Melanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole, and joining me today is Dr. Conley Carr. He's a specialist in physical medicine and rehabilitation, an assistant professor, the medical director of orthotics and prosthetics, and the director of the Spain Rehabilitation Center, amputee Clinic at UAB Medicine. He's here to highlight early rehabilitation management of lower extremity amputees. Dr. Carr, it's a pleasure to have you join us today. I'd like you to start by speaking about the prevalence of amputation in the patient population and what conditions generally require a patient to have an amputation, whether it's elective or traumatic.

Dr Conley Carr: So, just talking about the types of patients that may require, amputations. There's quite a bit. I mean, some of them are obvious, traumatic, from car accidents, motor vehicle accidents, any type of situation like that can even be something more mild, but ends up with some type of vascular injury that, ends up causing, an ischemic limb that requires an amputation. But, aside from trauma, there's other things that people don't commonly think about as much, you've got cancer, that can happen anywhere and, potentially require, an amputation to remove that tissue. You've also got, patients that are born with, congenital, situations where, they may be born without a leg or with a shortened leg or various abnormalities.

And so, that's another type. And then you've got, diabetes and peripheral vascular disease. A lot of those are, overlapping because you have, somebody with each of these conditions and a lot of times they're overlapping. So, it's hard to always tease apart whether it's specifically vascular or diabetic related. But that is the vast majority of patients and probably more like 70. 75%, are related, as far as the lower extremity, from peripheral vascular disease and diabetes. So those are the main types of, etiologies for amputation. Again, PVD, peripheral vascular disease, diabetes, 70, 75%.

Trauma, the next most common, and this is just, incidents, and then you have, cancer and congenital, much lower, just a few percent each. and so those are the type of patients that I work with, on an everyday basis.

Melanie Cole (Host): Well, thank you for that. And we are learning so much more about diabetes and amputation and limb salvage, but that's for another show. So is there an established protocol, Dr. Carr, that outlines the steps to be followed in individual's? With lower extremity amputation that can be used by your colleagues who have difficulties in using an approach, an appropriate approach due to lack of experience because not everybody is a specialist as you are.

Dr Conley Carr: That's true. There's not an exact protocol. However, there are groups getting together to, design protocols for different groups. And, I work very closely with the vascular surgery team. And we've implemented, an ERAS program, that most people have heard of ERAS these days. Enhanced recovery after surgery. Were essentially, you try to protocolize everything in the, pre peri and postoperative timeframes, and try to, basically. take care of the patients all similarly and in the best possible way that you can. And so that would include, proper pain management, proper surgical techniques, sterilization, techniques, getting nurses on the same page, as far as taking care of the patients and managing pain.

Getting therapy involved early so that patients are, starting to work with them, rather than staying in the bed and getting more deconditioned. So it's really just, it's something that we developed, in. . and once we have some of the results of how it's doing, you know, that's something down the road that hopefully we could publish and show that hey, this is something that we can push out to folks across other areas of the country and even beyond.

Melanie Cole (Host): I'm so glad you brought up ERAS, because that kind of generated protocol for the prehab planning as you discussed, and discharge planning because there's so much more that goes into it with the psychological planning, the potential of the patient to adapt to the rehabilitation program. at home. Can you tell us just a little bit, just expand a little bit Dr. Carr, on really what's involved because it is so complex and comprehensive? And there are so many factors of a multidisciplinary approach to everything from planning at home and support services and staff and supportive family, all of it plus work.

You know, there's a lot that goes into it. Can you just give us a little bit of a rundown? It's a lot for one podcast, but just a little bit of a rundown on what's involved in that. And we're gonna get to pain management on its own question. So just the other stuff.

Dr Conley Carr: Certainly it's a team approach and I try to educate patients, throughout our hospital to get me involved early too. Because no way that patients outside of my field are really gonna be able to, one, have the time where they can go over all the details about, recovery timeframe, timeline towards being able to get a prosthesis. How the wound heals, how long it takes to actually learn how to use a prosthesis, what type of therapy you need. So I do encourage, folks at UAB to get me involved, earlier, even involved in the clinic scenario. So if they know that something is not an emergency and it's a planned situation, surgeons are starting to realize that, hey, we can get them into, Dr. Carr's, pre amputation counseling clinic where we look at how they're functioning now, what is coming up, what type of surgery they're gonna have, what level of amputation they're gonna have.

And we try to predict just based on them, kind of explaining how much help they're needing now of where we think they can get to if they have amputation. A lot of people that I see the balls in their court. They've had multiple surgeries, and they can keep trying surgeries. They can, but they're struggling. They're having problems, walking because of pain, and they're looking for, a solution or at least something that can allow them to move on, obviously with an adjusted life and changes. But, a lot of these patients, they don't know what it's gonna be like to have an amputation.

How that's gonna work. Are they ever gonna be able to walk again? And so having someone with my expertise where I can sort of look at the big picture and give them, maybe not. A hundred percent accurate, but, but a very, educated prognostication of where I think that they'll end up. It helps them make a much better decision. And then I can also talk to 'em about the different things like pain and, wound healing and that kind of thing. But it's a comprehensive approach. I think, sometimes I can recognize early that psychologically someone's gonna need more assistance. And so of course we have, rehab psychologists that we can get involved before surgery, after surgery, while they're in the hospital still and beyond. so certainly, psychology's a big resource.

I do some basic, medication management for depression and adjustment and that kind of thing, so I do some, but if it gets more complicated, it certainly we'll get, psychiatrists on board and things like that. And most everybody's gonna have some adjustment to the new them, the new way of doing things, And so that's always something that I'm asking about. And not every patient is agreeable to some kind of counseling, but I think it's at least worthwhile to let them know that it's available if they feel like they're someone that would benefit from it.

In addition to the counseling and psychologic management. , therapists are huge physical therapists, occupational therapists, even speech therapists in certain scenarios if they've got preexisting conditions and just working as a team in the early period, the acute period, working towards just getting them independent and at a household level. So it's not, getting all the way out into the community necessarily, but we're just focusing on can they move around the bed? Can they sit up for prolonged periods of time? Can they transfer? Can they get from point A to point B, by, using their other leg, their sound leg, if they have just a unilateral amputation to kind of pivot over?

For some patients there are special cases. They might now be a bilateral amputee where they don't have legs that they can pivot off of. They might have other ways, where they're using their upper body just to kind of push themselves over. They might use a sliding board, but getting therapy involved to prevent down from getting deconditioned while we're working on pain management. Some patients are already very deconditioned even coming in, so we gotta try to help get them beyond where they were. And for some patients, some patients are very low level. And so then we're doing a lot of education and trying to help families learn how to take care of their loved ones.

So, there's a wide variety of patients that we take care of. Some that were previously a hundred percent independent, and then there's other people that you're more in a palliative role where you're trying to help live a longer life, say they've got an infection and, they're not mobile, but they're still of sound, mine and, having a good life and, able to enjoy time with family. So there's all different types and my job is to kind of tease out what is going to be the safest way of them getting around. and really my goal is to help improve the quality of life for these patients.

Melanie Cole (Host): Certainly is a multidisciplinary approach and complex, and we've mentioned pain management a few times. Can you just speak to other providers because we have, you know, so much more that we have learned about opioids and multimodal approaches, and can you tell us how pain is handled in the acute and chronic amputee?

Dr Conley Carr: So early on there're traditional medicines that we always talk about. But one thing that really has been something that we have implemented over the last, I would say, three to four years and this is, something that had been discussed in the past, but not really used, on a regular basis, but it's actually getting anesthesia involved, before surgery and placing, peripheral nerve catheters. So essentially they're doing, ultrasound guided approaches, finding the nerves that are near the areas, or proximal to the areas that they're gonna amputate. They put a catheter in there or essentially hook them up to a patient controlled anesthesia where, where it will, drip, local anesthetic and then the patient can also kind of add, bonus, through the pca.

But given that local anesthetic that drips in or around the areas that were, the nerves that were involved, has been. Extremely helpful. has also allowed patients to wean themselves off of those narcotics that obviously can be habit forming and cause, many other issues, long term by, staying on those. So, that has been a huge help. And something that's part of our, ERAS protocol with vascular surgery hasn't been initiated with, all the surgical services, but, it started with vascular surgery and some of the other surgical specialties, they don't necessarily follow ERAS, but, many of them are actually starting to get anesthesia involved to help patients with these, catheters as long as they're, appropriate.

So that's been the big game changer that has really helped patients. I've gone to seeing patients that are postoperative day number one from surgery, and they're smiling at you. I mean, you just had your leg taken off and it's amazing the differences in how, pain is managed just really over the last three or four years here at UAB. So that's huge. And then of course there's plenty of other medicines that we use. We do use some narcotics and we try to wean those off pretty quickly, for certain patient groups, we'll do Gabapentin or, pregabalin, nerve membrane stabilizers that can help with phantom pain. We'll do some alternative approaches.

There's, mirror therapy that we sometimes use, and you could do a whole podcast on mirror therapy if you wanted to. But in brief we're putting a mirror in front of them or in between the area that has been amputated and they're using that mirrored surface to essentially make their leg, show up on the other side. So it kind of makes it look like they have two sound limbs. And, by doing that technique and doing exercises and things that's been shown in some patients, not every patient to help with that phantom pain. So you've got really three types of pain that you're targeting. You're targeting phantom pain if they have it, you're targeting what we call residual limb pain, which is basically any pain that's on the tissues or the bones themselves.

And then you can have neuropathic pain, which is nerve related pain. So you really got those three types and a lot of the medicines sort of hit more than one of those. But really you want to tease out from the patients what type of pain they're having so you can really what you need to help them. There's also different massaging and, and desensitization techniques that we get the therapist to teach them and those could be helpful as well. But really what works for one patient may not work for the next patient. So you kind of have to explore, what's worked for patients in the past. And, if they haven't had any situations like this, then you kind of start from scratch and just try some things and if they don't work, then you move on to the next strategies.

But as with any pain management, there are, millions of different approaches of how you can manage it between medicines and, Psychological counseling and cognitive behavioral therapy and things like that. So, a little bit of everything. and a lot of those things kind of transition to the chronic phase two. A lot of those things can be done on a chronic basis and kind of something akin to the peripheral nerve catheters. You could actually do a peripheral nerve stimulator on the outpatient basis that it's kind of like a patch or something that patients will wear that kind of gives a numbing sensation, all the same medicines, Adjusting dosages and things like that. There's some antidepressants that can help with pain as well. People can try tens unit, they can try, acupuncture, some of those things can help too.

But really, you just don't know on every single patient what's gonna be perfect. So you kind of work with the patient and make adjustments to the plan, to see if you can get them, improving. And the good news is that the research shows that 90 to 95% of patients are going to get better, even without treatment. I kind of tell patients that a lot of these things are kind of like band-aids or bandages that kind of help while their brain is adjusting to what's happened. Now there are a few that are really cutting edge things as well that are starting to help. And those are actually, like surgical approaches where, instead of, just doing the amputation and hiding the nerves, inside the muscle bellies, they're actually rerouting nerves and connecting 'em to other nerves and that has been shown to be really promising.

We do have some surgeons here, they're starting to do that approach, primarily like on the first amputation, and then some are doing it, later on as revision. So that's an extra thing for either acute or chronic, types of pain that can help as well. And we're learning more and more about that all the time. And the research and literature for those, new types of procedures is really exciting.

Melanie Cole (Host): Well, it is an exciting time in your field, Dr. Carr, and this is such an interesting topic we're discussing. As we wrap up, I'd like you to speak to other providers about what you would like them to know about this unique rehabilitation situation. Because you've already mentioned that you would like early referral and why that's so important when they're counseling their patients about how long they can to stay in the hospital or some common issues when they start to obtain their prosthesis. I'd like you to just briefly summarize for other providers that are counseling their patients as to what they can expect from the specialists at UAB Medicine?

Dr Conley Carr: Yeah, I think you know, the best thing teach patients, I give them a timeline. That's really my big thing is looking at their situation. I kind of break them up into the traumatic and then everything else, and everything else being most likely the peripheral vascular disease, diabetic population. And I like to tell patients that, on the traumatic side, they're gonna heal faster. They're gonna heal on the four to six week range. I like to tell the patients that, Hey, even though you're healing, you don't have to stay in the hospital that entire time, you can learn how to get around on your sound side.

So, Just while you're waiting on the healing doesn't mean you're stuck in the bed, stuck in the hospital. we like to provide education that, hey, you'll be in the hospital for probably, four to seven days. Just depending on the situation. Some people might need to go to an inpatient rehab or a skilled nursing facility, basically an in-house therapy situation. That's another reason why my team is consulted to kind of help, figure out a plan for these patients. That may or may not need, some type of in-house therapy. And patients that end up not going to in-house therapy. They might go home with therapy coming out to the house. They might do outpatient therapy. But generally, the goals during that period of time are to, protect the limb are to prevent contracture. So that, would be detrimental to being able to use a prosthesis if they kind of keep their knee bent or they keep their legs, in positions that set themselves up for problems using the prosthesis.

So we like to keep the therapy going as much as we can, or at least have them enough education where they know how to do things to prevent these joints from, getting contracted And so, that's part of it. And then, the four to six week mark is what really what I tell the traumatic as far as our average towards being able to build a prosthesis. Prosthetic build time is typically gonna be about a month. So I usually tell them, it's about two, two to three months, before they're gonna be walking again essentially. And then for the diabetic population, the ones with more comorbid conditions, those people it's usually about two to four weeks longer. And so for those folks, I usually tell them kind of in the three to four month, mark is really when you're gonna be receiving the prosthesis and starting to learn how to use it.

There's obviously a lot of other things that we do counseling wise where we're talking about smoking cessation and doing things that can help them, heal faster and with less pain. And those are all things that I do to try to help my patients is really looking at from a hole and thinking of anything we can do to try to help them get to their new normal as quickly as we can and safely as they can, as well.

Melanie Cole (Host): What a rewarding career you have. Dr. Carr, thank you so much for joining us. Today in sharing your incredible expertise and for more information

Melanie Cole, MS (Host): please visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. Please remember to subscribe, rate, and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole.