So our next speaker is going to be Paul Pasquina. He's the Chair of Physical Medicine and Rehabilitation at Uniformed Services University. And he's going to talk to us about rehabilitation considerations. Yeah, thank you very much. I couldn't, obviously, Scott and Doug kind of paved the way here with a lot of very important topics. So I'll try to not recover things. I don't have any conflicts of interest to disclose. I think Scott already talked about this, but bottom line is lower limb amputations occur a lot more than upper limb amputations. And upper limb amputations are typically traumatic, 70% to 90% of which. And for that, there are oftentimes younger patients. The terminology for congenital limb amputation is much different than traumatic limb amputation. The old terms of amelia and miramelia don't exist. Really, the way you talk about those, according to the International Society for Prosthetics and Orthotics, is a congenital absence or deficiency of whatever bone is missing, and whether it's transverse or longitudinal. I don't necessarily need to go over this. It's just kind of some of the levels in epidemiologic and causes for trauma. You know, again, majority of upper limb amputations occur from trauma, then congenital, then tumor, and then disease. Obviously, working at Walter Reed and the Uniformed Services University for my entire career, we've been taking care of a lot of trauma victims or service members. From blast injuries, as Scott indicated, being that close to a blast that causes limb amputation, typically results in multiple other types of injuries. And the extent of the blast can affect large areas of soft tissue. So that was already covered by Scott. But again, being that close to a blast, it's very common to have a comorbid brain injury, spinal cord injury, peripheral nerve injuries, and even sensory impairments, vision, hearing. And as we all know, manipulating a prosthesis without vision or with impaired vision becomes very difficult. Our patient population, this is some more recent numbers, close to 1,650, as of now, major limb amputees, and total number of upper limb amputations in that entire population, about 18% to 20%, and multiple limb amputations, about 26%. Although I can say when we increased our number of patients I can say when we increased our deployment numbers and surge to Afghanistan, a lot more multiple limb amputations than single limb amputations, in fact, going above 60%. So it does make our patient population unique. It's very rare to have a single limb amputation happen in isolation. We talked about the other comorbidities. But to have the other upper limb extremity affected does create significant challenges to rehabilitation. As one is going through multiple reconstructive surgeries, in this case, on the right arm, starting with prosthetic fitting and training on the left arm, can't wait until those surgeries are finished. Our patient population, like many folks with upper limb amputations, are much younger because of trauma. And with that, creates significant challenges in terms of body image, changes in life roles, and so the psychological impact of that is pretty significant. But I think it's important to mention that even technology that may be 20 years away, for somebody that's 20, will help them significantly in their life when they're in their 40s and 50s. So some of the quick differences between upper and lower limb amputation. We talked about younger age. Usually they stay in the hospital a little bit less. They do most of their rehab as an outpatient. Being a younger age, they have a lot more difficulty figuring out what they're going to do for the rest of their life in terms of vocation, going back to school, various other things. Body image changes we talked about. Pain may be greater in folks with upper limb amputation versus lower limb amputation. Prosthetics are much more complicated, much more decisions to make, and much more expensive. They have fewer peers, and you can read the rest. Some historical perspectives, and I can only just say from Vietnam and from the last 13 years of war, you know how important rehab principles are, and they initiate during the time of injury, and I'll try to highlight some of those. But I think the important aspect of rehab care is really teamwork and bringing all these different disciplines together to provide holistic care and address all the issues going on with the patient, not just their residual limb wounds. So it starts with medical management, pain being very aggressive preoperatively, perioperatively, and postoperatively. We use a multimodal approach using a lot of regional anesthesia as well as PCAs. We've made adaptive devices for our PCA controls for people with multiple limb amputations to be able to give them that independence. In fact, you know, we use multiple medications and other types of, I can talk about that, preventing secondary complications, heterotopic ossification, DBT, PE. Most people don't think a lot about DBT or PE with upper limb amputations, but they do occur at the same rate and incidence. Differentiating pain, whether it's postoperative pain, residual limb pain, phantom limb pain, can be difficult, and so addressing that pain appropriately is important. So in rehab, we obviously look for the source of nose exception and then try to target our treatment for that source. And as Dr. Smith pointed out, neuromas are a big problem, so better management of peripheral nerves to prevent neuroma formation and pain will be a huge improvement in the care of upper limb amputees. Non-pharmacological and pharmacological treatment, we've done some studies looking at mirror therapy, and it is effective. Obviously, it's not a cure for all. There are numerous medications that are used. I can talk at length about all of those, but suffice it to say that none have been really extremely effective in managing phantom limb pain. And the other aspects of managing pain are looking at how is pain affecting other things, sleep, mood, irritability, relationships. All those things are extremely important. And so choosing your medicine based on its side effect profile and how it may improve sleep. If there's a huge anxiety component or depression component to their pain expression, then treating that is also extremely important. I mentioned DBT-PE, but heterotopic ossification occurs in about 40 to 60% of all of our blast casualties and can happen within the zone of injury or distal zone of injury, and needs to be assessed when assessing pain. Typically, preoperatively, we do get 3D imaging and model formation to help our surgeons with their surgical approaches. Early rehab goals, let me get into. So wound healing, monitoring infection, all these things are important in terms of rehabilitation. There is this golden period of introduction to an upper limb prosthesis. The earlier they're introduced to an upper limb prosthesis, the more likely they are not going to abandon their upper limb prosthesis. And we've had some trouble with that, particularly in terms of deciding whether or not to use a body-powered or a myoelectric prosthesis, and I'll get to that. In terms of pediatric rehab, obviously you could spend a day just talking about pediatric rehabilitation, but in terms of, I think the easiest way to remember that is just think of the normal developmental milestones and do anything you can to help a child reach those milestones with or without a prosthesis. So when they should be doing bimanual activities, that's the time to stimulate those things. And the other issue about pediatric rehabilitation is to try to stimulate the limbs to get them to grow and get their muscle development, bone development as much as possible during their development. So body-powered, and this becomes confusing for many people, body-powered versus myoelectric. Body-powered, it's really important, obviously, to have a full range of motion and strength of proximal joints. And if you just think through the way a body-powered prosthesis is designed, you have the shoulder harness. As you separate your scapula or protract your scapulas or flex your shoulder, you're gonna bring that bicycle cable kind of in tension and then pull a volitionally opening terminal device open. And then when you relax that, and as Dr. Smith was saying, even in body-powered prosthetics, you use the same motion to operate an elbow as you do with the terminal device. So you're using that scapula protraction to flex the elbow. Then once you get the elbow in place, you use an anterior cable to extend your shoulder, lock that elbow in place. Once you have the elbow in place, then you start managing the terminal device. And it's almost a similar stepwise fashion with myoelectric devices. So you have to think about all those ranges of motion during your assessment and treatment to help facilitate those motions. And as Dr. Smith also mentioned, elbow flexion becomes extremely important for functional activities. So maintaining good elbow flexion when you're fitting with prostheses, trying not to impair elbow flexion is important. And then if you have a comorbid plexus injury or peripheral nerve injury, that does limit a lot of what you can do in prosthetics. It certainly limits any effect that targeted muscle renervation will have, reduces your myoelectric sites of control, and impairs proximal joint and arm motion to control even a body-powered prosthesis. So here's kind of a myo boy. And with the complexity of wounds that we've seen, while folks still had open wounds, we could put electronic sensors on their forearm or on their biceps and triceps, get them to control those muscles so that when they were ready for prosthetic fitting, they were ready to go to control those. So you can get this computer feedback. They can work at isolating those myoelectric sites of control, controlling those very well. And then again, once they're ready to go for a prosthetic fitting, they can do that. Here's some of the problems with prosthetic upper limb prostheses. And Dr. Smith mentioned it. You're using your biceps and triceps to do unnormal action. So biceps and triceps to get the elbow in place, then co-contraction typically to lock that elbow in place, and then using biceps and triceps, again, to open and close the hand. And you can see with that person how it would just be much easier to just use the other hand and abandon your prostheses. Choice of terminal device, I know you guys are gonna talk about that next, whether it's a cosmetic or a hook or a hand. Don't forget assistive technology, other assistive technologies to help folks with functional independence and adaptive devices to allow them to participate in recreation and motivational types of activities can be extremely important in their recovery. I do wanna mention these things that I think are really important, long-term effects of amputation. There are definitely reports. Most studies lump a lot of amputees all together, but very clear evidence that they have lifelong problems with pain, skin problems, arthritis, osteopenia, cardiovascular disease, diabetes, you name it. So when addressing all the holistic measures, really trying to prevent any secondary risks for those conditions. Residual limb complications become problematic, as you know. For excessive sweating, we've done some studies looking at Botox and Myoblock, which is very effective at reducing sweating. Outcome measures are really important. There are many, not many, but some very good ones. Here they are, FIM, SF36, and I can provide that for anybody, the DASH, TAPES, ACMC. In terms of research, osseointegration has been used overseas, can be very effective as a way of improving patient-machine interface. Going back to what Dr. Smith said, you're increasing your sites of control with targeted muscle re-innervation. That sensory component, there are folks now working on tactors. So as Dr. Smith said, some of these sensory nerves will grow to the cutaneous nerves that grow into the skin. It does feel like the hand transmitting the signals now from my electric hand into that trust area can be one way of reproducing sensation into a prosthesis. Some of the problems, however, with targeted muscle re-innervation or skin sensors are that how do you have an array of sensors that can pick up all this stuff, whether it's pattern recognition or direct control. What do you do when you're sweating? What do you do when that socket rotates? And so we've now implanted our second patient with a first in-man trial of implantable electrodes. This is kind of what they look like, developed by the Alfred Mann Foundation. We injected two service members. Oh, maybe, am I stuck? All right, here you go. Here is our first patient. You can see we put in eight implantable myoelectric sensors into residual forearm muscles. As Dr. Smith mentioned, myodesis doesn't really help. Co-contraction of muscles doesn't really help. But if you have independent muscle activity, for example, of the pronator teres, of the supinator, of the, you name the muscle, you can then pick up those EMG activities and control a prosthetic arm. This is the first patient to ever have a simultaneously controlled three degree of freedom hand. So he has independent control of his thumb flexion and extension, independent control of pronation and supination, and independent control of hand opening and hand closing, and can do all of those degrees of freedom simultaneously with intent because he's using his initial, his originally intended muscles to do those. So this is not with targeted muscle renovation. So if you can preserve abductor pollicis longus, I mean, flexor pollicis longus, abductor pollicis longus, you've got active thumb flexion and extension. Here's him doing the SHAP metals test. And he's obviously doubled his time or reduced his time in half on all these activities using this device. And this is a take home device. We have FDA approval to do three patients and we just recruited our third patient who will be implanting hopefully next month. So a lot of exciting things happening in rehab and in prosthetics, but it all starts with effective surgical management. And even with the advances in technology, it doesn't really replace training. So that's as fast as I could go. Our talk. Thanks very much.

rehabilitation considerations

upper limb amputations

traumatic limb amputations

common comorbidities

prosthetic devices