Presentation on theme: "Exercise and sport for amputees"— Presentation transcript:
1 Exercise and sport for amputees Erin KennedyPhysiotherapist, Westmead Hospital2014
2 What does the research tell us about amputees and physical activity? The amputee population is largely elderly with low levels of fitness or activity (Davies and Datta, 2003).Those with limb absence could and should engage in physical activity to improve their health and social inclusion (Webster et al 2001).Common for amputees in a rehabilitation program to achieve a level of physical functioning which may not challenge them to move beyond the basic goal of walking (Deans et al, 2008).
3 Are people with amputations participating in physical activity? A recent review of 12 articles in Prosthetics and Orthotics International asked the following questions:Are people with amputations participating in physical activity?Are these people participating at the same level as before their amputation?What are their motivations and barriers to participation?Deans et al (2012)
4 And found…. People with amputation are generally inactive. 68% of amputee population V 40% general populationThere is a decrease in the level or leisure activity following lower limb amputation.However, satisfaction with changed physical status remains high.Likelihood of participating in physical activity exercise and sport increased if they participated prior to amputation.If they do return to physical activity they opt for less strenuous activities where a prosthesis is not required or not functionally dependent on a prosthesis to participateDeans et al (2012)Still satisfied? Low expectations… more concerned with maintaining relationships and socialisation then improving mobility.
5 Motivations for physical activity include: Health benefitsSocial interactionStress reliefIncreasing self esteemImproving body imageMastery theoryMastery of prosthesisincreased self efficacyincreased prosthetic useIncreased physical activityDeans et al (2012)
6 Barriers for physical activity include: Physical limitationLack of confidence / embarrassmentBody imageattitudeServicesClimate/physical environmentIncomeStump painProsthesisDeans et al 2012Inability to run, jumppoor endurance,decreased speedAll of these things can be improved with trainingPerception that participation in sport is only possible with specialised high performance prosthetic technology.May be true for competitive sport, not for general physical activity or recreation.Recreational legs not prescribed for persons over 18yo in NSW.Recommendation for bespoke terminal devises for children with UL amputation prescribed on individual consideration of children’s motivation to participate in certain activities (walker et al 2008).
7 So….How can we encourage our patients to engage in regular physical activity?Setting goalsEducationHealth benefitsRecommended daily activityAppropriate forms of exerciseLooking after skin/stumpAddress misconceptionsProviding a positive environment
8 And… Which patient should be challenged beyond walking? Those who were previously physically active and are medically wellAge range ??Level and number of amputations??K 3-4Community ambulation, able to vary cadence and perform activities beyond basic locomotionAmp pro score> 376mwt> 250mGailey et al (2002)Benefits of exerciseWeight controlImprove flexibility, strength & balanceIncrease endurance and energyImprove cardiovascular health and circulationControl of BSLReduce stress levels and depressionImprove sleepRecommended daily physical activity for person yoActivity to add up to 150min of moderate intensity exercise per week in bouts of 10 minutes or more (physical activity task force 2003).Lower limb amputees at risk ofCVD, HTN, later life obesity, joint pain, OA, LBP,Length of the residual limb and the amount of muscle mass retained play a significant role in determining the transfemoral amputee's (TFA) running potential. This has become very apparent in recent years as knee disarticulation amputee runners appear to be extremely successful in competition. The additional power potentially available to knee disarticulation runners should not overshadow the need for athletic ability and training, which also play a very important role.
9 How do we enable them to realise their potential? First rehab them to walk well!!!Flexibility, strength, balance, specific gait exercises….Gait asymmetries due to tightness, weakness, impaired balance (Kapp, 2004)altered base of supportdecrease weight-bearing and stance time on prosthetic limbincrease stance time on the intact lower limbincrease double support timeasymmetrical step length with a shorter faster stride on the intact limblonger stride on the prosthetic limblateral trunk bending toward the prosthetic sidereduced walking velocity.These gait asymmetries will cause limitations in the amputees ability to perform high-level mobility activities.
10 Flexibility General stretches Hip flexors Glutes Hamstrings Quads AdductorsLower backCalf
11 StrengthTo successfully walk and take part in sports or physical activity the amputee needs to be strong!Muscles critical to amputee mobilityHip extensorsHip abductorsKnee extensorsRemaining plantar flexorsHealthy amputees can increase residual limb hip and knee strength with training (Nolan, 2009).Can assess/measure/strengthen LL power functionally (Raya et al, 2010).STS, SIT, ↑↓Stairs can be used as measures of lower limb power, balance, coordination, speed, and gait symmetry to determine their impact on high-level mobility performance of lower limb amputees???Hip extensor and abductor muscle power have been found to predict mobility. (Raya et al 2010, Powers et al, 1996).Amputees compensate at the hip during walking running and jumping. (Czerniecki et al 1991).Nolan (2009) compared hip strength in sedentary TT amputees to physically active TT amputees and foundActive TT amputees have stronger hip muscles than sedentary amputeesActive amputees have stronger hip extensors than active age matched able bodied personsSo in terms of limb strength their should be no barriers to sports participation for healthy TT amputees in returning to sport or recreational activities.
12 Glute training exercises Hip ext in prone (neutral and 30 abd)Hip abd in SL with circlesTB in standingStair drillsBridging +/- gym ballSingle leg bridge foam rollerPlank with hip extCrab walks +/- therabandStairs- tighten core, stand tall , engage glute and drive hips forwards keeping head up.
13 Quads training exercises Step ups/downsSquats, +/- resistanceBulgarian squatslungesStair drills2 at a time, sideways, grapevineControlled SIT
14 Hamstring training exercises BridgingSingle leg bridgingGym ball hamstring curlsHamstring curls in 4pt kneelingHamstring pulses in prone
15 Core/abdo training exercises Supine crook lying establish core controlBridgingBird dog/supermanStanding with UL or LL TBAbdo crunches/obliquesAbdo roll with gym ballplank
16 BalanceLower limb amputees typically present with impaired balance due to motor and/or sensory deficits.For lower limb amputees, hip strategies need to be trained to work differently and more efficiently in order to compensate for the missing ankle strategy.Buckley et al (2002)
17 Balance weight shift Side stepping braiding Step taps Straddle stanceStep stanceSide steppingbraidingStep tapsThrowing and catching ballBouncing ballKicking and trapping ballWobble board
18 Walking drills Walking F/B/S Walking along line braiding High knees Monster stepsSki walkingWalking with resistance** concentrate on foot placement **** don’t forget arm swing **Marching/ high knees point toes to ceilingHigh knees and monster steps, drive hip extension on heel strike. Imaging you are clearing a stick in swing.
19 EnduranceRunning and Sports participation is hard work so need to work on endurance.WalkingSwimmingCyclingRowing machineArm cycleLow impact training activity to build endurance and strength without traumatizing soft tissues of residual limbLow impact endurance sport for the amputee athleteLimited risk injury to residual limbInjuries often related to bike set upsaddle positionCleat alignmentHandlebar positionBike set up to promote symmetrical riding posture
20 When to teach the amputee to run Walking well unaidedAmp pro >376mwt > 250m??Good socket fitMotivated -
21 The Comprehensive High-level Activity Mobility Predictor (CHAMP) CHAMP is a measure of agility typically used to test high-level performers who tend to max-out their ratings on other performance-based measures.This measure includes activities that are designed to test motion in all three planes, like turning, cutting, side-to-side movement, and backward running.It consists of four tasks and can be administered in minutes.SLSEdgren side step testT-testIllinois agility test
22 CHAMPFound to beSafeReliableValidClinically friendlyresponsive performance based outcome measure of high-level mobilityHas the potential to direct rehabilitation goals and treatment, determine when to return to high level activity and aid in discharge planning.
23 Amputee Running Technique Prosthetic trustreaching out with the prosthetic limb and knowing it will be thereGet used to the impact of landing on prosthetic sideTraining exercisesRepeated single hops onprosthetic side (TTA only)Side skipAs the transtibial amputee (TTA) strikes the ground with the prosthetic limb, a backward force is instantly created by the prosthetic-side hip musculature. This generates two to three times more work than the sound limb, partly to help move the body over the stationary foot, and partly to compensate for the loss of active plantarflexion at the ankleTA will also contract the muscles of the lower limb in an identical pattern to the non-amputee during terminal swing. The knee should be slightly flexed and, as stated earlier, there will be a reduction in forces as the limb prepares to strike the ground.TFA must land on an extended knee with the prosthetic limb. Initiating a backward force prior to contact will not only accelerate the body forward, but will simultaneously ensure that the knee will remain in extension. Many transfemoral amputee runners also adopt an extended trunk posture as they descend to the ground, although this is unnecessary.
24 Amputee Running Technique Backward thrustForceful hip extension on heel striketo propel body over prosthesisAccelerates body forwardsIncreases speedTraining exercisePush down and pull back with limb at same time inside the socketStanding with hip flexed 90. Therapist provides few seconds of medium resistance to extension then lets go and amputee drives heel to floor, pushing into back wall of socket.Use glutes and hamstring muscle groupsStick the landingAs the transtibial amputee (TTA) strikes the ground with the prosthetic limb, a backward force is instantly created by the prosthetic-side hip musculature. This generates two to three times more work than the sound limb, partly to help move the body over the stationary foot, and partly to compensate for the loss of active plantarflexion at the ankle"acceleration phase" of the running cycle, in which the body moves from stance phase energy absorption to acceleration. At this point, the majority of the forward propulsion of the body comes from the contralateral swing limb and the arms..
25 Amputee Running Technique Sound limb strideNovice athletes will havea shorter stride.Training exerciseextend hip by pulling down and back into socketLeap from prosthesis onto sound sideFocus on long stride with sound limbAt terminal stance, the transtibial amputee runner's total muscle work on the prosthetic side is half that measured in the intact limb and in non-amputee runners. This is not too surprising, considering the absence of the plantarflexors. To compensate, there appears to be approximately a 75 percent increase in energy transfer from the amputee's intact swing phase leg.
26 Amputee Running Technique Stride symmetryStrive for equal stride length and frequencyTraining exerciseChoose a comfortable jogging pace that produces equal stride length for both limbsConcentrate on maintaining stability over prosthetic limbRelax and jog a little
27 Amputee Running Technique Arm swingNovice runners keep arms close to their bodiesEncourages stride length and timingTraining exerciseFocus on arm swing and trunk rotationShoulders relaxedElbows flexed 90Hands…Should rise to shoulder level when driving forwardsShould point just behind hip when driving backwardsFor the amputee, arm swing is extremely important, yet often difficult to master. A concentrated effort must be made to maintain a symmetrical arm swing, especially as speed increases when the legs have a tendency to lose symmetry of movement.Transfemoral amputees have a tendency to demonstrate increased abduction of the prosthetic-side arm, especially when the prosthetic lower limb is abducted. This adverse position of both the leg and the arm creates opposing forces that tend to impede forward momentum and increase the metabolic requirement. Poor medial/lateral socket stability will also require additional effort by the prosthetic-side arm and facilitate unwanted trunk movement.
29 Socket design Well fitting prosthesis Comfort ROM Stability Shape, interface material, alignment, adapt to forces imposed at the stump socket interfaceROMAdequate hip/knee ROMStabilityAdaptability to volume changesConstant challenge for endurance athletesGailey and Harsh (2009)Finding a balance between stability and comfort is often a challengeStability V’s ComfortIC socketgreater proximal stability and use of hip musculature for running.BUT discomfort at ramus
30 Foot selection for running ConsiderationsResidual limb lengthClearance 17-25cmDistanceSprint: carbon fibre ‘J shaped’ footEndurance: carbon fibre ‘C shaped’ footMultisport carbon fibre foot with heelAthletes preferenceAthletes skillNovice V’s professionalGailey and Harsh (2009)Don’t need a running -Running foot designed for runningNormal foot - better in carbon fibre … better base of suport can pivot and turn
31 Knee selection running Use of a prosthetic knee permits a more traditional style of running with knee flexion and extension.Endurance kneesMauch (single axis, hydraulic)Ossur total knee 2100 (polycentric hydraulic)Ossur 3R55 (poycentric, hydraulic swing)Gailey and Harsh (2009)
32 Equipment Small towel Moist wipes Skin dressings Extra stump socks Perspiration constant problemMoist wipesCleaning socket, liners, suspension sleeves immediately after training/sportSkin dressingsIf abrasions or blister occurExtra stump socksLimb volume may change with muscular contractions, altered diet, weight loss due to training.Elastic sleeve or auxillary suspensionGailey and Harsh (2009)
33 referencesDeans S, Burns D, McGarry A, Murray K and Mutrie N (2012) Motivations and barriers to prosthesis users participation in physical activity, exercise and sport: a review of the literature. Prosthetics and Orthotics international 36(3)Czerniecki J, Gitter A, Munro C (1991). Joint moment and muscle power output characteristics of below knee amputees during running; the influence of energy storing feet. J Biomech 24:63-75Nolan L, Lees A (2000) the kinematic charateristic of above and below knee amputee long jumpers. Ergonomics. 43:Nolan L (2009) Lower limb strength in sports active transtibial amputees. Prosthetics and Orthotics international. 33:Wetterhahn K, Hansen C, Levy C (2002) effects of participation in physical activity on body image of amputees. Am J Phys Med Rehab 81(3):Davies D and Datta D (2003) Mobility outcomes following unilateral lower limb amputation. Prosthetics and Orthotics International. 27:Webster J, Levy C, Bryant P, and Prusakowski P (2001) sports and recreation for people with limb deficiency. Arch Phys Med Rehab 82(3):88-44Deans S, McFayden A and Rowe P (2008) Physical activity and quality of life: A study of lower-limb amputee population. Prosthetic and Orthotic International 32(2):Kapp S (2004) Ch 13:Visual analysis of prosthetic gait. In: Atlas of amputated and limb deficiencies: Surgical prosthetic and rehabilitation principles. Rosemont IL. pBuckley, J O’Driscoll D, Bennett S (2002) Postural sway and active balance performance in highly active lower limb amputees. Am J phys Med Rehab 81:13-20.Powers C, Boyd L, Fontain C, Perry J (1996). The influence of lower extremity muscle force on Gait characteristics in individuals with Below-knee amputations secondary to vascular disease. Phys therapy 76(4):Raya M, Gailey R, Fiebert I, Roach K (2010) Impairment Variables Predicting Activity Limitation in Individuals with Lower limb amputation. Prosthetics and orthotics intrnational.34(1):73-84.Gailey R (2003) accessed 20/3/14