- Welcome everyone to Wednesday Nite @ the Lab. I'm Tom Zinnen. I work at the University of Wisconsin-Madison Biotechnology Center. I also work for the Division of Extension Wisconsin 4-H. And on behalf of those folks and our other co-organizers, PBS Wisconsin, the Wisconsin Alumni Association, and the UW-Madison Science Alliance, thanks again for coming to Wednesday Nite @ the Lab. We do this every Wednesday night, 50 times a year. Tonight, I'm delighted to introduce to you Amy Paulios. She works with UW Health here in Madison in orthotics and prosthetics. She was born in Neenah, Wisconsin and went to high school in Neenah. Then she studied biology at Luther College in Decorah, Iowa. She got her advanced degree at Northwestern University. Tonight, she's gonna speak with us about restoring mobility to those who have experienced limb loss. Would you please join me in welcoming Amy Paulios to the Wednesday Nite @ the Lab?

- Thanks, Tom. Hello, everybody. I would like to talk to you tonight about working in the field of prosthetics. My 20-year career or so has been an enjoyable one, for the most part, and I find when I meet people, a lot of folks have a preconceived notion about what prosthetics is, who makes prosthetic limbs, and have a lot of curious questions about what somebody like me does. And so I'd like to share with you what has gone into my career, what I do on a daily basis, and what it's like to treat amputees. So the word prosthetist is a tricky one, as you might understand. It's taken my mother at least a decade to learn how to say it comfortably. So the word, if you break it into three parts is much easier, pros-the-tist. 

So a prosthetist is somebody who fits artificial limbs, and that's usually how I introduce myself because it's a tricky word and some people might think something else is gonna come outta my mouth. It's a really unique niche in health care, and I would love to teach you a little bit about it. This is a billboard that a company that I worked for circa early 2000s, mid 2000s, 2006 or so. We created for the company that I worked for, Prosthetic Laboratories, to celebrate what we all believe in, those of us who do this career, which is taking the dis out of disability. We have to think about what we can do to restore somebody's ability to ambulate again, to walk or to function even in the smallest capacity, and celebrate those things so that we can get people back to what they wanna do in their lives. So this is really what I believe in. I'm passionate about it, and I, that's why I'm talking to you about this career. So my normal work day is kind of all over the place and it includes a various list of things, such as patient care is obviously paramount. I work for UW Health, the Department of Prosthetics and Orthotics. I work out of three different facilities, both inpatient and outpatient. 

So primarily, my day is filled with patient care. When I'm not seeing patients, I'm working on cast work, which is the beginning process of making a prosthetic device. And I'll show you some pictures and explain that later. Documentation is obviously necessary in the medical field on every level, to document what we do and to get paid for it. I answer phone calls, return phone calls, answer emails, return emails, do ordering of components so that I'm getting the device, the components that are necessary to build each prosthesis. I do a bunch of teaching, so various aspects of our affiliates like physical therapy, nursing, even the surgical staff. We bounce ideas off of each other all the time and we all help each other learn what the other parts of the team do so that we can provide better care all around. And then the side things: driving, there are various companies that provide prosthetic care, which have to drive to go to various clinics or go to patients' homes, sometimes to nursing homes. I don't currently do that within the UW system, but I certainly drive between different offices. I'm involved in the bioengineering department and some studies that they're doing regarding prosthetics and the development of different prosthetic feet. 

That's the picture you see on your screen, which also entails research. We also do research within our department and give case studies presentations each month so that we learn about the latest interesting case that our colleagues are working on so that we can learn and better ourselves education-wise. And then I'm also on the exam team, and I'll get into this in a minute, for ABC, the American Board for Certification, which is the certifying body to credential those that provide prosthetic and orthotic care like I do. So I just mentioned ABC. The American Board for Certification is our national accrediting and certification board. And it has its beginning way back in 1948. It became the, it's the quality standard of care. And you have to sit for exams and go through these stringent requirements to be able to provide care for patients that we take care of and also to get paid for it. ABC is the only credentialing body with the recognition of ISPO, which is the International Society for Prosthetics and Orthotics. And it is closely affiliated with the National Commission for Certification Bodies and is heavily involved in education and recognizing those that are ready to get the credential to practice in our field. 

ABC is recognized and deemed the authority for facility accreditation by CMS, the Center for Medicare and Medicaid Services and the VA, the Veterans Administration, as well as many health care insurance providers throughout the country. NCOPE is the education arm of the field, and I'll get into that in just a second. So ABC certified individuals like me are considered leaders in the profession and they are expected to provide the highest-quality patient care and also be involved in research and device design. ABC certified individuals have to meet certain stringent educational standards, clinical training, and complete an assessment of competency. In other words, pass boards to get certified to do what we do. This is a very extensive list of all of the certifications that ABC awards for those that have met the standards required for each part of the profession. The two on the top are those that I will describe most closely because they go hand in hand. So I am the second one listed, the ABC certified prosthetist. I make artificial limbs for people and I am involved in the design, the fabrication, the fitting, the modification, and the maintenance and the repair of prosthesis to restore physiological function and/or cosmesis. A certified orthotist works with what exists on the body and helps change its function to perform at an optimum level. 

A certified prosthetist replaces what's missing in an amputee population; the two work hand in hand. Oftentimes when I'm treating an amputee, an orthotist in my office will be called in to treat a pathology perhaps on the patient's other leg, or I have to work with them to work on alignment or a pathology that involves both disciplines. This speaks to why the profession has now moved to a dual certification. So most professionals coming out of the master's level degree program at this time are going to be dual certified. They're gonna be certified, or they're gonna earn their certification in both prosthetics and orthotics. Not one discipline or the other, like I did. When I went to school in the early 2000s, you could go to school for just one discipline or the other or do both back to back. And now the master's level programs are for both disciplines. Running further down the list, the fourth thing listed is a certified pedorthist. Those are very important practitioners within our companies that deal with just below the ankle issues. 

So they're specialized in foot issues and fitting specialized shoes. Oftentimes those clinicians are the ones who help patients with wounds on their feet heal so that they don't become my patient ultimately. And then further down the list, we have certified fitters for mastectomy. We have certified therapeutic shoe fitters. Orthotic assistants and prosthetics assistants are exactly what they sound like. They can't do the entire job of a certified clinician, but they can assist in their work. And then technicians are those that are fabricating the devices in the various laboratories, or companies that make the devices themselves. They may or may not be involved directly in patient care, but they are involved very much so in the fabrication of the devices that are used. The ABC organization spans back to 1948, and I thought this was a fun thing to share this picture, where it was actually the beginning of ABC as it stands today. In the early early days, it's a CPO and three orthopedic surgeons who decided that they were gonna found this certifying body. 

Of course, it's gone through many, many, many changes since then. But here is a picture in 1951 of one of the first ABC certification exams administered in New York City in 1951. In that first year, 51 individuals attained their certification, and I bet you'll notice that everybody in that picture is not like me in one way. As you might guess, the field at that time was extremely male-dominated, and that has changed quite a bit over the past 60 to 70 years. The abcop. org website is an extremely helpful one. If anybody in the audience wants to learn more about this profession, the abc. org website is extremely helpful. It would allow you to look up what the career is all about, the certification requirements. You can find facilities that are accredited to take care of an amputee or an orthotics patient that you might know about. 

Anybody who is interested in the field can learn a lot more about this field of prosthetics and orthotics from this website. NCOPE is the educational arm of the career. So if anybody in the audience is interested in becoming a clinician or a technician or an assistant or a fitter in any realm of the previous list that I showed, the ncope. org, N-C-O-P-E. org website is where I would direct you to look up any and all information you want to know about the education program and the process that it takes to get certified to do what we do. This slide is a very interesting one because it shows all of the educational programs currently available for orthotics and prosthetics education. There aren't a ton of them, but there are many more than when I went to school at Northwestern University in 2000. That was an easier trip for me because from my home, I could ride the train to downtown Chicago. But there are several in the Midwest, including Eastern Michigan University, and the Concordia University of St. Paul and Century College up in Minnesota. 

But there are a smattering of programs across the country to choose from. So let's talk for a minute about amputation itself and how many amputees actually live within our community. Not many people realize just how many amputees there are within our everyday life. In current, in the greater Dane County area, you might come into contact with an amputee every once in a while, but within the three or four hospital systems within Dane County system, I believe we do between one and five amputations every single day. That is a far higher number than most people generally realize, and those are patients that I see a majority of, because of my position within UW Health system. Nearly 2 million people are currently living with limb loss, and 3 in 500 people in the U. S. A. have an amputation of some kind. It is a fact that there are 500 amputation surgeries done daily in the U. S. , and the following reasons are the reasons that account for people needing amputations. A great majority of the patients that we help are those that deal with vascular disease, primarily diabetes and peripheral artery disease. That accounts for 65% to 82%, and a majority of the lower limb amputations that we treat. Again, I'd like to emphasize here that I am talking specifically to lower limb amputation. I am not an upper extremity specialist by any means. I am aware of upper extremity prosthetic care, but I am primarily always treating lower limb amputees in my practice. Trauma is the next highest cause, and it's 16% to 45%. The key factors in this would be age, gender, war, and jobs. The third most common reason for amputation is cancer, which is about less than 2%. 

And congenital amputees are about 0. 8% of our patient population. In the Madison area, the area that I treat amputees, I would say I have a disproportionate number of trauma, cancer and congenital amputees that I treat because of being a level one trauma center. I treat patients with reasons for amputations such as motorcycle accidents, falls from construction job sites. And then I treat a fair number of cancer survivors because of our cancer treatment center. And I treat a fair number of congenital amputees because we have a children's hospital. So congenital meaning somebody who was born without a foot. So let's talk for a second about prosthetic types and the timing of when somebody gets a prosthesis. This is something that is not very well understood. When somebody first has an amputation, the only goal within the first six to eight weeks is to protect that limb and help that patient to heal. 

So an immediate postoperative prosthesis or a rigid removable dressing, which is a protective cast, can be used in that early acute care phase. We're basically protecting the residual limb to help the patient safely navigate around, transfer from a bed to a wheelchair, transfer from wheelchair to toilet, things like that. We're protecting that limb; that is paramount. The very first prosthesis somebody gets is not the one they're going to have forever. And that's another common misunderstanding by people. Some folks might think that you get one prosthesis for life and that's it, and that's not true. And it would be almost impossible to keep one device fitting as the anatomy in somebody's residual limb changes. So the very first prosthesis somebody receives is called a preparatory prosthesis, and that can be fitted at the very soonest about two months after surgery, which is a quite aggressive timeline. Generally speaking, we are right around three months after surgery that we're fitting the very first prosthesis. And that device will fit as long as we can modify and keep that socket fitting somebody's anatomy as it changes shape within the first 6 to 9 to 12 months. 

As somebody wears their first prosthesis, because of the tension that the socket puts on the soft tissue anatomy on the residual limb, the residual limb will change and the socket has to be adjusted to accommodate those changes. Ultimately, when the limb is more mature and it has stabilized in size, a definitive prosthesis is created and that's intended to last a lot longer, perhaps one, two, three, maybe five years. It's all dependent on how much anatomical change happens within the first several months of use of that prosthesis. And that is another factor that people have to, that you might wanna remember, that somebody will not just get one definitive prosthesis over the lifetime. If they were to gain or lose 15 to 20 pounds or their activity level changes, or perhaps, unfortunately, they might have another medical issue that changes the type of activity that they are doing every day, they might need a different type of prosthesis. And then lastly are the questions I get most often are about special use prostheses. Many people will ask if they can get a prosthesis that will allow them to run or to perhaps water ski or to go swimming. Those are all options, but they're not often paid for by insurance for one thing, and also might be above and beyond what an insurance or a payer, paying source would consider medically necessary, which is a bit frustrating for those of us who provide this type of care. We wish we could provide everybody with a device for every type of activity they want to do. When it comes to coverage for prosthetic care, generally speaking, the number one issue is medical necessity. 

What does somebody, what is medically necessary to help somebody continue to thrive and to live a healthy, safe life? That is our primary goal and hopefully we get that patient back to nearly 100% of what they did before. So as I mentioned before, the earlier goals after amputation simply involve wound healing and protection of that limb. We do a lot of post-surgical management, we do compression of the limb, and I'll show you what that looks like in a second. We are worried about preventing contractures in the body. So if somebody sits in their wheelchair while they're healing, their hips and their knee joints might get really, really tight and we don't want for that to become a permanent fixture. So we encourage that they stretch out their knees and their hips, and we have to manage edema or swelling within the limb. So application of a compression garment such as a, what we call a shrinker sock, is used after surgery. Once the suture line is able to tolerate it, we apply a compression garment to help minimize the swelling within the limb and aid in healing. And then we're also concerned that somebody get functionally independent much earlier, which means we wanna protect that limb so that they can move about safely so they're not getting sluggish and getting deconditioned and getting weaker because they have to feel like all they can do is sit. So the the ways we contend with that are twofold. 

One is through what we call an immediate postoperative prosthesis or an IPOP. An IPOP is applied in the operating room. The pictures shown are of my hands in the operating room, where we're putting many layers of padding and soft garments within a plaster cast, which is actually attached to a prosthetic foot, which will allow the patient to stand and do minimal weight bearing the day of or the day after their amputation surgery. As you might imagine, this is a very aggressive way of treating new amputees, but it has a huge mental component. So if somebody knows they have to undergo amputation, but they can wake up wearing a prosthesis and get up and stand up right away, and again, this is not for everybody, they might have a better understanding that they're gonna be okay, they are gonna walk again, they are gonna be active again because they're getting up right after their surgery. This takes a huge amount of coordination between prosthetics and the physical therapy specialists within the system because as you might imagine, this takes a lot of guidance for the patient to be told how to stand up, how to carefully maneuver, and not to bear all of their weight on this cast. It's for touchdown, lightweight weight-bearing at first. The other option that we apply for somebody who's newly, who has just undergone amputation, other than a compression sock, is called a rigid removable dressing. And that's a lightweight cast, a protective, removable device that's taken on and off as needed to both protect the limb and to allow the patient to check their wounds, but also to protect them as they get up out of their chair, use crutches or a walker or a wheelchair so that, heaven forbid, they bump their limb, they're not gonna break their suture line back open. The pictures shown in the slides are what we call a donning tube. 

So it's a means of applying a compression garment without four hands. These are my best friend when I go into fit a new amputee and get them fitted with compression socks so that the patient is not in a lot of pain as I apply that garment. An above-knee amputation can also be fit with compression garments. The difference is that that includes a belt to help that garment stay in place. So these are all acute care phase or immediate postoperative phase items that we do when we're first working with new amputees. And when we talk about moving them into their first prosthesis or perhaps from their first prosthesis to their second or their third to their fourth, what we have to consider is what they're able to do or what they're determined to get back to doing. And that involves what we call K-levels or ambulation levels is the Medicare determinant. The function levels K zero through four are the defined levels that we have to follow when it comes to the components that we can pick for somebody when we're fitting, when we're creating and making their first prosthesis. A level zero amputee ambulation level means that they have no potential benefit from use of a prosthesis. And this does apply to some people, unfortunately. 

It might be somebody who doesn't have the strength or the wherewithal to push up from sitting in a chair or lying in bed and can't get upright. As you might imagine, a prosthesis is not appropriate for that person. However, moving on to level one, this might be somebody who wants to stand and use a prosthesis to simply take a step or two or to pivot and transfer from their wheelchair to their bed or their wheelchair to toilet, things like that. Or maybe just take a couple steps across their kitchen and at a very low level of ambulation safely. That's a K-level one. K-level two would be somebody who can walk throughout the home and community at one speed. And this applies to a lot of amputees in various age levels. The difference between level two and level three is that level three involves somebody who can walk at variable cadence or different speeds. If they were crossing the street, for example, and the walk changed from walk to stop and they could speed up to get across. That would be an example of variable cadence, and somebody who can perhaps walk across uneven ground like across, up and down a curb or across grass. 

Level four is somebody who runs. This usually applies to the kids that I treat or the, a lot of cancer survivors, young folks that were previously very active and get well again, and plenty of our military survivors too from amputation. I like to explain what goes into making a prosthesis with a side note of an explanation of why prosthetic limbs are so expensive. This is a extensive list of what goes into making a prosthesis, and the dollar amount paid for a device involves an extensive amount of behind the scenes actions that not a lot of people understand, and I'll explain what I mean. So in making a prosthesis, it involves the following: evaluation, insurance authorization, the impression of the limb and measurements taken, modifying a cast that's taken of the limb, fabricating a practice socket or a test socket, the fitting of the test socket, fabricating the prosthesis itself after the test socket is fitted, the dynamic alignment of the socket after it's made, the final delivery when the patient is seen for actually getting the prosthesis, and adding a cosmetic finish at the end. That's most, but not all of the items that go into making and fitting a prosthesis, and all of that is wrapped up into the cost or the price tag of a prosthetic device. That's something that's not very well understood because people often, their jaw drops when I tell them that a moderately average cost for a prosthesis might be in the mid teens to high teens, thousands of dollars. The reason that the devices are so expensive is because it includes every single part of everything that I just mentioned and the components themselves, which can be, I mean, a prosthetic foot can vary between hundreds of dollars to tens of thousands of dollars just for the prosthetic foot component. So it's worth understanding that all of those things go into the price tag on a prosthesis, and then the adjustment and the follow up for 90 days after somebody gets their prosthesis. So I'd like to show a few pictures of what making a prosthesis actually looks like from the lab because these are kind of behind the scenes look into what we do. 

So evaluation and casting involves taking anatomical measurements, recording those on our measurement sheets so that we get a full dimensions fill-out of every limb that we're gonna make a prosthesis for. So we're taking circumferences, medial-lateral dimensions, anterior-posterior dimensions, length, height that it needs to be. We're measuring how much space there is for a prosthetic foot. We're measuring how much clearance somebody might have if they need a knee joint, and we're measuring for the socks that they're gonna need and the gel liners that are gonna be the interface within the prosthesis. Then what we'll do, well, there's two different ways to capture somebody's shape, and by that I mean, how do we get a negative impression of a positive model of somebody's limb? The picture on the right shows a plaster of paris model or a positive model after a cast was taken of a below the knee amputee's limb and filled with plaster, which is then being modified to help shape that first socket that's going to be made. And the check socket, or the first socket that's made for somebody is made directly from that cast. Another way of doing this is by digital tracing. Technology nowadays is wonderful and allows us to use scanners to take a shape capture of a residual limb and avoid the mess and the time that using plaster of paris creates when we're physically casting somebody. We can take a digital tracing and it recreates that limb on the screen for us. We can then modify the dimensions of that positive model right on a screen and send that information to a technician to create the socket for us. 

I as a, what somebody might call, a more conventional clinician, I still like hand-casting plaster models of my patients' residual limbs because I feel that gives me the most accurate shape and an understanding of exactly how tight I can make a socket, where it needs contour, where they might need a relief for a bony prominence, things like that. Sometimes it's hard to break old habits. After the cast is modified, we make what's called a check socket. And a check socket is generally a clear, kind of crudely assembled practice socket that we try on the patient to see what changes need to be made. The pictures shown are a variety of my patients, some missing one limb, some missing two. And as you can see, the ages of the patients I treat vary greatly from infants to adults. To date, my youngest patient has been I think eight and a half months old, and my oldest patient has been, is 98, I believe, years old. And it's a great joy to treat patients with that much variability in age. But the check socket fitting is again a trial of the shape that we've made. Oftentimes, we have to make small changes to this stage to help the patient get the right height, get the right alignment, get the right fit. 

Sometimes we do more than one of these fittings, and then this prosthesis gets sent to finish to look like a permanent device. So we take the first, what we call check socket, turn it into a finished laminated socket so that it's a safe and permanent device for somebody to use long-term. And the progression is really, really exciting. One of my favorite parts of what I do is when I first meet a patient, who I've seen only ever in a wheelchair, and then at some point they come walking in the office door. That is extremely gratifying. And then the progression from check socket fitting to lamination, and you can see this patient went from a check socket pair of legs to her first temporary pair of prostheses, to her first definitive pair of prostheses, and finally to her fourth pair of legs and is running around independently, and it's hard to keep up with her when she visits my office. So again, a preparatory prosthesis is the very first prosthesis somebody is fitted with and takes home with them. The goals of that first device are simply to allow the residual limb to mature to get less sensitive. Hopefully they're gonna become less painful throughout the use of this preparatory prosthesis. The limb is gonna change size and shape as they mature and as they get more active. 

The patient's gonna get stretched out a little bit more, learn how to walk again, learn how to use various gait aids, such as a walker or a cane or crutches, and then eventually return to some level of functional independence. From there, we go to the definitive prosthesis, which again is meant to last a lot longer. When we talk about prostheses, we talk about the terminology applying to the various levels of amputation. In other words, we don't just use one term to apply to any level of amputation. We get specific to where that amputation occurred, and that's how we term the prosthesis or the device that's needed. So anything from a partial foot, which is partway through either the toes or the transmetatarsal bones, which are the long bones in the forefoot, to a midfoot amputation to a Symes, which is an amputation at the ankle where the bones are taken apart. This is a unique amputation level because it allows the patient to bear weight through the end of the limb and it's a very, very active. . . Those tend to be extremely functional and very active amputees that have Symes amputations. 

By far the most common level of amputation is below the knee or transtibial level amputees. 70% or more of amputees across the country are at the below the knee or transtibial level. Those are the patients that we see by far most often and are some of our most successful. Retaining your own knee joint as an amputee is extremely valuable, and there's a very, very huge functional change when it comes to somebody who can use a prosthesis successfully that has their own knee joint to somebody who has to rely on a prosthetic knee joint, which is anybody higher than a transtibial level amputee. The one step up from a below the knee amputee or transtibial level amputee would be what we call a knee disarticulation. And that is what it sounds like, it's a disarticulation of the joint at the knee or through the knee amputation. So that patient has their entire femur and is able to bear weight through the end of the femur, which is an extremely advantageous fact for that level of amputee. They still do need a prosthetic knee joint, but they can bear weight through the end of the limb. Next is a transfemoral level, which is above the knee or through the femur, and then higher amputations would be through the hip or at the hip or through the pelvis. The highest level amputations are generally due to some sort of a tumor situation, is generally the reason why somebody would have an extremely high amputation level. 

These are pictures to show what residual limbs look like at the below the knee or transtibial level amputation. And as you can see, these people are all different ages, all different ambulation levels, and all different capabilities. The patient in the lower left was at one time missing one leg and due to diabetes and poor circulation ultimately lost the second residual limb below the knee. So she was bilateral. She went, if you can remember what we talked about earlier with the ambulation levels or the K-levels, she went from what I would have considered to be a K two level, which is the single speed ambulation, kind of getting around her house with a walker to when she went from one prosthetic leg to two, she was basically downgraded from a K level two to a K level one, where it really went from being able to get around her home and maybe get out to the car. She went from that to really needing a lot more assistance and basically using both prosthetic legs just to stand up and pivot transfer out of her wheelchair to the bed or to the commode or to the couch in very, very short distance ambulation. That's a very common story for somebody who has diabetic neuropathy and loses one limb and then the other. They may change ambulation levels up or down, but generally it goes down. The patient on the very right is that is a fully finished cosmetic cover. Very beautiful. 

It looks obviously quite good, I have to say. I really appreciate when somebody walks so well and the cosmesis on the device is finished so well that you wouldn't actually know that that's a prosthetic limb unless you've really looked hard at the device. But not everybody receives a fully finished prosthesis for a number of reasons. One can be cost; it is moderately expensive to get a fully finished cosmetic cover on the outside of a device, but some people just don't care. I would say compared to 20 years ago, many, many of my patients now don't worry about how their prosthesis looks as much as they used to. And that might be just a more, a common understanding about amputation and the prevalence of perhaps the wounded war veterans that have come and become much more active, and they're more seen throughout the community. The Paralympics has become really popular. So I think for all the right reasons, amputation is becoming a little bit more well understood and a lot, and it's something that people can show that they're able to wear a prosthesis and get on with life and be proud of the things that they're able to do rather than what they're limited from. Here are a couple pictures of transfemoral prosthesis, which are, again, that's an above the knee amputation level. That is significantly more challenging than if you retain your own knee joint in an amputation because you have to use musculature above the femur in your, mostly your gluteus muscles and hamstring muscles to pull that knee joint back and control it from flexion to extension. 

The exceptional advantage of microprocessor knees is shown in the picture on the right, where somebody is carrying a baby down a slope. This was something that would be unheard of 40 years ago, 50 years ago, for somebody to trust a prosthesis with an artificial knee to do this. But it speaks to the higher level technology that we have available to us now, and it's very exciting to be able to provide microprocessor knees to patients that basically help them to control their knee joint in ways that wasn't possible before the technology that exists now. Some of you might be wondering how much those things cost, and they are extremely expensive. I would say it's comparable to a pretty nice car, but the change in quality of life that people can enjoy if they have the advantage of microprocessor technology is quite significant. I wanna point out before I finish that there is an amazing organization called the Amputee Coalition of America that provides a lot of support and educational resources, and I wanna make sure that people understand if anybody in the audience needs any support or education or wants to connect with amputee communities throughout the U. S. , this is a fantastic way to do so. The Amputee Coalition not only provides educational resources, it provides peer to peer support. A few years back, my group was able to help about a dozen patients, amputee patients undergo peer support training and get trained so that when somebody new is going through a limb loss situation, they're able to call somebody within their community and get education and resources and support that they need. 

So anybody listening, if you need any sort of, again, education, support, or advocacy, the Amputee Coalition is a fantastic resource to turn to. The mission is one that's quite well understood. Their mission is to reach out and to empower people affected by limb loss to achieve their full potential through education, support, and advocacy and to promote limb loss prevention. I feel like this talk has allowed me a little bit of a way to do that for you, and I hope that you've learned a little bit about prosthetics, about amputation, about what somebody like me does on a daily basis. And our goal is to get people back to living on two legs and getting back to the life that they wanna lead and being more active. I really appreciate you listening, and have a great night.