Driving?!?

 Okay so the big question that is asked by every client I have worked with is, "When will I be able to drive?" This is completely dependent on what side your amputation was on and whether you lost part of your arm or leg? 

If you have lost part of your left leg and your right leg is fully intact than you are good to drive once your doctor says you are good to go. If you lost part of your right leg than adaptations will need to be made such as a left foot accelerator. 

If you have prosthetics or a loss of both legs than hand controls will need to be looked at. As it is not considered safe to drive with prosthetics as you have lost sensory input through your feet. This allows you to control acceleration and breaking by hand.

If there is an upper extremity amputation than there are a variety of things that may need to be addressed. This would include using turn signals, wipers, turning the steering wheel. Something else to consider is if you will be wearing you prosthetic arm while you are driving. The pictures below show several options for "gripping" the wheel.

Palm Grip

Spinner Knob

Three Pin

Spinner for prosthetic hook component

If you amputation was on the side of you turn signal than they will have you get an adapter to crossover the opposite side of the steering column.

If you are looking at all of this and going how do I know what to get? You don't have to figure it out. There is driver's rehab where you will be evaluated by an Occupational Therapist to see what modifications you will need and to provide you with a certificate stating that you know how to drive with the modifications and paperwork that you will take with you to a location that will properly hook up the components that you need. They will be able to provide you with resources as to where to go to get the recommended adaptions made. 

This is challenging sometimes because of some areas not having a lot of resources, I live in rural Maryland and my patients have very limited options for the driver training and places that are certified to complete the work on their car. These adaptions and training are not covered by insurance so it can also be cost prohibitive, check for possible funding through local and government programs near you.

Best Wishes as you regain your independence and meet your personal goals.

Adaptive Sports

Is this for me?

There are so many options for activities. Everything from land-based to water-based, low energy to high energy. I will make a list of some but it will not be a complete list simply because everything can be adapted. 

So for land-based sports you have wheelchair basketball, wheelchair rugby, sitting volleyball, adapted table tennis, wheelchair tennis, track and field events, archery, skiing, sled hockey, and so many more. I feel like the best way to introduce you to some of this is pictures and videos, so please feel free to follow the links.

CAF Wheelchair Basketball Training Zone | Level Up Your Game - YouTube

Maryland Mayhem (photo: The Baltimore Sun)

Adaptive Archery - USA Archery (usarchery.org)

Sitting Volleyball (photo: Wordpress.com)

Tatyana McFadden: Paralympic marathon legend | CNN (Adaptive Track)

Sit Ski (photo: Accessrec.org)

Water-based sports include any swimming event, scuba, kayaking, water skiing, and sailing.

The Downtown Sailing Center - Adaptive Sailing

Aquatic Therapy is Serious Fun - Amputee Coalition (amputee-coalition.org)

Water Skiing (photo: Numotion)

With so many options out there, you can find something to enjoy even if it is not a sport you had previously considered before amputation. I would recommend you take advantage of any opportunity to try whatever is available. Now for some of you this means no winter sports, but there are so many other options to try. Do NOT be afraid of the pool because it is an awesome place to restore freedom of movement and a sense of independence. Whatever you choose, may you have fun and enjoy yourself. Feel free to comment and leave pictures of activities that you have found near you.

My Leg Doesn't Fit

 So first question first...is there too much room or too little room in your socket? 

Too much room: you need to add socks. If you have socks on make sure you increase your number but are keeping to as few socks as possible. If you have 3 socks on of the same ply can you use one sock of a thicker ply? It reduces the chance of wrinkles and therefore can reduce the chance of pressure where you don't want extra pressure or get a sore from localized pressure for hours. If you have 8-10 ply of socks on have you reached out to your prosthetist or if you are actively in PT, please make sure your physical therapist knows. Rule of thumb for most sockets at 8-10 ply we need to start making arrangements for a new socket.

Too little room: if you have socks on take some off. If you don't have any socks on, do you have a flexible inner liner (typically white) that is able to be removed from your prosthetic, is so pull it out. If you do this you may need a sock ply or two on as this increases room quickly. If you don't have a flexible inner liner that you can remove try some seated cardio or if you have access to equipment get on an arm bike or recumbent bike/stepper. Helping circulate your blood can help your body reduce edema/swelling. 

Both scenarios above are pretty common. The first usually comes as your body changes after amputation. Muscles atrophy, swelling from surgery decreases, the shape of your limb changes and this process is called limb maturation. This is expected and it is the reason why you were given a "big" bag of socks when you received your leg from the prosthetist. The socks help you manage comfort and proper fit until you have changed enough for a new socket, which could be 4 months after you received your first prosthetic or it could be a year after.

The second scenario is usually due to swelling in the limb. Honestly you can be doing everything right and wake up one morning and your leg can be tight, think about from a jewelry perspective, some mornings you wake up and your rings are tight (most likely during the summer, especially here in Maryland) and some mornings you will wake up and your rings will spin around your fingers. If your rings on your hands are tight, your leg/arm may be tight. If your liner will go on get your liner on, but also reflect back on other things that you have done or eaten. Did you have foods high in salt the last couple of days...chips, pasta, seafood with Old Bay, beer? Did you drink enough water? Yes I did just type that, if you are swollen you may not have drank enough water, our bodies need water to process waste products out of the system properly. When we are dehydrated are bodies don't work efficiently. Coffee, iced tea, lemonade, diet sodas...none of these counts towards keeping you hydrated. Water is the bulk of what we are made of and it is the bulk of what we need for hydration. For those of you telling me that you don't want to have to run to the bathroom more, think about it this way, the darker your urine color is the more concentrated the uric acid the more it irritates the bladder. If you drink more water it will decrease the acidity levels and thereby help decrease it as a bladder irritant. Next possibility is, have you been wearing your liner or your shrinker over the last couple of days, if not than this may be your culprit. As above, get your shrinker on if nothing else, but preferably getting your liner on is better since it is typically a little less stretchy than the shrinker. It also controls the shape of your limb better and will help it return to the shape needed for a good socket fit.

If the above information is unable to help you problem solve your situation, please reach out to your prosthetist as a new socket may be needed or your socket may have the ability for minor alterations that your prosthetist will have you come into the office to address.

Please feel free to comment or leave suggestions for new topics. 

Pain, what can I do?

 Treatment options are many and varied. So when I give you a list of 10-15 options don't expect them all to work nor that the first one you try will work. You may try your first option and get good results but you may need to try half of the list before you get relief. Don't get discouraged. Here we go.

1) Patting/Tapping: This is gentle, think burping a baby. It is exactly like it sounds, patting or tapping the residual limb to provide a change in information that the nerves in the leg are taking to your brain. This is a part of desensitization of your limb, in the long run this will help prepare your limb for having a liner and a socket on.

2) Rubbing: Again this is gentle, you can also use a soft (think silk or microfiber) cloth on your skin. You are looking to give the nerves/brain something else to process. This is a part of desensitization of your limb, in the long run this will help prepare your limb for having a liner and a socket on.

3) Mirror Therapy: This has a lot of research behind in from the VA and it does work, again this is something that works for some individuals. You would place this between your legs with the mirror facing your non-amputated limb so that your eyes/brain see you with two legs again. Then you can move or rub your leg on the sound limb to address the pain in the region that amputated side that is no longer there.

4) Guided visualization/meditation: Okay so this one isn't for everyone, it does however help your brain with the distraction that it needs. There are so many options on YouTube, just search guided meditation and you will get options for taking walks on the beach or in the woods, or visualize yourself in a mountain hut or on a tropical island. Distraction is the key element, so finding something that works for you may take a few different tries. From experience try both male and female voices as that can definitely make a difference in being able to relax.

5) Virtual Reality (VR): This works along the same lines as guided visualization/meditation but is a more active approach. It is a great tool for distraction and changing the focus of what your mind is addressing. There are multiple platforms available for use with gaming systems or your cellphone. Research is key to finding what will work best for you. This can also be done as a therapy treatment where available where you would see yourself completing exercises with limbs intact.

6) Repositioning Limb: Sometimes the way we are sitting with our limb (arm or leg) can trigger phantom limb symptoms. Easy solution is to change position, may need to try several options to decide if this will work for you.

7) Biofeedback: Using EMG biofeedback has been shown to help with cramping PLP and is used to help with learning to relax the muscles that are involved. Temperature biofeedback is used when there is a "burning" PLP in the residual limb and you learn to raise the heat in the extremity by increasing blood, this is typically when you find that your residual limb is colder which is attributed to decreased blood flow.

8) Acupuncture/Accupressure: While there is not a lot of evidence to explain why it works, there has been evidence to show that it does help decrease the need for pain medication. Acupuncture would require going to someone who practices traditional chinese medicine where are accupressure can be performed at home with someone who knows which pressure points are needed to reduce the pain.

9) TENS: Technique has long been used for pain management with low back pain, ankle and knee pain has been shown to work with electrodes placed either near the end of the residual limb, on the opposite leg at the "site of the pain" or at the level of the spine where the nerves from the leg/arm come back into the spinal cord. Work with your physical or occupational therapist to figure out pad placement

10) Massage: This is generally safe especially if you have no sutures or staples present. You can have a licensed professional give you a massage, it can be a self massage or someone you trust with some guidance can perform a massage. It touches on so many benefits that include, relaxation and improving blood flow to the limb massaged that this is good even if it doesn't help with the pain.

11) Music: This is completely individual, it can be used to relax (maybe in combination with a massage) or as a distraction (favorite artist or radio station). Find something that works for you, if you don't have earbuds or headphones now may be the time to look into a pair so that you have access to music just about anytime anywhere. If you are focused on music and/or moving to the music this can give you relief from the pain.

12) Shrinker: Wearing your shrinker or liner for the majority of the day can also help manage symptoms by providing a general level of pressure over your residual limb. If you are just starting with a liner you may need to slowly increase your wear time of the liner and use a shrinker when you take the liner off as liners do not let your skin breath and for some patients this process takes time to build up for all day wearing.

Below is a link to an article published by the Amputee Coalition of America that has some of the above techniques mentioned as well as broader descriptions of the techniques. May you find a couple of techniques that assist in your pain management.

phantom-pain.pdf (amputee-coalition.org)

Where is this pain coming from?

 Pain after Amputation?

   Where does it come from? There are several types of pain following an amputation; acute/surgical pain, phantom pain/sensation, residual limb pain. We are going to work through each of these and try to take some of the mystery out of them. Okay, so let's start with the most obvious pain...surgical pain.

    Surgical pain is fairly obvious in that the amputation you had causes bone, soft tissue and nerve "injury." Bone heals in approximately 6 weeks (just like it would if you had broken it) this timeline can vary depending on age, overall general health, and each individual's history with healing. This pain decreases over time. It may not seem like it and that may be due to a different type of pain known as residual limb pain.

    Residual limb pain is pain in the remaining/residual portion of the limb following amputation. This is not typically felt in the days/weeks following surgery. This type of pain is more often present once the healing of bone and soft tissue have occurred and is only present in the limb without symptoms going below the level of the amputation. This pain can be triggered if there are neuromas present, if there has been delayed wound healing, if there were surgical complications, it can come from poor prosthetic fit, this is not all options but may be a possibility.

    Phantom limb pain this can be felt immediately after amputation surgery or start days/weeks/months later. This is pain that is beyond the end of the residual limb may be present in the area where a toe/finger or an ankle would have been, or it may travel from the site of amputation down towards the fingers or toes. The frequency and severity of the pain can vary from person to person and day to day. As a therapist who has worked with over a hundred individuals post amputation phantom limb pain is extremely variable based on the patient. It can be pain at the site of a previous wound, it can feel like an electrical shock going down the limb, or it can be a nebulous sense of pain where there is no limb. You are NOT crazy if you feel this, this is fairly normal for all individuals post amputation. 

   Phantom limb sensation can occur with or without pain and this can be sensations of itching or the sense that the rest of the limb is still there. This is what can put individuals with lower extremity amputations at risk for falls as most individuals will say something like, "I thought my leg was still there when I stood up to go to the bathroom." The limb may feel like it is moving when it is not or you may feel the surface that is under "your foot" even when nothing is touching the residual limb. This sensation can appear to be more intense at the end of the day when the prosthesis is off, possibly due to timeframe at the end of the day most people are trying to calm down and prepare for sleep so there is less distraction for what is going on with your leg. It could also be due to the fact that the input from wearing the prosthesis is now gone and the nerves are more primed for input.

To find things you can do at home for ways to treat pain after amputation please read my next blog post.

Thank you for any questions or feedback.

Terminology: What is all of this medical jargon?

Did you ever wonder what the words meant when you looked at your medical records? Or when you were talking to someone in the medical field and they forgot to use layman's terms. I want to make sure that you have some of the vocabulary down so that you can also better advocate for yourself. 

Residual Limb: This is the remaining portion of your arm or leg following an amputation.

Transtibial Amputation: This is an amputation of the leg below the knee but above the ankle

Knee Disarticulation: This is an amputation of the leg through the knee joint, leaving none of the leg from the knee down

Transfemoral Amputation: This is an amputation of the leg above the knee but below the hip 

Hip Disarticulation: This is an amputation of the leg at the hip joint, leaving none of the leg from the hip down.

Liner: This is the first part of the leg donned before you put on socks or your socket

Socket: Hard outer portion that contains the residual limb (in the picture below it is the flesh tone portion)

Flexible Inner Socket: In most prosthetic devices it is between the socket and your leg. Most of the flexible inner liner come out to help adjust for sock ply, for those days when your leg is swollen and you don't have socks on. (in the picture above it is the clear layer, though often it can be white)

Pylon: Is the section of metal pole that connects your socket to the next mechanical joint, it could above and below the knee or just below the knee depending on the level of your amputation. (below are two different examples of transtibial prosthetic legs, the one on the R has a long pylon and the one of the left has a very short pylon near the bottom or distal end of the socket)

Proximal: It is the portion of your closer to your center or point of attachment to your body. 

            Example: Your shoulder is proximal to your elbow.

Distal: This is the opposite of proximal and is the portion of you further from your center or point of attachment to your body. 

            Example: Your fingers are distal to your wrist.

Medial: This is the part of the body closest to midline or center of the body. 

            Example: The big toe is medial to the little toe.

Lateral: This is the opposite of medial and the side furthest from midline or center of the body.

Phantom Limb Sensation: This is when you feel numbness or tingling, itching, or any other sensation that is not pain extending below/distal to the level of the amputation.

Phantom Limb Pain: Any pain that extends below/distal to the level of the amputation. 

Neuroma: a very specific area of pain, sometimes a nodule or small ball like structure can be felt with palpation. This is where one of the cut ends of a nerve have "balled" up and may include some scar tissue creating a very tender area that can make wearing a prosthesis painful.

Hopefully you have found information to take away some of the mystery that medical language creates and if you have any questions regarding other words that maybe I should have included please comment with those and I will include in a new post or update this one.

Thank you for your time and may the next step in your journey bring you further success.

Socks

 These socks aren't for your feet!

When you picked up your prosthesis you were issued socks, and you probably wondered when you were going to use them and why you would need so many. Now some of you may still be wondering this and some of you may be laughing and going "yep that was me, but not anymore." So here's the information that you probably heard and didn't catalog while getting your awesome new leg.

You probably have 2-3 different thicknesses of socks, and it does matter what thickness you grab. Depending on the manufacturer and your prosthetist you may have 1ply, 2 ply and 4 ply; you may have 1ply, 3 ply and 5 ply; or you may have only two of these which may mean you most likely don't have a 1 ply sock. So your next question may be, when do I use these socks? 

Here we go...you may need to use socks if: 

1) you are getting pressure/pain on the end of your residual limb

2) your prosthetic is starting to rotate on your residual limb (typically noticed when the foot is no longer going the same direction as when you were at the prosthetists office)

3) you feel like your leg can move inside your socket and it is not as fitted as the day you received your leg.

4) if you have a transfemoral socket (aka above the knee) than your first clue may be that what was "comfortable" before is now inching too far up into your groin

5) there may be others and feel free to leave them in the comments as everyone experiences and describes socket fit differently.

If you feel you fit any of the above scenarios than start with your thinnest ply sock. You will don your liner as always and then apply the sock over the liner, if you place your sock under your liner you decrease how your leg is held on and this could cause your prosthesis to fall off. You should have a comfortable fit when you don your leg, it may feel a little tight but it shouldn't cause pain or feel like a torniquet has been applied. 

Below is one example of a sock. This one would be used with pin lock system or a lanyard based system. 

If you have any questions or concerns always call your prosthetist as they have more direct infomation regarding your socket and supplies.