Exercise is important for everyone, but for amputees it is especially so.  A strong core and higher stamina will enable you to complete your daily tasks more easily, and walk longer distances without tiring.  The following article not only provides you with info to help you begin a safe exercise program after amputation, it also addresses the fears that might be keeping you from getting started.  In the coming weeks I’ll be adding more info on exercise and recreational sports you may be interested in trying.

Exercise is for Everybody

by Kate R. Shult, M.S.

What separates those who are inactive from those who exercise? Is it that non-exercisers have more diseases, physical disabilities, or time constraints? Consider what the real reason might be: Fear fear of injury or medical problems, fear of the unknown, and fear of failure. Overcoming these very human fears is a process that starts with a safe exercise plan and ends with the continued successes of meeting personal fitness goals.

Close to 60% of Americans are inactive, even though the message to exercise becomes louder every year. What separates those who are inactive from those who exercise? Is it that nonexercisers have more diseases, physical disabilities, or time constraints? No. I believe there is more to it. Let’s level the playing field and consider what the real reason might be: Fear fear of injury or medical problems, fear of the unknown, and fear of failure. Overcoming these very human fears is a process that starts with a safe exercise plan and ends with the continued successes of meeting personal fitness goals.

Conquering the fear of injury or medical problems

Ken B. came to me at the request of his doctor. Ken is an above knee amputee, has diabetes, and received a kidney transplant a few years ago. Ken has put on considerable weight over the past years. He confessed that he would not have come on his own. Exercise scares him because he does not know what to do and he is afraid he will hurt himself.

An initial health screening is recommended before participating in a new exercise program. This is especially true if a person has been inactive, has a known cardiopulmonary, metabolic, or musculoskeletal disorder, or is a male 45 years and older or a female 55 years and older. The health screening should include a health history and a physical examination. At the very least, the doctor should be informed if someone is interested in becoming more active. The doctor may also have some recommendations on how to keep exercise safe.

Most exercise-induced injuries result from doing too much, too fast or from doing something above a person’s present skill level. Here are tips on how to avoid falling into these traps.

Conquering fear of the unknown

Ken has been exercising for two weeks now. He thinks he is comfortable following his prescribed exercise program, but he hasn’t gained the confidence to make modifications in his program.

How often, how hard, and how long should someone exercise? An easy way to answer this is to talk about the F.I.T. Principle. F.I.T. stands for frequency, intensity, and time of exercise. A F.I.T. prescription will change as a person becomes a more seasoned exerciser. For beginners, start with approximately three sessions a week on nonconsecutive days. Keep the exercise intensity low-to-moderate. Make sure it’s possible to pass the “talk test” while exercising, being able to talk comfortably with an exercise partner. Keep in mind that many people drop out of exercise because they perceive it as being too hard or painful.

During the first four to eight weeks of exercise, intensity should be down and enjoyment up.

Finally, let’s look at how long each exercise session should last. Start off with short sessions, letting the body adapt gradually. Make it a goal to progress up to 20 consecutive minutes of exercise during the initial four to eight weeks. Interval training is one way for beginners to work on endurance and take necessary rest breaks. Another way to increase endurance gradually is to add two to three minutes of exercise each session, until one reaches the 20 minute goal.

Start each exercise session with a low intensity warmup. Slow walking or cycling, along with light stretches, will help “wake up” the body and mind, get blood flowing and decrease chances for injury. Repeat this process at the end of each session to help pump blood back into the upper torso and decrease muscle soreness.

Make sure to include muscle strengthening exercises in the routine. Increasing muscular strength will make activities of daily living easier and exercise more enjoyable.

Ken is doing five-minute intervals of bike riding with one minute of rest in between. He does a total of four to five intervals, depending on how he feels. Gradually, he will increase his riding time and decrease his rest time until he can reach the 20-minute goal.

Frequency: Approximately three times a week.

Intensity: Low-to-moderate.

Time: Work up to 20 consecutive minutes.

Ken has been experimenting with the bike. He likes to ride with his prosthesis and now carries an Allen wrench in order to adjust his foot to the pedals. He wants to conquer the treadmill next.

Deciding which mode of exercise is best depends on the availability of equipment and facilities, present skill level, and likes and dislikes. I encourage people to keep it simple when they start out. Treadmill walking and stationary cycling (arm or leg) are excellent ways to build endurance and to begin adapting to exercise with a prosthesis. Swimming is another activity that many amputees enjoy: the key word is enjoy. Take time to do a little investigating into exercise classes offered through the local YMCA, Arthritis Foundation, and city recreation departments. Call local exercise sites and ask about handicap accessibility. For home exercise, consider an exercise video for amputees. Another excellent resource is the Home Exercise Guide For Lower Extremity Amputees by Robert S. Gailey, M.S. Ed., P.T.

Conquering fear of failure

Failure occurs when we set our goals too high. I believe that overcoming small hurdles is the way to make it over the mountain. If initial fitness goals are realistic, measurable, and obtainable, success will result. Focus goals on the behavioral changes that are likely to occur during the first four to eight weeks of exercise. Accept any physiological changes, such as a decrease in body fat or blood pressure, as a bonus.

Behavioral changes:

    * Increased sense of mastery and accomplishment.
    * Increased self-esteem.
    * Feeling energized.
    * Better sleep at night.
    * Conquering fear.

Make sure new plans are not too ambitious. Is driving 30 minutes to get to an exercise class realistic? Is club membership affordable? If it appears that a plan is too ambitious, come up with one that will work. Don’t get set up for failure. Gather support from family and friends. Who knows, it may motivate them to start an active life, too. Turn over a new leaf and make exercise a positive experience as well as a lasting one.

Exercise Resources

Home Exercise Guide for Lower Extremity Amputees
Robert S. Gailey, M.S. Ed, P.T.
Ann M. Gailey, M.S., P.T.
Sandra L. Sendelbach, M.S., P.T.

Seat-A-Robics: Exercise for the Disabled
(708) 831-4007 voice/fax
Chairobics
Cherly Spessart, BSN, RN
1-800-610-4270

Aerobics for Amputees
Produced by DS/USA
1-800-610-4278

Nancy’s Special Workout: For the “Physically Challenged”
Nancy Sebring, OTR
1-800-610-4278

Flex-ercise
Produced by Flex-Foot, Inc.
1-800-233-6263 ext. 23

About the Author
Kate Shult completed her M.S. in exercise physiology at the University of Tennessee. Presently a clinical exercise physiologist at the U.T. Medical Center, she handles a diverse caseload, and has also designed and implemented a kidney transplant rehab program. Certified by the American College of Sports Medicine, Kate has spent the past 10 years lecturing, training, and educating in the health and fitness field, and is the UTMC Heart at Work coordinator.

If you rode a bike before your amputation, you can ride again!  Depending on how serious a rider you want to be, there are several things you can do to make that happen. The biggest issue an amputee encounters when attempting to ride a bike is that it’s difficult to keep the prosthetic foot on the pedal.  The simplest fix is one I read about on the website of a former police officer who lost his leg above the knee (it’s the one I use).  You just wrap Velcro around the bike pedal and attach a large piece to the sole of shoe.  Mount the bike by standing next to it and swinging your prosthetic leg over the seat. Place your prosthetic foot firmly on the pedal, push off with your sound foot, and you’re off!  Your foot should stay securely on the pedal even when you encounter slight inclines and small bumps in the road. 
 
Some amputees (mostly BK’s) prefer to put a strap or cage on the pedal. The problem I’ve encountered with that (I’m AK) is that the heel of my foot tends to turn inward and hit against the bike. You could solve that problem by attaching a pedal extender.
 
For serious bikers who like to travel off of paved roads and bike paths, check out the following link: http://www.heathermills.eu/forum/index.php?showtopic=4371
 
Happy trails!

Because it affects many of our patients, I’ve chosen Phantom Limb Pain as our first topic of discussion. It is defined as pain in the missing or amputated part of the limb(s) or some part of it. It’s important to note the differences between phantom pain and pain in the residual limb. They are very different problems with totally different causes and very different treatments. Phantom pain is never experienced in the residual limb even though it can be triggered by something happening to the residual limb. Residual limb pain is always experienced in the portion of the limb that is present. More detailed info on residual limb pain will be given at the end of this discussion.
 
Unfortunately, phantom limb pain is experienced by 60-70% of new amputees and after a year as many as 40% of them may still be bothered by it in a significant way. Many amputees report that it becomes much less frequent and lessens in severity over time; however, when it recurs it may be just as bothersome as when it was first experienced.
 
There is tremendous variability of phantom limb pain. It can be extremely unpleasant and even disabling for some amputees. It is complex, resistant to treatment and very frustrating to the amputee and caregivers alike. The debate over what causes phantom pain rages on. Following are some of the suggested causes of phantom pain accumulated from discussions by people on internet amputee forums.
 
1. Prior experience with pain before amputation - If you have had continued pain in your limb prior to amputation, this is thought to have a “phantom” effect post amputation.
 
2. Incorrect surgical procedure - Chances are your surgeon (especially if it is a traumatic amputation) may not be wholly experienced in amputations.
 
3. Climatic conditions - Changes in weather, particularly related to changes in air pressure and temperature can dramatically affect levels of phantom pain. Other than moving to a different climate, this is a hard one to avoid.
 
4. Stress - Stressful lifestyles lead to different kinds of ailments and if you are an amputee, phantom limb pain is just another to add to the list.
 
5. Inactivity - Remaining in the same position for long periods of time.
 
6. Periodic illness - Viruses can increase the level of phantom sensation, sometimes to unbearable levels. This is particularly noticeable for people who only experience phantom pain when ill. If you experience this type of pain, it’s best to get prescription medicine from your doctor to control it.
 
So what can be done to relieve the pain? Listed below are some ways amputees have found helpful in relieving phantom limb pain without medication:
 
1. Wrap your residual limb in a warm, soft fabric such as a towel. Or use a heating pad. The warmth will sometimes increase circulation. Poor circulation is thought to be one cause of phantom limb pain.
 
2. Mentally exercise the limb that is not there in the area that is painful.
 
3. Mentally relax the missing limb.
 
4. Do some mild exercise to increase circulation.
 
5. Tighten the muscles in the residual limb, then release them slowly.
 
6. Put an ace wrap or shrinker sock on.
 
7. Change positions. If you are sitting, move around in your chair, or stand up to let the blood get down into your residual limb.
 
8. Soak in a warm bath. A hot tub is reported to do wonders.
 
9. Massage your residual limb with your hands or have someone else massage it while you try to relax your entire body.
 
10. Keep a diary of when pain is most severe. This can help you and your doctor identify recurring causes.
 
In many cases, increased blood flow to the amputated area will reduce the amount of pain. So exercise, whether it’s stretching, running, walking, bike riding or lifting weights can provide relief from phantom pain.
 
A promising new therapy is being used at Walter Reed Medical Center to help amputees fight their way out of pain and back to normal living. But it isn’t a new drug, it’s a mirror, about four feet long and a foot wide. This is the way it works: First, the amputee is seated on an exam table (or bed if at home) with their legs straight out in front of them. The mirror (which can be purchased at most department stores for less than $20) is placed between the amputee’s legs with the reflective side facing the sound leg. This will give the illusion of two sound legs in the mirrored image. Through the use of the mirror the amputee is able to visualize flexing or massaging the missing limb, which helps alleviate the pain.
 
A Navy doctor at Walter Reed set up clinical trials with 18 volunteer amputees, and he was astounded by the results. Participants in the trial used the mirror therapy technique 15 minutes a day, five days a week for four weeks. Every single person who used the mirror experienced relief, and some reported that their phantom limb pain disappeared.
 
Remember - When discussing pain management, it is important to note the difference between phantom limb pain and residual limb pain. Many amputees experience pain in their residual limb. Immediately after surgery it is expected due to the massive tissue disruption of the surgery itself. Later, the pain can be due to a number of mechanical factors such as incorrect prosthetic fit, bruising of the limb, a neuroma, chafing or rubbing of the skin and any number of other causes.  If the source of the pain is a neuroma the following link to an article on “Easing Nerve Pain Post-Surgery” written by Dr. Ducic, a plastic surgeon at Georgetown University Hospital may be of interest to you:  http://www.news8austin.com/content/headlines/Default.asp?ArID=227040&SecID=2
 
Since there are numerous problems that can result in pain in the residual limb, it’s important to discuss residual limb pain with your physician and/or prosthetist. They may be able to solve the problem before it becomes more severe. The problems of pain management are made much more complex by the differences between amputees.  A lot of guesswork is involved and there is much variability. Each case has unique circumstances and must be evaluated individually (ie.,  a teenager who loses a leg above the knee to cancer will require different treatment than the senior motorcycle rider who has his leg amputated below the knee after unsuccessful limb salvage attempts).
 
Although I have not personally experienced phantom pain in many years, I do have phantom “sensation” from time to time, usually when my prosthesis is off. It’s more irritating than painful, sort of a “pins and needles” feeling, but I find that a hot bath or shower helps diminish it.
 
If anyone reading this has had success using the above techniques (or any other method) to relieve phantom limb pain and you don’t mind sharing, I’d love to get your feedback!