PROSTHETICS

TRANFEMORAL

This booklet was created for informational purposes only. The information contained herein should only be used for reference material and is not intended to replace the advice of your healthcare provider(s). You should always consult with your physician or healthcare provider concerning any medical issues and before beginning any treatment regiment.

A PATIENT CARE MANUAL FOR THE NEW AMPUTEE

TABLE OF CONTENTS
INTRODUCTION...1 COMMONLY USED TERMINOLOGY...2 COMMONLY USED ACRONYMS6 BASIC ANATOMY......7 STATISTICS.........8 HEALING RATES..9 MEETING YOUR PROSTHETIST....10 POST OPERATIVE CARE.11 IPOP PROSTHESES..11 SHRINKERS....13 DESENSITIZATION....14 POSITIONING....14 PHANTOM LIMB SENSATION..16 PHANTOM LIMB PAIN.16 EXERCISE...16 TEMPORARY PROSTHESIS...17 PROSTHETIC PROCESS..18 CHECK SOCKET FITTING.21 TEMPORARY PROSTHETIC FITTING...22 PROSTHETIC FOLLOW UP..24 SOCK MANAGEMENT24 HYGIENE..26 PHYSICAL THERAPY..26 DEFINITIVE PROSTHESIS..28 PROSTHETIC PROCESS..28 PROSTHETIC HYGIENE....30 EXERCISE...31 ASSISTIVE DEVICES..31 AMPUTEE ATHLETIC RESOURCES..33 RESOURCES FOR THE AMPUTEE.....35 REFERENCES..36

INTRODUCTION
An amputation can be both physically and emotionally challenging for anyone. It is important to understand that many new amputees function very well and pursue the same active lifestyle as prior to limb loss. This booklet aims to provide you with answers to many of the questions that arise before and after an amputation. When speaking with your healthcare provider, it is important to know which questions to ask and have an idea of what to expect. Many questions will arise throughout the rehabilitation process. This booklet will answers to some of them and give you resources to get further information. Having the answers to commonly asked questions readily available will help you prepare for the steps and procedures that will occur before, during, and after your amputation. This information can assist you in your return to the things you need and hopefully enjoy participating in. This booklet also provides many other resources that you may find useful in your recovery. There are many organizations that offer a variety of assistance that range from driving devices to sports related activities. This booklet attempts to turn your disability into a possibility by sharing the collective rehabilitative experiences of others with you.

Commonly used terminology

Abduction a movement which brings the limb closer to the midline of the body

further away from the body

Adduction a movement which positions the limb Alignment the spatial relationship between the

prosthetic socket and the prosthetic foot

Anterior towards the front of the body Check Socket a temporary socket made of transparent plastic that is used by the prosthetist to diagnose the fit of the socket Contracture tightening of the muscles, tendons, or ligaments that prevents normal movement of a joint Cosmesis the outer covering of a prosthesis,

aesthetics

limb after all post-surgical swelling has subsided ankle, knee, hip)
Disarticulation amputation through a joint (i.e.

Definitive Prosthesis a replacement for a missing

Donning and Doffing the process of putting on and

taking off a prosthesis

Dorsiflexion pointing the toe or foot upwards Edema swelling of the tissues Eversion to turn outward

and has a rigid outer covering straightening out

Exoskeletal a prosthesis that is hollow on the inside Extension a position of increasing the joint angle, Flexion a position of decreasing the joint angle,

Occupational Therapist a person trained in gaining

greater independence for patients through rehabilitation and relearning how to perform activities of daily living efficiently and safely

bending

Gait Training learning, usually from a physical

Occupational Therapy evaluation and training performed by a licensed occupational therapist which focuses on maximizing the activities of daily living Pedorthotist a trained healthcare practitioner who

therapist, how to walk safely and properly with a prosthesis

specialized in orthopedic footwear and foot orthoses

limb that is applied in the operating room after the amputation has occurred
Inversion to turn inward

Immediate Post Operative Prosthesis an artificial

Phantom Limb Pain pain that appears to come from

an area below where the amputation occurred

amputated limb is still attached to the body

Phantom Limb Sensation the feeling that an Plantar Flexion pointing the toe or foot downwards

side

Lateral away from the midline of the body, to the

Liners a sleeve or covering of the residual limb that is used for suspension, cushioning and protection Medial towards the midline of the body Myodesis a process during an amputation where the

Physical Therapist a person trained in the rehabilitation process of patients who have limited or lost functions of mobility

muscles are attached to bone

by a licensed physical therapist which focuses on exercise, reducing pain and regaining mobility
Posterior towards the back of the body Prosthesis an artificial body part Prosthetics the profession of evaluating,

Physical Therapy evaluation and training performed

Myoplasty a process during an amputation where

the muscles are attached to opposing muscles

amputation that can ball up. Neuromas are usually extremely sensitive and painful

Neuroma a nerve ending that is cut during an

fabricating, fitting and adjusting an artificial limb

Prosthetist - a trained healthcare practitioner who

evaluates, fabricates, fits and adjust prosthetic devices

Pylon a structure that is used to connect the

prosthetic socket to the prosthetic ankle/foot complex

Commonly used acronyms

ABC American Board for Certification ACA Amputee Coalition of America AKA Above Knee Amputation AP Anterior-Posterior BKA Below Knee Amputation CP Certified Prosthetist CPed Certified Pedorthotist CPO Certified Prosthetist-Orthotist OT Occupational Therapy/Therapist PT Physical Therapy/Therapist PTB Patellar Tendon Bearing TF Transfemoral TT Transtibial SACH Solid Ankle Cushioned Heel

Residual Limb the portion of a limb that remains

after amputation

Shrinker a prosthetic sock created of elastic

material that is used in reducing swelling of the residual limb

and protects the residual limb; usually made of thermoplastic, laminated, or carbon composite material

Socket the part of the prosthesis that fits around

Socks a sock that is fabricated to fit the residual

limb. It is used to manage the loss of volume in the residual limb throughout the day

Sound Side Limb the non-amputated or non-

affected limb

Symes amputation through the ankle joint that still

maintains the fatty heel pad for cushioning

fabricated soon after amputation. This prosthesis is used until post-surgical swelling has subsided.
Transfemoral amputation that occurs at a level

Temporary Prosthesis a prosthesis that is

above the knee joint but below the hip joint the knee joint but above the ankle joint

Transtibial amputation that occurs at a level below

Basic anatomy
Femur Thigh bone

Statistics
It is important for you to know that you are not alone in your rehabilitation process as a new amputee. The number of people living with an amputation is rising in the United States, particularly as a result of diabetic and dysvascular conditions. In the United States, there are approximately 1.9 million people living with limb loss. It is estimated that one out of every 200 people in the U.S. has had an amputation.6 Loss of a limb can occur for a number of reasons. With regard to amputation of a lower limb, the most common causes of amputation include dysvascular complications (possibly resulting from diabetes), trauma, cancer and congenital limb deficiency.

Greater Trochanter Upper, prominent part of the femur Ischiopubic Ramus Flat, sharp bone that connects the Ischial Tuberosity to the front of the pelvis. Ischial Tuberosity Lower and back part of pelvis. The bone you sit on. Pelvis Bony structure located at the base of the spine

Pelvis

Greater Trochanter

Femur

Ischial Tuberosity
Ischiopubic Ramus
Amputation Statistics by Cause from the National Limb Loss Information Center, 2006

Healing rates after amputation

The recovery rate after amputation is different for each person. There are no two surgeries or people that experience the same healing times and rates. Following surgery, you will not return to your room until about four hours after you wake up. When you awake, many people say that they feel as though they have not had the amputation because they have the sensation that the limb is still attached. On your residual limb, there will likely be a drainage tube to remove the excess fluids following your amputation. This tube usually remains in place for 24 hours following the surgery. The surgical dressings are typically changed within 48 hours following surgery. Your physician may alter these times to suit your unique needs. Within 7-10 days, most patients are able to go home. Two to three weeks post-operatively your physician will remove the staples. During the healing period, which lasts anywhere from three to twelve weeks, the suture line will close and heal. When the suture line has healed, fitting for a temporary prosthesis may begin. Again, the time frames mentioned in this portion of the booklet are typical. Some people may experience shorter time frames, while others may experience complications that lengthen them.

Meeting your prosthetist

Choosing a prosthetist is an important step in your rehabilitation process. You will develop a life long relationship with your prosthetist and will be seeing them often for the care of your residual limb and prosthesis. When choosing a prosthetist, you should meet with several different practitioners in your local area to determine who you feel most comfortable with. Your prosthetist should be open to your needs and listen to what you have to say. A list of ABC Certified practitioners can be found at http://www.abcop.org When you meet with your prosthetist for the first time, you should be prepared to ask any questions that you may have about the prosthetic process. Consider making a list of questions to bring to your appointment to ensure that all of the questions that all of your questions are answered. Without a list, the experience may be overwhelming causing you to forget important questions.

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Post operative prosthetic care

After the amputation there are several ways of dressing the residual limb. The most common way of dressing the limb is with the use of simple gauze dressings. This is typically done in the operative room by your physician immediately following surgery. These dressings will then be changed periodically.

An IPOP prosthesis will protect the end of the residual limb should this occur. There are many different types of postoperative care and your physician will help you choose which the best is for you.

Ipop prosthesis
There are more aggressive approaches to post operative care that may include the use of a rigid dressing or what is termed an Immediate PostOperative Prosthesis or IPOP. An IPOP is an immediate postoperative prosthesis that is used as an early form of prosthetic intervention. The benefit of being fit with an IPOP prosthesis is early ambulation if allowed by your physician. An IPOP prosthesis is also said to help with phantom limb sensation, because you can see that there is a leg, or in this sense, a prosthesis attached. IPOP prostheses also protect the residual limb from being injured. Many times, a patient will wake up in the middle of the night to use the restroom, and forget that their limb has been amputated. When they get out of bed and try to stand on both limbs, they fall down and re-injure the surgery site.

Socket

Flo-Tech Brand IPOP prosthesis. This IPOP has all of the same basic components of a typical prosthesis (socket, knee and foot).

Knee

Photo from Flo-Tech. O&P Industries, Inc. Accessed 2May2007 online at: http://www.1800flo-tech.com/products.html

Foot

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Prosthetic shrinkers
At some point after your surgery, your healthcare providers will discuss several things with you including the use of shrinkers, desensitization, positioning, contracture prevention, exercise, phantom sensation and phantom pain. To manage post-operative edema, you may be prescribed a shrinker or ace wrap as a means of compression therapy.

Desensitization
Desensitization is important to prepare your residual limb for the forces that will soon be applied with a prosthesis. The most common and easiest way to desensitize the limb is to gently massage the entire area several times a day; this will decrease the skins sensitivity. There are several different techniques, you should speak with your physical therapist about which one is best for you.

positioning
Positioning is extremely vital to help prevent contractures that can cause problems when fitting a prosthesis. If you are going to be sitting in a wheelchair you should always sit up straight, keep equal weight on both hips and try not to slouch. Avoiding any prolonged periods of sitting is best if possible. If you sit with your hips bent (flexed) for a long period of time, the limb may develop a contracture and prolong the necessary therapy. This will negatively effect your rehabilitation. Contractures can cause you to be uncomfortable in your prosthesis and/or effect how well you are able to walk. If a severe enough contracture occurs, this will limit your prosthetic options and candidacy.

Shrinkers are elastic garments that are simply pulled on or wrapped around the limb. They are typically used when the suture line is reasonably healed. Until that time, an ace wrap may be used. Both methods help to expel excess fluid that remains inside the limb. This helps to prepare you to wear a prosthesis by providing an appropriate limb shape.

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Phantom limb sensation

Almost every amputee experiences the sensation that the amputated limb is still present.1 These feeling can occur due to a variety of factors including pressure or even weather changes. These sensations may disappear quickly or in some cases can remain for quite sometime. Phantom sensations are different for everyone and should not present any problems to prosthetic fittings.

Left: Person sitting in a wheelchair could be at risk of developing a hip flexion contracture. Below: person lying on the stomach (prone) to stretch the hip flexors. Consult your healthcare provider.

Phantom limb pain

In addition to phantom sensations, some people experience various types of phantom pain in the amputated limb.1 The causes of these phantom pains remain unknown but there are treatments available to help manage symptoms. If you experience phantom pain you should contact your physician or nurse so that they can recommend the appropriate treatment.

Proper positioning can be achieved with the use of a pillow while lying face down in bed. If you are lying on your back, avoid placing any pillows under your limb. One simple position that can greatly increase flexibility is to lay on your stomach and stretch the limb backward. When lying in bed remember to keep your legs together and try to avoid any type of rotation. Keeping these strategies in mind can help prevent unwanted contractures.

exercise
After an amputation it is common to feel weak and unsteady. This is why it is important to begin stretching and exercise as soon as you are able. There are many different types of exercises; some can be done while lying in bed, some standing, some

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sitting, and more. At times, home exercise is important and at other times you may need to visit your physical therapy clinic. Your physical therapist will be able to explain and demonstrate these and/or other exercises that are appropriate and beneficial for you.

4. helps you to learn to manage the socks you need to wear as your residual limb volume changes. In order to accomplish these things, the way this first prosthesis is designed and looks will quite likely be different from your future prostheses.

Prosthetic process
Upon successful healing and control of edema, your physician will most likely prescribe a temporary prosthesis for you. It is very important to inform the practitioner of any goals and aspirations you have. With your goals in mind, the process of prosthetic selection can begin.

Temporary Prosthesis
This section will attempt to guide you through the process of receiving a temporary prosthesis. A temporary prosthesis is fit about four to twelve weeks after surgery, depending on how well and quickly the suture line heals. The temporary prosthesis is your first prosthesis. It will help you(r): 1. get accustomed to putting on and taking off (donning and doffing) a prosthesis 2. skin get accustomed to the new pressures and forces of prosthetic use 3. learn to walk on a prosthesis

As a part of your first visit to the prosthetist, your residual limb will be evaluated for any scarring, redness, blisters, or any other problems that might effect the fit and function of a prosthesis. Your prosthetist will then go over the different options for prosthetic interfaces. Depending on your needs, you and your prosthetist will choose which is best for you. The most common types of prosthetic interfaces include pelite, flexible plastic and gel liners. Each has pros and cons that must be considered. Flexible plastic is a common choice in prosthetic design interfaces. There are many types of plastics

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available. Flexible plastics are moisture proof, will not compress and provide the ability to make numerous alterations to the fit of the prosthesis. They are very durable but do not offer the same amount of cushioning that gel liners do. Probably the most common type of interface is the gel liner. These liners are worn directly against the skin to provide cushioning while still allowing the ability for socket adjustments. It is important to understand that because the liner is worn directly against the skin they must be washed on a daily basis and allowed to dry thoroughly before reapplying. There are many different types of gel liners available and your prosthetist will work with you to choose the best one for you.

After the socket design and interface choices are made, the prosthetist will take a series of measurements from your residual limb that will be used in the fabrication process.

Your prosthetist will then take an impression of the limb using plaster wrap. It is from this impression that your prosthetic socket will be fabricated. This visit with the prosthetist usually takes about one hour. Following the visit, your prosthetist will schedule an appointment for you to be seen back in the office for a check socket fitting in about one week.

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Check socket fitting

When you return to see your prosthetist for the check socket fitting, you should bring a pair of shoes with you. This visit will last about one hour.

Your practitioner will work with you to make any necessary adjustments to the socket for a better fit and to optimize how you walk.

The check socket is typically made of a clear plastic that allows the practitioner to view the pressures exerted on the residual limb prior to fabrication of your temporary prosthesis. During this visit, the prosthetist will allow you to stand in the prosthetic check socket. After adjustments are made to the socket to alleviate pressure points, your prosthetists will ask you to walk in the parallel bars to dynamically align the prosthesis.

Following this visit, the practitioner will fabricate the temporary prosthesis. This process normally takes about a week from the check socket fitting.

Temporary Prosthetic socket fitting

A temporary prosthetic socket is usually fabricated out of thermoplastic. The thermoplastic is used for its high adjustability to accommodate the changes in volume of your residual limb. It is commonly worn for 3-6 months. During this time period, you will have several follow up visits with your prosthetist to

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evaluate and adjust the fit of your prosthesis. The need for adjustability is crucial and therefore the temporary prosthesis may not look like a natural leg.2 During this visit, your prosthetist will again have you walk in the parallel bars and make any necessary alignment changes to optimize how you walk. Once all the adjustments have been made and you and your prosthetist are satisfied with the fit and function of the prosthesis, you will most likely be able to take the prosthesis home with you.

Prosthetic Follow up
After you receive your temporary prosthesis, your prosthetist will provide you with follow up appointments. It is imperative that you maintain these appointments and follow any instructions given to you by your prosthetist. Some of your obligations in between appointments will be sock management, hygiene, skin assessment, and exercises. Follow up appointments are usually made once a week after receiving your temporary prosthesis. These appointments allow your prosthetist to monitor any changes in your residual limb, and proactively manage any issues that may arise. After the first two months, the follow up appointments are less stringent, and are usually on an as needed basis determined by you and your prosthetist.

Sock management
While wearing your prosthesis it is common to experience a loss of volume in the limb throughout the day. This is commonly referred to as sock management or volume management. As your residual limb loses volume, the space between your residual limb and prosthesis will become greater and must be filled. Your prosthetist will provide you

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with several socks, of various thickness, that will fill in this space. Sock ply is determined by the thickness of the sock. The sock ply can visually be determined by either a number on the sock or the color of the sock stitching. The lower the sock ply, the thinner the sock. It will be your job to determine when socks are required and what size will best fill in the gap. It takes some time to get proficient with this. Be sure to talk with the prosthetist and physical therapist when you have questions. You will be taught how to manage your sock wear. This skill will be frequently reviewed because it is important in maintaining the fit and function of the prosthesis and health of your residual limb.

Prosthetic hygiene
You should wash your residual limb on a daily basis to help prevent the accumulation of bacteria or development of cysts or pimples. Simply wash your residual limb with warm water and a mild soap. The soap should be fragrance free to prevent any skin irritation. A good soap to start with is the same brand you use to wash the rest of your body with. If this does not work for you, consult your physician or a dermatologist for other recommendations. Always be sure to rinse thoroughly and remove any residual soap from your limb. When drying, try to pat with a towel rather than rubbing the limb. While this action is soothing to some peoples limbs, it is irritating to others. During this process you should check your skin for any abnormalities such as redness, blisters or anything that is otherwise abnormal to you. Any signs of prolonged redness or soreness should be reported to your healthcare provider right away. Early identification of problems tends to result in less complications. If something does not appear to be normal, always ask a professional.

Left: multiple plies of socks (6 ply, 5 ply, 3 ply and 1 ply socks). Also shown are socks made of specialized materials (silver threads in this case). Right: Person wearing socks in a transfemoral prosthesis due to volume loss.

Physical therapy
Often times your physician will decide whether your physical therapy should be on an inpatient or outpatient basis.

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Your physical therapist will work with you on safety and gait training (walking) with your new prosthesis. Gait training is a process in which the physical therapist teaches you how to walk safely and efficiently with your prosthesis with either an assistive device or without assistance. Your therapist will train you on gait patterns as well as how to navigate stairs and any other every day challenges that may occur. You will be introduced to many different exercises that may be accomplished at the therapists office and/or at home. A physical therapist will begin with certain exercises to help strengthen the muscles needed for ambulation. Some strength training exercises may be able to be performed at home with the use of TheraBand, a rubberized and resistive material.

It is important that you follow the regiment given to you by the therapist. The exercises and training you get in physical therapy will help you improve strength, balance and efficiency for walking with your new prosthesis.

Definitive prosthesis
Receiving your definitive prosthesis is a similar process to when you were given your temporary prosthesis. Your prosthetist will take several measurements and an impression of your residual limb in preparation for a check socket. The process for fabricating the check socket normally takes about a week. Once your check socket is ready you will see the prosthetist again so that adjustments can be made to the fit and alignment of the check socket in preparation for the definitive socket. In about a weeks time your prosthetist will have a definitive socket fabricated. The visit to fit the definitive socket typically takes about one hour. The prosthesis is dynamically aligned for optimal performance.

Left: Physical Therapist assisting person learning to walk with a transfemoral prosthesis. Right: Person with transfemoral amputation, performing strengthening exercise with an elastic, resistive band.

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over the cosmetic cover. The prosthesis can typically be finished to match your sound side. You will be given follow up appointments which will allow your prosthetist to assess your progress and make adjustments as needed.

Prosthetic hygiene
During the time between follow up appointments with your prosthetist, it is imperative that you maintain a high quality of personal hygiene. Any part of the prosthesis that is in direct contact with your skin should be washed daily and all residual soap needs to be removed. This includes but is not limited to: washing your liners (if you have one), washing shrinkers that you may be using and washing any socks that are used to maintain proper fit inside the prosthesis. It is also very important to wash your residual limb everyday to prevent skin irritations, infections, and/or other complications. Proper hygiene instruction will be given to you by your prosthetist. As always, ask is something seems unclear.

The definitive socket may be fabricated of a laminated carbon or other composite materials. Definitive sockets may also be made of thermoplastics as well. Once all adjustments have been made, you will be able to take the definitive prosthesis home with you. You will be given a follow up appointment in about one week. At this time, if the prosthesis is functioning well and no changes have to be made, a cosmetic covering may be considered if you wish. Cosmetic covering may be made of a soft foam or a rigid foam. It gives the prosthesis a natural appearance, typically matching the previous shape. The outer coloring/tone is typically incorporated into a nylon or a rubberized prosthetic skin that is applied

exercise
Now that you have your definitive prosthesis you may be a candidate for new types of exercises and

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activities. This is an important time to reintroduce your goals and desires to be sure that your therapist and other providers are working with you to best accomplish them. Simple standing and seating exercises can greatly increase your stamina and make your road to recovery much quicker. If you feel that you can accomplish more than you are given, do not hesitate to ask your therapist and prosthetist what other types of exercises and activities are safe for you.

which device is best for you, how to use it, and how long you will use it. Many people express a desire to walk without the use of any assistive device and many people with an amputation are able to accomplish this. Again, be sure to talk with your healthcare provider about what is realistic for you. Assistive devices are not only used for walking. Some specific activities such as driving require them as well. If your amputation involves the right side there are devices available that switch the pedals of your car to allow driving with the left foot. In the back of this booklet there are several organizations that offer assistance in obtaining these devices.

Assistive devices
Throughout your rehabilitation process, you may be prescribed different assistive devices to help you transfer, walk, and exercise. In the early stages following your amputation your therapist will begin training you to utilize various assistive devices to aid in walking. Some of the most commonly used devices may include the use of a wheelchair, walkers or crutches or a cane . It is common to start off with one device before you receive your temporary prosthesis. After receiving the temporary prosthesis, you may switch to something else. The situation is highly variable between different people. Your healthcare providers will discuss this with you. Similarly, you are encouraged to ask questions if you are unsure about

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Amputee athletic resources

Living with an amputation does not mean that you cannot live the active lifestyle that you once had. Below is a list of amputee athletic resources that you may find helpful. Activeamp.org Activeamp.org is an online connection for amputees with active lifestyles. This resource has many links to sports related amputee associations. Please visit their website at http://www.activeamp.org/ for more information. Disabled Sports USA Disabled Sports USA is a national nonprofit, 501(c)(3), organization established in 1967 by disabled Vietnam veterans to serve the war injured. DS/USA now offers nationwide sports rehabilitation programs to anyone with a permanent disability. Activities include winter skiing, water sports, summer and winter competitions, fitness and special sports events.3 For more information you can visit their website at http://www.dsusa.org/ Extremity Games The O&P Extremity Games is an extreme amateur sporting competition for individuals living with limb loss or limb difference. The O&P Extremity Games allows participants to demonstrate skill, persistence

and passion while competing for cash and other prizes.8 For more information, contact Beth Geno at 586.354.2260 or visit their website at http://www.extremitygames.com/ National Amputee Golf Association The National Amputee Golf Association was incorporated in 1954. At that time, NAGA was comprised of a small group of amputee golfers who played friendly games that quickly developed into regional tournament play in various cities across the United States. Today, NAGA has over 2500 members worldwide.5 For more information, please visit their website at http://www.nagagolf.org

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Amputee resources
The following is a list of online resources for new amputees. These websites have valuable information for every situation imaginable! American Coalition of America http://www.amputee-coalition.org/ Amputee Information Exchange www.amp-info.org Amputee Information Network www.amp-info.net Barr Foundation http://www.oandp.com/resources/organizations/barr Diabetes Resource Center www.diabetesresource.com Ford Mobility Program www.fordmobilitymotoring.com Life Center at the Rehab Institute of Chicago http://lifecenter.rehabchicago.org National Center on Physical Activity and Disability www.ncpad.org National Limb Loss Information Center http://www.amputee-coalition.org/nllic

references
1. American Academy of Orthotists and Prosthetists. For the New Amputee. (1991). pp 67.

2. American Academy of Orthotists and Prosthetists. Patient Care Booklet for Below Knee Amputees. (1998). pp 8-9 3. Disabled Sports USA. Improving the Lives of those with Disabilities. (2005). Retrieved on March 2, 2007 from http://www.dsusa.org/ 4. Muilenberg AL, Wildon AB. A Manual for Below Knee Amputees. (1996). Retrieved on March 17, 2007 from http://www.oandp.com/resources/patientinfo/ma nuals/bkindex.htm 5. National Amputee Golf Association. What is NAGA?. (January 3, 2007). Retrieved on March 28, 2007 from http://www.nagagolf.org/ 6. National Limb Loss Information Center. Amputation Statistics by Cause. (2005). Retrieved on March 14, 2007 from http://www.amputeecoalition.org/fact_sheets/amp_stats_cause.html

For additional amputee related websites, please visit http://hometown.aol.com/alegnomore/amputee/alpha beticalamputeelinks.htm

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7. National Limb Loss Information Center. Facing Surgery. (nd). Retrieved on March 28, 2007 from http://www.abcamputee.com/facingsurgery.pdf 8. O&P Extremity Games. Never Say Never Never Say Cant. (2006). Retrieved on March 17, 2007 from http://www.extremitygames.com/event/ 9. University of Utah Health Sciences. Physical Medicine and Rehabilitation. (2001). Retrieved on March 14, 2007 from http://healthcare.utah.edu/healthinfo/adult/Reh ab/amput.htm

This Informational Pamphlet was made possible by the contributions of the following: Department of Education Rehabilitation Services Administration Award #H235J050020
Demonstration Project on Prosthetics and Orthotics

St. Petersburg College College of Orthotics and Prosthetics

University of South Florida

College of Medicine- School of Physical Therapy & Rehabilitation Sciences College of Engineering-Mechanical Engineering Department

Chris Lemonis, CPO(c) Amy Mountain, CPO(c) M. Jason Highsmith, PT, DPT, CP, FAAOP Samuel Phillips, PhD, CP, FAAOP Scott Sanford, MEd, CO

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