Sep 30 2016 - Another new socket...No.10

I have been wearing my latest socket quite a bit. It is very uncomfortable, but...
IT DOES NOT CAUSE PAIN!!!!

It is hard to explain the importance of that to me.

The end of my stump that is farthest from the body center, is called the "distal" end. Actually, distal is the farthest of anything from the center of the body. Proximal is the end closest to the center of the body.
This is Doctor talk, but does help is being precise about body directions.

The problems of my stump are mostly at the distal end. Pressure on the distal end is very painful. If the skin on the stump is pulled toward the hip (Proximaly), it puts pressure on the distal end. So when donning (that is medical talk for "putting on")  a socket, the friction force on the skin, toward the proximal end of the stump, causes skin to pull and puts pressure on the distal end. Of course this is also a factor when my entire body weight is on the stump inside the socket.

This latest socket is kind of weird. My stump is about 35 cm long (14 in). This socket is build so that the most distal half of my stump is not in contact with the socket. The distal end just floats around like a clanger in a bell. This means that 100% of by body weight is supported on just 15 cm (6 in) of the proximal end of the stump. By putting all the weight up high on my thigh fat, it makes the pain on the distal end zero. Having all the weight concentrated is a small area is not comfortable. Like wearing shoes that are way to small.

The big problem with having the distal end floating, is proprioception.
Wiki says:
proprioception pro·pri·o·cep·tion (prō'prē-ō-sěp'shən) 
n. 
The unconscious perception of movement and spatial orientation arising from stimuli within the body itself.

Proprioception is deteriorated with drugs and alcohol. That is why traffic cops have you close your eyes and try to touch your nose with your fingers. 
By having the stump distal end floating, I loose track of, and have no feedback of, where the prosthetic leg is. I must walk slow, and watch where the leg is to know if it is in front and ready to have weight put on it.

I spent 4 hours at the prosthetic place today. We were determined to improve proprioception, comfort, and control. 
This socket needs me to wear a silicone liner against the stump skin. The socket is made of fiberglass and carbon fiber. Inside the socket is a thick plastic liner. It has the feeling of a small tire. It is flexible, but tough.

Here is me bending the inside liner of the socket with my thumb.

The inside liner is riveted to the fiberglass shell. The vacuum is formed between the flexible socket liner, and the silicone liner on my stump. That is what keeps the prosthetic leg from falling off when I take a step. So there is the stump, silicone liner, flexible liner, then fiberglass shell.

What we have been doing the last few days was putting pieces of thin foam between the flexible liner and the fiberglass shell. These foam pieces are used to push against the stump closer to the distal end, to increase proprioception. This works, BUT, the pieces of foam also increase the force needed to push the stump into the socket. The more foam, the more proprioception, but more pain. :-(

Today we cut big holes in the fiberglass shell, and put thick foam on the pieces cut out.
At first we had a ratchet assembly that pulled a stainless steel cable. This broke before we could get enough force.
Then we used my big hose clamps to pull the cut out pieces in tight once the stump is inside the socket. So the stump fits in the socket easy, THEN we add the force near the distal end to aid in proprioception and control. These movable pads put force on the femur, without putting force on the distal end.

When tight, there is a LOT of force on the stump sides. This steadies the femur and really gives me good control and it makes the whole prosthetic feel so much more like a part of my body.

The next thing we need to work on is the force required. When I release the clamps, I feel the blood rush into the stump.

But there is NO pain. I can go shopping and get in and out of the car easily.I wore the leg about 6 hours today.
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I passed the learners test part of getting a South African drivers licence. Next is to get the car registered into my name from Maddie's name. She mailed me all the required documents express, registered mail, about 10 days ago. The post office advised me today that I can go collect the documents at the post office. 10 days for express mail to go 1300 km (600 miles).

To get the car in my name needs a roadworthy inspection. The tires won't pass because they are non standard. New tires are R3000. The one brake is leaking, and that is R1000. This money is coming out of the money set aside for plane tickets to go to America. Between this and the driving lessons, I have used half the ticket money. I am now way short of money. But being short of money, is nominal now days.

I decided I'll take the drivers licence road test, in my car. It is much easier to get in and out of than the driving schools cars. I have also removed the rest place for the left foot, to give my prosthetic leg more room. But first I need the car in my name.
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Today at the pharmacy I chatted about an hour with a guy that works there. He is a right leg, above the knee amputee. It is so nice to hear someone complain exactly about the things, that I complain about. :-)

He has been using one of the very first bionic knees for about 10 years. An OttoBock C-Leg. He got a loaner unit for 2 weeks of an Ossur Rheo-3 knee with a bionic foot.
He said after a few days he was walking up and down stairs, and up and down steep slopes without a thought. He said for 20 years he has had to concentrate on walking, but with the Rheo bionic foot/knee combination he occasionally, actually forgot about the prosthetic leg.
He has had many falls in his 20 years of amputation. He has been hospitalized 3 times from falls. Usually when accidentally stepping backwards, and putting weight on the toe that breaks the leg loose, and it suddenly collapses. His wife has been with him all three times.
While wearing the loaner Rheo knee/foot combination they went to a party, and were standing talking to a guy, that was opening a beer. The beer squirted foam all over. He and his wife both jumped back. Then she screamed and reached for him, knowing he would fall. But the computer cut in and locked the knee, and he didn't even stumble. She looked at him and said "We are buying that leg."
That leg costs R850,000 ( $70,000). They are selling one of their rental houses to buy the leg. He is very excited.
He had to give the Rheo back after 2 weeks. He says his old bionic leg feels like an dangerous antique.
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June 7 2016 - Life update, and prosthesis update.

Ten days since last blog.
Four of those days were at the prosthesis shop getting my socket reworked. My socket problems are now getting almost trivial. I am not concerned with walking, but concerned with walking fast for 5 km. A very small miss fitting of the socket while moving around the kitchen, can becomes a major problem when walking 5 km.

Last Saturday I did another Park Run. I finished in 1hr 24min. That is about a 25% improvement from the  run a week before. At that rate of improvement, I will break the sound barrier in just under 6 months. (26 weeks)

At the prosthetic shop I met a man with a left leg, above the knee, amputation. He lost his leg 5 years ago. He spent one year on a Mauch Knee, one year on a Total Knee 2000, and now uses a bionic Rheo Knee. I asked him a ton of questions in just a few minutes.
He is about 30 years old, and a livestock auctioneer. He spends 5 days a week walking among cattle, sheep and pigs. He is on his feet the whole day. He says the bionic knee changed his life even more than when he got his first prosthetic leg. He says the bionic leg doesn't even need thinking about. He puts it on in the morning, and next thinks about it that night when he takes it off. He said to "Don't try one unless you have cash to buy one."
The hardest thing for him was walking up and down the many ramps. Herding cattle into trucks and out of truck into pens. He said that ramps are shit things, literally. With the Total knee 2000 and the Mauch knee he battled. With the Bionic Rheo Knee he doesn't even think about them.

One thing you have to understand about prosthetics, is the "K" rating. Medical aid societies had to have a way of grading the potential for an amputee to use the prosthesis. They don't want to pay for a super expensive prosthesis, that will only live in the closet. They developed the K rating to describe an amputees mobility potential.
K1 - Inside the house, usually with a walking aid.
K2 - Slow walking around the neighbor hood, and ability to navigate small obstacles like curbs.
K3 - Long walking, and ability to go up and down stairs, usually step over step.
K4 - Athletics. Like Running, or Tennis.

If you are a K1, then the medical aid will not buy you a super running knee.
I am a K3.
The livestock auctioneer is a K2. The Bionic Rheo Knee is for K2 amputees. It is not an athletic knee. No bionic knees are rated for K3 or K4.
The Total Knee 2000 I am using now is a K3 Knee. The Mauch knee is a K2/K3 knee. There are very few K4 knees.
The K rating does not mean it is a better knee, or costs more. But it signifies usage. A K4 knee may be a problem in the kitchen because it needs to break loose easy and quick. Not very stable when reaching for a cup of coffee.
Of course, the best would be to have many legs, for different purposes. A K2 leg for weekend bar-b-ques or office work, and a K4 leg for sports.
 The auctioneer still uses his old Mauch Knee leg when he goes Bass fishing.
He isn't on Medical Aid, but has a rich father. The Bionic Knee cost almost 5 times what the Total knee 2000 cost him, and that was much more than the Mauch Knee.

I took my leg in yesterday. I am legless today and tomorrow. They are doing many mods to the leg. They are cutting holes in the socket. They put the socket in a laser scan machine, and it finds stress paths. Where there is no stress, they will cut holes. I think there will be 4 holes cut. Each about the size of my fist.
Since this socket has a thick silicone liner in it, the stump will be able to expand where the holes are cut. this will allow me to wear the leg much better in the morning when the stump is still swollen a bit. Now it takes 1 to 2 hours until my stump will fit all the way into the socket. Only then can I walk without limping. The holes should also reduce the chance of "hot spot" pressure points that may cause blisters.
They are re positioning the pylon attachment point to bring my feet closer together while standing. The closer my feet are, to my center of gravity while walking, means much less wasted energy.
My prosthetist found a used Total Knee 2100, and he will put it on, and let me use it for 2 weeks. :-) The Total Knee 2100 is an upgraded Total Knee 2000. It has larger hydraulics, and more adjustments. It is a K4 leg. Many of the special Olympic runners use a Total Knee 2100.
The best news is that Ossur will loan me a Bionic Rheo Knee. We will put it on in 2 weeks when the Total Knee 2100 comes off.

I would love a K2 bionic knee for going shopping, or trips to the mall. But I need a K3 or K4 knee for Park Runs.
In the back of my mind is the selling of my house in Texas, and the RV in Florida, so I can buy a good knee.
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Jan 9 - Learning to walk again.

07:00
I am starting this blog early because there have been a zillion things to write about, and I have been up about 20 minutes. I'll forget these things.

 Bradley told me a few times, that the morning procedure is to wake up, put on the silicone liner, put on the leg, THEN get up and start the day. Don't brush your teeth first, Don't pee first. Don't lay there first. He was especially concerned about today because of the strain the stump took yesterday, it will be swollen, and not fit easily into the socket.

 I wake up and lay there for a bit, after a great nights sleep, and I have to pee. I have been going to bed with out drinking lots of water. I know that is bad, but sometime it is so hard to get to sleep because of the phantom pain, that when I do get to sleep I want to stay sleeping for the maximum time. If I get up to pee, then I sometimes battle to get back to sleep. It is the maintenance of sleep that is a problem, as well as getting to sleep initially.

Then I realize, that the spray to lubricate the socket is in the other room. So I jump in the wheel chair and zoom to get the spray, lubricate the funny fold I have in the stump, put on the liner. (it is tighter than normal), then get in the wheel chair and fetch the leg, then head for the bathroom. All the grab bars in the bathroom make me feel comfortable. Then I lubricate the socket and slip it on, then stand up and bounce the stump into the socket. Well....Most of the way into the socket. I bounce and bounce. I press the vacuum release button and hear the whoosh, and feel the change in the stump. I figure that stump size will be greater if it is in a vacuum, so I release the vacuum, bounce, release the vacuum, bounce. Still not in all the way.
I reach down and remove the vacuum release button. I can now stick my finger in the hole, and feel how far the stump is into the socket. Still a few inches (5 cm) from where it was yesterday.
Poor Bradley goes and gets the new leg within millimeters of the correct length, and here I am within a few inches of the correct length because I can't get the stump into the socket, so the leg is about 5 cm to long. Duh!.

My main problem when walking with the new leg is when it swings forward. It swing forward in secret. I can feel nothing, yet the leg must be forward and the heel planted securely and the knee held back before it can take weight. If I think it is forward, and it isn't, then when I transfer weight to it, it isn't there,and I will fall. If it is forward, but the heel isn't down first, then it isn't locked even if it is forward, and I will fall. Now with the leg being 2 inches longer than it should be, the chances of it swinging all the way forward are very slim. It seems it always drags on the floor, and only the toe is on the ground which is the signal to the leg to collapse and swing forward, but it is behind me, and I don't know this.
It seems to be a percentage game...compute the probability of the leg collapsing and falling. 30% would be nice. I feel now there is a 50% chance the leg won't be locked when I put weight on it.
It needs something like a buzzer that buzzes when the leg is locked so I know it is ok to step forward. The only other way is to look. But looking requires being hunched over looking at the floor as I walk.

I still have to pee.

So I quickly sit in the wheel chair. but now the leg is dragging on the ground. Holding the leg off the ground requires one hand. One hand wheelchair operation is not easy. So I need to quickly find the left leg rest. I have not used the left foot rest since,... EVER. It is hiding behind the big chair. No way can I reach it. So I move the wheel chair to get a grabber while dragging the leg. I get a grabber, and get the leg rest, but it won't fit. All my adjustments to the wheel chair now make the foot rest unable to fit.

I still have to pee.

I grab the crutches and crutch/walk/stumble to the toilet, then proceeded to dribble all over my new foot.

Now I also remember Bradley saying. Always get the leg dressed for the day before putting it on. Opps..to late for that. Try to get a pair of shorts on a leg that you can't move, and the foot is permanent at 90 degrees, and it is "way" over there. I end up using 2 grabbers to get the shorts over the leg. But now how to balance while pulling the shorts up. I need some way to stand with both hands free to get dressed.
Then it dawns on me, Duh!....use the prosthetic leg as a leg, and just stand up. Duh! That works.

Yesterday I walked about 2 or 3 hundred meters total. Today if I make it to the bathroom without the leg collapsing, it is a major accomplishment. I do not trust this leg!

Now I want to sit at the computer. Back in the wheelchair, and drag the foot.
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18:00 Much Later
I have had a busy day. I decided I needed the glycerin, and alcohol to make the spray, that lubricates the inside of the socket before I put it on.
I crutch/walk to the car and drive to the local pharmacy. It is busy, and I have to park about 100 meters from the pharmacy. Once inside I gather up the stuff I want, but alcohol is only available at the prescription counter. ??
I wait in the line and finally get to see a pharmacist. He is an old man, maybe 55ish. I tell him what I want, and he looks at me and says that he is also an amputee. He said it sounded like I was mixing the spray for the socket. This is cool. We chat for about 20 minutes, and then he says "let me carry this stuff to the checkout counter for you." We then stood together in the checkout line for another 10 minutes. I must have asked a thousand questions.

He lost his leg due to bone cancer in the year 2000. He is an above knee like me, but his stump is much shorter than mine. He uses an OttoBock C-Leg knee. It is a bionic knee, and has a small computer in it.

http://www.ottobockus.com/C-Leg.html

Here is a picture from their web site:

How cool is that socket art. That's what I want.

 He says he needs a new knee, as he sent it for overhaul last year and they sent it back. They said a new one would be cheaper than fixing the old one. The C-Leg is supposed to last 3-5 years. He has worn that one 15 years. A new C-Leg is about R230,000. He says he will get the new ankle that talks to  the knee. When the leg swings forward, the toe is brought up by the ankle. This greatly reduces the chance of catching the toe during the swing forward phase, and also make sure the heel is the first thing to touch the ground..
He says that he no longer uses the socket mixture I was going to make. He says that the glycerin slowly builds up a layer of gunge, and is very hard to clean out of the socket. He also said that so much of what the prosthesis guy teach is to try to make you look as inconspicuous as possible in daily life. He said "F**k that. All that matters, is not falling."
He said that me using 2 crutches and the prosthesis is a great idea, and I should do that as long as I feel insecure.
He has had many falls. He broke his wrist on one fall, and his jaw on another. Face first onto a curb. His worst fall was at a friend house. He had just finished in the bathroom and he caught his toe on a rug. As he fell he grabbed a towel rail. The rail snapped in half, and one of the halves sharp end went into his palm, and came out near the elbow.
He showed me how he walks. He first unlocked his leg. While at work, he locks the leg straight, and only unlocks it when he gets in the car to go home. He does almost everything Bradley says don't do. He takes small steps with the bad leg, and large ones with the good leg. Bradley says to never do that.
He kicks the prosthetic forward hard. He can then feel when the leg is snapped straight, then he brings it down hard on the heel. I tried walking like he does, and it sure does feel a lot more secure. I can feel when the leg is straight, and the heel is down. It looks like a Nazi goose step. Bradley would have a heart attack if he saw me do that.

I walked about 400 meters today. All with the crutches, and the prosthesis. The left crutch is the fall protector. Most falls are toward the 10 O'clock position. I keep the left crutch pointed that way. The other crutch I use as an aid like I had a sprained left ankle. By keeping weight off the bad leg, I reduce the speed of a collapse if it happens.

I have learned a lot about things I like, and things I don't, regarding walking with a prosthesis. So much more to learn tomorrow.
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