Above Knee Amputee Group 1 Jeffrey Brooks, Rafal Gwizdala, Joseph - - PowerPoint PPT Presentation

Above Knee Amputee

Group 1

Jeffrey Brooks, Rafal Gwizdala, Joseph Johnson, Laura Morris, Kimberly Russell Jamie Brooks, PT, DPT, NCS Cheryl Ford-Smith, PT, DPT, MS, NCS September 14, 2017

Patient Details

• 59 yo female
• L AKA 3 months ago 2/2 distal femur

pleomorphic sarcoma

• Currently undergoing chemo & will need tx

for concurrent kidney CA

• PLOF: community ambulator, no AD
• Ambulates (hops) with RW in home and yard, drives
• Accesses kitchen ~2x/wk by scooting up/down stairs
• DME: manual w/c for home, manual w/c for community, RW, SPC
• Pt works from computer at home

Patient History

PT Examination

• BMI: 45
• Residual limb: fully healed, skin intact, scar thickening along

central and medial portion

• SLS: on R 20s with close spv
• ROM: B hip ext ROM full
• Strength:
• B hip abd MMT 4+
• B hip ext MMT 2+, unable to extend LE from mat in prone

The Prosthesis

• Dry fit socket with single ply sock (no

liner)

• Pelvic belt
• Single axis knee
• Single axis foot
• Pt req Min A to don prosthesis and

manage pelvic belt

Chief Complaint & Patient Goals

CC: Pt unable to ambulate independently with prosthesis Patient Goals:

• “I want to walk”
• Go on beach and casino trip in June

PT Diagnoses

• Deficits in static and dynamic balance

and coordination.

• Decreased muscular endurance and

strength of the hip extensors and abductors.

• Dependent on RW for ambulation.
• Gait pattern deviations.

Patient Problems (ICF Model)

Body Structure & Function

• Transfemoral amputation
• Multiple comorbidities

○ CA, HTN, Obesity, Pharma/chemo

• Inability to ambulate with

prosthetic device

• B hip ext & abd weakness
• Reduced activity tolerance
• Reduced balance

Activity Limitations

• No independent walking
• n varied surfaces
• Limited access to

downstairs kitchen Participation Restrictions

• Limited weekend

getaways

• Limited social life with

friends

Relevant Facts & Assumptions

• Prosthetic is definitive device
• She has never walked in her prosthesis
• No PT since AKA surgery 3-months prior
• Patient is capable, but reluctant to WB on prosthesis
• She does not have a PT cap on her insurance
• Has access to treadmill outside of PT sessions
• She has 14-15 weeks until casino/beach trip
• PT clinic owns a GAITRite system

Prognostic Question:

What are the prognostic indicators for return to PLOF and participation in social activities for a 59 yo obese female, with a non-traumatic transfemoral amputation?

PREDICTING WALKING ABILITY FOLLOWING LOWER LIMB AMPUTATION: AN UPDATED SYSTEMATIC LITERATURE REVIEW

Kahle et al. (2016)

Introduction & Methods

• Goal: identify predictive factors that can

assist with determining prosthetic candidacy

• Searched literature published between

2007-2015

• After applying inclusion and exclusion

criteria, found 21 articles

• High and medium quality evidence

Kahle et al., 2016

Methods

• 12,410 subjects with varying causes of

amputation

• 37% PVD, 27% trauma, 17% diabetic,

12% cancer, 6% infection, and 2% congenital.

• Mean Age: 57.3 yrs
• Mean BMI: 30.2 kg/m2

Kahle et al., 2016

Included study factors:

Kahle et al., 2016

Conclusion

• Moderately Supported Factors:
• Cognition/mood disturbance
• Etiology
• Ability to stand on one leg
• Strongly Supported factors:
• Amputation level
• Age
• Physical fitness
• Comorbidities

Kahle et al., 2016

Discussion

• Strengths: systematic review, use of high and medium

level evidence, multiple factors, recent evidence

• Limitations: author overlap, some factors had few

articles, some unclear conclusions, heterogeneous study designs

• Predictive factors for our patient:
• Positive- etiology, SLS, age, cognition
• Negative- fitness and comorbidities ???

Kahle et al., 2016

THE INFLUENCE OF BALANCE CONFIDENCE ON SOCIAL ACTIVITY AFTER DISCHARGE FROM PROSTHETIC REHABILITATION FOR FIRST LOWER LIMB AMPUTATION

Miller, W.C. & Deathe, A.B. (2011)

Methods

• Prospective repeated measures study design
• Data collected at:
• Inpatient hospital in Canada (n = 65)
• 4-6 week inpatient amputee program
• Discharge, 1-month & 3-months follow-ups
• Outcomes:
• Demographic data (only collected at discharge)
• Balance confidence — ABC Scale
• Basic walking ability — L Test
• Participation in social activities — FAI (only collected at 3-month f/u)

Miller & Deathe, 2011

L Test

Results

Miller & Deathe, 2011

Conclusion

• Balance confidence at discharge is LOW (~70%) and does NOT

improve after discharge, even though walking ability does

• Both balance confidence + walking ability at discharge =

significant independent predictors of future participation in social activity

Miller & Deathe, 2011

Discussion

• Mean balance confidence (71-69%) is below threshold (80%),

so specific intervention is likely warranted

• Relation to our patient
• Necessary outcomes to measure at discharge
• Aim for fastest walking speed and greatest balance confidence
• Initiate specific confidence-building interventions asap

Miller & Deathe, 2011

Strengths Limitations

• Specific to participation
• Moderate sample (n = 65)
• High statistical significance
• Inpatient rehab program
• Short follow-up
• Other covariates not

included

CLASS ACTIVITY

Intervention Question:

For a 59 yo obese female with a non-traumatic transfemoral amputation, can treadmill gait training be used as the primary intervention for return to ambulation?

GAIT TRAINING INTERVENTIONS FOR LOWER EXTREMITY AMPUTEES: A SYSTEMATIC LITERATURE REVIEW

Highsmith et al. (2016)

Purpose of this study:

Determine the current strength of evidence regarding different gait training approaches for LE amputees and to formulate statements to guide practice and future research.

Highsmith et al., 2017

Highsmith et al., 2017

Methods

Data Subset

Highsmith et al., 2017

Empirical Evidence Statements

Treadmill gait training Evidence statements

Level of evidence Overall confidence

1 Bioenergetic efficiency improves with reduction of loading, real-time visual feedback, or a structured home-based program.

Low (×2), Moderate (×1) Low

Overground and/or Treadmill gait training Evidence statements

Level of evidence Overall confidence

1 Overground training w/ verbal & tactile cues and treadmill training w/ body weight unloading increases ambulatory distance w/ reduced assistance

Low (×4) Low

2 Gait training under skilled supervision improves spatiotemporal gait parameters.

Low (×5), Moderate (×3), High (×2) High

3 Training under skilled supervision are safe and effective at improving walking.

Low (×10), Moderate (×6), High (×2) High

(Highsmith et al., 2017)

Empirical Evidence Statements (cont.)

Evidence statements Level of evidence Overall confidence 1 Auditory feedback improves loading on involved-side Low (×2) Low 2 Psychological awareness improves joint kinematics in TFAs. Moderate (x2) Low 3 Appropriate prosthetic foot can promote higher external work symmetry in community ambulating TFAs. Moderate (×1) Insufficient 4 Verbal and manual cues improves ground ambulation and stair negotiation in TFAs. Low (×3), High (×1) Moderate Overground training Highsmith et al., 2017

Conclusion

1. Overground training with verbal and manual interventions effectively improved gait.

2.

Treadmill training was effective as a supplement to

• verground training when augmented with visual

feedback and/or body weight support.

3.

Both approaches improved sagittal and coronal plane biomechanics, spatiotemporal measures, and distance ambulated.

Highsmith et al., 2017

Discussion

Strengths: systematic review; 14 years of data from 3 large databases; this systematic review supported the hypothesis that multiple gait training approaches are effective to improve overall gait quality in LE amputees. Limitations: aggregating data and analysis were not possible due to the high variability in interventions, amputation levels, etiologies, and outcome measures.

Highsmith et al., 2017

HOME-BASED TREADMILL TRAINING TO IMPROVE GAIT PERFORMANCE IN PERSONS WITH A CHRONIC TRANSFEMORAL AMPUTATION

Darter, et al. (2013)

Purpose

• To investigate the effects of a home-based, multiple

speed, treadmill intervention to improve gait performance in TFA patients

• Secondary purpose is to examine the rate of

improvement

Darter et al., 2013

Methods

• Participants were volunteers with >1yr unilateral LEA,

microprocessor knee unit, and a self-selected walking speed (SSWS) of 0.67 - 1.12 m/s

• N = 8 (41.4 yrs + 12.1)
• Training Protocol: 2 min cycles of 0.89, 1.12, and 1.34

m/s per 30 min session, 3 X week for 8 weeks

• Outcome measure included:
• Temporal-Spatial gait performance
• Physiological gait performance
• Functional gait performance

Darter et al., 2013

Temporal-Spatial Performance

• Intermediate Testing Results (P<0.05):
• 0.057 sec decrease in intact limb stance phase

duration

• 0.047 sec decrease in prosthesis limb stance

phase duration

• Post-Training Testing Results (P<0.05):
• Stance phase duration symmetry improved

Darter et al., 2013

Temporal-Spatial Performance

• Intermediate Testing Results (P=0.001):
• Step lengths increased 0.05m during SSWS
• Step length symmetry ratio: 1.25 → 1.17
• No significant improvement after 4 weeks
• Overall improvement Occurred (P<0.025)

Darter et al., 2013

Physiological Gait Performance

Darter et al., 2013

Functional Gait Performance

Darter et al., 2013

Conclusion

This study supports the use of a structured treadmill walking program for improving gait performance in individuals with a unilateral transfemoral amputation.

Darter et al., 2013

Discussion

Strengths

• Amputation due to trauma or cancer
• All volunteers have Transfemoral Amputations
• Specific Intervention described in article

Limitations

• Sample size (N = 8)
• Participants had microprocessor knee units
• No control group

Darter et al., 2013

How does the evidence relate to

• ur patient?

Functional & Measurable Goals

Short-term Goals: 1. In 2 weeks, pt will ambulate 20 ft in 2-min utilizing parallel bars and RPE <13. 2. In 4 weeks, pt will stand on prosthetic LE with eyes closed and CGA for 30 sec. Long-term Goals: 1) In 10 weeks, pt will ambulate 300 ft in 2-min utilizing LRAD with CGA and RPE<13. 2) Pt will adhere to treadmill-based HEP by time of discharge. 3) Pt will navigate 200 ft with 2-hand support through uneven terrain with min-A x 2 by time of discharge.

Plan of Care

1. Flexibility: slow, prolonged stretch to prevent muscular shortening and joint contractures. 2. Strength: isometric, isotonic, isokinetic activities; PNF 3. Gait training: focused on the temporospatial, biomechanical and physiological factors 4. Balance training: that includes sitting and standing, static and dynamic activities 5. Cardiovascular training: to improve endurance and functional mobility tolerance. Frequency: 3x/week for 8 weeks, then switch to treadmill-based HEP with biweekly follow-up

May B. J., Lockard M. A., 2011

Specific Interventions

• I. Pre-Gait (weight bearing and balance)
• Partial weight shifts with, then without support
• Pelvic rotation with, then without support
• Sideways walking with, then without support
• Full weight shifts with, then without support
• Heel strike with, then without support
• Balance board
• Stepping over obstacles
• Catching or kicking a ball

Begin between parallel bars with 2-hand support → between parallel bars with 1-hand support → outside of parallel bars with LRAD

May B.J. & Lockard M.A. (2011)

Specific Interventions (cont.)

• II. Gait training
• Stepping forward and backward with unaffected leg
• Stepping forward and backward with prosthetic leg
• Unaffected leg and prosthetic leg step through pattern
• Incorporate auditory, manual cueing & feedback
• Incorporate psychological awareness and

confidence-specific interventions

• Multiple-speed treadmill training HEP

Begin between parallel bars with 2-hand support → between parallel bars with 1-hand support → outside of parallel bars with LRAD

May B.J. & Lockard M.A. (2011)

Specific Interventions (cont.)

• III. Advanced exercises
• SLS on the prosthetic LE
• Walking on uneven

surfaces

• Bouncing a ball in stance
• Bouncing a ball walking
• IV. Function focused
• Rising from a chair
• Negotiating steps
• Negotiating ramps
• Practiced falling & floor →

standing transfers

• Ambulation with carrying

weight on prosthetic side

Begin between parallel bars with 2-hand support → between parallel bars with 1-hand support → outside of parallel bars with LRAD

May B.J. & Lockard M.A. (2011)

Body Structure & Function Measures

• Symmetry ratio of step length — temporospatial measure
• Symmetry ratio of stance duration — temporospatial measure
• RPE & HR — cardiovascular performance
• 2MWT w/ MWS — cardiovascular performance
• 2MWT w/ SSWS — functional gait performance
• L Test — functional gait performance

Activity and Participation Measures

• ABC Scale — balance confidence
• FAI — frequency of participation in ADLs, IADLs & social activities

Outcomes (ICF Model)

References

1. Kahle JT, Highsmith MJ, Schaepper H, Johannesson A, Orendurff MS, Kaufman K. PREDICTING WALKING ABILITY FOLLOWING LOWER LIMB AMPUTATION: AN UPDATED SYSTEMATIC LITERATURE REVIEW. Technology and innovation. 2016;18(2-3):125-137. 2. Miller, W.C. & Deathe, A.B. (2011). The influence of balance confidence on social activity after discharge from prosthetic rehabilitation for first lower limb amputation. Prosthetics and Orthotics International, 35, 379-85. 3. May B. J., Lockard M. A. (2011). Prosthetics and Orthotics in Clinical Practice. 4. Highsmith, M.J., Andrews, C.R., Millman, C., Fuller, A., Kahle, J.T., Klenow, T.D., Lewis, K.L., Bradley, R.C., & Orriola, J.J. (2016). Gait training interventions for lower extremity amputees: A systematic literature review. Technology and Innovation, 18, 99-113. 5. Darter, D.J., Nelson, D.H., Hack, H.J., & Janz, K.F. (2013). Home-based treadmill training to improve gait performance in persons with a chronic transfemeral

• amputation. Archives of Physical Medicine and Rehabilitation, 94,

2440-2447.

Questions?