Ampnation Magazine Vol. 2 Issue 4

AMPNATION

VOLUME 2 ISSUE 4 APRIL 2020

MAGAZINE MAGAZINE

NO WORDS NEEDED

https://pittplusme.org/studyarms/publicdetails?guid=cc4088a1-26d4-49f1-9d9c-8ba6cf4f1c88

2

CONTENTS INSIDE THIS ISSUE

14 Vascular & Ortho News

The Business of Medicine in the Era of COVID-19

8 Better Outcomes

Telemedicine and Telehealth

16

10 Clinicals

Pathophysiology of the Diabetic Foot

11 Correspondence

Stump For

Advocacy and Empowerment

21 Let’s Talk w/

Headline News and Opinions

AMPUTEE LIFECOACH KEVIN KAPPLER, PH.D. Amputee Survival in a Pandemic

18 Living With Limb Loss

23 TECH News TheraBody

Notion of Embodiment

26 The Amputee Life Coach

Sean R. Harrison Positivity During Tough Times

28 Amputees in Action

Gordon McDonald

32 Q & A

Skin Care of the Residual Limb

35 Health & Fitness

Plant-Based Diets for CVD Prevention

AMPNATION

3

AMPNATION

MAGAZINE

A publication of The Amp Life Foundation Ampnation Magazine publishes educational information which is the focus and mission of The Amp Life Foundation to provide 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. Ampnation Magazine is provided free electronically (digital) to anyone who subscribes subscribe@ampnationmagazine.com and hard copy available for purchase as well. Each issue covers health, well-being, better outcomes of amputees living and thriving, O&P News, Vascular News, Tech and products & services.

Article References

Pg. 6- 26 Pathophysiology and Principles of Management of the Diabetic Foot. David G. Armstrong, Timothy K. Fisher, Brian Lepow, Matthew L. White, and Joseph L. Mills.

The Diabetes Pandemic: Looking for the Silver Lining K.M. Venkat Narayan, MD, MPH, FRCP, FACP Clinical Diabetes 2005 Apr; 23(2): 51-52. https:// doi.org/10.2337/diaclin.23.2.51 Pg. 8 - Why are Telemedicine and Telehealth so Important in Our Healthcare System?

Pg. 10 - Mechanisms of Vascular Disease: A Reference Book for Vascular Specialists, Fitridge R, Thompson M, editors. Adelaide (AU): University of Adelaide Press; 2011.

“26 Pathophysiology and Principles of Management of the Diabetic Foot” David G. Armstrong, Timothy K. Fisher, Brian Lepow, Matthew L. White, and Joseph L. Mills.

Pg. 18 - Reachability and the sense of embodiment in amputees using prostheses. Adrienne Gouzien, Fréderique de Vignemont, Amélie Touillet, Noël Martinet, Jozina De Graaf, Nathanaël Jarrassé & Agnès Roby-Brami - Scientific Reports volume 7, Article number: 4999 (2017)

Contributors Editorial Staff Sean R. Harrison

Pg 20 - An Introduction to the Biomechanics of Prosthetics by Written by AZoRoboticsJul 10 2012

Kevin Kappler, Ph.D.

Pg. 26 - The Conscious Life

Max Conserva (Fitness Expert, Adaptive Athlete)

Pg. 30 - Skin Care of the Residual Limb

By Jan J. Stokosa, CP, Stokosa Prosthetic Clinic Last full review/revision Dec 2019| Content last modified Dec 2019

Sections and Features Editor’s Corner Better Outcomes Clinical Correspondence Vascular & Orthopaedics Stump For Health & Fitness

Living Limb Loss O&P News Let’s Talk w/ Kevin Kappler TECH The Amputee Life Coach Amputees in Action Q&A

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

4

TUNE IN WEEKLY WEDNESDAYS 5:30 PM (PST)

3

Editor’s Corner

number of people with diabetes worldwide The Real Pandemic in America The is expected to reach 366 million people by 2030, We have seen the healthcare industry and entire nation held captive by a flu virus that has been made in to the end all of life. But is it really as bad as they are claiming it to be? The 1918 flu devastated the world.

We have seen another pandemic of it’s magnitude since. Or have we?

What if I told you we are in the midst of the worst pandemic ever, would that make you change, would it make you listen, what would you do to help stop it’s spread? Everyone

more than double the estimated 177 million people affected with the disease in 2000. The increased disease prevalence is accompanied by an increase in associated comorbidities. The literature estimates that patients with diabetes have nearly a 25% lifetime risk of developing a foot ulcer with more than 50% of these ulcers becoming infected and requiring hospitalization. In fact, at least 20% of all diabetes-related hospital admissions are due to diabetic foot ulcers. Associated with foot ulcers and infection is the incidence of amputation. It has been conservatively reported that, worldwide, a major amputation takes place every 30 seconds with over 2500 limbs lost per day. At least 60% of all nontraumatic lower extremity amputations are related to complications of diabetes. People with diabetes who have had one amputation have a 68% risk of having another in the next 5 years and have a 50% mortality rate in the 5 years

following the initial amputation. It is estimated that up to now is preaching social distancing and wearing a mask if you 85% of diabetic foot-related amputations could be prevented care. Our entire economy was shut down. Well, there is somethrough prompt intervention and with centers directed at thing worst than this COVID-19 that the media has made int the educating individuals about proper foot care. “boogie-man”that everyone now is willing to alter their lives for, killing and spreading all over the world as I type these words.

The economic impacts on the patient, national healthcare system and economy also impose a great burden. Healthcare The incidence of diabetes continues to grow at a staggering pace. expenditures on diabetes are expected to account for 11.6% The United States’ Centers for Disease Control and Prevention of the total healthcare expenditure in the world in 2010. The estimate that 23.6 million people or 7.8% of the U.S. population estimated global costs to treat and prevent diabetes and its has diabetes, with 1.6 million new cases being diagnosed each complications are expected to total at least 376 billion USD year. These figures are even more astonishing when one considin 2010, with some projections exceeding 490 billion USD. ers worldwide estimates. Close to 4 million deaths in the 20–79 Between 22 and 27% of the total diabetes costs are attributyear old age group may be attributed to diabetes in 2010, acable to lower extremity disease. counting for 6.8% of global all-cause mortality in this age group.

6

AMPNATION

This is the real pandemic America wake up!

https://pittplusme.org/studyarms/publicdetails?guid=cc4088a1-26d4-49f1-9d9c-8ba6cf4f1c88

7

Better Outcomes One thing good from the COVID-19 situation that has overcome our country is innovation. •

Telemedicine and Telehealth Prove Important in Our Healthcare System

up to you to coordinate your care with your regular provider In some cases, the provider may not be able to make the right diagnosis without examining you in person. Or your provider may need you to come in for a lab test.

Telehealth or Telemedicine is emerging as a critical component of the healthcare crisis solution.

Telehealth holds the promise to significantly impact some of the There may be problems with the techmost challenging problems of nology, for example, if you lose the our current healthcare system: connection, there is a problem with the access to care, cost effective de- software, etc. Some insurance compalivery, and distribution of limited nies may not cover telehealth visits providers. Telehealth can change the current paradigm of care and What types of care can I get using allow for improved access and telehealth? improved health outcomes in cost The types of care that you can get using telehealth may include: effective ways.

• General health care, like wellness visits What is telehealth?

• Prescriptions for medicine Telehealth is the use of communications technologies to pro- • Dermatology (skin care) vide health care from a distance. • Eye exams These technologies may include • Nutrition counseling computers, cameras, videocon- • Mental health counseling ferencing, the Internet, and satel- • Urgent care conditions, such as sinusitis, urinary tract infections, lite and wireless communications. common rashes, etc.

What is the difference between telemedicine and telehealth? Telehealth reduces healthcare Sometimes people use the term costs: telemedicine to mean the same • Home monitoring programs can reduce high cost hospital visits. thing as telehealth. Telehealth is • High cost patient transfers for a broader term. It includes telestroke and other emergencies are medicine. But it also includes reduced. things like training for health care providers, health care administra- • Telehealth assists in addressing shortages and misdistribution of tive meetings, and services prohealthcare providers: vided by pharmacists and social • Specialists can serve more paworkers. tients using Telehealth technologies.

What are the problems with • Nursing shortages can be adtelehealth? dressed using Telehealth technolSome of the problems with teleogies. health include: • • If your virtual visit is with The O&P industry has implemented someone who is not your telemedicine as well in it’s care for paregular provider, he or she tients using it for non-essential visits to may not have all of your help cut done on risks to patients and medical history • After a virtual visit, it may be staff.

8

AMPNATION

What are the benefits of telehealth?

Some of the benefits of telehealth include: • Getting care at home, especially for people who can’t easily get to their providers’ offices • Getting care from a specialist who is not close by • Getting care after office hours • More communication with your providers • Better communication and coordination between health care providers • More support for people who are managing their health conditions, especially chronic conditions such as diabetes • Lower cost, since virtual visits may be cheaper than in-person visits Telehealth increases access to healthcare: • Remote patients can more easily obtain clinical services.

• Remote hospitals can provide emergency and intensive care services.

Telehealth improves health outcomes: • Patients diagnosed and treated earlier often have improved outcomes and less costly treatments.

• Patients with Telehealth supported ICU’s have substantially reduced mortality rates, reduced complications, and reduced hospital stays.

Telehealth improves support for patients and families: • Patients can stay in their local communities and, when hospitalized away from home, can keep in contact with family and friends.

• Many telehealth applications empower patients to play an active role in their healthcare.

Telemedicine has a bright future in the healthcare industry as well as the O&P as we all learn from this virus which caused such panic.

AMPNATION SUBSCRIBE TODAY

DIGITAL ISSUE IS FREE

N O I T A N P AM MAGAZ

SEP

ED G G E L E ON N A T R A P S NAS

A er, DApVuEteeG, SpartanaRnadcjust one Am ather and, F Husb de. u d s s bada

THE DE gh A tou

TO CISION P U T AisTioEn AM

emot

M PN A TI

ON M A G

ional

TO WHAT Some

A

INE

R 2 0 19 TEMBE

A

ZI N E . CO

dec

E X PPEARCTT1

s thing basic of the ed to know e n u yo

M

Printed Issues are Available Individual subscriptions Association subscriptions Club/membership subscriptions Partnership subscriptions

AMPNATION All sales go to The Amp Life Foundation.org

9

Clinicals

Mechanisms of Vascular Disease: A Reference Book for Vascular Specialists Fitridge R, Thompson M, editors. Adelaide (AU): University of Adelaide Press; 2011.

“26 Pathophysiology and Principles of Management of the Diabetic Foot” David G. Armstrong, Timothy K. Fisher, Brian Lepow, Matthew L. White, and Joseph L. Mills.

Pathophysiology of the Diabetic Foot creating an increased chance of infection. non-weight bearing. Plantar foot pressures can also be assessed with the use Neuropathy Other factors precipitating diabetic foot of a Harris ink mat or pressure sensitive Neuropathy, or the loss of protective ulcers have been identified and are listed infoot mat. sensation (LOPS) of the lower extremity, Table 26.1. is the predominant etiology for diabetic Angiopathy foot ulceration. The absence of this most Structural abnormalities/gait abnormal- In combination with the risk factors for basic nociceptive mechanism results in ities ulceration discussed above, the presence the patient’s inability to perceive local Structural deformities of the foot and of vascular occlusive disease increases foot trauma both from intrinsic factors ankle can be a potential cause of increased the risk of potential amputation. Vassuch as abnormal or faulty foot mechan- pressure and subsequent ulceration. The cular disease is a common finding in ics or deformity, as well as extrinsic development of foot ulceration is often individuals with long-standing diabetes. factors such as foreign objects or improp-based on a biomechanical abnormality.

While vascular insufficiency alone is not er footwear. These factors place the foot It is important to evaluate both feet of a usually the primary cause of ulceration, at increased risk for developing an ulcer, patient for any potential problem areas. As inadequate perfusion can inhibit ulcer which can lead to amputation. described earlier, motor neuropathy can healing, leading to further tissue necrosis lead to the loss of intrinsic foot muscula- and the inability to clear infection. Table Neuropathy can be subdivided into sen- ture causing a deformity (and subsequent 26.3 provides a list of other potential risk sory, motor, and autonomic categories. overpowering of the intrinsics by the largerfactors for amputation. Most cases of vascular disease in individuals with diaextrinsic muscles). Identification and Sensory neuropathy typically begins management of any of the following will betes, interestingly, affect the infrapopdistally, moving proximally, and is sym- assist in prevention of potential ulceration: liteal vessels with relative sparing of the metrical (Something that is symmetrical hammertoe, claw toe, bunion, tailor’s bun- pedal vessels. In many instances, this alhas corresponding similar parts: in other ion (bunionette), hallux limitus/rigidus, flat lows for a distal bypass to a pedal target words, one side is the same as the other.). feet, high arched feet, Charcot deformities, artery in order to increase the blood flow It is often described as a ‘stocking-glove’ or any postsurgical deformities such as to the foot (Figure 26.1). The vascular distribution. amputations. Limited joint mobility should examination is addressed in further detail later in this chapter. also be evaluated as it can cause an inMotor neuropathy results in intrinsic crease in vertical and shear force in certain muscle wasting, causing a progressive areas, particularly to the plantar hallux, Diagnosis deformity such as hammertoe, claw toe, and lead to tissue breakdown. The Achilles History and rapid visual screening and plantar flexion deformities of the tendon should be evaluated for any type A thorough history and physical exammetatarsals. These deformities can cause of functional shortening causing equinus ination of each patient presenting with an increase in focal pressure at the areas deformity. It is common to find an increase diabetic foot pathology should include of the interphalangeal joints of the digits in glycosylation of soft tissues and tendons a history of pedal wounds, history of and beneath the metatarsal heads, respec- causing contracture of the muscles in the prior amputations, and lower extremtively, increasing the probability of ulcer posterior compartment of the leg. ity vascular interventions. physical formation. examination should note the types of This will cause an increase in plantar pres- deformities present, neurological status, Autonomic neuropathy is associated with sures in the forefoot making this area more vascular status, and dermatological pathology of the sympathetic nervous presentation. The patient should be prone to breakdown. system. In the lower extremity, this instructed to remove both shoes and usually results in the absence of sweat Gait evaluation and muscle testing should socks for their examination. A systematproduction causing drying and scaling also be conducted to evaluate any poic approach should be taken in order to of the skin, increasing the likelihood of tential abnormality with ambulation and avoid missing any important aspects of cracking and fissuring. These cracks or muscle strength. Testing of the muscles in the examination. All surfaces of the foot fissures, especially in the heel, may then the lower extremity should be done both and ankle should be evaluated including serve as a portal of entry for bacteria, actively and passively, weight bearing and the nails, digits, interdigital webspac10

AMPNATION

Correspondence Poor sleep linked with higher blood sugar levels in African Americans African American men and women are up to two times more likely to develop diabetes over their lifetimes than white Americans. Diabetes occurs when your blood glucose (also called blood sugar) is too high. Over time, high levels of blood glucose can cause heart disease, nerve damage, eye problems, and kidney disease.

Previous studies in white and Asian populations have linked disturbances in sleep to increased blood glucose levels. These disturbances may be caused by sleep apnea, a condition where breathing stops or gets very shallow for periods during the sleep cycle. Sleep apnea reduces the amount of oxygen that reaches the organs of the body, potentially leading to many health problems.

To see if links between disrupted sleep and high blood glucose levels also exist in African Americans, researchers led by Dr. Yuichiro Yano from Duke University looked at data collected between 2012 and 2016 by the Jackson Heart Study. This community-based study looked at risk factors for heart disease among African American men and women living in the Jackson, Mississippi metropolitan area.

variability in these sleep patterns.

Measurements of blood glucose were taken in the clinic.

News, Opinion & Information

to determine if treating sleep apnea and encouraging better sleep patterns can improve blood glucose levels and prevent diabetes in African Americans.1

The participants were mostly women, and about 25% had diabetes.

Around a third were found to have sleep apnea, most of whom were 1References: Sleep Characteristics and Measures of not receiving treatment for the condi- Glucose Metabolism in Blacks: The Jackson Heart Study. Yano Y, Gao Y, Johnson DA, Carnethon M, tion. The study was funded in part A, Mittleman MA, Sims M, Mostofsky E, Wilson

by NIH’s National Heart, Lung, and Correa JG, Redline S. J Am Heart Assoc. 2020 Apr 28:e013209.

Blood Institute (NHLBI) and Nation- doi: 10.1161/JAHA.119.013209. [Epub ahead of print].

PMID: 32342760. al Institute for Minority Health and Health Disparities (NIMHD). Results were published on April 28, 2020, in the Journal of the American Heart Association.

Both sleep apnea and fragmented sleep patterns recorded during the study were associated with higher blood glucose levels. These associations remained after the researchers adjusted for other factors including age, sex, weight, smoking and alcohol use, and history of diabetes and heart disease.

People with the most severe sleep apnea had 14% higher fasting blood glucose levels than those without sleep apnea. In people who already had diabetes, greater disturbances in sleep were associated with lower sensitivity to insulin, the hormone that signals cells to take up sugar from the blood.

“Our results reaffirm the need to improve the screening and diagnosis of sleep apnea, both in African The analysis included about 800 Americans and other groups,” Yano participants who underwent home says. Past studies have found that sleep apnea testing. They also wore many people with sleep apnea don’t a wrist actigraph (a device that mea- know they have the condition. sures wakefulness and sleep) for a week, and kept a sleep diary. This Treatments for sleep apnea include information was used to calculate lifestyle changes and use of a conhow long people slept, how often tinuous positive air pressure (CPAP) they woke up during the night, and machine. More research is needed 11

CMS Announces Pay Parity for Audio-only Telephone Visits

The rule change was part of a broad package of waivers and rules shifts that were brought forward Thursday by CMS in to facilitate COVID-19 testing and expand access to telehealth.

The Centers for Medicare & Medicaid Services on Thursday said it will bump up payments for audio-only telephone consultations to match payments made for office and outpatients visits.

The American Medical Association called the pay parity “a major victory for medicine that will enable physicians to care for their patients, especially their elderly patients with chronic conditions who may not have access to audio-visual tech-

“ACP has repeatedly requested this change from CMS as the country has been dealing with the COVID-19 national emergency and we are heartened that they have heard our concerns,” she said.

“ACP has repeatedly requested this change from CMS as the country has been dealing with the COVID-19 national emergency and we are heartened that they have heard our concerns.”

Fincher said the increased payments are coming at a critical time for both providers and their patients.

“Right now, due to a drastic decrease in in-office patient visits, nology or high-speed Internet. This many practices are struggling to remain open and continue providing The new rule would increase payments change will help patients address their health challenges that existed needed care,” she said. “Many seniors for audio-only telephone consultations and other vulnerable patients lack the from $14-$41 to about $46-$110, CMS before COVID-19.” said in a media release. capability to conduct video visits with Jacqueline Fincher, MD, president of their physicians, so those patients are The rule change was part of a broad the American College of Physicians, being cared for with telephone-only package of waivers and rules shifts that said the “change in payment policy visits that were reimbursed at a much were brought forward Thursday by CMS addresses one of the biggest issues lower rate.”1 in to facilitate testing and expand access facing physicians as they struggle to to telehealth. make up for lost revenue and provide Physician associations cheered the news. appropriate care to patients.”

1HealthLeaders, By John Commins | April 30, 2020 12 AMPNATION

News, Opinion & Information

Correspondence

Image credit: Adobe Stock The hidden epidemic of prediabetes

You could have prediabetes and not even know it. More than one in three adult Americans—approximately 88 million— have the condition, but 90% don’t realize it.

Recent research by the Centers for Disease Control and Prevention also reports that nearly one in four young adults (ages 19 to 34) and half of people over the age of 65 are living with prediabetes.

What is prediabetes? And if so many people don’t realize they have it, what can you do—especially if diabetes runs in your family?

Certain factors can make you more likely to develop prediabetes. You are more at risk if you have a parent or sibling with diabetes and are age 45 or older. Race and ethnicity are also factors: African Americans, Hispanic/Latino Americans, Native Americans, and some Asian Americans are at higher risk for type 2 diabetes. Additionally, you’re more at risk if you are overweight or obese and are physically inactive. This is just a short list of risk factors. To see more and to take a test to learn about your own risk factors, visit the National Institute of Diabetes and Digestive and Kidney Diseases website.

Eating healthier food and becoming more physically active can help you lose weight, feel better, and lower your risk of developing type 2 diabetes.

Prediabetes means your blood sugar levels are higher than normal. The levels are not high enough to be diagnosed as type 2 diabetes, but it’s a warning sign that, over time, you could develop the disease. That’s why learning about risk factors is so important.

Prediabetes indicates a problem with the cells in your body.

It means that those cells are not responding in a normal way to insulin, an important hormone that helps sugar in the blood get into cells and be used for energy. If a person’s body can’t make or respond to insulin, blood sugar levels rise.

Getting more exercise and losing a small amount of weight can help prevent diabetes if you are at risk.

Eating healthier food and becoming more physically active—taking a brisk walk for 30 minutes a day, five times a week, for example—can help you lose weight, feel better, and lower your risk of developing type 2 diabetes. Even small steps—losing just 5% to 7% of your body weight (10 to 14 pounds for a 200-pound person)—can make a big difference in preventing type 2 diabetes.1

1

National Institute of Diabetes and Digestive and Kidney Diseases; Centers for Disease Control and Prevention 13

Vascular& Orthopaedics

T

The Business of Medicine in the Era of COVID-19

he United States will eventually get through the acute coronavirus disease 2019 (COVID-19) crisis but not without fundamental changes to the medical care system. Since the epidemic began, payment policy has stretched to remedy the bias concern even in this scenario. Will of the health care system for in-person treatment patients have concluded that some provided by physicians. In response to the need services are not so essential and thus for social distancing, new policies include broadernot return for them? Will the rush of patients who do seek services payment for telemedicine, expanded scope-ofpractice ability for non-physician practitioners, lead to delays in scheduling and the rationing of capacity, both of which and increased ability of physicians and nurses to practice across state lines. While these policy may lead patients to abandon valureforms address some of the immediate needs of able treatment out of frustration? this crisis, such as getting personnel to where they are most needed, they are not a complete solution If the COVID-19 shutdown lasts to the COVID-19 crisis. How the aftermath of the for months or the normal business current COVID-19 wave is handled will be just as of health care does not resume until important for the business of health care as what the fall, the implications for physicians and hospitals would be much is happening now. more severe. In the past month, the response of many health care orgaTwo issues about the medical system after the nizations to the reduction in primary current wave are particularly important: What and elective care has been to retype of organizations will be available to treat patients a few months from now? And how will duce staff providing those services.

Employment in health care declined those patients be most effectively served? by an estimated 43 000 people from What Will the Health Care Landscape Look mid-February through mid-March1 and has undoubtedly declined further Like?

Hospitals and physicians treating most patients since then. Approximately half the with COVID-19 have 2 financial challenges. The cost of primary care practices is direct costs of caring for patients with COVID-19 attributable to salaries, so furloughs help ensure solvency.2 But bills will are clear; many such patients are uninsured or require care that costs more than insurance pays. have to be paid, and remaining costs cannot be reduced as much. The bank Likely much larger, however, is the financial effect of having postponed nonemergency care, accounts of many practices are not large enough to absorb a long-term ranging from office visits to elective surgery.

These are the cases from which physicians and shutdown. hospitals derive most of their profits. Elective care has declined across the country, with reductions inSome organizations are more vulnerable than others. In the hospital some services of 50% or more. industry, rural institutions have lower The good scenario for population health is also margins than urban hospitals. This is the good scenario for the business of medicine. particularly true in the South, where It is possible that COVID-19 will be contained governors have been slow to enact sooner than expected and that the economy will stay-at-home measures and many states have not undertaken Medicaid recover earlier rather than later. In that case, physicians and hospitals will fare well; indeed, expansion. Nearly 100 hospitals have closed in the South over the past there could be excess demand for services still deemed essential. But there could be pockets of decade.

14

AMPNATION

Small primary care and specialty offices are also vulnerable because they are, in the end, small businesses: a significant share of primary care physicians work in practices with 1 or 2 physicians.3 If primary care or specialty visits are either deferred or foregone, the reduction in physician practice income could shutter some practices. It is unclear how effective the small-business loans that have been made available to many of these practices will be in ensuring they become operational again when social distancing ends.

This fall, and certainly into 2021, there could be additional consolidation of practices, both large and small. Smaller hospitals will look for capital infusions by merging with bigger hospitals, and physicians may find more security in larger groups. Several factors hasten these trends. Hospitals have started to work together to care for patients with COVID-19; merging may be a natural extension of that activity.

Further, hospital personnel will be exhausted by caring for patients with COVID-19. Some clinicians will have become ill while caring for patients or will, in the worst circumstances, have succumbed to the virus.

Additional physicians and nurses may thus be necessary. For services that do not come back, physicians in specialties that provide those services may need immediate job security.

The benefit of consolidation will be facilities that do not close and communities that maintain sources of care. But there are likely to be costs as well. Consolidation among hospitals and between hospitals and

physicians significantly increases health care prices.4 This trend will further increase health care spending at a time when the lingering effects of the virus will already be raising private insurance premiums.

How Will Patients Be Served?

For physicians, COVID-19 may affect how they practice in even more fundamental ways. In response to the need to maintain social distance, many physicians have turned to telemedicine. In March, the federal government substantially eased restrictions it had previously placed on Medicare reimbursement for care provided via telemedicine. To support this move, federal and state governments also provided physicians with greater latitude to practice across state lines. In addition, nurse practitioners and other non-physician clinicians were allowed greater ability to treat patients without direct supervision from physicians.

patients needing certain types of urgent system for delivering care.1 care during this crisis, it may be a useful outlet to serve the wave of elective visits that is currently welling up. Further, it 1David M. Cutler, PhD1; Sayeh Nikpay, PhD2; Robert S. Huckman, PhD3, JAMA. Published online May 1, 2020. may also be helpful once the system doi:10.1001/jama.2020.7242 returns to something approaching a “normal� level of volume. If keeping older patients and those with chronic disease home is necessary in an epidemic, it also could be beneficial outside of an epidemic. Many long-standing efforts to reform the health care system have suggested that this may well be the case.

But the push for mergers and remote practice could go much farther, changing in a fundamental way what it means to be a physician and to practice medicine.

Hospitals and medical practices have already reduced benefits and decreased hours for clinical staff.7 Might organizations decide that it is better to hire physicians on an as-needed basis rather than through employment? Emergency department care in the last decade offers a fitting analogy. Many hospitals, espeThe substantial increase in the use of cially those with small volumes, found telemedicine during the crisis has been it difficult to staff a full-time emergency pervasive across health care systems. department. As a result, they turned to For instance, the Cleveland Clinic based outside staffing companies. Having less in Cleveland, Ohio, reported being on to manage was good for hospitals, but track to complete more than 60 000 the outsourcing of emergency care was telemedicine for visits for the month of identified as a key driver of the surprise March compared with its prior average billing phenomenon the nation is still of about 3400 visits per month.5 Simi- addressing.8 To the extent that such larly, Jefferson Health in Philadelphia, practices become more widespread, new Pennsylvania, has seen an increase in forms of regulation may be needed just virtual visits on its JeffConnect telemed- as others are being relaxed. icine platform, from 60 visits per day before the pandemic to a recent figure of Everyone hopes that medical care will 2000 visits per day.6 These are but 2 ex- return to normal in the coming months. amples of a much broader phenomenon. But the new normal may be not as recognizable as some think. Some The rapid growth of telemedicine and changes may be good, but the road is the broadening of clinician license raise fraught with risk. It is possible, perthe question of what becomes of these haps likely, that the painful process of new approaches to treatment once the reaching a new health care equilibrium immediate COVID-19 crisis has passed. will last well into 2021. Ideally, this At this point, most of the easing of time will allow for thoughtful discussion regulation has been temporary. What is of how the intertwined forces currently not clear is whether, when, and to what affecting clinicians and other health care extent these regulations will be re-espersonnel, as well as hospitals, health tablished. There are many arguments care centers, and practices, can lead to for making these regulatory changes sustained improvement of the overall permanent. Just as telemedicine and the expansion of clinician capacity may help 15

Stump For

Advocacy and Empowerment We’re In Your Corner

Medical Bankruptcy: Still Possible Even With the Affordable Care Act Here we are in 2020 and people are still agencies in 2014. The cost for a hospitalfeeling the affects of the worst healthcare ization is estimated at $10,000 to $13,000, plan the world has ever seen “Obama with average length of stay of 4.5 days.3 Care” is causing people to file bankrupt- Our healthcare system is in need of cy. Filing for bankruptcy is often consid- an overhaul. According to Torio and ered a worst-case scenario.

Moore,3 implanted devices such as grafts are among the top four most expensive And for many Americans who do purconditions. As vascular healthcare providsue that last-ditch effort to rescue their ers, we have the capability to impact this finances, it is because of one reason: number. health-care costs.

As healthcare payers and consumers shift A new study from academic researchers to value-based healthcare, cost is driving found that 66.5 percent of all bankrupt- consumer decisions. How many times cies were tied to medical issues —either have we encountered a significant price should communicate information profesbecause of high costs for care or time out difference in diagnostic test and medica- sional service cost, 4) healthcare plans of work. An estimated 530,000 families tion cost? When seeking care for a family should provide real-time benefits and cost turn to bankruptcy each year because member, or ourselves, it becomes evident savings information for both in network and out of network providers, 5) health of medical issues and bills, the research that care in a hospital facility is quite found.1 expensive compared with a free-standing plans and stakeholders should collaborate outpatient facility. The focus is shifting to facilitate price and quality transparency for patients and physicians, 6) ensure Did the Affordable Care Act help reduced toward nonurgent/emergent diagnostic the burden of medical debt for people? testing in the outpatient setting. The chal- accuracy and relevance for price transparBased on this article I found by Jasmiry lenge faced by consumers is cost trans- ency tools, 7) all-payer claims database Bennett, DNP, RN, ACNP-BC titled, parency. Poor health literacy coupled with should be supported and strengthened, “Healthcare: Let’s talk transparency” and the complexities of healthcare pricing has and 8) electronic health records vendors other information people and the health- lead to ineffective and inefficient use of should include features that assist in facilcare system are worst. Despite gains in healthcare dollars. It is quite challenging itating price transparency for providers coverage and access to care from the to know the cost of medical care because and patients.2 ACA, our findings suggest that it did not there are a multitude of complex conHow we render healthcare in our commuchange the proportion of bankruptcies tractual agreements between facilities, nities is changing. We are transitioning with medical causes,” an article on the providers, and third-party payer.2 The from healthcare being rendered in an study published in the American Journal consumer is left to figure out costs, but acute care facility to providing care in of Public Health states. Read her article unfortunately, the cost is known after the community. Consumers of healthcare below. the care has been rendered. It has been note increasing high out-of-pocket costs estimated that approximately 66.5% of Healthcare costs in the United States Americans go bankrupt because of medi- and deductibles, the need to shop around skyrocket every year. This is evidenced cal debt.1 As patients become more active for the best price while receiving high by the increased social media solicitation consumers of healthcare, the American quality. As outpatient community service for financial assistance to pay medical Medical Association proposes eight ways demands continues to grow, I believe bills. Himmelstein, et al.1 state the US to increase healthcare price transparen- consumerism will drive the imperative need for price transparency and health litConsumer Financial Protection Bureau cy. The American Medical Association reported that they were the most common recommends the following: 1) developing eracy, forcing all in healthcare to become cause of unpaid bills sent to collection resources to help patients understand the competitively priced for the services provided.2 complexities of healthcare pricing, 2) 1 This is the real reason most Americans file for make pricing information for common bankruptcy Published Mon, Feb 11 2019 by Lorie procedure a requirement for all health Konish professions and entities, 3) physicians 2 Journal of Vascular Nursing Volume 38, Issue 1, 16 AMPNATION March 2020, Page 1

13

Living With Limb Loss Even though the psychological and emotional experience of wearing a prosthesis is different for every patient, very few use theirs all day long (25%), most of them only when they need it for a particular activity (50%), and around 25% abandon it after a time. However, the loss of a limb is a major handicap for those patients who are mainly young active people, and technological advances keep on making prostheses more and more efficient to compensate for this disability. One hypothesis to explain why their use remains limited is that, more than the specific technological issues described by patients (weight, battery failure, discomfort on the residual stump, etc.), the problem is the sensorimotor challenge to embody a prosthetic limb.

Notion of Embodiment

has been shown that using a tool quickly modifies (i) the perception of the space surrounding the body (also known as peripersonal space), (ii) the kinematic of subsequent bodily movements and (iii) the perceived size of the limb6. These modifications can even occur in hemiplegic patients when the tool is hold by the examiner’arm in a position allowing its embodiment by the patients. Yet, little is known about the subjective dimension of tool embodiment. Prostheses can be conceived as tools insofar as they are a technical medium between the body and the environment. However, they are peculiar tools because they look like bodily parts and their aim is to replace the missing limb instead of extending an existing one. The crucial question is whether these differences make their embodiment One can define the notion of embodieasier or more difficult. On the one hand, ment at two distinct levels. At the imMiller et al.9 found that morphological plicit level of body representations, an similarity between a tool and an effector object is said to be embodied if some of increased its embodiment at the implicit its properties – or all of them – are pro- level9. On the other hand, it has been cessed in the same way as the properties shown that subjective feelings of embodof biological body parts. Embodiment iment could be induced for non-bodily can also be associated with a large range shaped objects10. Here we thus analyzed of subjective explicit feelings, including the embodiment of prostheses in ampufeelings of bodily ownership, feelings of tees, at both implicit and explicit levels. bodily control, of bodily integrity, affective feelings, and so forth. Both implicit In Summary and explicit levels of embodiment for Amputated patients are hardly satisfied extraneous objects have been extensive- with upper limb prostheses, and tend to ly discussed in the context of the Rubber favor the use of their contralateral arm Hand Illusion in healthy participants. to partially compensate their disability.

In the classic experimental set up, one This may seem surprising in light of sits with one’s arm hidden behind a recent evidences that external objects screen, while fixating on a rubber hand (rubber hand or tool) can easily be presented in one’s bodily alignment; the embodied, namely incorporated in the rubber hand can then be touched either body representation. An investigated of in synchrony or in asynchrony with both implicit body representations (by one’s hand. In brief, in the synchronous evaluating the peripersonal space using a condition participants mis-localize their reachability judgment task) and the qualhand in the direction of the location of ity of bodily integration of the patient’s the rubber hand and report that it seems prosthesis (assessed via questionnaires) as if the rubber hand was their own4. was performed.

A similar illusion can be induced by visuomotor congruency. Tool use is As expected, the patients estimated that the other main paradigm to assess the they could reach further while wearing malleability of body representations. It their prosthesis, showing an embodiment 18

AMPNATION

of their prosthesis in their judgment.

Yet, the real reaching space was found to be smaller with their prosthesis than with their healthy limb, showing a large error between reachability judgment and actual capacity. An overestimation was also found on the healthy side (comparatively to healthy subjects) suggesting a bilateral modification of body representation in amputated patients. Finally, a correlation was found between the quality of integration of the prosthesis and the way the body representation changed. This study therefore illustrates the multifaceted nature of the phenomenon of prosthesis integration, which involves its incorporation as a tool, but also various specific subjective aspects.

In conclusion, amputation and the wearing of a prosthesis modifies the body representation on both the prosthetic and healthy sides. The subjective quality of the integration of the prosthesis, including the feeling of embodiment, appears to influence these modifications. It seems that good integration of prostheses depends as much on their use, sparing the healthy limb as much as possible, as on the knowledge of their imperfections and limitations.

The negotiation of an embodied self arguably becomes more visible and complex when inhabiting a body that is seen as ‘non-normative’, ‘damaged’ or ‘disabled’ (Murray, 2008, 2009; Radley, 1998). According to Rapala and Manderson (2005), when a body is disabled, conventions of normative sexuality and gender are actively challenged; as Gershick and Miller (1995) argue, the experience of becoming disabled can hence lead to a crisis, or at least a renegotiation, of gender identity. Specifically, they argued that the construction of masculinity as strength was problematical by a contradictory construction of disability as weakness.

es, the soles, and the heels, inspecting for cracks, blisters or bullae, hyper/ hypopigmentation, fissuring, calluses, and ulcers. The footwear should also be inspected for signs of wear patterns, foreign bodies, and any irregularities. Any gross deformities as described above can be identified during this rapid visual screening.

Neurological examination As stated earlier, peripheral sensory neuropathy is the major risk factor for the development of a diabetic foot ulcer.

There are many simple, noninvasive examinations that can be performed to test and monitor sensation. A simple history of neuropathic symptoms such as tingling, burning, numbness, the feeling of insects crawling on the feet (formication) can help to identify those patients at risk for developing foot ulceration.

Monofilament Testing One of the most common methods used to assess neuropathy is the use of the Semmes-Weinstein monofilament (10-g) wire. The nylon monofilament is placed on ten different pre-determined locations on the foot and pressed down manually until there is a slight bend in the wire.

The patient is instructed to say ‘yes’ if he or she thinks they feel slight pressure or sensation. If the patient is unable to feel the sensation at two or more locations then it is safe to assume that protective sensation is lost.

Dermatologic Examination Following assessment for any loss of sensation, evaluation of the integumen is a critical part of the foot screening. The skin can be evaluated for color, texture, turgor, quality, and presence of any areas of dryness or fissures. Calluses, if present, can be problematic as they indicate areas of increased pressure and an ulcer can form under the hyperkeratotic lesion, which may cause hemorrhage beneath the callus. Debridement of these areas is recommended in order to reduce a potential focus of pressure.

Appearance of the nails should also be noted. If there are nails that are incurvat-

Clinicals ed or ingrown, these could be a potential area for skin breakdown and possible infection. Other nail issues to be aware of are onychomycosis (fungal nails), dystrophic nails, atrophy or hypertrophy, or paronychia (infected ingrown nail), as all can be potential problems.

a major amputation the contralateral limb develops a serious lesion in 50% of cases.36 The 5 year adjusted mortality rate after a major amputation of a limb is 46%;6 this is alarming and is higher than the mortality rate for many forms of cancer. It has also been shown in more than 85% of lower extremity amputations a Evaluation for any ulceration to the foot wound was a critical aspect of the causal or lower leg should be assessed. Import- pathway. The cost of treating diabetic ant characteristics of ulcers are depth, foot ulcers is also growing at a staggersize, presence of fibrotic or granulation ing pace, reaching nearly $30 billion in tissue, location, and whether or not the the United States in 2007.39 area appears to be infected.

Offloading Clinical Problems and Principles of Numerous products are available to Management assist in redistributing pressure over a larger unit area (off-loading) on the Ulceration foot. Some examples include removable Initial presentation of the diabetic foot cast walkers, non-weight bearing casts usually entails the presence of an open with crutch/walker assist, wedge sandals ulcer, located on the plantar aspect of a (either forefoot or heel wedge), healing patient’s foot. Most patients will not sus- sandals with a multilaminar, multidupect an ulcer on the bottom of their foot rometer foot bed. However, the choice until they, or a loved one, notices blood of modality should be chosen with either on the floor after walking or on a respect to the patient’s functional status. sock. Advising the patient that ambula- For example, if a patient presents with tion is contraindicated with an open ul- a plantar forefoot ulcer, a wedge shoe cer is often challenging especially if the that does not allow the forefoot to bear patient is neuropathic, as they have lost weight would be an appropriate device. the ‘gift of pain.’33 However, reduction However, if the patient is not properly of pressure to the foot is essential for educated on use of the device and/or treatment. By effectively off-loading the has issues with balance, the offloading area, the risk of continued trauma and modality could cause the patient be resultant infection is decreased. unstable when walking. In regards to diabetic shoes, whether custom-made or Epidemiology and risk factors off the shelf, it is important to keep in Ulceration of the diabetic foot is one mind one key fact. While diabetic shoes of the single most common problems are effective in preventing ulcerations, for which medical assistance is sought they are (in general) not very effective in in a diabetic individual. Up to 25% healing them. of patients with diabetes will have a foot ulceration during their lifetime.4 For many years the gold standard in Remarkably, at least 50% of those offloading an ulceration on the foot has ulcerations will become infected, and been the total contact cast (TCC). This in 20% of those cases an amputation is fully weight-bearing cast consists of a required.34 There are 81,000 major am- multiple layers of both fiberglass and putations performed on individuals with plaster with minimal padding. When diabetes in the United States annually. applied properly, the TCC allows the Conservatively, 60% of all non-traupatient to be ambulatory. The TCC matic amputations occur in the diabetic redirects pressure from the bottom of patient.35 Studies have shown that after the foot, which is then redistributed over 19

O &P

News

An Introduction to the Biomechanics of Prosthetics

A prosthetic limb is defined as a mechanical device that is used to replace a missing human limb. The device is designed to help the user coordinate better control of an amputated limb. This could be as a result of motor control loss by a traumatic event, a congenital-related defect, or dysvascular related.

According to statistics by Ziegler-Graham, et al. (2008), an estimated 1.6 million civilians were living with the loss of a limb. The research also revealed that approximately 38% of these people suffered an amputation of a limb as a secondary consequence to a dysvascular disease. Shockingly, it has been predicted that this statistic is likely to information back to the actuator. double to 3.6 million by 2050.

• Actuator - the end device that will Dysvascular disease is only one major receive information from the controller contributing factor to the amputation of a and mimic the movement of a muscle. limb. It is commonly known that war veterans often become wounded in combat and The study of prosthetic limbs is vast considering the current affairs, it is estimat- and complex. For the scope of this ed that the number of veterans wounded in article, attention will focus on the Afghanistan is increasing. According to the prosthetic hand in more detail. As Department of Defense statistics, to-date mentioned, the main pathway involved more than 1000 soldiers have returned from in the function of a prosthetic limb Afghanistan with the loss of a limb. With is based on three main components: current limb-loss statistics in perspective, a biosensor, controller, and actuator. there is a clear demand for the use of pros- User preferences need to be considered thetics from the healthcare angle. before designing a prosthetic limb and if focusing on a hand prosthesis, the Robotic Prosthetics - Structural Com- following preferences are important: • Grasp function for a size range of ponents objects A robotic prosthetic limb is made up of the • Intricate finger movements should be possible for grasping and pinchfollowing components: ing motions • A prosthetic hand needs to be • Biosensors - these are required to detect lightweight to allow for better neural transmission from the human nervous movement in continuous space and neuromuscular junctions (i.e., wires to • Finger projections need to be detrack neural activity near the surface of the signed with active joints to allow skin). The video below by Bio Tac is a great for intricate movement example of how biosensors are applied to • Aesthetically, the prosthetic hand study sensing modalities of a robotic finger. needs to appeal to the patient and • Controller - the main connection allow for comfort of use between the neuromuscular systems and the end device and so this receives the inforThe use of biosensors is fundamental mation from the biosensors and feeds this

20

AMPNATION

Andrii Zastrozhnov / Shutterstock

to initiating a pathway that will result in movement of the actuator. To allow for the control of a prosthetic limb, the actuators are attached to the residual part of an amputated area, which will provide feedback on tactile information generated by the biosensors.

The actuators are also connected to a hardware interface system that acts as the controller, which initiates sensory feedback to the actuators.

The Actuator The actuator is the key element to a fully functioning prosthetic hand and it is what displays the end result (i.e., grasping an object). To begin with, the actuator system to this prosthetic hand is made up of micro-actuators. These drive the metacarpophalangeal (MP) joints of the thumb and the proximal interphalangeal (PI) joints. The distal interphalangeal (DIP) joint is controlled by a link connected to the proximal interphalangeal (PIP) finger joint.

It is important to consider the number of individual pieces of information that will predict how

Let’s Talk w/ AMPUTEE LIFECOACH

KEVIN KAPPLER, PH.D.

Amputee Survival in a Pandemic Almost everyone is unusually anxious because of COVID-19. However, being in a constant state of anxiety and stress will not do you any good. After all, stress is known to affect our immune system. So, what should we do? We can try coping with anxiety and building mental resilience by turning to psychology.

If you ever face a Brown Bear in the woods, stand together, and the bear will think you are an even bigger bear. It counteracts the ill effects of social distancing. You will find you can put a lid on that free-floating anxiety. A robust social network,

Self-Tolerance This pandemic has rearranged our self-perceptions. What we took for normal has been substantially challenged. We must bend in the wind rather than break because of our resistance. Now is the time to live with uncertainty and a profound lack of leadership. Self-tolerance is the new rule.

We need to counterbalance the desire for stability when this virus takes its toll. We create a new sense of certainty about the future. However, in times like this, it’s okay to be anxious, and the first step to coping with anxiety is being patient with yourself.

However, watch out that your anxiety doesn’t turn into sustained stress, which is detrimental to your health. Instead, identify the things that you can control. Practice self-care by adhering to the World Health Organization’s guidelines: wash your hands frequently; maintain social distancing; avoid touching your eyes, nose, and mouth; and practice cough etiquette. If you have a cough, fever, and difficulty breathing, seek medical care as soon as possible.

Control Your News Input

whether this comprises the people you live with at home or a group that you meet virtually, will go a long way in helping you become mentally resilient.

Make time for reflection

Experts say that crises often bring significant societal changes.

Setting aside time to process everything that’s happening is When a virus that you don’t know you have infects every- vital for your mental well-being. Reflection can mean a long one around you before you even suspect it is time to rethink conversation with a friend or a family member, or you can write what you do control. Realize what is burning you like a in your journal. Whatever your chosen method of reflection is, press gone wild will show how much you need to control make sure to do it regularly to avoid feeling emotionally overyour news input. We are in uncharted territory, which is whelmed. why we may feel helpless and anxious. More often than not, we turn to the news and social media platforms to seek About the Editor information and maintain an illusion of control. However, As a fellow amputee, I know the psychological difficulties consuming too much news or related content can lead to a people face after losing a limb. I have helped people on the vicious anxiety cycle. phone and texting for the last ten years as a Life Coach with these specific issues. I understand what you are up against when We recommend controlling your news diet by identifying you realize you have lost a limb. Prior to that, I was a clinical when to read or watch the news from reputable sources. psychologist for over thirty years specializing in treating panic This can be an hour once a day or twice a day. A schedule disorders and post-traumatic stress. My post-doctoral work was ensures that you get essential information. Remember that at the VA in San Francisco with vets coming back with lost not every bit of news helps. limbs and traumatic body images.

Stand Together 21

Clinicals

into this category with the exception of an amputation. Rarely are amputations done as an elective procedure.

Only in the case of severe deformity the bottom of the entire foot and up or instability from a previous injury or the cast. Some disadvantages of using a TCC is the time it takes to apply, the surgical procedure, will an amputation be considered. Assuming good glycemic bulkiness for the patient, and the fact that the patient must wear the cast for 1 control, patients grouped to this class are not at any increased risk for the developweek intervals requiring weekly visits to the clinic. Newer TCC variants have ment of complications than correspondreduced the time required for application ing patients without diabetes. of a traditional device whilst retaining many of the desirable therapeutic char- Class II: Prophylactic Procedures in this class are indicated to acteristics. alleviate a deformity in a patient who is neuropathic however does not have the In many instances, proper off-loading may be all that is necessary to achieve presence of an ulcer. The goal of prophylactic surgery is to reduce the plantar wound healing. However, if wound sheer and vertical stresses. Many procehealing fails in the midst of proper dures for prophylactic surgery would be off-loading, adequate blood flow, and considered elective if the patient did not satisfactory nutritional status, surgical suffer from neuropathy. Several examintervention may be warranted. ples of procedures in this class include a Charcot foot reconstruction, a metatarsal Non-vascular surgical treatment head resection, a Keller arthroplasty, an Surgical management of the diabetic a chilles tendon lengthening or a hamlower extremity can be a challenging and frustrating task, but can be ultimate- mertoe repair. ly rewarding both to the physician and Class III: Curative patient upon healing of an ulcer and Curative surgery often is identical to correction of the underlying cause of the deformity. Surgery in the absence of prophylactic surgery with the exception critical limb ischemia is based on three that procedures in this class are designed to speed the healing rate of an open fundamental principles: presence or absence of neuropathy (LOPS), presence wound but also to eliminate any potenor absence of an open wound, and pres- tial recurrence of the ulceration. Surgience or absence of acute limb-threaten- cal procedures frequently utilized in this category may include exostectomy, diging infection. ital arthroplasty, sesamoidectomy, single A classification system has been devel- or multiple metatarsal head resection, joint resection or partial calcanectomy oped outlining non-vascular surgical treatment of patients with diabetes and as well as Achilles tendon lengthening.

Some surgeons may also elect to comhas been divided into four categories bine a plastic surgical flap and/or skin and highlighted in Table 26.4 and is based on indications and perceived risk. graft to help expedite healing.

Class I: Elective The goal of elective surgery is to reduce or eliminate any pain associated with a particular deformity and improve function. Examples of these deformities include bunions, hammertoes and bone spurs, all in patients without peripheral neuropathy and with a low chance for ulceration. Basically any type of reconstructive surgical procedure can fall 22

AMPNATION

Class IV: Emergency (Urgent) Urgent procedures are performed to limit the spread of acute, limb and potentially life-threatening infection.

Most often these procedures are done in the presence of significant ischemia.

They require the removal of all infected and necrotic tissue to the level of viable soft tissue and bone and usually involve some level of amputation. When at all possible these procedures should be performed to allow for maximum

TECH

THERABODY

The massage device looks like a power drill and rapidly pounds the body at 40 beats per second, using something called “percussive massage therapy” to supposedly relieve muscle pain. The newest version, the G3PRO, costs $599, and is marketed for at-home use.

The TheraGun was invented by chiropractor Jason Wersland, D.C, after a motorcycle accident left him with a herniated disc and back pain. To help manage his pain, Wersland decided to try percussive massage therapy, which he defines for SELF as a “form of deep soft tissue manipulation.” Think of the percussive motion as a beating or hammering movement, versus just vibration.

He created the TheraGun to bring this therapy to athletes looking for ways to improve muscle recovery.

“The idea behind [the TheraGun] is to improve blood flow and circulation, which is good for short-term relief of acute muscle soreness, but it doesn’t have long-term benefit,” Oswald explains. You can use the TheraGun the same way you would use a foam roller or massage ball to roll out a tight or sore muscle, he adds, but the force it produces may actually help you reach deeper muscles.

“Percussive massage therapy can be used on anyone,” Dan Giordano, D.P.T., C.S.C.S., cofounder of Bespoke Treatments Physical Therapy, tells SELF. Its potential to relieve pain is based on a medical idea known as the gate control theory, he explains. In essence, the theory suggests that providing a sensory input, like the nonpainful stimulation from the TheraGun, to a spot that hurts, may help temporarily block the pain signals (or “close the gates”) traveling to your brain.

Keep in mind that while the TheraGun—and other massage devices—may be a temporary fix for local, low-level, muscle-related pain, they are not a cure.

Pros about this product Massage therapy is used to prevent and treat physical dysfunction and pain through applying various manual techniques to the soft tissue of the body (muscles, connective tissue, or fascia) and joints. It is recognized as a noninvasive therapy, which, when applied by a trained licensed massage therapist, can have several highly beneficial effects.

23

Clinicals amount of function to the extremity to be maintained.

With respect to any of the above classifications it is best to evaluate the vascular status of the patient to consider the necessity of any prior or subsequent arterial procedure that may be needed.

Post-operative management The management of the diabetic foot patient in the post-operative setting is much the same as a patient without diabetes.

Adequate pain control, rest, elevation of the extremity and proper dietary intake are all recommended. One key difference is the time-frame for protected weight-bearing or complete non-weightbearing. It is often stated that diabetics require twice the healing time as a non-diabetic. That means that if a simple bunionectomy in a non-diabetic requires 4 weeks of protected weightbearing, the same procedure in a diabetic may require 6-8 weeks of protected weightbearing.

The same can be said for a procedure requiring non-weightbearing. Most surgical procedures done for class 1–3 can be managed with protected weightbearing.43 most class 4 procedures will require some period of non-weightbearing or protection. The same can be said for any type of surgical implant or skin closure technique. For example, leaving skin sutures in place for an additional 1–2 weeks is advantageous over early removal to allow for the tissue to heal.

Surgical and non-surgical complications in this patient population are to be expected. Joint dislocation, bone fracture, surgical incision dehiscence, new ulceration or re-ulceration, and infection are all commonplace, not infrequently leading to re-hospitalization. Proper management by use of off-loading, local wound care, antibiotics and patient education will all be beneficial when dealing with any potential complication. It should also be kept in mind that not all diabetic foot complications can be prevented, but all can be adequately managed.

24

AMPNATION

to promote limb salvage. This is an interdisciplinary team model whose core involves the ability to rapidly diagnose and provide treatment to patients with lower-extremity complications of diabetes, utilizing seven basic skill sets. AT the forefront of the team are members from podiatry (Toe) and members from vascular surgery (Flow). These specialties, with adjunctive teams added as necessary, combine to collectively posses the ability to perform the 7 essential skills, stated above, to be effective in promoting limb salvage. This model has been effective at the University of Arizona’s Southern Arizona Limb Salvage Alliance (SALSA) in which the Vascular Surgery/Podiatry team approach Prevention has been able to significantly reduce the Diabetic foot care requires an interdisci- number of major diabetes-associated plinary team approach given the progres- lower-extremity amputations as well as sive nature of the disease in the foot. It provide a framework for prevention of is unlikely that one individual medical diabetic ulcers. In fact, abundant data or surgical specialty is able to manage suggest that establishing such compreall aspects of diabetic lower extremity hensive diabetic foot care teams can disease and appropriately manage these significantly reduce the incidence of patients. Recent evidence suggests a major amputation in both community reduction in major amputation rates fol- and academic hospital settings. lowing the development of an interdisciplinary approach to limb salvage.51 The Conclusion components of a limb salvage team are Treating the diabetic foot, but moreover predicated on the pathology at presenta- the patient with diabetes, is an extremetion. The core of the team typically starts ly challenging yet rewarding experience. with clinicians caring for the structural As the incidence continues to grow aspects of the foot (podiatrists), along worldwide the likelihood of people with clinicians caring for the vascular with diabetes constituting a significant integrity of the lower extremity (Vascular proportion of a vascular and podiatric Surgeons). Other specialties of the team, surgical practice is quite high. Common, to add a more comprehensive care model seemingly trivial foot problems such may include Endocrinology, Infectious as calluses, corns, ingrown nails, and Diseases, Orthopaedic surgery, Physdry scaly skin, may provide sufficient iotherapy, plastic Surgery, Nursing and trauma to develop into limb-threatening Orthotics/Prosthetics. problems. Early recognition and diagnosis of these factors combined with Vasculopathy and neuropathy are two aggressive preventive measures and a major contributors to diabetic foot multidisciplinary team approach will disease and subsequent ulceration. all be beneficial in the treatment of the Therefore, appropriate utilization of an diabetic foot with the ultimate goal of interdisciplinary team approach, as stated amputation reduction and prevention. above, will help to address the varying factors associated with lower extremity ulceration and reduce amputation. A diabetic rapid response acute foot team has been proposed in an effort to combine the knowledge of certain specialties Infections The Infectious Diseases Society of America (IDSA) has produced a classification system for diabetic foot infections, which is based on clinical signs and symptoms. The IDSA divides infections into four categories, uninfected, mild, moderate, and severe. These guidelines and classification system has become a reliable clinical predictor of the outcome of a diabetic foot infection. It is important that initial antibiotic therapy cover the broad range of potential aetiological organisms in the diabetic foot until targeted therapy can be instituted once appropriate cultures have been obtained.

25

THE AMPUTEE LIFE Positivity During Tough Times Quit being a victim. It is easier to assume the role of a victim during tough times than taking responsibilities for yourself. But doing so will only prolong your suffering and put off people who may be able to help you out. Letting go of the woe is me label also frees you from resentment and bitterness which will only jam up the creative energies you need to get out of the mess.

Take stock with meditation. Meditate on what really happened and your response to the crisis. Learn to see the crisis for what it really is. Begin by practicing breathing meditation, and then ask yourself: “What has really happened in spite of what have been reported?

Are my fears and worries real or imaginary? If they are real, what can I do about them?” Contemplate also on the nature of the crises you have experienced in the past.

Understand that each one has a distinct start and end, and may even exhibit a cyclical trend.

also helps you to put things in perspective. And who knows, they may be the ones who lend you a helping hand when the table is turned the next time.

Get enough sleep. During stressful time, we’re likely to skip on sleep, either voluntarily or not. But in reality, you will need more quality sleep during stressful times than ever so that you can remain energetic, clear-headed and focused to figure out your next steps.

Limit bad news intake. Being constantly fed with gloomy news is enough to make even a dog panic for no reason. Hearing bad news once is enough, not ten times of the same news in different versions from every gadget that you own.

Join forces with others. When bad things happen, it is easy to become close-minded. But chances are, you are not alone during difficult times. There are likely to be many people who feel the same way as you do even though they may not voice out loud. For instance, if you are worried about job security, recruit the help of your Focus on the positives. No matter how dire a situboss by discussing the implications of the crisis on your ation may be, there are always some positives you can job and what you can best do to keep it. Your boss will find in it. It is our unwillingness to look at them that appreciate your proactive approach and may even be blind us to the brighter sides. In the book, Prisoners of glad that there is someone who shares the same senOur Thoughts, the author Alex Pattakos recounted how timent. If you are unemployed, besides making trips he managed to pull a female driver to safety when he to recruitment and government agencies to cast your saw her school van crashed into a parked car. Then in an employment net, connect with others who are in the attempt to calm down the distraught woman, he asked same boat as you. Take this lull period to expand your her to list ten positive things about this accident. You network. The many talented friends that you will make probably thought he was insane, but they managed to during hard times could become lifetime friendships, list the positives which included the fact that the van and even turn into unexpected help in the future. And if and the car which she crashed into were both empty at you are an employer, this is a great time to boost your the point of the accident. The attempt may seem absurd but it worked. The driver was calm enough to break into business with skillful and experienced people to a smile and had probably saved herself from going into help you ride out the crisis. a shock. Now it is your turn, think of ten positive things Get close to nature. Finnish researchers found that would happen from this crisis.

Give thanks. Having listed the positives you can think of, give thanks for the current situation as well as the things that you already have. For one, things could be a lot more worse! It won’t be easy to be thankful in the face of harsh challenges, but focusing on what you do have, instead of what you have lost, will put you in a better position to solve problems on hands than being in a self-pity and sorrowful state.

that spending time in your favorite outdoor area and woodlands are more relaxing and restorative than time spent in your favorite urban settings or city parks (Korpela KM et al. 2010). Taking a mindful walk through the woods is also a great way to clear the mind and regain mental balance.

Re-evaluate the meaning of your life. Tough times present hard but valuable lessons that force us to re-evaluate the meanings we have been atReach out to others. Do you know of people who might be badly affected by the crisis? Some may have taching to our lives. Ask yourself: “Do the meanlost their jobs because their companies were put out of ings and goals I’ve been living by before the crisis business, while others have suffered huge losses due really worthwhile? Through this crisis, what are to stock market crash. Talk to them, listen, and if it is the things that I’ve found to be really important? within your means, offer your help, however small it And what are those that are not as precious as may be. Helping others who are less fortunate than you what I once thought to be?”

26

AMPNATION

COACH

By

Sean R. Harrison Amputee

21

Amputees tees IN

ACTION Gordon McDonald, former military paratrooper and survivor of a rare auto immune disease.

In 2015 he underwent a stem cell transplant, although cured, Gordon was left with permanent damage to his legs and confined to a wheel chair.

In 2018, in an attempt to gain mobility, He made the elective decision to amputate both my legs below the knee.

Within the year he was fitted with new legs, adventure was within his grasp.

Three years prior he started to follow Wim Hof, He needed help with PTSD and Wim’s breathing method and cold exposure really helped him gain control.

“I was hooked and wanted to take it further”.

Setting his sights on climbing Mount Kilimanjaro in record time with the Legend Wim Hof. An opportunity to ask Wim Hof himself in person was possible if he made a trip to Portland for a five day workshop. Where he had to climb a local mountain bare chested, completing this would open the conversation about Mount Kilimanjaro.

He was able to attend week six of the winter expeditions, the last one before the Covid-19 shutdown. One-hundred and twenty people from all over the world gathered in one place. All here for various reasons; some personal goals, hidden fears, curiosity, reconnecting or an unknown attraction. He planned on attending as a precursor to Kilimanjaro, 28

AMPNATION

“I learnt how to feel pain, to feel it without suffering. I learnt a deeper understanding of myself, I learnt not only love for others but love for myself, I learnt how to be kind to myself, to re connect with my soul, to my self.”

nothing more than a stepping stone to a fur- this is called “Suffering.” ther goal. What was intended as a stepping stone turned out to be a discovery. Here To remain in the ice water without suffering Gordon found himself. is to Surrender. The object of the exercise is to relax, catch your breath, match the His first session with Wim, was guided breaths until calm can be integrated. While breathing, one hour of deep intentional maintaining calm breathing there is freebreathing at a rate of 50 breaths per mindom to explore, question, observe what you ute. 3000 deep breaths in rapid succession, are feeling, what is this urge I feel to get which allows for accessing a deeper level out? of our subconscious, a place where past traumas and pain can be observed and His group was solid, compassionate, unreleased. Tears poured from his closed derstanding, each and every one of them eyes, taking him back to unresolved pain connected, “the feeling was amazing!” or torment. Gordon was able to reconnect, realizations of why he was there in the first Day 4, the day he was there for, or so place. he thought, the warm up climb for Kilimanjaro. Gordon had the honor, to lead After a breathing or ice bath session they the group of 120 up the mountain. They would debrief, sharing their experiences were dressed in shorts and boots, no shirt. with the group. A very helpful technique, They had to integrate everything they had verbally expressing to an audience has a learned during the week about breathing, way of opening you up, vulnerability of self surrendering and committing to achieve the is a valuable teacher. It was “Self Love” he goal of the exercise. The first 10km of the was there to access, not adrenaline, adven- climb were steep, however manageable, ture nor the highest summit, just LOVE. it was a towards the summit where he had problems. His body was all over the place, Cold exposure, another element within Gordon’s legs were getting intermittent the three pillars of Wim’s principals that signals making it difficult to step, his friend prove one has the ability to have influence Silvana placed her palm on his lower back, over their autonomic nervous system. Cold somehow that helped with the signal to his exposure, breath work and commitment are legs, like an in-line signal amplifier. Watchthe key to accessing this level. ing the ground just inches in front of him, only focusing on what lies just ahead. It The next day they were to meet outside was his “will” alone that helped him in the dressed only in our shorts, everyone but final mile. He had been searching for the Gordon was barefooted. They all walked summit his whole life, parachuting, rock as a group to the local waterfall, barefoot climbing, martial arts, motorcycles, speed, on a rocky trail was a leveler. Watching danger and adrenalin. He never saw his the group gingerly take their steps, needlimit before, always saving a little reserve, ing concentration with footing, much like for the way back. The unnamed peak in Gordon with every step he take on a daily the Czech Ranges became his inner mounbasis. After a brief horse stance and some tain. For the first time in his life he saw his warm up exercises, the group was motioned limit, it surprised him. Gordon found peace to follow Wim whom had just plunged off there, no longer feel the need to chase the a cliff into the ice water below. Mahdi, one summit. He surrendered to the chase and of two instructors and Gordon scaled the choose to live a life of connection and love. small cliff down to the edge where he could Happy healthy and Strong.... take off his legs and follow the group into the water.

“When the world settles and this time of segregation subsides, everyone will Dominic, the second instructor had prebe ready for connection. I would love to viously explained to the group the water be part of that, my intention would be to is ice cold, the autonomic reaction is to become a WHM instructor and share that remove yourself or to retract, to clench beautiful gift to our youth in their schools.” shoulders and rapid breathing takes over, 29

Skin Care of the Residual Limb One of the most talked about topics for amputees other than insurance and who will pay for my leg, is skin care.

I read numerous social media post about amputees doing some very usual things with their residual limbs. From applying harsh chemicals (bleach and detergents), alcohol (which is a whole other topic) and using a shower loofah to clean their not healed limb.

In this Q&A let’s go over so simple straightforward care advice for taking care of your residual limb.

Q&A

Q: What causes skin breakdown?

A: Skin breakdown occurs at sites of pressure and where lateral (shear) forces are applied to the skin, particularly when moisture is present. Common pressure and shear injury locations include bony prominences, the margin of the prosthetic socket, and the distal residual limb.

Skin that comes in contact with the socket of the prosthesis must be cared for and monitored meticulously to prevent skin breakdown and skin infection.

Q: What is the first sign that you might a problem brewing with your residual limb?

A: Pain is the first indication of a problem, and the patient should remove the prosthesis and inspect residual-limb skin when an unpleasant sensation is initially felt. Skin problems can be serious and should be evaluated and treated as necessary by the patient’s health care practitioner in consultation with the prosthetist. As patients become familiar with recurrent problems, they may be able to identify which problems are minor and manage them on their own.

However, anything unusual, persistent, painful, or worrisome should be evaluated by the practitioner.

Q: What are some risk factors for skin problems?

A: Disorders that decrease circulation to the lower extremities (eg, peripheral vascular disease, diabetes) and put patients at risk of amputation also increase the risk of skin breakdown and infection after amputation.

Disorders that impair sensation (eg, diabetic neuropathy, other neurologic disorders) can delay diagnosis by preventing patients from feeling discomfort or pain from skin breakdown 30

AMPNATION

Q: Why is a proper fitting socket important?

A: If the prosthetic socket fits optimally, skin problems are minimal. But even with good fit, normal morphologic changes such as muscle atrophy and fluid volume fluctuation can alter the stump-to-socket relationship and increase risk of problems. Proximal constriction of the socket leads to vascular and/or lymphatic congestion and distal edema, with increased pressure over the distal residual limb.

Sean R. Harrison

Editor & Host of Amp Life Talk Radio

or infection. Patients with a sensory disorder should remove their prosthesis several times a day to check the skin for redness and other signs of breakdown or infection. Other patients should check for these signs at least twice (before & after use) daily.

TIP: Skin problems and difficulty fitting the prosthesis are more likely when the residual limb has certain features, including excessive distal tissue beyond bone termination, loose skin, thick scars, skin and tissue invaginations, skin and tissue adherences, and terminal bone exostoses. These outcomes should be avoided as much as possible during surgery, although this is not always possible in traumatic cases.

The first sign of skin breakdown is erythema (Erythema” means red-colored.), which may be followed by pain, swelling, blisters, and ulcers. Continuing to wear the prosthesis causes more serious skin damage and can lead to skin infection.

TIP: Although it is not possible to prevent all skin breakdown, several measures can help prevent or delay skin breakdown: • Residual-limb hygiene (morning and evening) wash with a mild body soap and rinse thoroughly two times a day and more often for patients who sweat more than normal.; your prosthetist can provide antiperspirant products specifically designed for amputees.

• Maintaining interface and socket fit • Maintaining a stable body weight, this is the best way to make sure the prosthesis continues to fit; even small changes in weight can affect the fit.

• Eating a healthy diet and drinking water throughout the day. This helps control body weight and maintain healthy skin.

•For patients with diabetes; monitor and

control blood sugar.

• For patients with a lower-limb prosthesis; ensure that the prosthesis is aligned optimally.

Q: What should you do if you notice skin breakdown?

A: When patients see signs of skin breakdown, they should promptly see their prosthetist to rule out prosthesis fitting as the cause and if necessary have the prosthesis adjusted. When possible, patients should avoid wearing the prosthesis until it can be adjusted. If the prosthesis is not the cause, or if fitting adjustments do not correct the problem, medical evaluation should be done.

TIP: Skin infection In normal, healthy skin, bacteria and fungi are kept in balance by dry, intact epidermis. However, the residual limb is contained within an interface, some form of viscoelastic gel layer or plastic, that creates a warm, moist environment that encourages growth of bacteria and fungi and development of infection.

Q: How does moisture affect the skin?

A: Damp skin tends to breakdown, giving bacteria easy entry into the body. As a result, infection may spread.

Q: What are some signs of infection?

A: They may include tenderness, skin erythema, pustules, ulcers or necrotic areas, and purulent discharge. A bad odor may indicate infection or poor hygiene. Minor bacterial infection may progress to cellulitis or produce an abscess; in such cases, patients may have fever and general malaise.

Any of the following sign of infection should be evaluated promptly. Patients should seek immediate evaluation for the following symptoms: • The residual limb feels cold (indicating decreased circulation).

• The affected area is red and/or tender.

• The affected area gives off a bad odor.

• Lymph nodes in the groin or armpits proximal to the residual limb enlarge.

• Pus or a discharge is present.

• The skin becomes gray and soft or

black (either may indicate gangrene).

Q: What is the treatment for an infection in the residual limb?

A: Treatment of bacterial infection typically involves local cleaning and topical antibiotics. Sometimes debridement, oral antibiotics, or both are needed.

TIP: Typically, the prosthesis should not be worn until the skin infection is resolved. Erythema can indicate serious medical issues, which must be diagnosed and treated by a physician. Measures described above to prevent skin breakdown also help prevent infections.

Fungal infection can be treated with an over-the-counter antifungal cream.

Q: What are some other skin problems with the residual limb?

A: Ingrown hairs and folliculitis, although not dangerous, can cause substantial pain and discomfort. Not shaving the hair on the residual limb can help prevent these problems.

Verrucous hyperplasia is a rare, serious skin condition of the distal tissues of below- and above-knee residual limbs consisting of rough, erythematous papules that coalesce to form plaques and warty bumps. It is caused by a combination of an ill-fitting prosthesis socket that compresses veins and lymph vessels, the loss of the normal venous and lymphatic return due to muscle contraction, and dependent edema of the distal stump. Verrucous hyperplasia is rare today because of improved socket design that incorporates distal/terminal compression of tissues to provide a back pressure. If the disorder does develop, patients should remove the prosthesis for a week and have socket fit adjusted, which typically corrects the problem within 2 to 4 weeks. However, this disorder can lead to serious infection if untreated. If bumps resembling warts appear, patients should immediately consult the prosthetist to have the socket adjusted.

Q: Edema of the Residual Limb, how long does that last?

A: Even after the residual limb matures 18 to 24 months post amputation, edema can still occur. Having a well-fitting prosthesis socket is the best way to maintain a consistent residual-limb size and volume.

TIP: Measures that can be used when not wearing the prosthesis include applying external compression with: • Elastic bandaging • An elastic compression garment • The viscoelastic interface used when wearing the prosthesis It also helps to follow a consistent nutrition and exercise program and do exercise and/or physical therapy to maintain muscle mass. Edema is much less of a problem when the amputation procedure is done in a way that preserves some active function of the transected muscle.

Q: Does weather affect the residual?

A: In hot and humid weather, the residual limb may swell and sweat, making the prosthesis hard to put on.

TIP: Showering, or immersing the residual limb in cold water for 3 to 5 minutes, and patting it dry immediately before putting the prosthesis on may help. After the prosthesis has been on for 5 to 15 minutes, it should be removed and immediately put back on.

This strategy helps get the residual limb properly positioned within the socket.

If cold immersion is not readily available, wrapping the residual limb with an elastic bandage or wearing the viscoelastic interface and elevating the limb for 20 minutes or more helps. Although prosthetic suspension systems that hold the prosthesis in place using vacuum (created by an electric or mechanical vacuum pump) might be expected to cause edema, they do not when the socket fits optimally.

Always seek the advice of your doctor if you notice or think something is not right with your residual limb, do not post photos on Facebook and seek medical advice.

31

LIMB LOSS AWARENESS EVENT

Run, Walk & Kick SATURDAY, APRIL 18, 2020 | 8:00 A.M. – 4:00 P.M. Encompass Health | 1303 Mable Avenue | Modesto CA, 95355 April is limb loss awareness month, and Encompass Healthcare and Hanger Clinic have partnered up to bring you Run, Walk & Kick, an event aimed at raising awareness for the limb loss and limb difference community, their families, and caregivers. The day will be filled with expert knowledge and education for those affected by limb loss as they build their independence through increased mobility. This event is open to anyone in the limb loss and limb difference community, family members, therapists, caregivers, and volunteers.

EDUCATION + ACTIVITIES + PEER SUPPORT •

Gait training and assessments

•

Prosthetic evaluations, assessments and physical therapy tips

• • •

Walking clinic and walking course Two mile fun run & walk Nutritional advice for diabetics

• •

Virtual Reality: MiGO peer support Amputee classes: Putting on & cleaning liners, socks, prosthetic sleeves, etc.

FOR QUESTIONS OR TO VOLUNTEER, CONTACT: Sean Harrison, Hanger Clinic | (209) 672-7347 Lisa Clawson, Encompass Health | (209) 404-9876

CONNECT WITH US (877) 442-6437

|

HANGERCLINIC.COM

AMPNATION

O &P

News

a certain parameter will behave (degrees of freedom [DOF]). With this in mind, it is known that each finger to a hand has 4 DOF and the wrist has 3 DOF, which means that a prosthetic hand has to be designed to function with 23 DOF. It is quite difficult to control the movement of such a complex machine and so a basic two to three fingered prosthetic hand is usually designed for better control over the monitoring of signal patterns. The thumb actuator works with two degrees of freedom (DOF), which are comparative to the MP and IP joints. The modeling of heavy actuators results in a lower DOF, which can affect the ability of the prosthetic hand to grasp objects effectively. The following video is a good example of a patient adapting a myoelectric prosthetic hand controller with signal activity being monitored.

To take this journey of prosthetic hand construction a little further into detail, we need to consider the application of the sensor-controller-actuator system when measuring micro-electric signals. An electromyography (EMG) signal is used to detect electrical stimulus from the robotic hand, as would have been the case if the real limb was present. Electromyography involves the use of surface electrodes to monitor muscle activity and when considering bionic signals, this method of signal control is ideal to monitor exactly how the mechanical device is moving and responding to stimuli. The EMG is particularly important as it provides the functionality to amputees and the basic principle of EMG signals is to pick up a signal based on the movement of a limb or robotic form. The video below demonstrates the use of a robotic hand with one degree of freedom to pick up an object and how EMG is used to map the electrical signals during this movement.

34

AMPNATION

HEALTH & FITNESS

Nutrition, Exercise & Healthy Living Tips for Amputees

Plant-Based Diets for A plant-based diet is a power ful CVD Prevention In our clinical research studies here at the Physicians Committee for Responsible Medicine, we’ve put a plant-based diet to the test with thousands of patients who have type 2 diabetes.

tool f or preventing, managing, and even rever sing t ype 2 diabetes .

In a 2003 study funded by the NIH, we determined that a plant-based diet controlled blood sugar three times more effectively than a traditional diabetes diet that limited calories and carbohydrates. Within weeks on a plant-based diet, participants saw dramatic health improvements. They lost weight, insulin sensitivity improved, and HbA1c levels dropped. In some cases, you would never know they’d had the disease to begin with.

Studies show that eating a diet high in fatty foods can cause fat particles to build up inside our cells. These fat particles interfere with insulin’s ability to move sugar out from our bloodstream and into our cells. Instead of powering our cells, the glucose remains in our bloodstream, eventually leading to diabetes. A plant-based diet is low in fat, which allows insulin to function properly.

Evidence shows a diet of fruits, vegetables, whole grains, and legumes can prevent and reverse diabetes.

Diets high in animal products and added oils are linked to increased diabetes risk.

Beans, oats, sweet potatoes, and other low-GI foods do not spike blood sugar.

Found only in plants, fiber helps improve blood glucose control.

“ A plant-based diet is a powerful tool for preventing, managing, and even reversing type 2 diabetes. Not only is this the most delicious ‘prescription’ you can imagine, but it’s also easy to follow. Unlike other diets, there’s no calorie counting, no skimpy portions, and no carb counting. Plus, all the ‘side effects’ are good ones. ” 1 1Neal Barnard, MD, FACC, President, Physicians Committee

35

Services Offered Video & Audio Sound Effects & Foley Creation Live Action Shoots Audio Mixing & Mastering Editing Visual Brand & Content Strategiszing Contact Rich@souleffective.com https://www.souleffective.com/ 36

AMPNATION

O &P

News

Research to Consider The present article has introduced a basic overview of the design and modeling of a prosthetic hand, a study referred to as biomechatronic design. Though the design of prosthetics is continuing to develop and benefits many patients living with an amputated limb, there are still challenges ahead in the design of a prosthetic limb that satisfies intricate requirements, such as easy control of the prosthetic limb and a to make this mechanical device cosmetically appealing.

There is also the challenge of understanding the issue of tissue reactions to material used for the prosthetic limb and how an inflammatory response to such a reaction may interfere with the signal transmission of biosensors.

replicate the tendons of the hand rather than conventional mechanical joints and transmission systems.

This enabled the easier control of fingers as information about movement could be directly passed on to the prosthetic, rather than using complicated control systems.

The latest designs combine machine learning and neural networks to enable a user to simply think of a movement and the prosthetic performs it, just like a natural limb. A recent study reported a prosthetic hand combined with a neural network that can allow the wearer to think and move the hand. Electrical signals from the nerves are meaRecent Developments A lot of work has gone into further un- sured through the skin and sent to a computer that decides what the derstanding and replicating the movements of a human limb to better design movement should be. The computer robotic hands that can perform as well learns what the movement should as or better than human hands. Anal- be using a neural network trained to recognize different movements. ysis of available prosthetic hands using computational approaches, Another aspect of research into revealed that symmetrical designs prosthesis has been enabling a prospreferred by roboticists or the random designs generated come close to thetic limb to feel. One report used the abilities of a human hand. Thus, sensors in the fingers to send sigprosthesis designed with anatomical- nals to the nerves of the limb via an ly plausible asymmetry in joints and array of microelectrodes and wires tendons can perform even better than that translate into a sensation. They may also be used to feel pain and human hands. temperature. Another approach has Another approach is to replicate the been to use a layer of artificial skin biomechanics of a human hand using with sensors that are placed over the biomimetic, mechanical design. The fingers on a prosthetic hand. The sensors relay the stimuli back to the hands can be controlled via methods such as using electromyography nerve endings of the limb. Such a system can be used with any type of signals from the residual limbs or by implanting tiny electrodes in the prosthetic hand. motor region of the brain or nerves responsible for controlling the hand. Although there have been significant developments in prosthetics in the To control the movement of the last few years, there is still a need fingers, new approaches have used cable-driven systems where strings for cheaper and more accessible

Made by hand in small batches with 90 to 98% certified organic ingredients, with intention to heal. We make herbal infusions in an olive oil base to ensure excellent skin absorption and delivery of potent healing benefits. A Product I personally use.

prosthetics. More prosthetics are moving out of lab-scale testing and into the real world, opening up new opportunities and challenges.

37

38

AMPNATION

Amp Life Talk Radio Listen on Spreaker.com

Transcripts from Amp Life Talk Radio - The Podcast Hook Approximately 134,000 amputations occur annually in the United States, resulting mostly from peripheral vascular disease. The risk of amputation increases with age, peaking among those 85 years of age and older. As a lifesaving and life-defining procedure, amputations result in physical and emotional changes affecting quality of life. Phantom pain is problematic for many patients, and agents approved by the Food and Drug Administration for phantom pain are nonexistent. Pharmacists should be knowledgeable about weightbased dosing as well as patient education guidelines.

tions, and try to help ease nerves and work to help the patient have the best possible outcome for a functional prosthesis. The team approach of the surgeon and patient advocate or company accomplishes a common goal—restored mobility where possible.

By consulting with a surgeon on the exact location of an amputation—sometimes even during surgery—I am able to affect how easily the patient may adapt to a prosthetic limb.

Segment 2 - 5mins “The length of the limb and the amount of surface area makes a big difference when My limb was amputated and I was not conit comes time to fit a patient with a prosthesis,”. “For sulted. example, the more surface area there is at an amputation point reduces the risk of pressure ulcers Normally, there are a couple of reasons an emergency and blisters, and it also increases the leveramputation may be performed. The first is when a traumatage area for applying the prosthesis which ic accident occurs. The limb could be lost at the scene of the sets the patient up for better balance. The team approach is all accident or maybe so badly damaged that it must be removed about making it easier for our patients to adapt to their prosin a hospital. The other common reason an emergency ampu- thesis and get on with their lives.” tation may be done is if a severe infection has set in, and the individual is going into septic shock. Septic shock can quickly While I recognizes that having a prosthetic limb is certainly a kill if not treated. In some cases, amputation may be the only lifestyle change, it does not have to be a lifestyle ending expeappropriate treatment. rience. Advances in technology and the evolution of prosthetic products have made a big difference for today’s amputees.

Emergency amputations are very rare. Normally, there is time for a patient to discuss the pros and cons of amputations and Segment 3 - 5mins what other options may be available. The patient may be able My goal is to get people back to their normal lives,” and the to salvage the limb, but in some cases that may not be a good doctors I work with this is our goal. “Or if they want to do solution. more or different activities I want them to be able to do so, with the right prosthesis so they aren’t limited by their mobilIn most emergency amputations, the doctors struggle with ity.” the decision to amputate and may do everything possible to consult with family members and/or the patient. However, If you are facing a limb amputation, are struggling with a if a doctor truly believes that an amputation is the only way poorly fitting prosthesis, or something in between. to save the patient’s life, it may occur without the amputee’s approval. ..... Show Closing

Show

Notes

Segment 1 - 5mins How Prosthetic Companies & Surgeons Can Work Together For Your Benefit I work with certain doctors to offer a unique model of care for patients who are facing a limb amputation. By partnering with a patient’s surgeon, I discuss concerns, answer ques-

39

INFLUENZA (FLU) Cleaning to Prevent the Flu Cleaning to Prevent the Flu

48 hours

How long can the flu virus live on objects, such as doorknobs and tables?

The flu virus can “live” on some surfaces for up to 48 hours. Routine cleaning of surfaces may reduce the spread of flu.

What kills flu viruses?

Flu viruses are killed by heat above 167° F [75° C]. Common household cleaning products can also kill the flu virus, including products containing: • chlorine • hydrogen peroxide • detergents (soap) • iodophors (iodine-based antiseptics) • alcohols

How should a caregiver handle a sick person’s tissues or other items?

Make sure to wash your hands after touching the sick person. Also wash after handling their tissues or laundry.

For more information call CDC info at 1-800-CDC-INFO (232-4636) or go to www.cdc.gov/flu.

PUBLIC SERVICE ANNOUNCEMENT U.S. Department of Health and Human Services Centers for Disease Control and Prevention CS 290778-A/2018

Shop at: