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Exercise and sport for amputees

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1 Exercise and sport for amputees
Erin Kennedy Physiotherapist, Westmead Hospital 2014

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 population There 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 participate Deans et al (2012) Still satisfied? Low expectations… more concerned with maintaining relationships and socialisation then improving mobility.

5 Motivations for physical activity include:
Health benefits Social interaction Stress relief Increasing self esteem Improving body image Mastery theory Mastery of prosthesis increased self efficacy increased prosthetic use Increased physical activity Deans et al (2012)

6 Barriers for physical activity include:
Physical limitation Lack of confidence / embarrassment Body image attitude Services Climate/physical environment Income Stump pain Prosthesis Deans et al 2012 Inability to run, jump poor endurance, decreased speed All of these things can be improved with training Perception 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 goals Education Health benefits Recommended daily activity Appropriate forms of exercise Looking after skin/stump Address misconceptions Providing a positive environment

8 And… Which patient should be challenged beyond walking?
Those who were previously physically active and are medically well Age range ?? Level and number of amputations?? K 3-4 Community ambulation, able to vary cadence and perform activities beyond basic locomotion Amp pro score > 37 6mwt > 250m Gailey et al (2002) Benefits of exercise Weight control Improve flexibility, strength & balance Increase endurance and energy Improve cardiovascular health and circulation Control of BSL Reduce stress levels and depression Improve sleep Recommended daily physical activity for person yo Activity 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 of CVD, 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 support decrease weight-bearing and stance time on prosthetic limb increase stance time on the intact lower limb increase double support time asymmetrical step length with a shorter faster stride on the intact limb longer stride on the prosthetic limb lateral trunk bending toward the prosthetic side reduced 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
Adductors Lower back Calf

11 Strength To successfully walk and take part in sports or physical activity the amputee needs to be strong! Muscles critical to amputee mobility Hip extensors Hip abductors Knee extensors Remaining plantar flexors Healthy 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 found Active TT amputees have stronger hip muscles than sedentary amputees Active amputees have stronger hip extensors than active age matched able bodied persons So 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 circles TB in standing Stair drills Bridging +/- gym ball Single leg bridge foam roller Plank with hip ext Crab walks +/- theraband Stairs- tighten core, stand tall , engage glute and drive hips forwards keeping head up.

13 Quads training exercises
Step ups/downs Squats, +/- resistance Bulgarian squats lunges Stair drills 2 at a time, sideways, grapevine Controlled SIT

14 Hamstring training exercises
Bridging Single leg bridging Gym ball hamstring curls Hamstring curls in 4pt kneeling Hamstring pulses in prone

15 Core/abdo training exercises
Supine crook lying establish core control Bridging Bird dog/superman Standing with UL or LL TB Abdo crunches/obliques Abdo roll with gym ball plank

16 Balance Lower 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 stance Step stance Side stepping braiding Step taps Throwing and catching ball Bouncing ball Kicking and trapping ball Wobble board

18 Walking drills Walking F/B/S Walking along line braiding High knees
Monster steps Ski walking Walking with resistance ** concentrate on foot placement ** ** don’t forget arm swing ** Marching/ high knees point toes to ceiling High knees and monster steps, drive hip extension on heel strike. Imaging you are clearing a stick in swing.

19 Endurance Running and Sports participation is hard work so need to work on endurance. Walking Swimming Cycling Rowing machine Arm cycle Low impact training activity to build endurance and strength without traumatizing soft tissues of residual limb Low impact endurance sport for the amputee athlete Limited risk injury to residual limb Injuries often related to bike set up saddle position Cleat alignment Handlebar position Bike set up to promote symmetrical riding posture

20 When to teach the amputee to run
Walking well unaided Amp pro >37 6mwt > 250m?? Good socket fit Motivated -

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. SLS Edgren side step test T-test Illinois agility test

22 CHAMP Found to be Safe Reliable Valid Clinically friendly responsive performance based outcome measure of high-level mobility Has 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 trust reaching out with the prosthetic limb and knowing it will be there Get used to the impact of landing on prosthetic side Training exercises Repeated single hops on prosthetic side (TTA only) Side skip As 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 TA 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 thrust Forceful hip extension on heel strike to propel body over prosthesis Accelerates body forwards Increases speed Training exercise Push down and pull back with limb at same time inside the socket Standing 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 groups Stick the landing As 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 stride Novice athletes will have a shorter stride. Training exercise extend hip by pulling down and back into socket Leap from prosthesis onto sound side Focus on long stride with sound limb At 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 symmetry Strive for equal stride length and frequency Training exercise Choose a comfortable jogging pace that produces equal stride length for both limbs Concentrate on maintaining stability over prosthetic limb Relax and jog a little

27 Amputee Running Technique
Arm swing Novice runners keep arms close to their bodies Encourages stride length and timing Training exercise Focus on arm swing and trunk rotation Shoulders relaxed Elbows flexed 90 Hands… Should rise to shoulder level when driving forwards Should point just behind hip when driving backwards For 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.

28 Considerations!!

29 Socket design Well fitting prosthesis Comfort ROM Stability
Shape, interface material, alignment, adapt to forces imposed at the stump socket interface ROM Adequate hip/knee ROM Stability Adaptability to volume changes Constant challenge for endurance athletes Gailey and Harsh (2009) Finding a balance between stability and comfort is often a challenge Stability V’s Comfort IC socket greater proximal stability and use of hip musculature for running. BUT discomfort at ramus

30 Foot selection for running
Considerations Residual limb length Clearance 17-25cm Distance Sprint: carbon fibre ‘J shaped’ foot Endurance: carbon fibre ‘C shaped’ foot Multisport carbon fibre foot with heel Athletes preference Athletes skill Novice V’s professional Gailey and Harsh (2009) Don’t need a running - Running foot designed for running Normal 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 knees Mauch (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 problem Moist wipes Cleaning socket, liners, suspension sleeves immediately after training/sport Skin dressings If abrasions or blister occur Extra stump socks Limb volume may change with muscular contractions, altered diet, weight loss due to training. Elastic sleeve or auxillary suspension Gailey and Harsh (2009)

33 references Deans 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 24:63-75 Nolan 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):88-44 Deans 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. p Buckley, 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

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