Exercise and sport for amputees

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
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)

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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)

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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)

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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

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

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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
• gt 37
• 6mwt
• gt 250m
  
• Gailey et al (2002)

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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.

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Flexibility

• General stretches
• Hip flexors
• Glutes
• Hamstrings
• Quads
• Adductors
• Lower back
• Calf

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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).
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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

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Quads training exercises

• Step ups/downs
• Squats, /- resistance
• Bulgarian squats
• lunges
• Stair drills
• 2 at a time, sideways, grapevine
• Controlled SIT

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Hamstring training exercises

• Bridging
• Single leg bridging
• Gym ball hamstring curls
• Hamstring curls in 4pt kneeling
• Hamstring pulses in prone

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Core/abdo training exercises

• TrA
• 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

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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)

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Balance

• weight shift
• Straddle stance
• Step stance
• Side stepping
• braiding
• Step taps
• Throwing and catching ball
• Bouncing ball
• Kicking and trapping ball
• Wobble board

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Walking drills

• Walking F/B/S
• Walking along line
• braiding
• High knees
• Monster steps
• Ski walking
• Walking with resistance
• concentrate on foot placement
• dont forget arm swing

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Endurance

• Running and Sports participation is hard work so
  need to work on endurance.
• Walking
• Swimming
• Cycling
• Rowing machine
• Arm cycle

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When to teach the amputee to run

• Walking well unaided
• Amp pro gt37
• 6mwt gt 250m??
• Good socket fit
• Motivated -

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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 15-20 minutes.
• SLS
• Edgren side step test
• T-test
• Illinois agility test

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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.

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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
• http//www.oandp.com/articles/2003-12_05.asp

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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
• http//www.oandp.com/articles/2003-12_05.asp

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
• http//www.oandp.com/articles/2003-12_05.asp

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
• http//www.oandp.com/articles/2003-12_05.asp

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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
• http//www.oandp.com/articles/2003-12_05.asp

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Considerations!!
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Socket design

• Well fitting prosthesis
• Comfort
• 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)

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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 Vs professional
• Gailey and Harsh (2009)

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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)

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Equipment

• Small towel
• 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)

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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)
  269-269.
• 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 2463-75
• Nolan L, Lees A (2000) the kinematic
  charateristic of above and below knee amputee
  long jumpers. Ergonomics. 431637-1650.
• Nolan L (2009) Lower limb strength in sports
  active transtibial amputees. Prosthetics and
  Orthotics international. 33230-241
• 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)194-201.
• Davies D and Datta D (2003) Mobility outcomes
  following unilateral lower limb amputation.
  Prosthetics and Orthotics International.
  2716-190.
• 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)186-200.
• Kapp S (2004) Ch 13Visual analysis of prosthetic
  gait. In Atlas of amputated and limb
  deficiencies Surgical prosthetic and
  rehabilitation principles. Rosemont IL. p
  385-394.
• Buckley, J ODriscoll D, Bennett S (2002)
  Postural sway and active balance performance in
  highly active lower limb amputees. Am J phys Med
  Rehab 8113-20.
• 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)369-377
• 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) http//www.oandp.com/articles/2003
  -12_05.asp accessed 20/3/14