.

I thank you for watching PBS for Wayne tonight it's HealthLine and I'm your host Mark Evans and we do have a very interesting program.

In fact I've done this show what now 13 or 14 years and we've never had this topic before at least to my knowledge we're going to be talking about amputee medicine.

>> So if you're an amputee or if you have a relative or a friend who is I'm sure you're going to learn a lot of information about what they go through and what kind of treatments are available and prosthesis.

>> We'll talk about that as well.

And in fact we have a doctor who's never been on the show before and I'm excited because he's so far seem to be a very nice person and I'm sure you're going to be filling us with informing us with a lot of information filling our program with that.

>> And Dr. Corey Johnson, nice to have you, sir.

Oh, thank you.

Physical medicine and rehabilitation and doctor physician is what you are.

>> That is correct.

It's a mouthful.

It is.

But it sounds like a full day full as far as duties and things of that nature.

>> So but you don't actually do the amputation but explain what you do for the amputees.

>> That is correct.

I do not perform the amputations that is usually an orthopedic surgeon or a vascular surgeon.

I am a physical medicine and rehabilitation physician so we actually take care of a very diverse area of medicine.

We take care of a lot of neuromuscular disorders, musculoskeletal disorders and I have a particular interest in medicine and that's why I would like to present this topic to the viewers today.

>> OK, where we're going to open up those phone lines.

The telephone number of course is on your screen at two six zero (969) 866- (969) 27 two zero.

Give us a call any time in the next 30 minutes.

Remember it is public television so we won't be stopping down for commercials.

So give us a call any time maybe as we talking about this topic something is going to come to your mind.

So you know I like to call about that so please do.

>> That's what this program is for .

So Dr. Johnson, let's go ahead and talk about the amputation as far as the prevalence of it, you know who has it right now and what are we doing?

>> So you know, I certainly always like to lead off with statistics because this is going to show the importance of this kind of topic and why we should be well informed in it.

So currently in the United States about one hundred and eighty five thousand patients undergo amputation of either the upper or lower extremity and in two thousand or twenty five there was approximately one point six million people living with an amputation and that's one out of about every two hundred people.

So it's likely that we know someone who has had an amputation or will have an amputation in their life and it's actually predicted that this statistic is going to increase to three point six million people in two thousand fifty.

>> Wow.

Yeah, it's a crazy number now is that because of population growing or well tell me why.

>> Well I think it's multifactorial.

So first of all it's important to understand that traumatic amputations are actually decreasing in rate and that's likely because our surgeons are getting great technology and and able to salvage limbs now.

But this vascular disease or like peripheral vascular disease disease the vessels of the legs and arms and of the body that's in an increase that's due to increase in rates of diabetes, increased rates of smoking.

All of these things are leading to an increased rate of amputations that you hope by the year that you just mentioned.

>> I mean that's rather far off in the distance people are going to learn not to smoke and people are going to learn to prevent diabetes but well that is always the hope and I hope we have a bright future in that and I like to remain optimistic but certainly I think what this program is an opportunity for us to provide that education so that we can reduce the risk.

>> Absolutely.

>> And that's what it's all about.

What are the main causes of amputation?

You mentioned a couple of them but let's go down the list here.

>> So first that we'll just go ahead start with some risk factors of amputees or amputation.

So diabetes is a very common thing.

We all know someone who has diabetes and poorly controlled blood sugar can increase the risk of having an amputation because it increases the risk if you're not able to be in it being able to heal wounds and increases your risk of infection and also increases the risk of something you may have heard called peripheral neuropathy.

Yes.

So peripheral neuropathy is where we have damage to the nerves and because we have those damage to the nerves we're not able to have that sensations and that feedback that we usually would do so a lot of diabetics end up with wounds on their feet because they can't sense that feedback and so they're not sure if they step on something.

They're not sure if they have a cut on it.

So it's very important for diabetics to take care of their feet and to follow with their physician to make sure they're taking good control of that.

In addition to that we have high cholesterol which increases your risk of amputation, peripheral vascular disease, high blood pressure, obesity, smoking is a very significant one as well.

The statistic is actually if you're a smoker you have a twenty five times more likely chance of having an amputation versus a non smoker well in place I'm sorry to interrupt but I mean what what Lims would be affected by cigaret smoke so typically we have vascular disease which can be vastly throughout the body.

So like patients with coronary artery disease if they have heart disease they likely have peripheral vascular disease as well because it's nonselective.

Oh I see.

Yeah.

So they're going to have it diffusely throughout the body but it's going to affect both the upper and lower extremities but it's more likely to affect the lower extremities because the length of it and those those vessels are more prone to getting that vascular disease.

>> All right.

And have you completed the list?

>> No, there's more.

Oh, wait, wait.

There's more.

Go ahead.

So a sedentary lifestyle of course is going to certainly increase your risk in as well as advanced age people over 65 years of age or an increased risk of also having an amputation and that's due to those other risk factors becoming more prevalent as well as the African-American race because they have a higher prevalence of vascular disease and hypertension.

>> When you said sixty five years I'm not quite there yet but it won't be long.

Let's go ahead and talk about the prevention then obviously don't get diabetes and don't smoke but I mean let's go a little deeper than that.

>> Yeah.

So certainly I wish if we can control not getting these types of diseases that would be excellent.

I think prevention is what we should really focus on because it's stated that about 60 percent of non-dramatic amputations are preventable.

So what can we do to prevent this?

Well, if you have diabetes certainly controlling your blood sugar is going to be a number one way to help that but also improving your diet, exercising regularly, having wound prevention and stopping smoking can also help this very good.

So in regards to a diet, you know, I certainly recommend patients who are diabetic look at the American Diabetes Association for their dietary recommendations but also planning your meals can help in that.

So I recommend that patients we eat like more whole grains such as brown rice eat healthy fats such as that found in the salmon eating tomatoes, eating non starchy vegetables, especially your dark green vegetables.

>> You got peppers, mushrooms, asparagus, broccoli, spinach and carrots are all very healthy and helping prevent this.

Also legumes such as beans can help sweet potatoes fruits such as berries, fat free dairy as well as nuts.

Now foods that we want to avoid are our sweets, our high carbohydrate foods such as potatoes, peas and corn and also processed foods.

I love potatoes.

I know, right?

So that's what a lot of patients do say is duck.

>> You're taking away a lot of this from the way my JOHANNAH and that's why I always like to promote things in moderation.

Of course you know significantly if you've already had an amputation I'm going to be a little bit more strict and what my recommendations are.

>> But I still think that, you know, we got to promote a good quality of life.

Absolutely.

Absolutely.

Now let's talk about the uh the amputation process and you're not an orthopedic surgeon but you know, when I think of amputation I have to admit the memories go back to those those grisly civil war films, you know, in the tents and all that.

>> And you know, back then they used to have divisions of the army and so forth.

>> They weren't even physicians.

They just were trained on how to solve bones and to save lives.

>> So the advances I'm sure have just really escalated over the years.

>> So how would you explain the amputation process if you don't mind going into that?

Of course.

So like you said, I see a lot of my patients after the amputation it's already been performed.

But typically, you know, a patient will present to a hospital or an outpatient and have peripheral vascular disease or limb ischemia is what we call when it's not able to get adequate blood supply and they have to have an emergent amputation or one that scheduled.

And so in that regards they would go to see the surgeon.

They would have an operation time and date and go get their amputation after they have their amputation.

Of course there needing to be typically in the hospital for a day or two prior to them coming to acute inpatient rehabilitation where then we start to work through the different processes to be able to make sure that they're having their pain well controlled, that we're performing what we call edema control or control of the swelling of the post amputation side because as you can imagine, we're selling through bones, muscle nerves the whole nine yards.

So there's going to be a lot of swelling in that area and if our patients need to be able to get into a prosthesis, we're going to need to be able to shape that residual limb which is what we call the remaining limb after an amputation need to shape it, control that swelling and then we also like to start doing what we call scar scar mobilizations, which is where we provide gentle massage to the scar initially as the patient's able to tolerate it and that's going to help with pain because it provides some sort of feedback and it's also going to tell the brain that hey, the limitations here as we'll talk about later, there's a phenomenon called Phantom pain and phantom sensation.

I want to ask about that.

Yeah.

So we can go ahead and jump to that because I think that's a very important topic and it's actually shown that about around fifty to eighty five percent of amputees are actually going to experience phantom pain and phantom sensation.

Okay.

And so why that occurs is because over time the body develops more of a memory of proprioception and proprioception is our minds the ability to know where the limbs aren't in time and space in the 3D world and as we do activities our brain develops these memories so that we can perform these activities faster and more efficiently after we have an amputation.

The theory is that those memories still stay around and that's why some of the patients can still feel like they're moving their toes or they're having sensation in the foot or they're having pain.

It's because we've developed those memories well and so with the scar massage we can show tell the brain Triscuit or tell that the realistic is that hey, the limb ends here and then in addition to that that helps outcomes in the future because as time goes on the patient is able to progress a little bit further.

We're able to provide more deep tissue massage to that scar and that's going to break up any adhesions or any attachments to the soft tissues below as well as the bones below which can certainly cause significant pain once the patient does start becoming more ambulatory and mobile and can pull on those bony and soft tissues again exemplifying the pain.

I'm trying to be graceful with my words.

What do you call the limb that has been amputated?

I mean think of the word stump and I hate to use that is that word.

>> So it's commonly used the stump.

We certainly prefer to use residual residual limb OK residual in I want to write that down so I don't forget it with a residual limb.

This is what I'm I guess I'm driving at when when the bone is cut is it cut perfectly straight or do you have an angle I mean or a little bit of both are how is the bone cut so that that's a much better question for a surgeon.

>> OK, my perspective we need to have more of a tapering shape so that we can get into appropriate fit at the prosthesis.

But it's also variable depending on where the the amputation site is, whether it's in the upper extremity below the elbow upper extremity above the elbow and the lower extremity again below the knee or above the knee.

All of these really play a role into not only the rehabilitation that these patient get and also their treatment plan but also how the amputation is performed.

Well, I'm asking these questions because we're talking about prosthesis here in a couple of minutes.

But when the bone is cut, do you have do you cap that somehow before it's covered with skin so usually they can wrap some muscle around that area that can provide some extra cushioning down to the middle part of that residual and part.

>> All right.

That makes sense.

We have a call coming in.

In fact, it looks like Jackson and Jackson is preferring to be off the air which is fine.

>> At least he's calling in to ask questions and we appreciate that.

Jackson do people who are a diabetic need to take the same precautions as people who are diabetic?

>> So having pre diabetes certainly still does predispose you to having an amputation.

>> So it is important to take some of those precautions.

The biggest thing that a pre diabetic can do is certainly get their blood glucose under control, make sure one of their number is called the agency is actually under control as well.

And what that is is that's kind of like a three month average of what their average blood glucose is.

>> And so having those things under control can certainly reduce your risk.

But they should take the same precautions.

They should still be doing daily foot care, checking their feet each day, cleaning them, making sure they're completely dry before putting on new socks.

They should avoid walking barefoot because that's going to increase their risk of having trauma as well as wounds to their foot or getting cuts and they should certainly let their physician know immediately if they do have some sort of cut wound or abnormality of their foot because even small breaks in the skin can lead to infection which is then going to lead to amputation certainly now when the residual limb has healed and there will be some pain after surgery about how long is that pain last so that pain typically will last that post surgical pain usually about a week with appropriate care and treatment and then we can usually start raining down on the pain medications.

Of course there are people who've had chronic pain and they're more predisposed to having uncontrolled pain because they are not opioid naove.

So a lot of the medications we're giving may not be as effective and as the general population.

So it is variable but typically one week it should resolve.

But then we're also having to deal with a lot of that neuropathic pain which is pain coming from the nerves as well as the phantom limb pain and phantom sensation.

>> And once the pain is gone, well the patient feel sensation at the end of the residual limb they most certainly should and that's a good thing because to be able to have sensation in that residual limbs important and being able to take care of the skin if you think about how a prosthesis works, we're putting it into a very not very breathable pocket called a socket and that's what helps hold the prosthesis onto the residual limb.

>> So there's a lot of sweat in that area, a lot of moisture which can lead to skin breakdown.

So it's very important that they have good sensation in that residual them so that they can take good care of it and they can know that if the prosthesis isn't fitting correctly correctly and creating shear forces that it's increasing the risk can break down and that should be taken care of .

>> OK, let's talk about the process the prosthetics prosthesis if you will.

>> Are there several different types?

There most certainly are and you know, varies depending on where the level of amputation is for this program.

I would like to keep it above the knee amputation below the knee amputation, below the knee amputations usually referred to as a trans tibial amputation because we know the tibia or shin bone in our lower leg.

That's how we come up with that terminology.

And so the one above the ESA transfemoral amputation OK and then in the upper extremities we have a trans radial amputation which occurs below the elbow and a trans humoral amputation which occurs below the above the elbow and of course the amputations can occur distal further out from that in the hands and the digits and even more proximal to that some more towards the shoulder and even parts of the shoulder can be amputated as well.

>> And high risk scenarios the cure rate if you will and once everybody is once the surgery is done and you go through the healing process and then you finally get fitted with a prosthesis, what is that time span usually so that time span usually about around three to six months.

So usually I would recommend acute inpatient rehabilitation for a patient who's undergone especially a lower extremity amputation and that's multifactorial.

We want to be able to help strengthen those areas that need to be strong to be able to use the prosthesis appropriately as well as stretch other areas to make sure that we're not getting contractures which are kind of tightness of the muscles that's not really able to be range of motion through and so that can lead to a poor fitting prosthesis so we won't be able to stretch and strengthen the appropriate muscles so that when they do get into what we call a trial prosthesis or a temporary prosthetic then they can see how exactly it's going to work and we can make further adjustments from there.

So the reason it's a temporary prosthetic and the like with the first three months is because the limb is still getting a lot of swelling in it and that's going to fluctuate and it's not until about the six month point to where we've got the limb nicely shape the residual and nicely shaped as well as swelling under control and it would be inappropriate to fit a prosthetic prior to then because then it would just need more modifications.

Sure.

And be more cost to the patient and it would be too early as well.

>> What once you're fitted with a prosthetic and I'm sure you ask your patients to come back and see you from time to time and what are the things you were checking for ?

>> Of course.

So the first thing you'd like to check for is to make sure that the patient's comfortable using the prosthetic.

You want to make sure they are using it and if they're not, why are they not using it?

So really it's you know, prosthetics have come a long way throughout history and they've become very highly advanced in technology.

But if they're not aligning with the patient's goals and desires or if it's uncomfortable to use, then of course they're not going to be compliant with that.

So not only are we checking to make sure that the patient's using the prosthetic, we're checking to make sure what kind of issues they have with it.

Are they having any imbalance or are they having any falls?

Are there any adjustments that need to be made to the socket area of the prosthetic that is up against the residual them?

Because the goal is is that we don't want there to be a lot of pressure and pressure sensitive areas such as like bony prominences because that's going to increase our risk of those shear forces and wounds developing.

>> Yeah, that makes sense.

>> We have another call coming in from Judy prefers to be off the air.

She's asking what does the rehab process look like if someone doesn't want a prosthetic?

>> It's a very interesting question.

>> You thank you for asking.

So the rehab process of someone who doesn't want a prosthesis is still very similar because we still want to be as ambulatory as mobile and as functionally independent as possible.

So we're going to still try to strengthen the extremities.

>> But more importantly we would focus more on the sound leg, the leg that still has not been amputated to be able to strengthen it.

And then we would also make sure again to make sure that we're controlling that pain.

We would still want to control the edema because if there's still significant swelling in that extremity that's again going to increase our risk of wounds, increase our risk of infection so we'd be strengthening that non amputated extremity.

We would be working with multiple assistive devices to see what aligns with the patient's goals and dictating our therapies from there.

>> OK, and you were talking about prosthetics earlier.

What about the robotic prosthetics?

Am I calling them the right name?

>> So robotic works, you know, but we have a very fancy terminology for it called myoelectric prosthetics and these are mostly used in the upper extremity amputees and it's a very cool technology.

>> What it is is we use electrodes that are within that socket that lie upon different muscle bodies of the arm.

And so when a patient contracts a muscle group that sends that electrical impulse to that electrode which is then powered by a battery which then can go to what we call the terminal device, that is kind of what I think of the hand of the device.

>> There's multiple different terminal devices but can help control it so they can do finger flexion, finger extension depending on what muscle group they they active just by thinking it just by well they have to actually contract that muscle group and that's why it's very important to do like prosthetic training with them to make sure that hey, this is what this feels like the therapist goes through with the patient now you do it independently and then so they get that feedback and they know what things are supposed to feel like and how it's supposed to go.

>> All right.

If you're just joining us, we're talking to Dr. Corey Johnson who is a physical medicine and rehabilitation physician and we're on the topic of amputee's medicine tonight.

We still have a few minutes left in the program if you'd like to give us a call 866 nine eight six I say this phone number every week 866- (969) 27 two zero.

So give us a call.

Let's go and talk about and you mentioned a couple of them in earlier conversation some of the complications were the most common complications and issues faced by an amputee patient, of course.

>> So firstly dermatologic issues are skin issues.

One very important one is what we call Coke syndrome and that's where when they wear the socket it's very tight at the proximal portion.

So the upper portion of the residual limb and then it's not very tight and doesn't have a good intimate fit like it should the distal part of that residual limb and because of that you get a lot of swelling and that swelling is not able to be able to go down because it inhibits the blood flow returning back to the heart, the veins bringing the blood back so you continue to and continue to get that swelling and then you eventually get what we call hypoplasia a lot of proliferation of the skin at that distal residual limb and it creates like a wart like texture that's very painful and it's very difficult to be able to then treat that.

>> It's much easier to prevent it.

I see.

All right.

And treatment options for immediate will separate and immediate and long term amputee care.

>> OK, so we've already talked about a little bit of the immediate amputee care including that edema control that swelling control and using different devices to be able to help that.

So one of them is is what we call a shrinker and it does exactly what the name is.

It wants to shrink that residual limb into an appropriate shape to be able to get that prosthesis.

But it also again creates that biofeedback at the end of the residual them to be able to help with those painful sensations and again telling that brain that the elements here which is a very important thing to do.

>> Yeah, some of the other things we spoke of Skar mobilizations already but contracture management is also very important contracture contractures where those muscles get real stiff.

>> So this is again easier to prevent than it is to treat.

So a lot of above the knee amputees get what we call a hip flexion contraction.

That's a contraction of the muscles that flex the hip up and as you can imagine when you go to stand up straight, if you're your hips always flex, you're not able to fit into that prosthesis very well and not able to walk well in it in the below the knee amputees a lot of it's commonly a knee flexion and fracture.

So what we want to do is we want to prevent that.

So typically we'd recommend patients to prone for about 15 minutes three times a day so lay on their stomach and that's going to allow the knee to expand and extend.

And then we also recommend for them to gently push the knee down into a firm mattress bed so that it can create that extension movement.

And then of course the therapists are going to continue to stretch gently as the patient's able to tolerate, prevent and help treat those contractures.

>> Well, Dr. Johnson, we only have about a minute and a half left and I would like for you to maybe provide some words of encouragement for those who are watching right now who are either have gone through the amputation process or will go through the amputation process or someone who knows someone who's going to go through this .

I was wondering you can provide some words and let them know it's it's not the end of the world most definitely.

And I think that's the most important thing to understand is that this is a traumatic event someone's life it is a life changing event.

So there are going to be a lot of emotional concerns that do arise and it's very important to treat those.

But I think it's also important to know that we can retain function.

A lot of the most amazing people I've seen and very active people who have been amputees.

So I think it's important to understand that just because you had this amputation doesn't mean that your life , your function and your more importantly your quality of life ends there.

>> And I and I can attest to that.

I've been involved in theater for many years along with broadcasting and gentlemen, I know very well I have known them for over 20 years and just recently I found out that he has an artificial leg, he has a process and you wouldn't have known it and he has had one since he was a child.

>> But he can dance he could walk like nobody's business and even run.

I've seen the man run on stage so it's just amazing.

>> It is quite amazing.

Thank you for all the great work that you've done and we hope that you come back.

Oh, I would love to and thank you for having me.

This has been an absolute pleasure and you know, I hope that we can continue to educate the community on these topics.

That's what it's all about.

>> Thank you, Doctor.

Dr. Corey Johnson, we will see you next week seven 30 HealthLine here on PBS Fort Wayne on Tuesday night.

>> Thanks for watching.

Until then, good night and good