditions will improve wound healing. In addition to the aforementioned aspects of residual limb care, the patient should be taught mobilization of the suture line, which will decrease adhesions and desensitize the residual limb. Continued use of a semirigid residual limb dressing or a compressive elasticized cloth wrap dressing will reduce edema and begin to shape the residual limb in At surgery, attention is paid to appro- anticipation of fitting a prosthesis. Many priate soft-tissue coverage of the resid- references contain specific instructions ual limb and placement of the suture for wrapping the residual limb. These line away from bony prominences so dressings can slip when the patient that the remaining limb will better tol- moves and require reapplication severerate a prosthesis. A semirigid residual al times a day to maintain appropriate limb dressing (eg, Unna dressing) that positioning and compression. An elastic is fabricated and applied at surgery shrinker stocking can be used after the or in the recovery room can decrease sutures are removed. Typically sutures post-operative residual limb edema, are removed 3 to 4 weeks after surgery. healing time, and pain, and it can aid in shaping the residual limb and proPositioning the patient is important in tect the new incision against traumatic the preprosthetic phase. A leg board damage. placed under the amputated limb will prevent a knee flexion contracture and Epidural medication for patient-conreduce dependent edema. Patients who trolled analgesia usually provides bet- are unable to lie in a prone position ter postoperative pain control. Phanshould lie supine and actively extend tom limb sensations are typical soon their amputated limb while flexing the after surgery and do not necessarily other leg. Physical therapy at this stage require treatment. is progressive. Early training in safe and independent wheelchair mobility will Initial elevation of the residual limb improve a patient’s outlook and restore reduces the development of edema the locus of control. Timely, appropriate that can cause pain and delay healrehabilitation is essential to enhance ing. Beyond the first 2 days, however, functional status within the remaining continued limb elevation can lead to a lifespan of the elderly amputee patient. hip flexion contracture that could affect Coordinated or dedicated multidiscifuture mobility. Similarly, placing a plinary teams can definitely improve pillow under the patient’s back or thigh rehabilitation outcomes. The rehabilican lead to a hip flexion contracture. tation program for a geriatric amputee A pillow placed between the patient’s patient should be individualized accordlegs can lead to a hip abduction coning to the patient’s health, physical statracture. Beginning on post-operative tus, functional status, motivation, and day 1, the patient should be asked to support systems. For the patient whose lie prone to prevent a hip flexion con- amputation was the result of vascular tracture. Early mobilization will reduce compromise, the preprosthetic phase of the development of orthostatic hyporecovery typically lasts 6 to 10 weeks. tension.

Recent changes in prosthesis design Rehabilitation efforts must be conand the use of ultralight materials have tinued immediately after surgery to enhanced amputee function. Factors prevent muscle weakness, orthostasis, relevant to the prosthesis prescription contracture, and other immobility-reinclude the patient’s general health, lated medical problems. An overall abilities, cognitive status, living armedical plan to guard against immobil- rangement, vocational and recreational ity-related problems (ie, deep venous needs, level of amputation, and the thrombosis, deconditioning) should be condition of the residual limb. A great implemented. variety of prosthetic components, socket fabrication techniques, and prostheThe preprosthetic phase of rehabilisis suspension systems are available. tation includes continued attention to A prosthesis can be prescribed by a wound healing and appropriate control rehabilitation medicine physician or your surgeon.

14 of residual limb pain. Enhancing

A patient with a partial foot amputation requires a shoe filler (usually of sponge rubber or foam), shoe modification, or a slipper-type prosthesis according to the type or level of amputation performed.

Because the prosthesis is adjusted to a particular heel height, the patient should be instructed always to wear shoes of similar heel height.

A permanent prosthesis is prescribed after a period of ambulation on a temporary device. The goal of prosthetic training is gradually to improve prosthesis wearing time and functional use. Initially the prosthesis should be worn for only 15 to 20 minutes a day.

Full-time use will require a minimum of several weeks of training. An elderly patient with an amputation will often require a gait aid for ambulation. If a cane is prescribed, it should be held in the hand contralateral to the prosthesis.

It is important not to set lower goals for gait training because a patient is elderly.

Factors associated with successful prosthetic use include good general medical condition, a lower level of amputation, good muscle coverage of the residual limb, nontraumatic operative technique, and absence of residual limb pain.

Depending on the study quoted and the level of LEA, from 20% to 80% of elderly patients return home after LEA rehabilitation. Independence in activities of daily living is a key factor for a successful home discharge. Although the amputee patient might return home, poor mobility in the community and difficulty reintegrating into work and recreational activities often occur.

Possible social isolation is a particular concern with elderly patients. Specialized instruction and automobile modifications are required for the patient to resume driving. The patient should be instructed to bring crutches or a walker on any prolonged trips in case of mechanical failure of the prosthetic limb.

Amputee patients requires life-long care for their functional, medical, emotional, and prosthetic needs. The amputee patient should be knowledgeable about good foot care for the contralateral limb. The patient must also maintain a program of regular residual limb and prosthesis care. Appropriate local hygiene is key. Inadequate cleansing in the skin folds of the residual limb can lead to mechanical irritation and surface infections. Conversely, overzealous cleansing can dry out the skin and

cause eczematous changes. Maceration of the skin within the socket can also cause the skin to break down and leads to fungal and bacterial infections. Cornstarch, unscented talc, or an antiperspirant can control excessive moisture.

Prosthetic socks are often used at the interface of the limb and the socket of the prosthesis to adjust for physiologic volume changes throughout the day.

Natural fiber materials will absorb local moisture. The sock must be pulled free of wrinkles and the seam positioned away from any bony prominence or scars before donning the prosthesis.

Unless the patient wears the prosthesis consistently, an elastic shrinker stocking should be worn to maintain proper pressure and control local swelling.

An often unattended need of amputee patients is attention to sexual concerns.

The LEA patient might interpret silence on this subject as a sign of prohibition.

The patient’s overall health and the couple’s previous attitudes, beliefs, and experiences should be elicited. Amputee patients should be told that they might expend slightly more energy during intercourse, which could result in mild fatigue. Phantom limb pain can also occur with orgasm. The rehabilitation physician or the physical or occupational therapist can provide helpful information if the patient’s balance or movement during sexual intercourse causes problems. Psychologic issues affecting sexual function include an altered body image, depression, and anxiety about disease progression.

Because of frequent changes in the size and shape of the residual limb within the first 6 to 18 post-operative months, the patient should return to their physician during this time for any socket adjustment needed. Otherwise, yearly follow- up visits are recommended.

The family physician should also attend to issues relating to the LEA during continuity care visits. The frequency of visits to the family physician is often dictated by the care needs of any comorbid medical disease, but they should usually be no less often than every 6 months. Aggressive treatment of comorbid medical conditions, such as diabetes and arthritis, is important to prevent deterioration of the residual limb. It is important that the patient maintain a consistent body weight, because a change of as little as 5 pounds can lead to poor socket fit.

[4,11] A poorly fitting socket can lead to skin irritation and breakdown and cause local pain. The family physician should inquire about residual limb or

phantom limb pain, especially if the former occurs with ambulation. Precise localization of the pain can help to focus subsequent physical examination. The family physician should also inquire about any problems with prosthesis fit or function. The occurrence of any falls, along with the circumstances, might highlight prosthesis problems. At each visit, the patient’s functional status and mobility should be documented, and potential reasons for any deterioration explored.

might be necessary.

A contact or allergic dermatitis can develop from the materials used in the socket liner or soap residue left on the liner. Chronic ulcers of the residual limb can be the consequence of persistent edema, bacterial infection, vascular disease, or localized pressure from an ill-fitting prosthesis. Malignant change can occur in these chronic ulcerations, and recurrent ulcers could lead to scarring that affects socket fit.

The patient should contact their phyBoth of the patient’s lower limbs should sician and not wear their prosthesis if be inspected for skin abnormalities, es- irritation or ulceration develops. pecially areas of redness or ulceration.

The scar on the residual limb should be The skin of the residual limb contains mobilized to ensure movement in all many more bacteria than normal, and directions. Adherent scars can become resistance to infection is lowered by a source of pain. Any erythematous or local skin irritation. In addition, the painful areas should be palpated. For skin within the prosthesis is always the transtibial residual limb, there are somewhat moist, which can lead to pressure-tolerant and pressure-sensiincreased bacterial and fungal growth. tive areas (Figure 2). Localized pain, Excessive heat and humidity, poor hytenderness, or erythema over a presgiene, uncontrolled diabetes, and poor sure-sensitive area requires a visit to prosthesis fit are all associated with an the rehabilitation physician, because increased likelihood of local infection. there could be a problem with prosthe- Infection can occur as an area of celsis fit. Because of the differing anatolulitis, superficial crusting pyoderma, my, there are no similar high-risk pres- folliculitis, or furuncle. Skin infection sure areas on the transfemoral residual in the residual limb can require oral limb. Next, the prosthesis should be or parenteral antibiotics depending examined for cracks or instability. The on severity and response to therapy. average life expectancy of a prosthesis Bacterial infection is usually caused is 3 to 5 years (but you are allowed to by coagulase-positive staphylococci get new devices once a year). Finally, or beta-hemolytic streptococci; therethe physician should watch the pafore, an antistaphylococcal penicillin tient ambulate. Malalignment or other or first-generation cephalosporin is an prosthesis problems can cause limb appropriate antibiotic choice. A furpain and recurrent skin breakdown and uncle requires warm compresses and affect the balance, stability, and effiincision and drainage. Fungal infections ciency of gait. require extended periods of treatment with fungicidal creams or powders or, Problems with the Residual Limb in severe or recurrent cases, with oral antifungal agents.

Changes in the residual limb or prosthesis can cause or contribute to multiple Epidermoid cysts develop from perlong-term patient problems, including sistent frictional damage and are residual limb pain, phantom limb pain, usually found at the margin of the neuroma formation, choke syndromes, prosthesis. Treatment is incision and skin irritation or breakdown, skin ledrainage and avoidance of prosthesions, and gait abnormalities. sis use until the lesion is healed. The prosthesis will likely need to be refit.

Causes of residual limb pain include The patient should be referred promptskin irritation, infection or ulcer, under- ly to the rehabilitation physician for lying osteomyelitis or osteophyte, limb any recurrent or chronic skin problems ischemia, neuroma, epidermoid cyst, a as seemingly minor abnormalities can, poorly fitting prosthesis, sensitive scar, with inattention or mistreatment, deand reflex sympathetic dystrophy. Per- velop into problems that could imperil sistent or late-onset residual limb pain future ambulation. can be secondary to all the causes of pain mentioned above. Palpation over a A choke syndrome is a potentially neuroma, a common cause of late-on- serious cause of residual limb pain that set residual limb pain, will charactershould be detected. If the prosthetic istically elicit lancinating discomfort. socket fits tightly around the proximal Neuromas can be treated surgically or residual limb, but the distal residual with a local injection of an anesthetlimb is not in good socket contact, 15 ic-steroid mixture. Socket adjustment there will be obstruction of ve-

O &P News Josh Tacca, a doctoral student in mechanical engineering, traveled to Quito, Ecuador, last year and saw the great need of amputees to find prosthetics with well-fitting sockets.

Grad student helps make prosthetic sockets out of recycled plastic

“I envision we could reach a lot more people if we could go into the field to reach them. We could scan the limb in the field, send back the information to the prosthetists in a central location, print it and then send the prothesis to the person.”

CU Bolder Today - By Kenna Bruner

Tacca, whose research focus is on biomechanics and prosthetic devices, worked with the Range of Motion Project (ROMP) for his practicum, which is one of the requirements for the Graduate Certificate in Global Engineering from the Mortenson Center in Global Engineering at CU Boulder.

“Most of the world has a lot of need for prosthetic care,” Tacca said. “There’s a severe lack of access in many parts of the world. And if there is care, it’s only in major cities.

And the care is very expensive. ROMP is working to help get access to prosthetic care to people who need it.”

“I envision we could reach a lot more people if we could go into the field to reach them.

We could scan the limb in the field, send back the information to the prosthetists in a central location, print it and then send the prothesis to the person.”

When Tacca was an undergraduate at Vanderbilt University, he worked in a lab helping researchers develop prosthetics. Patients became excited when they got to try out the new devices. That inspired Tacca to come to CU Boulder to pursue that area of research.

countries where high-quality, consistent health care is often lacking. Access to rehabilitative services and technology is minimal. Only one in 10 people in need of assistive devices such as prostheses and orthoses have access to them, according to the Standards of Prosthetics and Orthotics at the World Health Organization.

prosthetic legs. Although the prosthetists were from Ecuador or otherwise fluent in Spanish, Tacca was not as fluent. In the rush of all the patients the prosthetists were meeting with, it was difficult at times for Tacca to ask questions and get all the information he needed ROMP is a nonprofit organizato make modifications. To tion that provides prosthetic speed things along, he stanand orthotic care to peodardized the way informaple without access to these tion was gathered from the services. ROMP partnered Traditionally, fitting a socket patients. with tech startup Tukuna to uses a great deal of labor develop and test a 3D printer and materials. Using a 3D He also determined the 3D filament made from 100% scanner and 3D printer settings and would troublerecycled plastic bottles, speeds the process. shoot the printing process. which could be made into The method they used for limb sockets. The plastic bot- After a 3D scanner creates making a socket started by tles are collected by people in an image of a patient’s scanning the patient’s limb.

Quito who pick them up from residual leg, a computer Then they would modify the streets and dumpsters model is modified to make the digital model of the leg, and sell them to Tukuna. a digital socket that is then create a digital socket, print sent to a 3D printer. After the socket out of recycled The socket wraps around plastic bottles are shredplastic, prepare the socket the limb and must be fitted ded and melted, extruded (sanding, buffing, adding a for each individual. Since polyethylene terephthalate valve, etc.) and fit it to the the residual limb inevitably (PET) plastic is used to patient. changes shape over time, make a filament, which the the prosthetic leg socket will 3D printer uses to make the By adjusting printer setlose its fit. Patients may need individualized socket. tings, prosthetists were several adjustments to the able to obtain consistent 3D socket over time. For amWhile in Quito, ROMP held prints. Tacca standardized putees living in developing week-long clinicals when operation procedures, from countries, traveling to clinics amputees traveled to the scanning to modifying to specializing in this work can clinic—some making an fitting the socket. be difficult. arduous journey from many miles away—to have the “It’s difficult for people to Amputation is more prosthetists fit them with travel to the clinic,” he said.

16 prevalent in developing

The skills and knowledge he learned in classes at the Mortenson Center for Global Engineering and in the Applied Biomechanics Lab were helpful for his ROMP internship.

Tacca is working on projects in the lab of Assistant Professor Alena Grabowski in the Applied Biomechanics Lab. He’s processing data for a study that examined how the biomechanics and gait symmetry of sprinters with unilateral, below-the-knee amputations changed when running with different stiffnesses, heights and models of running-specific prostheses. And he worked on a pilot study to see how subjects with unilateral, abovethe-knee amputations walked across different slopes and at different speeds when using a standard suction prosthetic socket compared to the way they walked using an adjustable socket.

“I am starting to work on a project with the Department of Veterans Affairs that will be my main project over the next few years,” Tacca said. “For that project, we are examining walking with a powered ankle prostheses attached to a passive foot. We plan to systematically determine the effects of changing the power supplied by the prosthesis and (whether) the stiffness of the

nous outflow, and distal limb edema will develop.

If unchecked, erythema, induration, and eventual skin breakdown ensues. Treatment is a socket revision.

V & O

Phantom limb discomfort should be differentiated from residual limb pain. Phantom limb pain is often described as knife-like, burning, aching, squeezing, or similar to the pain felt in the ischemic limb preoperatively. Phantom limb pain should be differentiated from phantom limb sensation, which is the feeling that all or part of the missing limb is still present.

This later sensation is felt by most amputee patients and is usually mild and transient. A patient with phantom limb sensation should invest in a night-light to decrease the chance of injury secondary to an attempt to ambulate on a nonexistent extremity.

Far fewer patients have phantom limb pain that becomes physically, functionally, and emotionally debilitating. Phantom limb pain persisting for more than 6 months will likely be chronic and difficult to treat. The cause of phantom limb pain is not precisely known. The perceived intensity of phantom limb pain is related to anxiety level, mood, and problems with prosthesis fit. A variety of techniques have been devised to treat phantom limb pain. None are consistently or permanently successful. Of the neuropharmacologic medications mentioned, the use of a tricyclic antidepressant is best supported by the literature. For elderly patients, nortriptyline or desipramine are used because of their reduced anticholinergic side effects.

Dosing should start at 10 to 25 mg at bedtime. The effective dosage range is 25 to 75 mg at bedtime. Opiate analgesic agents and sedatives or hypnotic medications are transiently, if at all, successful and fraught with the usual concerns about chronic use.

Prevention of prolonged periods of limb pain preoperatively could reduce the incidence of subsequent phantom limb pain. Phantom pain might also be more common when there is residual limb pain. For a particular patient, pain triggers (eg, exposure to cold) might be discernible and avoidable. Overall, nonsurgical approaches are more successful than surgical procedures.

In summary, the family physician can help prepare the LEA patient for surgery, provide psychological support, prevent and treat complications, manage comorbid illness, assist in rehabilitation, and attend to chronic care needs. The relatively short longterm survival of amputee patients heightens the need for aggressive medical and rehabilitative care to enhance the quality of the patient’s remaining years.

Reference: https://pdfs.semanticscholar.org/4a0e/ b313e1033f32d0eaf7de54396601c6dc1ea9.pdf

17

BetterOutcomes facial expressions, more pronounced

time? Offer yourself a chance to be heard and understood for your own experiences.

remove your hands from the computer completely and turn to face the patient.

Empathetic Listening (cont.)

If you do need enter something into the gestures) as these signs can provide EMR, you can announce the transition clues to what the speaker values most. You can use empathy to reflect on your by letting the patient know that you Embrace silence to allow for a compas- own underlying feelings and experienc- need to put some information into the sionate experience. es using the same steps outlined here. computer. It may be helpful to turn the For emotionally charged situations, screen towards the patient so that you writing narratives about your experican review the information together.

Step 4 Look for Cues That the Paence can be helpful.

Consider asking a tient Has Finished Speaking. supportive person to listen to you, and What are some benefits to connectif you want, request that they listen ing with empathy?

There are opportune moments for without offering advice or solutions verbal responses to what the patient is to problems. It may also be helpful to • Tangible and intangible benefits to sharing. Cues might be a decrease in seek trusted colleagues and mentors listening with and demonstrating emotional intensity, a deep sigh, or a with whom you can share some of the empathy include1: shift in the focus of the conversation. At emotional impact of patient care.

• Greater therapeutic efficacy. this point, it may be natural to respond • Increased patient trust, which may to their message and attend to the Listening to others with empathy is a increase the amount of information medical care needed. Verbal reflection skill that can foster trust in the pathe patient discloses and improve may be helpful when you need more tient-physician relationship, increase adherence to treatment. description or explanation from the collaboration among co-workers, and • Improved communication between patient, or when you sense the patient enhance personal well-being. Focuspatient and practitioner, which may would like confirmation that you are ing on a patient’s underlying feelings decrease anxiety and improve the listening and understanding. demonstrates that you are committed patient and physicians’ ability to to understanding their experience, cope in emotionally charged interWhen you respond, keep this quesand your choice of language and other actions. tion in the back of your mind: non-verbal responses is key to drawing out their feelings and values. In a clin- I have a habit of keeping a profes“Is the patient feeling [this emotion] ical setting, patients are more likely to sional distance. Will this impact because they have this particular [value hear you and be open to your counsel if my ability to engage in empathetic or need]? they sense your empathy. listening?

As you respond, it is important to speak naturally and be yourself. At this point in the dialogue, the focus is still on listening and it is not the time to share your experiences or opinions. Listening with empathy has a reflective quality that allows the patient to reach a deeper level of self-understanding.

Q&A

Communicating with empathy involves I am caring in all my interactions. How emotionally engaging with the speaker, but it does not mean that you have to will this help me? lose your professional boundaries. Empathetic listening does not demand that Caring is a natural part of the patient-physician relationship. Empathetic you become responsible for resolving all feelings or needs expressed by a listening reinforces the care that you patient or co-worker, but that you listen have for your patients, and that you with focused attention. As you continue are fully invested in listening to and You may also want to consider actions understanding their emotions. Empathy to practice empathy, you may become that may suggest a lack of empathy. is not a character trait, but a skill that more comfortable listening to the needs These include: allows you to have meaningful interper- and feelings of others as you discover that empathy facilitates more effective sonal connections with your patients.

• Interrupting or finishing the paYour patients may know that you care relationships. tient’s sentences. about their health outcomes, but they • Challenging the patient’s feelings.

I’m already busy managing my pamay share more information and de• Speaking in a manner that sounds velop better trust if you are attuned to tients’ medical conditions, how do I patronizing. begin to acknowledge their emoverbal and emotional messages.

• Describing what the patient ought tions as well? to think or feel.

How do I give a patient my full • Lack of emotional acknowledgment attention when I have a responsi- Strengthening the patient–physician by changing the topic and proceed- bility to keep the electronic medical relationship will lead to more effective ing with medical questions. and efficient clinical care. The physician record (EMR) updated? should listen and encourage patients to talk about their feelings, and even Step 5 Reflect on Your Experience.

When using an electronic medical record (EMR), there is a natural tempta- though you don’t have the capacity As you reflect on a conversation in tion to multitask during the encounter to change their situation, you demonwhich you listened with empathy, begin by typing while listening to the patient. strate an understanding that the pato think about how you are feeling. Is A more effective strategy is to alternate tient will benefit from. After listening to there anything you are grateful for in between working on the computer and her underlying emotions, the physician can then re-focus on medical care. this specific interaction? Is there anycommunicating with the patient. In 18 thing you would do differently next moments where empathy is called for,

Medically Prescribed AppsWear Your Health Now Medgadget.com

In Avengers: Infinity War when Vision came to Wakanda to get treatment, Shuri was quick enough to detect the waning vital signs of the body. She started straight away with the predictions made by gadgets. Yes, the medical industry has not reached that far in terms of technologies. But the vision is right there, if not further ahead. The intent for a better life has been hovering around for long.

Technologies are getting developed so that the battle with diseases can never be lost without giving a proper fight and sometimes, physicians turn fate towards the patient’s side.

But now doctors are looking for measures that can predict the state of the health beforehand. A wellknown proverb is showing the way; prevention is better than cure.

Avail Free Sample Copy at https://www. marketresearchfuture.com/sample_request/752 Doctors often advise maintaining a healthy lifestyle but are they all? Is it good enough to stay away from diseases and lead a longer life? Mankind’s fascination with eternal life and the constant worry of death are giving rise to technologies that can provide an update about how the body is performing. And the results would be delivered on the smartphone, through medically prescribed apps. It will inform the patient about how much care he or she should take off his body. What things should they do and what to avoid, and every other detail.

What Can Be Termed as Medically Prescribed App? A whole lot of stuff is now available on the phone. Some are well-designed, some just there for the profit. The app store has become a constant search engine for such apps. It is happening due to the rise in concern people are having after leading sedentary lives for long. The effects are visible; short breaths, love handles, joint aches, high cholesterol, blood pressure, and sugar. These are symptoms that can lead to early admittance into hospitals. So, what the government is doing? It is just as concerned as we are. Why? Due to

TECH

The market for the medically prescribed app can surge with a CAGR of 18.8% in the years between 2017 and 2027, which Market Research Future (MRFR) has defined as the forecast period.

How To Spot the Best Apps

What is Happening?

Using medical apps may require a bit more vetting than just picking the one with the highest user review score. For instance, it’s best to rely on those approved by the US Food and Drug Administration (FDA).

In November 2019, Sheba Medical Center announced a collaboration with XRHealth, a company known for its extended reality and therapeutic applications, that would see fruition in the creation of the world’s first fully virtual reality hospital.

Browse Complete Report with TOC at https://www. marketresearchfuture. com/reports/medically-prescribed-apps-market-752 About Market Research Future:

the growing bills, the government would have to pay in case of reimbursements. That is why they are taking initiatives to make guidelines. For instance, the FDA has a guideline for such medically prescribed apps. This clearly sets the parameters. It has to be with an external, regulated medical device or it is good if it transforms the mobile device into a medical device.

Several types are in the round.

These medically prescribed apps can be like something that can measure body mass index or ovulation date for want-to-be parents who wants to have their pregnancy options maximized. These apps can be of a type that reminds the user about when to take medicines and it would be immensely helpful for people with diabetes. Some apps also assist in doing exercises and fix appointments with doctors. But a certain type is fast gaining momentum that includes easy counting of steps and heartbeats that can make the user aware of what is going to happen or record daily activities. For instance, Fitbit has made quite a name for itself in this segment. Apple’s association with Nike is also bearing fruits. Some apps are even trying to go further as they are attempting to predict a cardiac arrest on the basis of such innovations.

So What Can Be the Future?

At Market Research Future (MRFR), we enable our customers to unravel the complexity of various industries through our Cooked Research Report (CRR), Half-Cooked Research Reports (HCRR), Raw Research Reports (3R), Continuous-Feed Research (CFR), and Market Research & Consulting Services.

MRFR team have supreme objective to provide the optimum quality market research and intelligence services to our clients. Our market research studies by Components, Application, Logistics and market players for global, regional, and country level market segments, enable our clients to see more, know more, and do more, which help to answer all their most important questions.

Want your company or services to be added to the TECH guide? Please email your request to media@ampnationmagazine.com with the URL of the “TECH page” in the subject line.

19

O &P

News

Grad student helps make prosthetic sockets out of recycled plastic passive foot affects subjects’ biomechanics, muscle activity and metabolic energy consumption when walking at a range of speeds.”

Tacca’s first-hand experience this summer in Quito emphasized the importance of work conducted by organizations like ROMP for people with limited or no prosthetic and orthotic care.

“I’m not totally sure about my career path yet,” Tacca said, “but right now I think I would like to pursue an academic role where I would be able to continue conducting research New 3D printing company in on biomechanics and prosthetic devices. I also think I of prostheses By Brandon Davis would like to incorporate inBenjamin Srulevich jumps forward with his ternational development proj- right leg – and showing no hesitation, he ects, like the one I did with jumps forward with his left prosthesis as if ROMP, into my career path.” he’s pushing off from a starting block at a race.

He merely skips, and the former New York Police officer and double amputee hasn’t skipped in years.

Srulevich, 39, lost his left arm and leg 17 years ago after he was driving his Suzuki GSX-R600 sports bike and was broadsided by a car. His arm and leg were severed at the scene. With years of wearing 50 different traditional prostheses, Srulevich now places on a flexible 3D-printed leg socket made by Additive America at EastPoint Prosthetics & Orthotics, Inc. in Kinston.

“It’s the lightest socket I’ve had in 17 years,” he said. “It is extremely comfortable. I can step right into it and it was a perfect fit from the get-go. The weight is second to none.

“I can skip. I haven’t skipped in a long time.”

20

Kinston changing the future ing game.

“I was looking for a market that had customization and had scale – and it was just sitting there. No one was attacking it.”

Holcomb said. “Everyone wanted to talk about why you couldn’t do this and why the economics wouldn’t make sense.

“The way we’ve been able to position that in prosthetics is if it doesn’t take any longer for you to get it and it weighs less and it costs the same or less, tell me why you wouldn’t try it.”

Holcomb places several prosthetic-designed parts from a 3D scan of a patient’s limb inside a box on his computer through a 3D nester program as if he’s filling a jar full of candy, sand, soda and other items. The computer then transfers the file to the HP printer where fresh powder is fused, creating an actual prosthesis part in a build unit.

From there, the build unit is moved to the post-processing station where 80 percent of recycled powder forms around the prosthesis.

Holcomb produces between three and four Srulevich and other patients at Eastbuild units per week with 3D printing. A Point have enjoyed the weightless feel of 3D-printed socket weighs 650 grams, while 3D-printed prostheses produced by Additive a traditional socket weighs 900 grams.

America president, Zac Holcomb.

“Think of it as you can go get a custom oneHolcomb saw the future of 3D-printed pros- of-a-kind tennis shoe just for your foot,” theses and met EastPoint prosthetist Brent Holcomb said. “That’s what we’re trying to Wright on-line at LinkedIn over a year ago. provide for these patients.”

Wright learned of Holcomb’s knowledge of additive manufacturing – or 3D printing – Sugg has been making prostheses since and his passion to move from the traditional 1993 – the traditional way. He will wrap a methods of plastering and molding prosthe- cast around a patient’s residual limb and

With a present propulsion to pass the Amputee Coalition’s Insurance Fairness bill, Wisconsin limb difference activists continue to promote insurance equality for all within their community.

‘Limbs are not a luxury’: Impending insurance fairness legislation

There are currently two million people living in the United States with limb loss — Shawn Faessler is one of them.

The UW-Madison alum was fortunate enough to have insurance that would cover a prosthetic, restoring his mobility and independence.

However, the majority of amputees cannot say the same due to the inability to afford high insurance costs and the onerous obtainment process.

In 2002, his left leg was amputated after he survived trauma. A few months later, he saw what he thought his life could have become — an experience that would send him into a three-year depression and cause him to question his own abilities for over a decade to come.

If the bill passes, Wisconsinites could see the per member per month cost of insurance increase by $0.12 to cover the cost of prosthetics for all, as determined by eight states’ independent studies.

“The consensus in each study Local amputee activists advocate for the eradication of insurance found that the cost of care inequities within the limb difference community, amidst a current would be minimal and the momentum for the implementation of the Amputee Coalition’s benefit to the individual, their Insurance Fairness bill. -- Image By: Lyra Evans family, and society, would be significant,” the Amputee for unemployment,” Jackson ment, Faessler worked Coalition synthesized. told Swimming World Maga- alongside other activists

to end disparities among amputees. Recently, his efforts have been dedicated to advocating for legislation changes, including the imHowever, Faessler was forplementation of the Amputee tunate enough to never face Coalition’s Insurance Fairthe threat of homelessness ness bill within Wisconsin. after his amputation. He went on to receive a job pro- The Amputee Coalition is a motion, raise three children nonprofit organization whose “I saw three people out in and enjoy an active lifestyle. mission is to “reach out to public missing limbs. They and empower people affectwere all panhandling,” He expressed those accom- ed by limb loss to achieve Faessler reflected. “So I saw plishments would not have their full potential,” through that and I had this mindset been possible without the education, support, advocaof, ‘If you’re missing a leg, high-caliber insurance cov- cy and to promote limb loss you’re going to be panhanerage he had at the time of prevention. dling. This is the life you have his amputation. in front of you.’”

The non-profit coalition “When I had my amputaauthored the Insurance Such a perspective is not tion, I had zero restrictions Fairness legislation, and has abnormal or irrational for that I was aware of. I had lobbied for its implementathe amputee and limb differ- zero cost. Once I had taken tion for over a decade. Thus ence community to possess. the ambulance and was at far, the legislation has been Roderick Sewell Jackson, the the hospital, everything was ratified in 20 states and refirst above-the-knee bilateral covered. So, I had incrediceived bipartisan support. amputee to finish an Ironman ble insurance at the time,” and a hopeful 2020 paralym- Faessler said. “This doesn’t Although the bill has not pic, has been outspoken with happen in this day and age. been attempted in Wisconhis homelessness experienc- And look at where I am now sin yet, it is currently being es. because of that. So for me drafted and awaits a formal personally, it’s given me the introduction to the state Due to the financial burden opportunity to live a happy Legislature by Rep. Robert of being an amputee without and full life.”

Brooks, R-Saukville. adequate insurance, Jackson and his mother were forced He is lead advocate and The bill would potentially into homelessness for five certified peer visitor for the require all insurance policies years.

Amputee Coalition since July within the state to provide “She had to make the decision to get my legs amputated and she didn’t really have the funds necessary to get me prosthetics, so she filed

“Really the goal [of the Insurance Fairness legislation] is to end discrimination and to have external prosthetics treated the same as internal prosthetics,” Faessler said.

“Conceptually, it really is as simple as that.”

zine. “Even though that got me the prosthetics I needed — the ability to walk — it put us in a financial bind.”

The current reimbursement for prosthetics in Wisconsin ranges from $1,000 to $5,000 with prices of some devices reaching upwards of $50,000, according to data from the Hospital of Specialized Surgery.

Another barrier for amputees with private insurance plans is the common feature of “one prosthetic per lifetime” caps, which can be insufficient since prosthetics are not made to last a lifetime.

“But even then, the most expensive prosthetic limbs are built to withstand only three to five years of wear and tear, meaning they will need to be replaced over the course of a lifetime — and they’re not a one-time cost,” according to an ABC News article.

Until the bill is introduced to Wisconsin’s Legislature, Faessler and other activists will continue working towards the realization of the proposed law.

“My bigger picture and vision is to raise the standard of care for people with limb loss and limb difference and 2017, giving him the oppor- coverage for prosthetics and eliminate the stigma that just because you’re missing a limb tunity to volunteer and sup- orthotics equal to or better doesn’t mean you aren’t a port others with amputations than the federal Medicare whole person,” Faessler said. and limb differences. program. Additionally, it would abolish coverage caps 21 Since his time of involveand lifetime restrictions.

ses.

“We can show people how to do it on a computer,” Holcomb said.

“Knowing what I can do with scanning and 3D printing, this can all be digitized.

“Brent was the first person to believe in me.”

Though Wright had been working with fused deposition modeling (FDM) 3D printing – with the use of a hot glue gun – for three years, Holcomb introduced Wright to a Hewlett-Packard (HP) Jet Fusion 3D 4210 printer. EastPoint president Paul Sugg purchased the printer and the post-processing station, and Holcomb and his family moved to North Carolina from Ohio this summer to start Additive America inside EastPoint, located at 310 Airport Road.

“A big thing with additive manufacturing for me is that it’s manufactured in the USA,” Holcomb said. “We’re taking jobs that would go to China and we’re keeping them here. And manufacturing here in Eastern NC, there’s such an opening for that.”

Holcomb began programming machines for 3D printing seven years ago and entered the world of additive manufacturing between 2015 and 2016 when 22 HP stepped into the 3D-print-

then pour plaster inside the cast to mold the socket. But prostheses have advanced throughout the years, way before Sugg’s time.

having an additive manufacturing company in town is going to be a great selling point for Kinston and Lenoir County,” Holcomb said. “We’ve been hearing the most that people are excited about a new manufacturer coming.”

“The old way of doing it, you would literally bring in a tree trunk to the guy and he would hollow it out,” Sugg said. “He But what’s most important to Holcomb would press it on your leg, whittle it some and Sugg is the feedback they receive more so you could wear it. from patients like Srulevich.

“It’s been developed from wood to lamination to now 3D printing.”

“I woke up from surgery with no arm and no leg,” Srulevich said. “It was a challenge. I wore legs that were held on with Holcomb said the $500,000 printer is the an air cushion. They were heavy as anyonly privately-owned HP 3D printer in the thing else. The 3D printer does a better state. job than traditional prostheses.

“The Global TransPark is a huge draw and “I haven’t skipped in 17 years.”

In the United States alone, approximately 185,000 amputations occur each year, and over 2 million people are living with the loss of a limb. I called upon more than I would like to say to consult with patients who are facing one of the toughest life decisions - to amputate or not. Most have not choice in the matter they just don’t know it.

I work with several doctors and help them and their patients by providing valuable insight to life as an amputee.

I speak with patients and their loves ones about what to expect. As an amputation specialists and editor of this publications and host of Amp Life Talk Radio, answering questions about the process, from the reasons for amputation, to returning to favorite activities, sex & intimacy after the procedure.

Q&A

What to Expect When Facing Amputation

1. The limb has been affected by gangrene, which is when the body’s tissue begins to die as a result of lack of blood supply.

2. There has been a life-threatening danger to the person’s health, such as when the part of the body has been affected by cancer or serious infection.

3. The limb has experienced a serious trauma, such as an injury that has crushed the limb or a significant wound.

Q: What are the different types of amputation?

A: There are many different types of amputation. The easiest way to explain is to divide them into lower limb and upper limb categories.

Lower limb amputations: • A partial foot amputation involves the removal of one or more of the toes. This type of amputation affects walking and balance.

• A below elbow (or transradial) amputation involves removal of the forearm below the elbow joint.

• In elbow disarticulation, the forearm and the elbow joint are removed.

• Above the elbow (or transhumeral) amputation is the removal of the arm above the elbow.

• Shoulder disarticulation is the removal of the entire arm, including the shoulder blade and collarbone.

I decided to do a Q&A on this topic, below you will find some of the most common questions I get from patients and family.

Q: What are some reasons for amputation?

A: An amputation is the surgical removal of part of the body, usually an arm or leg. There are three main reasons for amputation.

the hand on the wrist joint.

Sean Harrison

Hanger Clinic Patient Advocate Manager Amputee Life Coach

Q: What can someone expect following an amputation?

A: Immediately following surgery, the focus is on healing the residual limb, which is paramount for longterm recovery goals. Healing of the wound at the amputation site typically occurs within 3-4 weeks.

The scar takes significantly longer, approximately 12 to 18 months, to heal on the inside. Wound management during this early phase is very important to promote healing of the underlying soft tissue and to reduce the risk of infection. The goal is to maintain a soft, pliable tissue over the scar and shape it through compression to allow for a prosthesis and weight bearing moving forward.

Coming to terms with the psychological impact of an amputation is often as important as coping with the physical effects. It’s very • A through-the-knee empty amputation common to experience negative involves removal of the lower leg and the thoughts after an amputation, espeknee joint. The residual limb is still able cially if it was done in an emergency to bear weight, as the whole femur (the situation without time to prepare longest bone in the leg) is still intact. for the effects of the surgery. Many people report feeling emotions of • In a hip disarticulation, the whole limb grief, similar to experiencing the is removed, including the femur. When death of a loved one. It is importpossible, a variation of this procedure is ant to seek support from trained done to retain part of the upper femur professional peer visitor as needed and hip joint for better shape and profile to help in the process of emotional when sitting. healing. common amputation in the older population.

• A trans-pelvis amputation (or hemipelvectomy) involves removal of the entire leg and part of the pelvis.

• Ankle disarticulation involves amputation of the foot at the ankle level.

Upper limb amputations: • A partial hand amputation can include fingertips or part of the fingers. The thumb is the most commonly lost digit, which limits grasping ability.

• A below the knee (or transtibial) amputation is an amputation of the leg below the knee joint, so the individual retains use of the knee. This is the most

• A metacarpal amputation is the removal of the whole hand, leaving the wrist intact.

• Wrist disarticulation involves removing

Q: What is a prosthesis and how does it work?

A: A prosthesis is an artificial limb which is created by a certified prosthetist. The parts vary depending on the level of amputation and the mobility of the user. The rehabilitation team collaborates to ensure that the prosthetic user has the most appropriate prosthetic components to allow for optimal mobility and activity.

23

Q

&

A

Q: How does rehabilitation help?

A: Physical therapy training begins shortly after surgery. This is the time period in which wound healing is occurring. The focus is on residual limb management, positioning, maintenance of range of motion, strengthening, and functional transfer training.

In a perfect world once the wound has healed, prosthetic training with a temporary prosthesis typically occurs. But in most cases the prosthesis does not arrive until a patient is discharged from physical therapy. This therapy addresses range of motion, strength, balance, endurance, and mobility.

The overall goal of rehabilitation is to ensure safety and provide as much independence as possible while achieving the highest level of functional mobility.

Q: How long does the rehabilitation process take?

A: Rehabilitation needs vary widely from person to person. The rehabilitation team will help the new amputee and prosthetic user set realistic goals to achieve throughout his/her personal plan of care.

What to Expect When Facing Amputation with Sean Harrison A: This probably the number one question I get from patients and family members. It’s not an easy one to answer because all patients are different but here is some basic information that will help guide you.

Before attempting prosthetic fitting, the residual limb changes shape and volume, muscles re-adapt and the limb “matures”. Time and maturation are necessary in order to avoid a painful mismatching between the shape of the residual limb and prosthetic socket.

Without proper patience and preparation, a prosthesis can be fabricated too early, only to become the result of a socket that is incompatible with the changing shape of the stump. In these lamentable cases, the patient is left with a fancy, expensive and high technology limb that is useless to him, because it does not fit. This can be a costly mistake, resulting in the patient needing to be refitted, the patient often has to wait for approval of a new socket by a funding or insurance agency. Most of these are denied. Once the patient has approval, they have to go through the time-consuming process of another socket fabrication, reassembly and realignment. It is far wiser to instead to use progressive protocols that allow for the incision line to heal completely, and apply shrinker to help with shaping the stump. These protocols can allow ongoing rehabilitation combined with appropriate management of the healing process and inevitable volume changes before definite fitting and thereby avoid this all too frequent and very frustrating scenario.

Q: Can people still participate in favorite activities following amputation?

A: Most activities can be completed with the use of a prosthesis. It is best to discuss returning to these activities with a skilled therapist and prosthetist if there is any concern for safety. If the limb that is worn for daily use is unable to tolerate certain activities, there are specialty prosthetics designed for specific activities like swimming, cycling, snow skiing/boarding, and water skiing/ Q: What’s better soft dressing vs rigid boarding. dressing?

A: Compressive wound dressings have Q: What are the primary goals of long been recognized as essential post-surgical amputation managefor controlling swelling, minimizing ment? post-operative pain and promoting A: Post-Surgical amputation manstable limb volume. agement begins immediately after you come out of the OR, it includes Soft dressings are sterile, compressprompt, uncomplicated wound healing, ible and cover the wound beneath a control of edema, control of postlayer of elastic bandages. The bandagoperative pain, prevention of joint es support the amputation site under contractures and rapid rehabilitation compressive pressure, but care must to optimum levels of activity. Don’t be be taken that they not be so tight as surprised if the PT/OT staff is trying to to lead to proximal constriction or a get you up and moving once you get tourniquet effect. While an unquesback to your room. tionable benefit to the healing process, elastic bandages need frequent changQ: How long until the prosthetic ing and require close monitoring to 24 process can begin? maintain the correct amount of pres-

sure. Proper soft dressing protocol requires careful judgment, technical skill and vigilance. The advantages of soft dressing management include the apparent ease of application, and because they provide easier access to the wound, the surgeon can inspect the wound site frequently as it heals.

However, complications can arise from poor wrapping of the residual limb, and it is not uncommon to develop joint contractures. When used exclusively, soft dressings frequently make muscle conditioning and pain control more difficult. Even though many surgeons consider simple soft dressings outdated, in comparison to the semi-rigid and rigid postoperative prosthetic techniques available, they are still the method preferred by many amputation surgeons.

Rigid dressing, for many years, both open and closed amputations have been treated by the early application of rigid dressings.

Injured tissues heal best and are less painful when supported and placed at rest. When the injured limb or amputation site is immobilized and the appropriate local pressure and elevation protocols are applied, the inflammatory response and edema associated with early healing is minimized. Immobilization, application of gentle distal pressure and infrequent dressing changes are tenets of good post surgical care.

Rigid dressings can be fabricated using a variety of materials, including conventional plaster of Paris, elastic plaster of Paris, thermoplastic materials, and any number of other splinting materials. The dressing is applied at the end of surgery and is typically changed in intervals of five to fourteen days. Proper rigid cast protocol requires a therapeutic degree of terminal pressure while promoting a sterile, dry wound surface with no restrictions to hinder circulation. No proximal constriction should be applied to the dressing and the dressing must be adequately suspended to maintain distal pressure. Maintaining distal pressure is aided by means of a compressible material placed at the site of surgery, such as close-cell foam or distal end pads. Suspension is initially managed by molding the cast as it sets and is later reinforced

HEALTH & FITNESS G

ratitude.

What Is Gratitude?

Gratitude is an emotion expressing appreciation for what one has. It is a recognition of value independent of monetary worth. Spontaneously generated from within, it is an affirmation of goodness.

Research shows that people differ in the degree to which they are inclined to experience and express gratitude.

As a result, gratitude is said to exist both as a temporary feeling and as a dispositional trait. In both cases, gratitude involves a process of recognizing, first, that one has obtained a positive outcome and, second, that there is an external source for that good outcome.

A social emotion, gratitude strengthens relationships. Its roots run deep in evolutionary history—emanating from the survival value of helping others and being helped in return.

Studies show that there are specific areas of the brain that are involved in experiencing and expressing gratitude.

Gratitude is a spontaneous feeling but, increasingly, research demonstrates its value as a practice—that is, making conscious efforts to count one’s blessings. Studies show that people can deliberately cultivate gratitude—and there important social and personal benefits to doing so.

Why Is Gratitude Important To Your Health?

Psychologists find that, over time, feeling grateful boosts happiness and fosters both physical and psychological health, even among those already struggling with mental health problems. Studies show that practicing gratitude curbs the use of words expressing negative emotions and shifts inner attention away from such negative emotions as resentment and envy, minimizing the possibility of ruminating over them (a hallmark of depression).

Gratitude starts with noticing the goodness in one’s life.

As an amputee or someone dealing with limb difference how do we tap into this thing called gratitude?

Cultivating Gratitude, in today’s society of a materialistic culture that encourages “selfies”, fake butts, lips, hair and that is consumed by looks as the source of happiness it is not the most fertile ground for cultivate gratitude. But it is not an insurmountable barrier to developing it. Envy and especially cynicism and narcissism are similarly “thieves of gratitude.”

To get started on the path of gratitude, consider integrating the following four steps into your daily life: • • • •

Focus attention outward.

Be mindful of what you have.

Keep a gratitude journal.

Re-frame situations as positive.

Focus attention outward Your attitude plays a large role in determining whether you can feel grateful in spite of life’s challenges. Gratitude is defined by your attitude toward both the outside world and yourself. People who are more aware of the positives in their lives tend to focus their attention outside of themselves.

Be mindful of what you have You may assume that those with more material possessions, better health, no limb issues have more to be grateful for. However, research has shown that people who “have it all” suffer from low levels of life satisfaction, just as those living in poverty do. These findings suggest that it’s not how much you have, or how you look but how you feel about what you that makes the difference.

Keep a gratitude journal Recording what you feel grateful for in a journal is a great way to give thanks on a regular basis. Studies have found that those who listed five things they felt grateful for in a weekly gratitude journal reported fewer health problems and greater optimism than those who didn’t.

Re-frame situations as positive It’s not actually a challenging situation

Nutrition, Exercise & Healthy Living Tips for Amputees that is upsetting. It’s how you perceive the situation. The next time you find yourself complaining about your situation, see if you can mentally “flip the switch” to frame things differently. For example, I am on a team of four guys, we all have missing limbs but one of my teammates has no legs and racing on his hands. So, when I start to complain about my single below the knee amputated foot, I look at him and think how good I really have it. There is always someone who is dealing with worst than you.

Benefits of Gratitude Gratitude opens the door to more relationships.

Not only does saying “thank you” constitute good manners, but showing appreciation can help you win new friends.

Gratitude improves physical health.

Grateful people experience fewer aches and pains and report feeling healthier than other people.

Gratitude improves psychological health.

Gratitude reduces a multitude of toxic emotions, from envy and resentment to frustration and regret.

Gratitude enhances empathy and reduces aggression.

Grateful people are more likely to behave in a pro-social manner, even when others behave less kindly.

Grateful people sleep better.

Writing in a gratitude journal improves sleep. Sleep is important.

Gratitude improves self-esteem.

Gratitude increased athletes’ self-esteem, an essential component to optimal performance. Other studies have shown that gratitude reduces social comparisons. Rather than becoming resentful toward people who have better health, money or better jobs—a major factor in reduced self-esteem—grateful people are able to appreciate other people’s accomplishments.

Gratitude increases mental strength.

Gratitude not only reduces stress, but it may also play a major role in overcoming trauma.

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Q&A

What to Expect When Facing Amputation with Sean Harrison ogy will change radically after the limb is mature and the patient’s activity level has increased. For example, traumatic amputees are typically younger patients with more muscle mass than commonly seen in the dysvascular and diabetic amputee group. They often suffer more swelling, and have more dramatic volume changes in the residual limb. This can make the first year of socket fitting particularly difficult as the volume of the residual limb is changing dramatically.

Ambulatory activity in a check socket or temporary socket can help relieve edema over several months. Pelite liners are also an excellent option for the first socket fitting. Instead of fabricating a brand new socket, the Pelite liner can be padded in appropriate locations and thereby specifically adjusted to take up changes in volume in the appropriate location, thereby saving both time and money. This is a good option when there are insurance issues.

It is the amputation surgeon’s job to help supervise prosthetic care.

When a leg is swollen and not fully mature, even if the patient and the prosthetist are pushing, the surgeon must resist the urge to form a definitive prosthetic socket too early. The intermediate time period is essential to the healing process, and impatience will only cause later disappointment.

One especially frustrated patient had five definitive sockets made the first year following amputation. Following each successive failure, by the fifth socket his insurance provider refused to fund further prosthetic care just when he needed it most. Thanks to Some surgeons are daunted by the impatience, ill-timing and poor decirigid dressing application process, but sion making by all parties involved, the while application requires skill, it repatient will be ultimately left with a quires neither more nor less skill than prosthesis that does not fit, and a dethe application of a soft dressing and vice they can not use. This is far from supportive wrap. In comparison with the appropriate standard of prosthetic soft dressings, rigid dressings have care, and scenarios like this should the advantages of improved patient be avoided at all cost. Similarly, it is a comfort and easier mobility, as well as grave disappointment when a patient an improved wound healing environhas limited prosthetic funding and the ment. Regardless of dressing choice, funds are exhausted too early in the amputation surgeons must have a firm course of prosthetic care. In a worst grasp of modern post-operative amcase scenario, the patient has a prosputation management and the proper thetic device that looks great and has application of postoperative dressing high tech components but no longer techniques. fits, and funds are no longer available to correct the situation. Patience and Diabetic patients are not candidates for financial caution should be taken to a rigid dressing. avoid this predicament.

Typically when a recent traumatic transtibial amputee loses volume they suffer redness and pain at the distal end of the residual limb. Red areas on the limb are called “hot-spots” where pressure is being applied by the socket which may be harmful and cause skin breakdown. The first step to remedy pain (hot-spots) is to increase the ply and number of socks to modify fit. The second step is to pad the anterior-medial and the anterior-lateral tibial flair regions of the socket or the liner. These are the regions that support the tibia and push it away from the front of the socket, thus protecting the distal end. Padding can provide a successful fit with fewer socks. When volumes decrease more substantially, the posterior region of the socket can be padded or the tibial regions can be padded a second time.

It is not uncommon to pad the liner up to four times before fabricating a new socket. Padding techniques save time, keep the course of rehabilitation smooth and continuous and prevent the hassle of re-authorization for a new prosthetic limb until absolutely necessary.

by the devices such as waist belts or shoulder harnesses. Careful attention to suspension will minimize the distal ‘falling away’ of the cast, a process by which the cast slips down away from the end of the stump. When a cast falls away, terminal edema can develop, often with dire results. At this point in the healing process, patients should try straight leg-raises and towel pull exercises in order to provide intermittent pressure and control edema.

The primary objection to the rigid dressing as a postsurgical form of management is that the dressing itself prohibits frequent inspection of the operative site. However, that rigid dressing prevents frequent inspection of the wound site actually proves to be advantageous. Any experienced surgeon knows that an operative site heals best when properly supported, undisturbed and uncontaminated, and the rigid dressing promotes this environment.

However, unusual pain, temperature, leukocytosis or other evidence of complications does require cast removal and wound inspection, which is indeed more difficult with a rigid dressing.

Q: What can I expect the first year of amputee care?

A: It is essential that the amputation surgeon be familiar with the course of amputee care and the elaborate nature of the prosthetic fitting process (ref Fergason, Smith). The surgeon must understand that the first year of amputee care is very different from the following ones. Because this first year is so different, what is useful in terms of components and prosthetic technol-

Socket replacements, is a term you will hear a lot if the company is doing their job right. As within the first few years your amputated limb will change a lot and require new sockets. Reinforced multiple check socket protocols have proved very successful. They allow the patient to be re-valuated when they are experience changes in the residual limb, typically when the amputee is wearing more than 12 ply of socks or about every 3 months.

The elastomeric liners recently introduced on the prosthetic market have gained in popularity. Soft and pliable, these liners have immediate tactile appeal to the amputee and to the provider, but they can be problematic because they can cause skin reactions and are not universally tolerated by every patient. Complications reported include skin irritation, constriction and distal traction edema. One randomized study revealed that patients might actually ambulate less in the elastomeric locking liner systems than they do in traditional systems (ref Coleman). While many protocols have been advanced to use elastomeric 27 liners and total contact socket

The 2019 Para Spartan World Championship was held again in Laughlin, NV setting the stage for one team’s return here for redemption.

The Para Spartan Championships this year had in my opinion became a legit “Elite Race” as the “new” rules set an even playing field. When I say new rules there were really no new rules, they just were going to enforced this year as some teams from last lack character in following them. With that being said the Para Spartan Race challenged the rigor, the minds, and the hearts of 40 of people who dared to step into the shoes of an “Elite” Para-Athlete world. It was gut check time.

Before most of people finished their first cup of coffee on the this Sunday morning, these athletes took to the sandy hills, fighting against gusting headwinds, on a race route filled with 27 obstacles designed to test them and their abilities in every imaginable way.

As we waited for this time to come back around I remember what I felt like last year as we crossed the finish line 5th. And I told myself never again, this year will be different, very different. I know for me losing is hard. I take it to heart. My teammates also did too. They didn’t say anything but I could tell it hurt. We knew we were the better team with over 200 Spartan Races complete between two members of our team loosing was not our plan.

You see quotes all the time on social about getting back up after falling or failing to reach to the top. Well, my life had become one of those, I came back home and faced the music of explaining why we didn’t win. 12 months of swallowing that pill and to make things worst the footage that came out on Spartan TV, hearing a female announcer trash talk our team really put salt in the wound. As the year went we sat back and watched the trash talkers talk and as we did race after race training as a team to get better/ faster.

“Winning is great, sure, but if you are really going to do something in life, the secret is learning how to lose. Nobody goes undefeated all the time. If you can pick up after a crushing defeat, and go on 28 to win again, you are

This year there were several members who travel from other countries to be apart of this event.

The 10 elite teams were composed of athletes from the USA, Netherlands, Kenya, UK, and elsewhere. Each team featured one wheelchair athlete and three other athletes, medically classified to Paralympic standards.

The famous words every Spartan hears before they go on course; “you gone learn today.” Lives were about to be changed forever. Something Spartan racing has a way of doing, weather good or bad.

2019 Para Spartan World Champions going to be a champion someday.” As a team we pulled together last year and decided to put in Wilma Rudolph the time training together as This quote speaks is our team. well as individuals. With one gaol in mind... This would be Just because were adaptive our year. We were the only athletes that does not mean Para Spartan team to take on were not competitive. I know Tahoe and complete a Beast, this may be shock to some making history as the first ever reading this story but people Para Spartan team to do so. living with limb-loss can be fierce warriors weather in com- Completing that race was the final step in molding us as a petitive sports or normal life. team with “Grit”.

Learning to lose is a part of In the days prior to the race, life, it’s apart of Spartan racathletes met with officials to ing, there are only 3 top spots review rules and regulations to on the winners podium. They must be earned. And some will ensure a fair competition. not get there.

Our team set out to set the pace for this race at 12 minutes per mile, may not seem like that fast but when you add in a wheelchair and obstacles it becomes a daunting task. We had trained like this all year, pushing it hard, even in Tahoe at the Beast 9,000ft. elevation we did this just for this event.

Our strategy was simple, a 100+ yard sprint to separate the pack and see who would dare to keep this pace with us.

Whoever took the bait would soon realize it was a setup.

Amp Life Talk Radio Listen on Spreaker.com

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Q&A shapes early in the post-operative period, these systems can be more difficult to frequently adjust and modify than other systems.

The best advice I can give a new amputee. Beware of prosthetic companies that promise you latest and greatest, they are looking to take advantage of your insurance. I use to work for a company like this and know of other companies like this out there.

Many young traumatic amputees are adamant about obtaining the highest tech prosthetic components for their prosthesis. The prosthesis becomes a part of their body and their desire for the finest is understandable. However, many of the high tech components are not optimal for the first year of amputee care. Some of the highest-end foot and ankle components are actually too stiff for the first 6 to 12 months of ambulating. Other less technologically deluxe components actually make adapting to the prosthetic device easier. A new prosthetic prescription should only be generated after the amputee has established a steady symmetric gait, can engage in impact activities and is ready to advance to a higher level of activity. He should be able to maneuver barriers, manage stairs and negotiate inclines and ramps.

This typically does not happen until between months 9 and 18. Only at this point is a new, higher-tech prosthesis useful. The old prosthesis can be refurbished to become a spare limb or a water limb.

It is important that the thoughtful amputation surgeon understand the entire course of the amputation process, from the initial emergency room visit or office visit to the final selection of the perfect prosthesis. They must have a reliable and trustworthy team of professionals provide honest prosthetic care for the patient. As devastating as it is for the patient, amputation will always be a difficult and a complex process for the surgeon as well. It asks the surgeon to successfully balance exacting surgical technique and knowledge, his intimate familiarity with the entire course of 30 amputee care and his human

What to Expect When Facing Amputation with Sean Harrison understanding of each of his unique patients. Using every resource he can to help the patient adjust to this new way of life as an amputee.

Having a certified trained amputee peer visitor or counselor is a valuable tool in helping patients find information, emotional support and guidance on this new journey.

If you’re in need or know of someone who is struggling with amputation please refer to the resources at the end of this article for help.

The surgeon capable of making an amputation successful, can indeed help make the patient whole.

Resources: Amp Life Talk Radio.com Ref:

Atlas of Limb Prosthetics - Surgical and Prosthetic Principles, Edition 1, 1981.

Berlemont M, et al: Ten Years of Experience with Immediate Application of Prosthetic Devices to Amputations of the Lower Extremity on the Operating Table. Prosth. Orthot. Int., Vol 3, No. 8, 1969.

Burgess EM: (1 st edition of the Atlas, 1981, Mosby) Burgess EM, Romano RL, Zettl JH: The Management of Lower-Extremity Amputations. TR 10-6, US Government Printing Office, 1969.

Burgess EM, Romano RL, Zettl JH, Schrock RD: Amputations of the Leg for Peripheral Vascular Insufficiency. J Bone and Joint Surgery. 53-A, 87490, 1971.

Coleman K, Boone D, Smith DG, Laing L, Mathews D, Czerneicki J: Cross-Over Trial Comparing Alpha Liner with Pelite Liner for Trans-Tibial Prostheses Using Ambulatory Activity and Questionnaire Responses. Transactions of the Tenth World Congress of the International Society for Prosthetics and Orthotics. July 4, 2001, Glasgow, Scotland.

Fergason JR, Smith DG: Socket Considerations for the Transtibial Amputee. Clinical Orthopaedics and Related Research, Number 361, pg. 76-84, April 1999.

Harris WR, Silverstein EA: Partial Amputations Of The Foot: A Follow-Up Study. Can. J Surgery.

7:6, 1964

Our plan was simple; divide and conquer, let “burpees� crush their spirits. As a team were pretty strong at the obstacles, as we had spent all year training on them doing as many races as possible. I even built a rope climb in my backyard.

Two teams dared to keep this pace with us, in fact they passed us. We as a team said to each other stay

the course, steady as we go and let the obstacles do their job. And they did, as we passed them by the 5 & 6th. obstacles.

The team was moving so fast even I was struggling to keep this blistering pace with my nose clog from allergies, we did not bring hydration packs and tried

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to drink two cups of water at each watering station. Moving this fast it was like an “Indy Car pit-stop”, seconds to drink two cups of water. Now if you have never been in this situation, drinking water with a clogged nose and the only hole working is doing the most important thing; breathing. Forcing water in is not a good look. It’s like self water-boarding, not pretty at all.

I have never seen my team more focused, I knew in order for us to accomplish this win I needed to pass every obstacle. As a team we approached each obstacle with purpose. I remember telling my teammates no matter what don’t let me stop, do whatever or say whatever you need to keep me moving.

Dave Ganas, our Captain did just that, he got in my “ass” when I hurting from the pace and unable to breathe he told me basically to “cowboy the f#*k up!” I remember thinking; pain is temporary. It may last a minute, or an hour, it eventually will pass. But winning lasts forever. Let’s do this! I blocked out everything except what I needed to do.

Then I heard it, cheering, faint but it got louder... the crowd from below at the finish line could see us coming out of the desert over the last hill. We were approaching the last obstacles. There was no other team in sight behind us. We as a team were about to do something special, keep a promise we made each other over a year ago. The last time here we faced defeat but as a team we did what it took to better ourselves to

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come back and complete in a record time of 1:14 minutes a win as the Para Spartan Champions.

The event was a momentous and a complete success for Para Adaptive Athletes who have wanted an opportunity to compete on one of the biggest stages for all the world to see. Every team gave it their best and I am proud of them all. They are true inspirations. I know for my team we hope inspire both disabled and able body people to get off the couch and outside.

“Straight Outta Legs” 1st-place team member Kacey McCallister said “The race was not the most important thing that happened today. The most important thing will be who will SEE this race.” This event reminds us that it’s never about individual gain— it is, and will continue to be about showing athletes of all types that no obstacle not even barbed wire, vertical walls, and 30-burpee punishment is insurmountable.

Thanks to Niki, Rick, the officials and volunteers who dedicated their time and efforts to these athletes. Thanks GRIT chair for providing the wheelchairs. The word ATHLETE is what you make it.

Thanks to Spartan for the images - There will be additional coverage and photos on Ampnationmagazine.com

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