FUNCTIONAL PERFORMANCE IN LOWER LIMB AMPUTEES: PAST AND FUTURE AREAS OF RESEARCH DISCIPLINE OF EXERCISE AND SPORT SCIENCE, FACULTY OF HEALTH SCIENCES DR NATALIE VANICEK, SENIOR LECTURER

MY BACKGROUND › PhD research: Biomechanical and psychological factors that distinguish fallers from non-fallers: A comparative study of transtibial amputees and able-bodied individuals › AIM: To inform the clinical recommendations for amputee rehabilitation to reduce falls incidence and to improve falls monitoring, prevention and treatment in physiotherapy practice - A review of current amputee rehabilitation as it relates to falls monitoring and the use of outcome measures to inform amputee practice - A biomechanical comparison of level gait, stair ascent and descent and postural control - Balance confidence and quality-of-life measures in fallers and non-fallers were examined using psychological instruments and their relationship with functional measures were explored 2

FINDINGS 1 – REVIEW OF CURRENT PRACTICE › No clear consensus about criteria for discharge › Falls monitored informally and infrequently  monitoring system should be developed › Raise awareness about the different outcome measures  physiotherapists are actively encouraged to reach a consensus about the use of appropriate outcome 3 › Only 35% of physiotherapists used psychological outcome measures or referred patients to a psychologist or counsellor › Psychological tools were not used to monitor patient progress or inform physiotherapy discharge

CLINICAL OUTCOMES › Advocate use of following outcome measures to inform treatment planning or to monitor change after intervention or after discharge: 1.ABC-UK 2.Amputee Mobility Predictor with a prosthesis (AMPPRO) 3.Houghton Scale of prosthetic use in people with lower-extremity amputations 4.Locomotor Capabilities Index 5 (LCI-5) 5.The Trinity Amputation and Prosthesis Experiences Scales (TAPES) 6.Timed Up and Go test (TUG) 4

FINDINGS 2 – BIOMECHANICAL COMPARISONS › Amputee fallers walked quickly and loaded prosthetic limb more › Biomechanical differences between fallers and non-fallers led to the following recommendations for increasing muscle strength: › Eccentric control of the ankle plantarflexor muscles on the intact limb to control the forward progression of the tibia during terminal stance › Knee extensor eccentric strength on the affected limb should be improved to prevent the knee from collapsing during the loading response/controlled lowering phase › Hip flexor eccentric control on both limbs to slow deceleration of thigh extension during late stance › Handrail use in stair walking and other compensatory strategies › Intact limb should control push-off forces because the affected limb would need to control larger accelerations during single support 5

FINDINGS 3 – BIOMECHANICAL COMPARISONS › Using computerised dynamic posturography..... › Non-fallers bore more weight through intact vs. prosthetic limb - Amputees should practice moving their COP rapidly towards the intact limb in dynamic conditions › Amputees rely more on visual input, even when input is inaccurate - Amputees should practice postural control during quiet standing under more challenging conditions, such as with eyes closed (no vision), or when standing on different support surfaces (moving, flexible or uneven surfaces) - Interpreting somatosensory feedback from the residual limb should provide important sensory information in the absence of the biological ankle & foot and plantarflexor muscles › Weight distribution under the affected and intact limbs could be evaluated in a rehabilitation setting with the use of simple scales 6

FINDINGS 4 – QOL AND FUNCTION › The TUG test, 10m walk test and MFES showed ceiling effects and were not sensitive enough to differentiate between independently living fallers and non- fallers - New measures may be needed to monitor function in the more able and active amputees › Perceived quality-of-life was related to performance on daily tasks such as walking and the TUG test, and was considered a good indicator of overall function › Low scores of the functional tests were correlated with lower quality-of-life scores › Consequences of falling may have more negative effects on mental, rather than physical health 7

EARLY WALKING AIDS › AIM: Using an RCT-design, to investigate the longitudinal gait patterns of transtibial amputees using either the AMA or PPAM aid prior to their functional prosthesis, during rehabilitation until discharge › There were no significant differences between the PPAM and AMA groups in terms of total rehabilitation time (days), time to receipt of prosthesis or the total number of physiotherapy treatments received during rehabilitation › Both groups had improved walking, reaching an acceptable level of walking ability, despite very different gait patterns with the EWAs during early rehabilitation  the most significant gait adaptations occurred following receipt of a functional prosthesis 8 AMA PPAM

BACPAR › British Association of Chartered Physiotherapists in Amputee Rehabilitation, specialist group under the Chartered Society of Physiotherapists 9

MY RESEARCH INTERESTS › Broadly speaking, the underlying aim of my research is to provide evidence-based recommendations to inform clinical standards. Through biomechanical analysis, appropriate and targeted exercise intervention strategies that are aimed at attenuating the loss of musculoskeletal function, reducing falls and improving quality of life can be designed, implemented and evaluated. › My current research interests are: › To investigate stair walking as a more challenging locomotor task in lower limb amputees and understand the relationship between function and quality of life factors › To explore the relationship between physical performance and quality of life to develop disease-specific outcome measures › To establish an amputee-specific database of biomechanical and psychological health status › To investigate whether (and how regularly) falls are monitored in current healthcare practice and the implications of falls on a patient’s treatment programme › To evaluate the effectiveness of a falls prevention programme on functional performance in lower limb amputees 10

MY RESEARCH INTERESTS › WHY ? To investigate stair walking as a more challenging locomotor task in lower limb amputees and understand the relationship between function and quality of life factors - WHO ? Transfemoral and transtibial amputees; vascular and traumatic cause - WHAT ? 3D motion capture testing - Functional tasks (e.g,. TUG & L-test, Berg balance, 10m walk test, etc...) can be completed during physiotherapy rehabilitation or in lab - Questionnaires (e.g., ABC-scale, SF-36) can be completed anywhere/ anytime - WHERE ? Participant would need to visit laboratory at UniSyd Cumberland campus in Lidcombe - ETHICS: NSW HREC and UniSyd ethical approval 11

MY RESEARCH INTERESTS › WHY ? To explore the relationship between physical performance and quality of life to develop disease-specific outcome measures - WHO ? Transfemoral and transtibial amputees; vascular and traumatic cause - WHAT ? Functional tasks can be completed during physiotherapy rehabilitation - Questionnaires can be completed anywhere/anytime, but before/after treatment best practice - WHERE ? Physiotherapy treatment - ETHICS: NSW HREC and UniSyd ethical approval 12

MY RESEARCH INTERESTS › WHY ? To establish an amputee-specific database of biomechanical and psychological health status - WHO ? Transfemoral and transtibial amputees; vascular and traumatic cause - WHAT ? Functional tasks (e.g,. TUG & L-test, Berg balance, 10m walk test, etc...) can be completed during physiotherapy rehabilitation - Questionnaires (e.g., ABC-scale, SF-36) can be completed anywhere/anytime, but before/after treatment best practice - WHERE ? Physiotherapy treatment; sub-set of population would attend laboratory in Lidcombe for 3D motion capture testing - ETHICS: NSW HREC and UniSyd ethical approval 13

MY RESEARCH INTERESTS › WHY ? To investigate whether (and how regularly) falls are monitored in current healthcare practice and the implications of falls on a patient’s treatment programme - WHO ? Lead physiotherapists; multi-disciplinary team - WHAT ? Determine falls monitoring practice; influence on patient’s treatment; review of falls education  lead to implementation of standardised monitoring system within the AustPAR group and among the multi-disciplinary team - WHERE ? Group meetings; phone interviews; online questionnaires  need a good response rate representative of Sydney or NSW - ETHICS: Need NSW HREC approval? Audit vs. Research? UniSyd ethical approval 14

MY RESEARCH INTERESTS › WHY ? To evaluate the effectiveness of a falls prevention programme on functional performance in lower limb amputees - Are there currently standardised prescribed home-based or supervised falls prevention programmes that physiotherapists prescribe their patients? Has anyone evaluated their effectiveness? - WHO ? Transfemoral and transtibial amputees; vascular and traumatic cause - WHAT ? Design and implement an evidence-based exercise programme - 3D motion capture testing pre- and post-intervention - Functional tasks (e.g,. TUG & L-test, Berg balance, 10m walk test, etc...) can be completed during physiotherapy rehabilitation or in lab - WHERE ? Intervention: patient’s home or supervised exercise class - Testing: laboratory in Lidcombe for 3D motion capture testing - ETHICS: NSW HREC and UniSyd ethical approval 15

HAND-OUT 16 › Please return to Naomi at the end of today’s session (or to me if you complete it before the end of lunch) › I am happy to discuss other possible ideas for research, so please share your thoughts as much as possible › Please contact me if you’d like an electronic copy of the handout or any of the articles listed on the next slide › Thank you

CONTACT DETAILS › Natalie Vanicek: › References: › Barnett C, Vanicek N, Polman R. Postural responses during volitional and perturbed dynamic balance tasks in new lower limb amputees: A longitudinal study. Gait and Posture 2012; in press. › Barnett C, Vanicek N, Polman R. Temporal adaptations in generic and population-specific quality of life and falls efficacy in recent lower limb amputees. Journal of Rehabilitation Research and Development 2012: accepted. › Vanicek N, Strike S, Polman R. Falls efficacy, health status and functional performance in transtibial amputee fallers vs. non-fallers. British Association of Chartered Physiotherapists in Amputee Rehabilitation 2012; 36: › Mazari FAK, Mockford KA, Barnett C, Khan JA, Brown B, Smith L, Polman R, Hancock A, Vanicek N, Chetter IC.. Hull early walking aid for rehabilitation of transtibial Amputees - Randomised controlled Trial (HEART). The Journal of Vascular Surgery 2010; 52: › Vanicek N, Strike S, McNaughton L, Polman R. Gait patterns in transtibial amputee fallers vs. non-fallers: biomechanical differences during stair ascent. Prosthetics and Orthotics International 2010; 34: › Vanicek N, Strike S, McNaughton L, Polman R. Postural responses to dynamic perturbations in amputee fallers vs. non-fallers: a comparative study with able-bodied subjects. Archives of Physical Medicine & Rehabilitation 2009b; 90: › Vanicek N, Strike S, McNaughton L, Polman R. Gait patterns in transtibial amputee fallers vs. non-fallers: biomechanical differences during level walking. Gait and Posture 2009a; 29: › Barnett C, Vanicek N, Polman R, Hancock A, Brown B, Smith L, Chetter I. Kinematic gait adaptations in unilateral transtibial amputees during rehabilitation. Prosthetics and Orthotics International 2009; 33: