Pre Prosthetic Exercises For The Lower Activity .

Pre prosthetic exercises forthe lower activitytransfemoral amputeeCarolyn HironsBACPAR West Midlands Regional Study dayApril 23rd 2015

Your presenter Pace Rehabilitation Manchester, UK Private independentclinic Trauma amputees mainly Some lower activity dueto other injuries, lowconfidence, poor fitness 24 years experiencechirons@pacerehab.comOlder amputee experience: 15 years NHS Vascular surgery unit Regional Limb Centre Prosthetic rehab:inpatient, outpatient &community settings

Presentation objectives Theory behind preprosthetic exercises Knowledge todevelop an effectiveprogramme Improvedassessment skills Effective results

Who are we talking about?A typical UK patient with amputation: 80% over 65 years age Predominant cause vascular and diabetic disease Multiple pathology Fewer demands from prosthesis Well served by NHS teamsSIGAM grade C limited/restricted; walk up to 50m, on evenground, with or without walking aids a frame, b crutches/sticks, c 1 crutch/stick, d no aidsK2 limited mobility; ability or potential to use aprosthesis for ambulation, ability to adjust to lowlevel environmental barriers (curbs, stairs, unevensurfaces). Limited periods of walking, without significantvarying speed

Considerations for successfulrehabilitation programmes Elderly - Ageing process Co-morbidities Sedate lifestyle pre amputation De-conditioned Established posture andmovement habits, changed gaitpatterns High risk of falls Cognition – how can you test? Prosthesis – how do you choose?5

Useful objective prosthetic assessmenttools Amputee MobilityPredictor TransfemoralFitting Predictor Kendrick ObjectLearning Test

AMPnoPROThe Amputee Mobility Predictor:an instrument to assessdeterminants of the lower-limbamputee ability to ambulate.(Gailey RS, Roach KE, Applegate EB,Cho B, Cunniffe B, Licht S, Maguire M,Nash MS.Arch Phys Med Rehabil2002;83:613-27.) Physio Tools

Transfemoral Fitting PredictorThe trans-femoral fittingpredictor: a functional measureto predict prosthetic fitting intransfemoral amputees-validityand reliability.(Condie ME, McFadyen AK, Treweek S,Whitehead L Arch Phys Med Rehabil2011 Aug;92 (8): 1293-7)

Kendrick Object Learning Test (KOLT)Do psychologicalmeasures predict theability of lower limbamputees to learn to usea prosthesis?(Larner, Van Ross, Hale ClinRehabil, 2003; 17: 493 -498)

Background knowledge &accurate assessmentWhat should we be thinking about?

Goal – minimise prosthetic gait deviations Lateral trunk bend Abduction Circumduction Vaulting Lack of trunk rotation Excess lumbar lordosis Uneven step, timing andarm swing Poor knee control

Normal posture – side view Mid ear Shoulder Pelvic tilt Spinal curves Greater trochanter Behind patella In front of ankle Equal weight distributionover foot

Normal posture – AP view Level eyes Level shoulders Level pelvis (iliac crests, ASIS,PSIS) Body creases Knee symmetry Equal weight bearing Spinal curves Tip - Use a plumb line &compare in sitting

Normal postural changes!

Normal posture changes in the amputeesover timeWithout a prosthesis: Shift centre of gravity Small base of support External rotation L Hyperextended knee L Retraction & elevation Rpelvic girdle Depression R shouldergirdle

Creep Phenomenon Prolonged postures changestissue length Change in inclination PSIS toASIS Short hip flexors and backextensors Long weak abdominals,hamstrings & glutealsWiemann K, Klee A, Startmann M(1998) ‘Fibrillar sources of themuscle resting tension and therapyof muscular imbalances’ DeutscheZeitsschrift fur Sportzmedizin 49(4),111-118.

‘Postural asymmetries intransfemoral amputees’ (2011) Leg length discrepancies(88%) Pelvic inclination Innominate asymmetry Increased lordosis Limited lateral trunkflexion Limited hip extension Gaunaurd I, Gailey R, Hafner B,Gomez-Marin O & Kirk-Sanchez NPros & Orthot Int 35 (2) 171-180

Normal ageing process Weak antigravity muscles Less elasticity in soft tissues Reduced range of motion Exaggerated posture Reduced balance reactions Slower cadence

Energy expenditure in amputees Unilateral TTA: 9% morerequired Unilateral TFA: 49% more Bilateral TFA: 280% more(reference?) Individuals with traumaticamputation demonstrate amore energy efficient gait thanthose resulting from vascular orneuropathic disease

Ageing and exerciseExercise programmesoffset age relateddisabilities.(Bennet KJ, 2000,Geriatr Aging 3;12)

Diabetes and exercise Exercise lowersblood sugar Rehabilitation (PT &OT) TF casting (stand) Prosthetic fitting Monitor Be prepared!

Effect of pain on movementPain inhibits orprevents musclerecruitmentComerford MJ and Mottram SL(2001), ‘Movement and stabilitydysfunction – contemporarydevelopments’, Manual Therapy 6(1), 15 -26.Comerford MJ, Mottram SL,Gibbons SGT (2005) ‘KineticControl – understandingmovement and function, part Acourse manual’ pg 2-2

Why is gait pattern reallythat important in thelower activity amputee?

High falls risk population! Significant absence of sensory feedback Changes in body weight distribution Postural instability & muscle imbalances Negative influence, external force of prosthesis Higher level and multiple amputations An aged population suggests 4 co-morbidities,cognition, 2 medications Vulnerability, liability and opportunity

Falls management Cochrane Review 2006Specialist MDT, multi-factorial assessmentsincluding health screening, individuallytailored home exercises OTAGO exercise programmesStrength, balance, flexibility and walking(John Campbell, Prof in Geriatric Medicine & M ClareRobertson, Senior Research Fellow, University of OtagoMedical School, New Zealand) Stumble recovery – work the extensors NICE Guidelines (Nov 2004)Multi-factorial risk assessment‘Falls: the assessment and prevention of falls in olderpeople’ (www.nice.org.uk/CG21NICEguideline)

Targeted exercise programme Tailored to individual needs Use combined muscle actions which relate to normalgait Facilitate normal movement of residual limb Discourage neglect Improve muscle strength, recruitment & co-ordination Promote weight transference Re-educate proprioception Facilitate static and dynamic balance reactions Increase cardiovascular fitness & exercise tolerance

Different muscle roles – alteredrecruitment in amputeesMobilisers - moveStabilisers - control

Postural Awareness Find neutral position Normal tissue length Postural stabiliserscreate stable base Improve musclerecruitment &movement control

Finding neutral, greater support Excessive posterior tilt Excessive anterior tilt Neutral, equal WB Start with support Engage deep stabilisers transversus abdominis

Bridging/spine curls – strength &flexibility Maintaining core positionand strength asfoundation Control the movement Flexibility of vertebralsegments, aids balance Low back protection

Trunk rotation Elongate the deepstabilisers Oblique mobilisers Stable, neutralshoulder girdle Bed mobility anddressing

Facilitation Use proprioception Guide themovement Enhancerecruitment Low thresholdstimulus

Trunk control & strength Maintain hip andpelvis in neutral Keep shoulders andneck relaxed Dual abdominal action High intensity exercise

Assisted abdominals Safe strengthening ofabdominals Reduced strain onneck Controlled spine,encouraging flexibility

Trunk mobility & weight transference Strong stable centrewith increasedmovement Transfer of weightover base of support Trunk elongation andstretch Reduce tight tissues

Improve proprioception Stimulate trunk agility Promote balancereactions Stabilisations,challenge the system Recruit activity fromsmall stimuli

Back extension Deep abdominalssustained to protectlower back Shoulder girdlestability & position Hip extensors &adductors Hip flexor stretch

Extension with length Strengthen extensors Recruit gluts first Lengthen joints Active stretching offlexors Pelvis held neutral Slow motor units

Applied postural set Change postural set toneutral & moreapplied Abductor strength Engaging trunk,neutral spine

Flexibility Relaxation of tighttissues Increase range ofmovement Contracture prevention Symmetrical activities

Facilitate flexibility ProprioceptiveNeuromuscularFacilitation (PNF) Reciprocal relaxation Hands on to improveeffectiveness

Facilitate strength ProprioceptiveNeuromuscularFacilitation (PNF) Repeated contractions Ensure can stabilisefirst

Postural awareness, less support Reduce base ofsupport Explore extremes ofpelvic tilt Find neutral,lengthened position Ease of movement,low effort level

Postural stability challenged Reduce base ofsupport further Add movement Maintain posture Girdle stability

Rhythmic stabilisations Challenge stabilisers Low load co-activity Hip or shoulder girdles

Core stability Simultaneoustransversus abdominisand multifidus Postural control Pelvic stability

Functional strength Multi muscle groups Integrate hipadductors with trunkstability Functional activity

Challenge patterns Further challenge tomaintain neutralposture Work the limbsegments - Balls,Theraband

Progress recruitment Unstable base ofsupport

Facilitation Increasedproprioception ‘Feel’ movement Target stability oftrunk and hip rotators

Effective Stretching Lengthen spine andhamstrings Equal weight ischialtuberosities Static holds 20-30seconds

Smooth trunk agility Relaxation Lengthening Strong centre Range of movement Better breathing

Combined muscle actions Combined muscleaction: Back extension Hip adduction Always from a stablecentre/posture

Combined actions Combined muscleaction: Hip extension Control anteriorpelvic tilt(TF -smaller box)

Combined actions Combined muscleaction: Hip adductors Hip internal rotators

Combined actions Combined muscleaction: Hip abductors Lateral pelvic shift,eccentric & concentric(stance phase)

Variation & challenge to create change Strengthen oncesomeone hasawareness, stabilityand control Change speed, needquick reactions Change range &repetitions Muscle adaptation

Assessing kinetic control – how dothey move? Stabilisers Mobilisers Posture Control Recruitment Flexibility Proprioception Strength Centring/midline Flowing movement Alignment Co-ordination Relaxation Joint integrity Concentration Stamina

Early walking aidsPre prosthetic exercise

PPAM AID Transtibial, throughknee and longtransfemoral Easy to apply Very cost effective 40 mmHg (NWB) No knee joint or foot Partial weight bearing

PPAM AID Precautions Pain Unhealed wounds Infected wound Flexion deformity (hipor knee 30 degrees) Short femurs difficult Bilateral use (unlesswith prosthesis)

FEMURETT Sold through Ossur Consists of adjustable pylon with standarduniaxial ankle and foot 6 adjustable laminated quadrilateralsockets – left and right, small, medium,large Single axis knee joint – spring extensionassist Single shoulder strap Knee can be locked or free Assessment tool for prostheticrehabilitation

FEMURETT precautions Pain Open/unhealedwounds Wound infection Hip flexioncontracture

FEMURETT - advantages Greater stability – containsshort residual limb Full weight bearing – canprogress to minimal walkingaids Promotes early weightbearing through ischialtuberosity Prepares residual limb forrigid socket use Assessment tool for freeknee use Early gait re-education witha bending knee

4 common TF movement faultsUncontrolled movement: Femur into flexion at hip (stance) poor hipextension, unequal strides Femur into abduction at hip (stance) lateral trunkbend Lumbar spine into extension (stance) excessivelordosis Pelvis into retraction (swing) poor trunk rotation,uneven timing Test range, test control, re-educate into walking

Uncontrolled movement Uncontrolledmovement of thefemur into flexion atthe hip (stance)

Test & correct

Applying the Thomas test!

Assess hip range & control instanding, includes lumbar spine

Uncontrolled movement Uncontrolledmovement of thefemur into abductionat the hip (stance)

Test & correct

Uncontrolled movement Uncontrolledmovement of thelumbar spine intoextension (stance)

Test & correct

Uncontrolled movement Uncontrolledmovement of thepelvis into rotation(swing)

Test & correct