Welcome, everybody, to the last session of the day. Oh, well. Somebody's got to do it, and we're going to do it. So I'm Joe Burris. I'm the session director for this session entitled Case Studies and the Longitudinal Management of Patients with Amputation. I am the program director for many years of the amputee rehab program at University of Missouri, and I'm the department chair there now as well. And I have joining me today Tracy L. Hello, everybody. And Tracy is the owner and chief prosthetist of Hitech Limb Embrace in Columbia, Missouri. I will go ahead, and in terms of our conflicts of interest right now, just say I don't have anything to disclose any relevant financial elements for that. So we're going to talk about amputation today and with these objectives. Our goal in the next hour-ish plus here is to try to increase your ability to manage patients with amputee rehab needs for pre-prosthetic and for prosthetic training needs, understand the complications and challenges that patients in those areas have, increase your knowledge a little bit of wound management and really of limb shaping that occurs with patients and how we're going to manage that in a longitudinal fashion for patients in both the pre-prosthetic and in a prosthetic phase after predominantly lower limb amputation. We're also wanting to increase your knowledge about how to make prosthetic adjustments for fit as the patients are undergoing prosthetic training and trying to optimize patients' functional outcome, of course, with that. So we're going to have an overview of how we do at our institution and in our health system the amputee rehabilitation process. And it will be different in different systems, but I'm going to talk to you about how we do it and why we do it that way. We'll talk about some of the options that we have within our system, and hopefully you can take that and extrapolate it to the systems that you work within in terms of the systems-based practice. We're going to focus more on lower limb today just because that's where the numbers are, right? And so we want to be able to give you guys a good look at that rather than the more rare cases with upper limb amputation. And we've got some cases to present after we kind of go over our system that we have. So start out talking about, you know, are we even doing in physiatry? Are we doing amputee rehabilitation? And, you know, my answer to that is yes. I've been able to do it in my career, which it hurts to say, but is over a course of 25 years now. And we've absolutely shown some significant growth in that, and I'm going to give you some reasons why it's grown at our place, and it would have potential to grow at your place if it's not already a robust system. But, you know, why is PM&R so ready to manage patients with amputation? Because we really need to provide the medical leadership for these patients. We can provide the rehabilitation leadership for these patients. We have to deal, especially in the insurance world, with the nasty word of medical necessity. And so we have to be able to navigate that and advocate for our patients on that. And really, it's our opportunity to provide holistic care for patients with amputation. And we do that at our system in a variety of inpatient and outpatient programs. We do a lot of education. A major role of the physiatrist is, right, to do that education for patients. And in terms of what are the realistic expectations that a patient can have after amputation, because they come to the table with all kinds of a spectrum of different expectations that they have, and we need to be realistic with them. And oftentimes, we have the opportunity to be thrust into that role where other people may not be able to provide that. There's a lot of fear with amputation, patients not being able to manage their bodies after the amputation. Time and again, I will have done consults in the acute care hospital for patients, and they don't even know how to get out of bed. And so, you know, at that very basic level, patients having a lot of fear about what's going to happen next in their lives, and really be able to provide that hope for them down the line. In terms of support, though, it's not all about just the prosthetics device. We need to do pain management for patients. They have a lot of other durable medical equipment needs. They deal with issues with disability. We've got vocational rehabilitation issues in many of the patients. A lot of the patients have adjustment issues and mood disorders that we need to recognize and we need to intervene with. Although, I'll tell you, one of the best antidepressants I'm aware of is a prosthetic device. That is really a marker of a good outcome for many patients. So I got some stats here. I'm not going to focus a lot of time on that. I want to point out, and you've got the slides for reference on this. So I'm going to kind of buzz over to the next one here and talk about what I think is the most important statistic, and one that I've seen living out in my career, is that a 2002 review that was done, and it stated that the incidence of geriatric dysvascular amputation in the U.S. would double by 2030. And if you practice in this area, I am sure that you're seeing that incidence on the rise, rise, rise with this. And we're talking about, you know, in another estimation, 3.6 million amputees by 2050 in the United States. So going to do a lot of flipping around here this afternoon, and kind of moving from one area to the next. But how our usual encounters start with patients with amputation is either in the hospital or sometimes in a pre-amputation clinic visit that we would have with the patient. So if we're fortunate enough in certain situations to have a preoperative consultation with patients, that can set the stage and provide the patient and their family and caregivers with the ability for us to be seen as the leaders of their amputee rehabilitation journey. So, you know, usually we're going to get the surgeons obviously are going to be involved in the case. Very often we'll have the prosthetist in the case. With the preoperative clinic visit in our system, we've gotten to the point where we can have the surgeons referring over to us and they want us to come in and talk with the patients about what they're going to be experiencing in the short term after an amputation and also in the longer term. So fortunately, we've gained their trust over the years and they really turn it over to us to do all of the management of the patients. And they focus on the surgery and they focus on the wound really with this. So as I said, it can happen in the office sometimes and in your clinic, but very oftentimes it's in the acute hospital and the prosthetist often will have the same situation where they're encountering the patients in these locations. Sometimes, of course, we're not able to get in front of the patient until after the operation. So we're in there early afterward in post-operative day one, two, three. Earlier the better, of course, with that. Situation changes, though. We're going to be talking about residual limb management a little bit more and in a little bit more focused fashion if it's post-op. We'll be involved in pain management with the surgical teams and possibly with pain anesthesia teams as well and really your chance to do the assessments and provide direction for the patient for medical and rehabilitation management. So we do a lot of educating and that goes even back to the acute care teams. Those tend to change a lot in most of the acute care hospitals, so it seems like you're constantly having to re-educate new folks that are coming along. We're at a training hospital as well, so we've got trainees on the acute care side that are going to recycle every July for us as well. So we try to tell them here's how it works in our system and you've got to, I think, go ahead and open that dialogue about how we're dealing with insurance and then describing what the follow-ups will be. I'm always encouraged when I have a patient or a family member that's sitting there doing some writing down for us as well or we might provide them some limited written information as well regarding the nature of follow-ups and the frequency of follow-ups. Usually people are in the hospital about five days with amputation. That's my experience with what I would call an uncomplicated amputation. Of course, the complicated states with patients can be much more diverse than that. So we try to, in our system, push patients over to inpatient rehabilitation hospitalization, if at all possible, because we have, in our case, a joint commission advanced accreditation amputee treatment team at our inpatient rehabilitation hospital. So we've got a lot of therapists that have extra training in both the pre-prosthetic and the prosthetic phases of training and they'll be able to provide a very high level of care for our patients. Our goal, of course, as with any IPR, is to try to get about 80% of your patients back home. And my experience with our team over the years in the pre-prosthetic phase, we're getting 90% to 95% of our patients home, which has got some special challenges associated with it, that's for sure. We usually have PM&R as our admitting physician, but we very commonly have the hospitalists in consultation. Many of these patients, of course, dysvascular, elderly, diabetic, and multiple medical comorbidities. And that's going to really have a lot of benefit with having the hospitalists working alongside us in consultation. So as a reference here, when we talk about mortality, you know, the numbers are pretty sobering that we could have nearly 1 in 10 having mortality within a month after amputation in general. And in patients in the transfemoral amputation, it's almost 1 in 5. So it's really sick patients, a lot of complications that they have, and we really have to be thinking about that as we're doing the management with these patients. PT and OT, I think those are pretty obvious for the mobility, self-care, and equipment needs that the patients have. But we use a lot of speech therapy. The patients very commonly may have had premorbid cognitive impairment, and certainly around the time of their operations, post-anesthesia and with pain management, they're going to have a lot of delirium. And so our speech therapists help us out quite a bit with trying to cognitively reorient the patients. Rehabilitation nursing, of course, we all know the statistics that the higher number of CRRNs that you have in an inpatient rehab hospital, it's associated with improved outcomes. And then specifically wound nursing, especially if we're dealing with more complex wounds. But typically those wounds may not be the amputation but may be the contralateral limb, and we'll talk about that here a little bit more as we go forward. Psychology consultation for that mood and adjustment, also evaluations of cognitive status. This might be the first time that they become involved with that. Prosthetist consultation. This is oftentimes the opportunity to provide a shrinker as an opportunity to have a sit-down conversation. So we'll have the prosthetist join us at that time. So issues that we deal with, of course, pain control, right? So we're going to be dealing with residual limb pain, phantom limb pain with the patients, and residual limb management in terms of volume management. And those really kind of go together. A great way to manage nonoperatively is typically to provide mildly compressive dressings, which will enhance wound healing, it will reduce pain, and it will also begin limb shaping such that we can get time to prosthesis shortened for the patient. And so for all of those reasons, we use various methods to perform compression and even some protection of the residual limb. We have done a significant educational campaign with all of our therapists and with our nurses such that they go through an annual competency and an onboarding competency, and they learn the figure-of-eight wrapping methods with Acewrap to provide low-tension figure-of-eight Acewraps for patients. And then we also are aggressive about trying to do education with the patients and get them to the point where they can self-manage with a low-tension figure-of-eight Acewraps. We also do use shrinkers, though our tendency is not to while the patients have sutures and staples in place for below-knee. I would say in above-knee amputation, we use a very low-tension shrinker and really this often provides the ability to hold a dressing in place. And if you're trying to do the Acewraps for above-knee amputation, usually it's going to be left behind on the bed once you start initiating bed mobility and transfers. So much easier to deal with the shrinkers for above-knee. Occasionally we'll use removable rigid dressings. I've got some pictures I'll show of that later. And this is a good method, but not without some caveats associated with it. At times patients may not understand it. It can be both an education opportunity and also a limitation for patients. And we'll talk about that a little bit more as I show you some pictures coming up. Occasionally, very occasionally, we'll use a bivalve orthosis, oftentimes like you would use for spasticity management of a foot and ankle, but we use it on the residual limb, and that's a good way to provide protection of the limb, but it also gives us the opportunity to remove it and provide inspections of the limb on a regular basis. We use a lot of knee immobilizers in below-knee amputation, and that not only helps us with preventing knee flexion contractures, but it also gives the patient protection. They have a device that is covering the residual limb and extending that intentionally beyond the end of the residual limb in the below-knee segment gives them some protection as they initiate mobility. In terms of wound management, really monitoring for any dermatologic complications with pressure and, of course, watching for infection. And the presence of edema is very common and the presence of blisters that will develop and this is really the blisters and the bullae that can develop at times on the residual limb are from a lack of using compressive dressings and then the limb has expansion of edema rapidly and can result in blisters. You see a fair number of contact dermatitis. People get allergic to something or have reactions to materials that are placed in contact with the limb. Teaching desensitization techniques as a pain management method. The other thing is this act of trying to empower the patient to return what I say is returning the residual limb back over to their management rather than having it be something that medical personnel manage. This is the opportunity to get the patients looking at and touching their residual limb and, of course, avoiding wound areas with that but giving them the chance to learn the new them a little bit more. Dealing with those depression, anxiety, and PTSD that patients will have, especially in the case of traumatic amputation, may be an issue and certainly adjustment for all patients. In terms of the therapy, we talked about it a little bit earlier to drill down on a few areas but, of course, in terms of the patient's safety, wheelchairs and appropriate seating for them as that's going to be their primary means of mobility until they obtain a prosthetic device, and it may still be a primary means of mobility even after they obtain a prosthetic device. So we want to make sure we have good fit and good adjustments for their wheelchair and seating needs. Assistive devices that are appropriate, whether those are most commonly front-wheeled walkers but occasionally will have people on axillary crutches or forearm crutches, although much more the exception rather than the rule. And ambulation is generally pretty limited. If we look at the typical crowd, the patients are just vascular, elderly, and they're just not simply able to perform at that high of a level. Of course, we have all of the patients that want to return to some form of ambulation and mobility, and even in the short term, I always say that being able to perform transfers so that you can do toileting is what gets people home. So we want to be able to have a solid management for bowel and bladder management and being able to do all of those types of transfers, the bed to the wheelchair and back and toilet transfers and bathing and then car transfers as well. We use a car transfer practice device for that. But if you don't happen to have one at your place, you can pull up a car and most of the time find some covered area in order to be able to do some of that practice. So we're, of course, working on balance, working on strengthening, working on endurance, working on flexibility, especially prevention of contractures at the hip and the knee are going to be a significant part of the rehabilitation interventions on the therapeutic side. So you're always trying to balance their therapeutic needs and their functional needs, especially in the first IPR stay, because you've got to get the patient functional enough to be able to return to community as a primary goal. In terms of, you know, and then there's, I think the most important point over here to the right side of the slides is just that practice over and over and over. An advantage of coming to the IPR location is that we get that 3-hour therapy guideline, and so we get a lot of opportunity for practice, practice, practice with patients. A typical length of stay for our program is 7 to 10 days. And so these patients are returning to home very quickly. And if we think about that first, the acute care length of stay being about five days and then another seven to 10 days and the patient is back to the community. We wanna give them information about a home exercise program and provide printed information so that they're able to follow that. And also an aspect of this is the opportunity to do therapeutic community outings. And it's not only for the physical issues in trying to deal with getting back into the community, but also the mental issues in getting back out in front of the public with an amputation status. And we try to help people get through both aspects of that. Over here on the left side, we're dealing, and this is just an example that I put in there of a common limb appearance early on if we haven't had some of the compressive dressings and we got a very bulbous limb here, it's gonna have to undergo a significant amount of shaping in order to eventually get on to prosthetic fitting. And of course, the opportunity to reduce the edema and encourage healing with that. Dealing with the contralateral foot, that's quite a challenge and we sometimes get surprises if you haven't seen the patient in the acute care hospital and you go in and do your initial exam and you find out they've got a significant problem on the other side with a plantar wound. And that can change your transfer methods very quickly. I happened to shift a patient from weight bearing on the contralateral side to non-weight bearing and all of the issues that come along with that. So managing the other foot, a lot of the patients, this is your chance to assess whether they have diabetic-associated polyneuropathy and specifically impaired plantar sensation with 10-gram monofilament testing. This can provide your justification for extra-depth diabetic shoes and for custom accommodative foot orthoses. So you want to make sure that you have that as part of your care for the patient in this environment. So from a nursing standpoint, I mentioned about CRRNs and wound nurses, but then that teaching of the patient for that independent management is very important. We also educate our nursing aides in a lot of detailed aspects of amputee patient care because they actually have more touch hours than anybody else does. The doctor makes the rounds, the therapists have their three hours, and then the RNs are in there, but the techs are the ones that are oftentimes having hands-on with the patients. So being able to carry over, for instance, transfer methods and the most independent way that a patient can perform transfers, and then being able to do that more on a 24-7 basis rather than just inside the realm of therapy can increase the number of practice opportunities for a patient to have a more independent type of transfer. Our case manager's critical, right? They're gonna be doing discharge planning, and that timeline is short, in seven to 10 days, to get somebody back to their home. Oftentimes, we're scrambling to get a ramp into a place and talking with patients about their insurance benefits, again, performing those therapeutic community outings, and sometimes using an overnight apartment that we have where we'll have the patient and family caregivers go into the apartment, and they're within the facility, but otherwise, we expect them to function independently and only call for help if needed. So a good luxury item that we have is that overnight apartment within the facility. With this community reentry, we wanna set up back with local providers for their primary care. We gotta set up home health, and that's going to include nursing and AIDS and therapy, outpatient therapy, transitions, or directly to outpatient therapy, and then arranging all of the patient's follow-ups. Just another case of limb edema as an example here. So challenges of managing that. I don't think Tracy would agree that we're not quite ready for prosthetic fitting with that limb shaping that we have there or with wound healing status. But the patients think they are. That they're ready to go, yeah, yeah. So other examples, things you have to watch for, wound margin necrosis in this case, and the patient in this case required a higher level of amputation. It just wasn't going to heal at this level. So being able to have the patient in a monitored environment, we were able to identify this, which actually happened in the course of 48 hours in this patient's case, and then get the patient back over for surgical evaluation. So talking a little bit more. Yeah, and this was not a staged event. I actually came down to the gym one day, and the patient, they were on the mat exercising and had this. I thought, well, that's a very creative way to look at your residual limb management. So let's talk about it just a little bit. I mentioned before BKA shrinkers and how we use those, but we tend to not transition to those until after we have sutures and staples out. And also, as you could see a couple of slides ago, if you're trying to get a uniform compressive shrinker on a limb that looks like that, we're going to have significant pressures over that bulbous end, perhaps creating too much pressure in a very critical area where the suture line is, and that may interfere with healing. So if we can individually wrap the patient with the figure-of-eight method and provide a pressure gradient for trying to get edema to resolve out of the distal limb to more proximal levels, then that's going to be much more customizable than a BKA shrinker can be. So an example here with our Manny the Mannequin, where we do teaching with our staff of the residual limb and a figure-of-eight, and then trying to avoid what happened on the right here, where a patient comes in and they're circumferentially wrapping the residual limb, and this patient actually, when we took it off, was quite bulbous and in no way ready to proceed with prosthetic fitting, even though the patient had reasonable healing of the primary incision line. Example here just of the BKA shrinker and what it should look like, and then the above-knee classic shrinker that has the waist belt. There are also single-layer shrinkers that have proximal silicone bands, and at times we'll use those if we have issues with roll-down in particular. Some patient that may have a very large thigh circumference compared to the knee circumference, the shrinkers like this would roll down on a patient, or if they have a little more girth up in the adductor region we'll use a gusset in that area, and that just allows more expansion in there and doesn't give too many skin pressures for the patient. I mentioned earlier the removable rigid dressing, an example here. Advantage of this is that the patient sort of has a prosthetic socket here, they're not weight-bearing in, but it does give them an opportunity, as the residual limb is typically going to be shrinking in volume, that they can add socks to that, and they can learn that sock-ply concept early on. You can start teaching how to put them on properly, how to do adjustments, try to keep the RRD snug to the residual limb, and be able to demonstrate that concept early on. Preprosthetic pain control, just to touch on that a little bit more, we talked about residual and phantom limb pain, and distinguishing that from phantom limb sensations, which we don't treat. So some patients will have only sensations that they're feeling, but the definition of phantom limb pain would be a sensation by the patient that is uncomfortable. And so crossing over that line from I feel my foot to I feel my foot and it's uncomfortable, I've got this numbness and tingling, or I've got these sharp shooting pains that are occurring, and distinguishing those is really important. So I don't treat phantom limb sensation, but we do treat phantom limb pain. Also the relationship between residual limb pain and phantom limb pain. Early on, you actually need to be more aggressive about treating residual limb pain as it can induce phantom limb pain. So there's that crossover between the two, and usually you're using a combination of opioids, and then you're using the typical medications that I'm not going to detail today due to time interests for phantom limb pain. Obviously classics of gabapentin, pregabalin would be high on that list. Spasms that are occurring in the patient too, and those oftentimes will need management. And so treatments are really different. So you've got to distinguish what these different types of pains and sensations are for the patient. Over here on the right side, a little bit more about non-pharmacologic management. And of course, advantage of that is that we don't have side effects of medications. And so we talked about the use of the ACE wrap and the shrinkers as compressive dressings. We use a lot of ice. Ice will really help us in terms of edema control as well, and visual imagery that we use with patients. Of course, there's mirror therapy out there, and our very practical mirror therapy that we do is one of those little behind the door mirrors and set it down between the patient's legs. And time and again, experientially, I'll tell you that it actually does reduce the patient's pain. And of course, it's something that they can do independently once they obtain an appropriate mirror. Getting it back over to where the patient is comfortable moving the residual limb on their own. They're afraid to move it initially, right? And so you got to get them comfortable being able to move their residual limb again, and such that they can stretch and exercise the residual limb in order to reduce pain. Occasionally, the use of TENS units, don't use them very often though. All right, back to what are we gonna do next with folks? We're trying to get them out of the inpatient rehab hospital. We're going into community re-entry then. And our goal number one is to try to get home discharge for patients. Sometimes, of course, they need to go to other levels of care and skilled nursing facilities and arranging the therapies and doing wound care. Sometimes patients are on IV antibiotics and we need to make arrangements to continue that and make sure that they have appropriate IV lines in place. Follow-ups with surgeons, follow-ups with infectious disease, follow-ups with primary providers so that they can initiate the general management of the patient once again. And so that the primary provider is actually aware that the patient has undergone this significant life event. Following up with the surgeon, of course, we want them to be okay and give that clearance okay to proceed with prosthetic fitting from their standpoint. Now, that may be a little bit different than are they okay from the physiatrist standpoint to initiate the prosthetic fitting and training. In other words, the weight bearing. And we wanna make sure that that wound has good primary closure or secondary closure before we initiate that process. So I know there are times when I'll be in clinic with Tracy and I'll say, it's okay to go a little slower on this one and give the patient just a little bit more time. They're obviously generally very excited about wanting to proceed with the prosthetic fitting and then the training and they'll come in and say, hey, the surgeon cleared me, so let's roll. And it's like, well, I'm glad they said those words, but I'm not comfortable as the ordering physician for the prosthesis that we're quite there yet. And so we may extend that process just a little bit for them. Some of the negative pressures and suture line strains don't really present as a pain response to the patient. So they go to try to put on a prosthetic and immediately we have some disruption and then steps backwards. That may sometimes get me a FaceTime call from Tracy where they'll be over in his office on a diagnostic test socket and he'll say, this happened. Okay, well, let's stop and send them back by. We'll get them some wound management materials and have them follow back up. But again, that's an open communication line that we can go back and forth on and have that good relationship to be able to discuss these issues in real time. Physiatry, of course, our amputee clinic follow-up. Letting people be aware of amputee support groups and the opportunities sometimes for peer counselors that you can have for your patients. Patients will get on social media. So that has, of course, the double-edged sword associated with that. At times it can be helpful to patients, but there's also opportunities for some misinformation that's out there. And so it's important if the patient brings up questions and relates it to items that they've read to kind of talk about, well, here's how it has worked in our experience and in our system. The Amputee Coalition of America, of course, you've gotta bring that up as a potential resource for patients that's out there as well. So now we've got a patient coming back to the amputee clinic and we, as a core, work in our system with having prosthetists present. And occasionally we'll have the therapist. We have the good fortune of having one of our therapy sites within the structure of the building. And so sometimes they can pop over and we can talk about issues with patients or vice versa. I go track them down over in the therapy gym and say, hey, what's going on here and there with the patient? What do you think about that? Same with the wound nurse. So our goal is to try to hit the patients at about four weeks. They usually have seen the surgeon and follow up in that time. We get an update on their wound status, look at any complications that they may have sustained. Again, hitting back on pain management. How are you doing? We should be ideally tapering away from opioids significantly at this point, but we usually are gonna keep phantom limb pain treatments that we've initiated going for several months once we've initiated that. I'll back up for a second and say, that discussion usually happened in the IPR realm. And we talk about once we start this, we're probably looking at three to six months of treatment and then tapering away medications. Residual limb management. So are we ready to make a switch, for instance, from a low tension figure of eight over to shrinkers if we haven't done so, or updating to a smaller shrinker from one that was larger because the patient has lost volume. We talked about sufficient healing, not in addition for, sorry, it's my daily medical director checkout. But do they have sufficient healing to be able to get into a prosthetic device yet and that shaping? This is where we're gonna go back to systems-based care also, and we're gonna talk about funding and those conversations occur sometimes outside the door, going in to see the patient and sometimes in with the patient and just dealing with the different challenges of that. The Medicare functional K levels I have on here, we don't wanna spend a lot of time on that today because we've got other priorities. And then talking with the patients about their training options. So whether we're going to go back to an inpatient rehab setting, whether the patient is in skilled and needs to stay in that setting, various outpatient training options that the patient may have. In our area, we have an outpatient facility that is, again, within our walls that has therapists that have a lot of expertise in amputee rehab. But if I go about 20 miles to the south, I don't have therapists that they may have never seen anybody that has an amputation and a prosthetic device and has no knowledge of being able to do that training. So challenges there in finding referral networks where you've got therapists that have education sufficient to be able to perform proper prosthetic training for patients. So just one of the systems issues that's out there. That first prosthesis we talked about and we'll just mention briefly K levels because there's a lot of references out there on that. And you have the slide if you need to look at that. We sometimes use the AmnoPro and because we've obtained that in the IPR setting, we try to do that before the patient discharges to home. And that gives us a baseline and really an objective justification, if you will, for a patient at a certain K level. There can be some caveats associated with the AmnoPro though and its predictive ability, but it is a somewhat evidence-based tool that is certainly out there and provides at least some objective data for you from which to make decisions about prosthetic componentry. We certainly wanna be talking to the patient about what are your vocational needs and interests? What are your avocational needs and interests? Around our area, we get a lot of hunting, fishing, wildlife out in the country folks. So we wanna be able to talk about those activities that they're doing and make sure that our prosthetic devices are going to be able to function not on that fresh carpet or linoleum surface that we've got out here that's nice and level, but for our patients that are out in rural areas and have special challenges, sometimes even just to get in and out of their homes as well. Surprisingly enough, Medicare has a special guideline that if the patient hasn't indicated that they have a desire to walk in your notes, then they aren't a candidate. Yeah, so making the simple statement, this patient we believe has the abilities and they've expressed a desire to use a prosthetic device. So that one flows out of me pretty automatically because that's certainly how it's dictated at whatever time in the evening when I'm trying to catch up on my notes. The prosthetic prescription though, what are the componentry specific items that we have? And certainly we wanna try to make sure that we've got the patient comfortable. We're gonna talk about adjustment features that we build into our devices because those inevitable limb volume and contour changes that occur with residual limbs. We also wanna make sure the patient is safe in the componentry that we order. And then we also are going to think about, the patient is at this point now, but we may have opportunities for advancement in componentry that might correlate with the patient's advancement and abilities as they continue to recover from the amputation. Here are the K levels and I'm just gonna skip right over it in the interest of time. You've got a reference there if you do need it and it's an easy one to pull up on the internet as well. So always think about the energy costs that are associated with the prosthetic devices and going to cardiovascular, cardiopulmonary needs that the patient will have. And when you lose these muscles, I try to talk to the patients and have our trainees and prosthetists and sometimes acute care providers like the surgeons say, we've lost muscles. We don't know where the position is of the limb, the residual limb in space. They don't have a sense of what the load is when they put weight on it. And so we have to use different measures in order to be able to reteach these that are automatically in our natural anatomy, but not when we have a prosthetic device. It's always going to be associated with an increase in energy costs for ambulation, right? And there are plenty of graphs that are out there that show board exams certainly that we will take or have taken, depending on where you're at in life, that are going to talk about those increases in energy expenditure based upon levels of amputation. So we talked about where should the patient go. I've mentioned some of these different venues that we have. Another function that the physiatrist performs for the patient's sake ultimately, but in working with the prosthetist, is the paperwork part and doing the medical justification for specific componentry. And that's going to make their job easier. They can't operate on an island. They have to have an order for all durable medical equipment, including prosthetic devices. And the more detail we can give them in terms of justification of specific componentry, the easier it is to get that componentry for the patient to punch it through the insurance justification needs. We also talk with the patients about working with a prosthetic and orthotic company. What's the one of your choice? And what are some features associated with the different companies? But ultimately, leaving that to a patient decision. But this is an opportunity to provide guidance for the patient when they have no idea. Many patients, you'll talk about this feature and that feature of a different prosthetic company. And they'll sit back and say, so what do you want me to do? And I say, actually, it's your decision. But this is why you might want to consider one company versus another. And some of that in our location is simply geography, where it is easier for patients to get follow-up care, such that they're not driving 80 or 100 miles in order to get care. But sometimes, it actually is worth driving 80 to 100 miles to get that care because of some difference that's associated with it. You want to talk about this a little bit? Yeah, especially for that initial training. Oftentimes, we'll see patients that are coming from several hours away. And they might have their initial prosthetic in the area where the therapists are most experienced. Some of what we do once the prosthetic is ordered, we'll go through our fitting procedures. And what you see here is a few different various diagnostic test sockets, where we fill them or adjust them and basically put that patient through the protocol to come up with the best prosthetic fit, all while we really are hoping to get your paperwork and the authorization, hopefully lands at the same time. And if done well, some facilities that you might work with might begin right away in doing diagnostic testing. Some might say, I need all your paperwork, and we need authorization. And so depending on where you go and the facilities you work with, there's a protocol there as well. Typical timeline, three to six weeks, somewhere in there? Yeah. There's a typical timeline for all of that to occur. So also an opportunity for further healing to occur while you're in this waiting process. And I think the biggest thing is probably the initial volume measurements that you take, which is really more, and we're going to show what the technology looks like for that, but a CAD CAM measurement that is done. But getting into a diagnostic test socket is the time when the patient's going to be putting weight on the residual limb and stressing the areas of the primary incision line or other skin-sensitive areas that they may have on the residual limb. So when we do bring patients back in our system for inpatient prosthetic training, so this is back at the inpatient rehabilitation hospital, we initiate that therapy on the date of admission. So I have a little deal cooked up with the admissions office and with the therapy teams that we want to get the patient in before they have lunch. We want to get them admitted, and then we initiate our therapy that afternoon. So the patient, we try to say, hits the ground running, but more like walking with this. And bringing speech back into the picture if we do have cognitive concerns. Not to be overlooked is the medical management of the patient in the prosthetic phase of training. Yes, they've been at home. Yes, they've been self-managing back with their general health, including oftentimes their diabetic care. But what happens often is as we increase our training with the prosthetic device and the energy demands that are necessary for ambulation with below and above knee prosthetic devices, we actually tend to see blood sugars drop. So we're often reducing medications for patients as they undergo their prosthetic training. So hypoglycemia is actually something that you're often dealing with, as opposed to many times in the pre-prosthetic phase, you may be having to deal with hyperglycemia with patients. So we do, of course, that gait training, picking out appropriate assistive devices and advancing through those as indicated. Most people starting out in the parallel bars and on a front wheeled walker, many advancing to single and bilateral forearm crutches, sometimes a quad cane, sometimes a single point cane, or no assistive device, depending upon their physical abilities as they go through the training time. Additionally with that, we've got to do very close skin monitoring because we've got the pressure of the prosthetic device on oftentimes very fragile skin status that patients have. And we try to teach the patient as we're going along to look for increased skin pressures, whether those be positive pressures or negative pressures. And I'll show you examples here in just a minute. And what to do with those when you see them early on, such that they not become more profound, and thus maybe even get to the point where we have to stop training. In terms of the prosthesis itself, the prosthetist has them in. They do a bench alignment. And of course, they do the final fitting. But we find oftentimes that patients are going to need close follow-ups as they're rapidly undergoing limb volume changes. And we need to make adjustments for both fit and for alignment with the patients. We not only, of course, are working on basic self-care, but this is a great opportunity for OT to work on IADLs. So getting patients back into the kitchen, back out, maybe even outside if they're wanting to do activities that would be associated with being outdoors, and getting them as quickly as possible. Therapeutic community outings, going out into the world while ambulating now would be the big difference and change for a patient. And then we often do an ampro for the patient at the time of discharge, although it is very early on in order to make a justification for their K level. We can also follow that up as an outpatient if we need to do so. It's a chance to revisit with the psychologist regarding adjustment and mood, a chance to revisit with case management and demonstrate and go ahead and set up their community re-entry needs. Are they going to go to home health or back to outpatient? And what needs they have for that. Our usual length of stay, I think when I did this slide, 10 to 14 days, I'd probably snip it off a little bit more now. We're usually getting our insurance friends to close us down around 10 to 12 days on this. And even the Medicare length of stay is shrinking when we do our estimated length of stays with comorbidities at the time of admission. So residual limb management, we want to have patients taking on that in a different way with the prosthesis, donning and doffing the device, doing it over and over and over. Lots of practice, lots of adjustments with the sock ply so that patients understand when it feels like this, this is the adjustment that I make. And empowering the patient, educating the patient to act early. It's when to do something with the prosthetic adjustment. And the answer is always early if you think something is going on. Over and over, I see patients in the subacute and chronic phase. The time they get into trouble with residual limb wounds is when they knew something was off in their fit, but they didn't take the time to stop and make an adjustment. And so you just want to emphasize with them, stop and make that adjustment when you have a need. Excuse me. Being very preventive instead of reactive, of course, with that. Our goal is to try to get a patient up to about six hours of wearing time before they discharge at least. Just some examples of prosthetic componentry here. Most important item on that. I want to talk about the long-handled mirror. So that gives them the ability to inspect the end of the residual limb and also to inspect the other foot, oftentimes with diabetes, that being critical for their management. And then on this page, I think the most important item I wanted to show was the alcohol spray bottle, such as the patient could clean their gel liners and ensure that they're keeping bacterial and fungal counts down in those gel liners and external gel sleeves that are commonly using. And keeping those clean such the patient not get dermatologic complications. Talking about that other foot now and remembering that we've got so many patients with the neuropathic foot with either current or older scars from pressure wounds that they have had and dealing with the challenges of that. Of course, these patients wouldn't be considered ready for prosthetic training because they have too many contralateral foot problems. Then after we're discharging the patients, we've got to have follow-up in the amputee clinic. And this is where we get into challenges. And I think we'll show with some cases about prosthetic fit and alignment adjustments that you need to make as people mature with their residual limbs and as their abilities advance. We still follow up with those touches. Now we're talking about weaning away pain medications once again. PTSD, depression, anxiety, and adjustment issues, we want to touch on those again. Those further therapy needs as they've transitioned back to the community and how long those need to continue. And oftentimes, just visits, check-ins with the prosthetist between appointments. They're at the amputee clinic with us, but then they're also going to their office and making adjustments in between our appointments together. Then, of course, ultimately, decision-making about refit and adjustments. Or do we need to move on to a next socket or prosthetic device based upon the patient's status? Continuing with that other foot diabetic management to reduce that 550 terrible statistic about losing the other limb within five years. Addressing vocational needs, avocational needs, return to driving, work comp, voc rehab. Those are all issues that fall into the PM&R realm. So our intervals for follow-up vary. Usually, four to six weeks is that typical first follow-up. Usually, every two months for the first six months as a general rule. If patients have that diabetic profile, we're going to see them twice a year in the chronic phase. And this is down the road, even years. In the trauma profile, a little bit more lax with that. We'll say, call us if you need us. Oftentimes, an interval is nine to 12 months on that. And really, we're looking at the need to come back. One of those big needs is just making sure that their componentry and supplies stay up, the gel liners that wear out, and the sock ply that they need, et cetera. Also, offering to the patient and just confirming with them, hey, we're here for you for a lifelong follow-up. So we're here as long as you're interested in using the prosthetic device, and we're going to work together with you for as long as you have those needs. When we talk about these prosthetic adjustments, we'll start getting into some of that a little bit more here. Examples, a lot of adjustments made here with additions to a soft insert. One of my former trainees holding, I think he was holding 26 ply of socks in this patient's case. And so quite a few limb volume changes. Commonly, the use of lambswool pads that are placed inside of the soft inserts that we like to use inside of hard sockets, especially for first devices. And these are the common areas. You can Google pressure-sensitive and tolerant areas and get a nice little diagram that shows you where you should put pressure on a residual limb for below knee and where you should not. And this is just an example of real-world changes that occurred on a soft insert. More examples here. More examples here, though we prefer an above knee to put these pads between the flex liner and the hard socket. When we're following up with patients, we're also looking for wear. This person had a lot of work down on their knees and chewed up the front end of their socket. And actually, it was a very unstable socket and required socket replacement. And then patients that come in, this is a little too late to come in, in my opinion. We would like to see them well before showing up with a gel liner that looks like this. Letting patients express themselves, they often like to. So there's the artistic flair that Tracy gets to enjoy as part of his job. We do a lot of Chiefs gear these days in Missouri for patients that are Chiefs fans. We'll see how that goes. I guess we're going to have Taylor Swift ones. I bet anyway. But examples of dermatologic complications here, this example of positive pressure issue, so too much pressure at the distal residual limb. A bursa that develops when we actually have lack of consistent contact at the distal residual limb on a BK patient. Here's a patient. And this is really more of a post-operative. You can see all of the edema and the shaping needs the patient has. But I was talking about blisters and bullae that develop earlier. So oftentimes, in a prosthetic device, though, a blistering is an indication of lack of contact. And this is the complication that the patient will get. So they're actually not making contact at the distal end with the skin close enough to the socket. One of my most unique cases here was a patient that showed up with a nice combination of a raging tinea corporis infection here, some satellite lesions that were present here, and then a nice area of cellulitis and folliculitis. So he kind of cashed out everything in one visit right there. So that was some complex management with antifungals, antibacterials, and a good talking to about making sure he was cleaning his gel liners with alcohol. Implications of not making contact over time, the choke phenomenon that can happen, bursa and blisters, but then changes that happen in the skin. And this is Verrucas hyperplasia that occurs with patients. And it increases the chances that they will have residual limb wounds when you have that. So when we're dealing with wound management with patients, a primary issue is, hey, do you keep in it or do you try to get out of it? And I'll tell you, a very hard thing to do is that negotiation of trying to get the patient to not wear the prosthetic device. And usually, you're going to lose that argument. And you can't actually keep the device for them because they own it once it's delivered to them. But why did it happen? Was there a volume loss that happened or a shape change that created an abnormal pressure, positive or negative for us? Was there a fit issue in those terms? Or is there an alignment cause? Do we need to adjust their prosthetic alignment? And then dealing, of course, with, hey, what dressing would we put on this for management and to nurture wound healing? And more often than not, these patients do not have an infection associated with a wound from the prosthetic device, but they need to be watching for signs and symptoms of infection. So you want to educate them on that and making sure that they follow up with you immediately or with a local provider if they would sustain signs and symptoms of infection. Going to switch gears again here and talk about gait and deviations a little bit. If you guys notice, some pretty extreme pieces and parts here, oftentimes we are explaining to the patients that the proper dynamic alignment is more vital than just the static position. So if you guys see where the offset is there, somebody with a really wide base gait might need component offset. And sometimes you have to explain to them why these pieces and positions are in that fashion. You'll see some internal rotation on the slide on the right. And it's compensating for what may or may not be there at the hip. So aesthetically, this looks way off. But biomechanically, this patient was actually very well aligned and had an excellent gait pattern. So you have to educate the patient as to, well, why is my pylon way over here with an offset plate when my residual limb is here? And so just an opportunity to educate. I know if you have to, you can always try to do some cover up with a nice protective, not cosmetic, cover in terms of semantics. This was just thrown in here. When I'm thinking about looking at that alignment with the patient, it goes back to, and I use the determinants of gait from Inman very commonly, just qualitative gait analysis when the patient is in the clinic, usually keeping these items in mind. And with a prosthetic device, what is unique is if I've got a prosthetist there and they're good at turning a wrench, we can actually adjust somebody immediately on the spot, oftentimes, and make a significant improvement in their gait pattern. Example, for instance, if a patient is walking with an abducted gait here, and there are the classic gait deviations, and in the books and the sites that are out there, you can look at prosthetic causes and amputee causes of these gait deviations, but usually you see a list like this, so then it's, okay, I see an abnormality of gait, what could be the etiology of this, and what are we going to go do about that? Switching gears again here, just talking about how you can build an amputee program, and this is just on the inpatient side, that when this was early in my practice, and with our amputee program back in the year 2006, we admitted 32 patients with pre-prosthetic and prosthetic training needs. This last year, you can see we've advanced to 158 with that. So it is an opportunity to get in there and develop a program, and again this is just on the inpatient rehab side, the numbers are really quite large for us in terms of our amputee clinic. We actually have three providers, three prosthetic companies, and we're seeing over 700 patients a year with amputation needs. Interestingly, you know, there's not a lot of inpatient that is going, that's changing out there in inpatient rehab hospitals in the nation. If we look all the way back to 2006, remember that slide I had where we talked about the doubling of the incidence of limb amputation, but in this case, we're seeing in inpatient rehab 13,000 in 2006, 16,000 in 22. So not a lot of inpatient rehab hospitals are admitting rehab patients, and we're not seeing that correlation between the increase in the incidence of amputation and the number of patients that are admitted to inpatient rehab hospitals. Just threw this in here for coping and adjustment, find it very interesting that a lot of patients get tattoos that they like to show off a little bit about their amputation. And in terms of life, you know, things that happen with patients, the patient we share that, you know, went on to, she had a traumatic amputation, very proximal level here at transhumeral. She's a medical assistant, works in an OBGYN's office and helps with procedures. She got married and she's got two children and adjustment in life has just been fun to watch as she's gone on in life from a difficult early in life situation to what she's been able to accomplish. I had to throw this in there because this happened at Halloween. So I had clinic that day, I walk in the room and one of my patients looked like this. So it's just, hey, you get relationships going with patients. And he was just, he was very happy with his prosthetic device that day. We had put him in a new one and he had a good outcome. But I walked in the room and this is what met me. So you can certainly have those long term relationships with patients. So switching gears. Yeah, go ahead. You don't get on time, just a little bit. Yeah, we're getting close. So I was going to try to buzz through a few cases here and talk about these. So our case study number one, traumatic multi-limb amputation that occurred, 37 year old guy and he was in a high speed motorcycle accident, multi-limb trauma. He had above elbow amputation, below knee amputation, both on the left side. He had a hip fracture and pelvic fracture on the left side. And we went to early prosthetic fitting with him as early as we could considering all of the soft tissue injuries that he had. So our challenge in this case, and I'll show you why, was after we got him up ambulating, even though they had performed an operative repair on his acetabulum, he had difficulties with his femoral head and with his hip joint and required actually further surgery for that. This is what he looked like when we started. This was a trauma picture that they had and ultimately they performed a skin graft for this. And this is his left side where he had the below knee amputation. When he came to inpatient rehab, we had the patient, so he had the left BKA and the left transhumeral amputation. And then this was his right hand. And so he had K wires in a couple of his fingers here. So he had very limited weight bearing that he could do with the hand and really just mostly use of it. And then his right lower limb, he was actually able to use. So this was the area where ultimately they had performed a skin graft. And he really did later on demonstrate good healing. So we were able at this point to proceed with prosthetic fitting what we started that training program. And as I said, he was having significant pain. This is not a guy who complains about pain. He was able to, even though he was just about four limbs out here. Sorry, this thing is trying to go backwards and it doesn't. It only wants to get on to five o'clock. So, but he went home with all of this and all of the limitations that he had and was actually able to live at home with help, but using a power chair. When we brought him back in for his prosthetic training, this hip was so painful. We actually had to stop and he had to go get this. So we had difficulties in dealing with that hip and underwent a hemiarthroplasty, an example of his upper limb body powered prosthesis here. In his lower limb, you can still see he was very excited about his motorcycle still. We had to put some extra features in there, such as these donning straps, made it easier for him to do management of the soft insert for his prosthesis with just one hand. OK, talk about his limb volume a little bit. Let's see what we got here. A little bit, a little bit of bulbous at the distal end for sure. To the left of the slide, you'll see where the the graft originally around the patella area was was pretty inflated. And then as we move forward into the overlay, you'll see to the right the mid and circumferential reduction. And so with these digital assessment tools, we can catch people's limb volume early on and then we can I'll report back to the clinic. Hey, these are the changes we have. This is the actual real time limb volume today. Helps us a ton on adjusting before bad things happen and then also justifying the future. Any changes in the prosthetic and if you see at this point, distal end is still pretty filled out. And then we'll also be able to actually get what is super beneficial for us is an actual liters of volume. So I can basically tell you this is the actual liters of volume, not just a generic ply change fit. And if you're getting this data, it really helps in justifying future refits. Super great cross section here to the right side. What you'll notice is that we spend a lot of time with prosthetics adding socks. You all see it all the time in the clinics. Only what you see on the right is an actual shape change, not just a volume change. And so the triangulation maturation of the limb and also the distal gapping that is shown, that would be what we'd throw silicone distal end pads, lambs wool, anything we can to fill that space to prevent negative pressure. And then what we'll do, this is jumping to the left upper upper extremity. And what we see here is a basis of pre-fitting volume and it basically captures the number and again, a starting point. And this moves on to some ridiculous distal edema reduction and maturation. And then what we also notice on the right, I find it pretty fascinating and I know this is geeking out on the CAD, but the program shows me an ML change, but not an AP change, which means getting him into a prosthetic fast, getting him through the prosthetic clinics and getting him to physiatry, we actually have less of a reduction of the bicep and tricep AP dimension over the early therapy stint. And just for fun. This is, is this day two or day three? Day two, yeah. He's already writing his last name. He's pretty good with a prosthetic device right off the bat. He was disappointed in his calligraphy here, but I was pretty impressed with his ability to do that. And, you know, for the things that we want to return people to, yes, that's his left above elbow prosthetic on that side. It doesn't control any active acceleration or braking, but getting him back to what he wants to do, super important. Activities. So we'll go over a couple more cases here. I'm going to skip over one of them in the middle, but say case study number two, a 22 year old had a motor vehicle accident here and sustained a very severe traumatic brain injury, but also a right below knee amputation, a right femur fracture. Interestingly, he had a caudal regression syndrome, obviously congenital. So his baseline status was ambulation with bilateral AFOs and intermittently with one or two loft strand forearm crutches. So our challenges that we dealt with were his previous gait pattern because he did not have the normal gait pattern even prior to these severe injuries. With his TBI, I think his management method for anything that felt off in his prosthesis was add a sock, add a sock, add a sock. And so it would be not unusual, Trace, how many? My probably several appointments that he'd show up in 15 ply of sock, the prosthetic is too tall, my condyles hurt and I'd take him down to five ply of sock and everything was all good. So his swing on a typical follow up appointment was 15 down to five ply with that. And so we tried to do a lot of education with that, but it was an extra challenge. Tried to incorporate his family in on management with that as well. So this is what his limb volumes did look like, though, over time. And this was his admission to inpatient rehab about a month later, had significant healing that had occurred along his primary incision line, which actually was very good right off the bat. And this was his status at initial fitting in December of 22. If we look in October of this year, though, and I should have put these maybe on the same page, you can see some slight immediate recognition changes in limb volume. So he had some massive limb volume reduction in the first 10 months of wearing the prosthetic device. Can you guys see the various distal maturation? And so having these overlaid, which is kind of nice, you can see at the lower slide, we have a pretty big, significant, probably 0.5 centimeter reduction distally. And then the nice thing about the digital mapping is we can basically follow it during the fitting. We can do, they come to the clinic and we have these reports. And then we can basically, the patient's adding socks, adding socks. And at one time, it's more than just a volume of reported in sock ply. Other challenges? Yes. Longitudinally. So here, what we've got is, yes, after all the good work and all the ambulatory management of how to add socks and change socks, and then he gets, because there's, you're not going to hold up harvest season, sets in a combine. So this is actually a setting pressure at the distal anterior tibia, a little bit of maybe folliculitis that then was pressure aggravated. And so the fix to that isn't necessarily change the prosthetic as I normally do, is to look at the... Spend 12 hours in the combine. So where the person actually sits in a pretty deep squat in the positioning in a combine. So put a lot of pressure over the distal anterior tibial end. Dynamically, what we see here is a pretty vertical prosthetic, surprisingly, and a lot of compensatory things that have always happened over his whole life on the left side. We have a clip. Yeah, we'll show that. So you can imagine what his contralateral foot was prior to the amputation. You see. We don't really have that limb and the AFO that he used for that. Notice how we had to align the prosthetic device. Yeah, we don't really even have a acceleration on either side now. The non-work prosthetic foot that's just reactionary and AFO that's really limiting plantar flexion on the left as well. So some compensatory circumduction. Definitely the trundelenburg. But he gets back to life and he does these hunting events with a hunting dog and they go out into fields and the dogs are retrievers and he's able to get back to that activity, which he enjoyed doing before he had the amputation and the brain injury. So ultimately, we feel pretty good about that aspect of his outcome. Right. I think we have time. We'll do one more here and then let you guys get out of here. I understand we got a little late start, but 68 year old. Our challenge here is this patient had amputation six weeks prior to coming to IPR, but the complication of morbid obesity. So our challenge was a very bulbous limb and extreme reductions that the patient had in residual limb that was associated with her baseline. And you want to talk about these sockets, what's typical and what her case was here. Couple examples of some of our other patients and their volume and size upon admission versus her prosthetic on admission. And so definitely we are expecting some massive reduction. So the pre-planning that it takes in clinic and prosthetically to either order the proper device that's really adjustable. And in this case, we had a ridiculous amount of adjustment in just five days of IPR. So you can see a lot of pads that were placed on the patient's soft insert here for limb volume reductions. And if I'm counting right, that's 14 ply of socks within about five days of admission and it really initiating ambulation with prosthetic training. Of course, you know, her original appearance was this and this was the size of her residual limb, you know, about ultimately over two months out. She had some nice improvement in the following couple of months down to this volume, but you can see it was still quite large. But eventually we had sufficient healing here and we did about everything we could for residual limb volume management up here. And so we went ahead and we've got to go ahead and initiate prosthesis for her. And with the with the stats on this, we've seen enough patients come in with socks. So from this slide to the next, we probably have volume measurement that would equal at 0.4 millimeters per ply, somewhere in the near 50 ply of sock. So how many legs should have she had? But because we pre-planned allowing inserts to go into inserts, thicker gel liners to be added, and then just multiple, multiple pads until we lost containment eventually and we'll have to go to a smaller interface overall. And this is her. This is her second socket, actually. But she did like sunflowers. So but the good news about this patient is she ultimately, even though we had to go to a second socket, actually, and I'll just say we made one in a hurry. These guys did a 48 hour turnaround on a socket replacement and which was generous. And she was able to go ahead and do her training and was able to return back to home and live independently by herself. So good outcome with that. So, all right. I think we're going to get you guys on with life here. So we'll skip over some other case presentations that we had here. But I want to leave you with a good parting thought at least. Thank you. Happy holidays. Questions. Happy to entertain questions. Are those your heels? Not my, not my shoes. Thank you for a great presentation. Thank you. I was curious to tap into your experience and knowledge regarding desensitization and when you would implement that specifically mirror therapy. You know, really ASAP in our system, we've got that advantage of getting the patients, you know, as soon as post-op day six over to the inpatient rehab environment. So, you know, the forms of desensitization, you know, that can vary quite a bit. But we really want the patient to get some of those dressings off and begin touching their residual limb. It's not only to be able to have the physical sensations occurring there, but also the patient adjusting to this is what my leg looks like now and being able to have that adjustment from a.

amputation

physiatrists

pain management

residual limb management

patient education

prosthetists

compression dressings

follow-up care

therapy

functional outcomes

community re-entry

mirror therapy