Cheryl Martin (Host): Navigating life after losing a limb can be overwhelming, but having the right teams and resources in place can make all the difference. We learn more from Olivia Bloom. She's a physical therapist supporting the Limb Loss Program at WakeMed's Inpatient Rehabilitation Hospital. This is WakeMed Voices brought to you by WakeMed Health and Hospitals in Raleigh, North Carolina. I'm Cheryl Martin. Olivia, thanks for coming on.

Olivia Bloom: Thank you for having me. I'm excited to be here.

Host: Great. So, first, how does amputation affect the body?

Olivia Bloom: Absolutely. So, amputation in nature is a traumatic injury and a traumatic surgery. So after amputation, not only are there psychological changes that we help our patients manage, but there's a whole whole new way of learning how to navigate your home environment and the community after amputation.

Host: So, why is rehabilitation after limb loss important?

Olivia Bloom: Yeah. I think at WakeMed, we think it is very important to not only have the opportunity to relearn how to move your body and what's important after limb loss. So, we spend a lot of time educating our patients on what has changed and what to expect. And it's so important for these patients not only to have their physical body, but to know that psychologically, they're not alone in this. While I have not gone through that surgery, we have a support group and we have other supports in place for our patients after amputation.

Host: Go into more detail about the goal of inpatient rehabilitation after limb loss.

Olivia Bloom: Absolutely. So, our goal is to help these patients get stronger and prepare for that prosthetic. We spend a lot of time focusing on how to preserve the sound limb, but also how to develop strength in the amputated limb in preparation for the prosthetic so they can be successful in that use after amputation.

Host: You mentioned sound limb. What is the sound limb?

Olivia Bloom: Yes. The sound or intact limb is the limb on the other side of the amputation. So if a patient underwent a below-knee amputation on their left side, their right side, if had not gone through another amputation, is their sound or intact limb.

Host: And why is it important to protect the sound limb?

Olivia Bloom: So, I think firstly to talk about why that is important, we want to establish how prevalent limb loss is. So, it's estimated that 3.6 million people in the U.S are living with limb loss. And of that 3.6 million people, there are many different causes of amputation. It's estimated that a little over half of these patients experienced an amputation due to a vascular cause. So, a lot of what we're talking about today, we'll talk about that vascular patient population. It's estimated that 55% of these people will experience a contralateral amputation in two to three years. So, that's why it's so important to try to preserve that sound limb. We want to try as therapists and in rehab to try to reduce any risk of a contralateral amputation, not only because that limb is so important to bear weight on, in addition to the amputated limb when a prosthetic's attained, but also to try to mitigate that risk, like I said, of a subsequent amputation.

Host: And contralateral?

Olivia Bloom: The other side, yes.

Host: Okay. Now, what should a limb loss patient expect in rehab?

Olivia Bloom: There's so much to learn in rehab. So, we will spend a lot of time educating them on what they're feeling, what they're going through, and what to expect in the future. We will spend a lot of time working on strengthening and stretching both the surgical limb and the intact or sound limb. We spend a lot of time strengthening the hips, back, and core in prep for a prosthetic, in addition to the upper extremities. There are a lot of studies that talk about how important these hip muscles are to successful weight-bearing on the prosthetic, on the amputated limb. And then also, we want to strengthen that sound limb to be successful with a prosthetic in the future.

We're also going to spend a lot of time stretching. So, preventing any hip or knee flexion contractures after below-knee amputation or above-knee amputation is really going to help them with their success in prosthetic use as well. We also spend a lot of time teaching our patient's residual limb care, how to care for that surgical limb, how to monitor any breakdown, desensitization techniques, mirror therapy if they're dealing with phantom limb pain. We'll work on standing balances if appropriate. We are going to pack them with so much new information and equip them with the right tools for home to be successful in the future.

Host: Is there a general length of time for this rehab to be effective?

Olivia Bloom: The average length of stay in rehab after an amputation is two weeks. Now, there is some give and take in that depending on the patient's insurance and what we need to work on. But in general, we'd expect them to stay with us for two weeks.

Host: I want to get back to the sound limb. What are the negative impacts of too much activity? For example, hopping on the sound limb after amputation.

Olivia Bloom: Absolutely. So, too much activity on that sound limb, especially in this vascular patient population where we know that the sound limb likely has a vascular process already going on, with compromised blood flow and likely impaired sensation, is going to predispose that limb to the risk of an amputation.

There are some studies that have looked at how likely this is and what the risks of hopping or too much activity are. And one study looked at after below-knee amputations and they found that there are adaptations with walking in that sound foot, that changed the plantar pressure distribution. So if I'm standing on two limbs to walk versus one, there's going to be a change in the pressure in that one limb. So, it's a smaller surface area to take on the same amount of weight. They found that this is going to increase the risk of ulceration in that foot, which we know can contribute to another amputation.

There's another study that also looked at the intact knee on that side opposite of the amputation, and found that single leg forward hopping is going to increase the mechanical load on the intact knee. And they found that this increases the risk of structural damage. So, the study used a predictive model and found that one hop was equivalent to eight strides of normal walking in terms of structural damage to that limb. And that one meter of hopping is equivalent to 12 meters of walking in terms of structural damage to that sound limb. So, too much activity. We're not talking about just a small increase in structural damage or ulceration. We're talking about exponentially increasing our patient's risk for damaging that knee and further ulceration, which can consequently contribute to a further amputation on that side.

Host: So Olivia, how would you recommend limb loss patients negotiate their home or environment if they're not hopping?

Olivia Bloom: For our patients in rehab, we set the expectation that they'll discharge at a wheelchair level. And this is for preservation of that sound limb, but also to reduce their fall risk. While they're with us in rehab, we will only emphasize hopping if required for household negotiation. This tends to be less than 10 feet and is likely for bathroom negotiation. Whether the door frame's too narrow, or once the chair gets in the bathroom, maybe it cannot negotiate safely for a commode transfer. So, we'll emphasize wheelchair propulsion there. There's also barriers to enter the home. Many of us have stairs to enter. So, we will encourage a ramp when feasible. But this is not always realistic from a financial or a timeline perspective. So if that's the case, we have adaptive methods to teach our patients how to negotiate the stairs. We have a few different methods in that, but a lot of factors come into play: what the weather is that day, the patient's mobility status are their handrails. And so, we'll only resort to hopping if that's a last ditch effort to get them in the home. But our goal is safe negotiation inside and out of the home from a wheelchair level.

Host: So if you're not encouraging hopping in rehab, what are you working on in rehab and prior to obtaining a prosthetic? Just cover that a little bit more.

Olivia Bloom: Yes. Kind of like we talked about at the beginning, what we're going to emphasize is stretching; strengthening of the hips, back; and core functional mobility. We teach functional transfers, which are typically squat pivot transfers. We teach wheelchair propulsion on level and unlevel surfaces. Standing balance, if appropriate, residual limb care, all of these things that they can use between acute amputation and the prosthetic, but that will also apply after prosthetic attainment.

Host: So, what are some common misconceptions regarding the timeline after limb loss and mobility status?

Olivia Bloom: So, a common misconception is that when patients come to rehab, they often assume that the prosthetic will be attained in rehab. However, after acute amputation, there is a timeline of healing. We need to see that amputated limb heal appropriately. We want to see that residual limb heal to the standards of their physician. And then, also, they'll be working with a prosthetist for a casting process. So, that prosthetic will not be attained in that acute stay right after amputation. It will likely be a few months down the line.

In addition, another misconception is that patients often feel once they get that prosthetic, they may simply just start walking again. And that is the case for some of our patients, but it is also a learned skill. So while some patients may not need further rehab, other patients may benefit for further training with that prosthetic. And we do have a step forward program for that, which is our prosthetic training program that we do both inpatient, outpatient, and in home health so that we can teach these patients how to utilize their prosthetic, how to walk with it, how to care for it, and how to complete their activities of daily living with it.

Host: So, I know this timeline may vary for each person. But if a person is looking for a realistic average would you say from the time someone is in rehab and then they have that timeline of healing, and then they get the prosthetic and then they learn that skill, how many months are you talking about?

Olivia Bloom: It's tough to answer in terms of how long it takes somebody how to use one, but we would expect that the attainment would probably be between two and three months or more. But that's if healing goes according to plan. And then beyond that, we would hope that they would be up on the prosthetic that month as long as their wear time increases with it.

Host: Olivia, anything else you want to add just about life after a limb loss? Just any words of encouragement.

Olivia Bloom: We see these patients come through after acute amputation and we see some return for the step forward program, but we also have our patients come visit us, and our patients are living fulfilled full lives, oftentimes returning back to work, returning to their hobbies and things they want to do. Many of our patients attend our support group while they're here or attend it virtually. There's not much better than seeing your patient come walk back through on their prosthetic and tell you that they're return to everything they want to do.

So while the time I think between acute amputation and attaining the prosthetic probably feels incredibly long, we're so encouraged by seeing our patients live these fulfilled lives, both waiting for the prosthetic, but after they attain it, achieving all their goals in that way.

Host: Olivia Bloom, thank you for sharing your expertise and your passion on this topic. To learn more about WakeMed's Amputee Program, visit wakemed.org. And if you found this podcast helpful, please share it on your social media. And you can check out our entire podcast library for other topics of interest to you. Thanks for listening to WakeMed Voices, brought to you by WakeMed Health and Hospitals in Raleigh, North Carolina.