Exercise and sport for amputees Erin Kennedy Physiotherapist, Westmead Hospital 2014
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).
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)
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)
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)
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
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
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)
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.
Flexibility • General stretches • Hip flexors • Glutes • Hamstrings • Quads • Adductors • Lower back • Calf
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).
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
Quads training exercises • Step ups/downs • Squats, +/- resistance • Bulgarian squats • lunges • Stair drills • 2 at a time, sideways, grapevine • Controlled SIT
Hamstring training exercises • Bridging • Single leg bridging • Gym ball hamstring curls • Hamstring curls in 4pt kneeling • Hamstring pulses in prone
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
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)
Balance • weight shift • Straddle stance • Step stance • Side stepping • braiding • Step taps • Throwing and catching ball • Bouncing ball • Kicking and trapping ball • Wobble board
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 **
Endurance • Running and Sports participation is hard work so need to work on endurance. • Walking • Swimming • Cycling • Rowing machine • Arm cycle
When to teach the amputee to run • Walking well unaided • Amp pro >37 • 6mwt > 250m?? • Good socket fit • Motivated -
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
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.
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
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
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
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
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
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)
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)
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)
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)
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 international36(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 Biomech24:63-75 • Nolan L, Lees A (2000) the kinematic charateristic of above and below knee amputee long jumpers. Ergonomics. 43:1637-1650. • Nolan L (2009) Lower limb strength in sports active transtibial amputees. Prosthetics and Orthotics international. 33:230-241 • Wetterhahn K, Hansen C, Levy C (2002) effects of participation in physical activity on body image of amputees. Am J Phys Med Rehab81(3):194-201. • Davies D and Datta D (2003) Mobility outcomes following unilateral lower limb amputation. Prosthetics and Orthotics International. 27:16-190. • Webster J, Levy C, Bryant P, and Prusakowski P (2001) sports and recreation for people with limb deficiency. Arch Phys Med Rehab82(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 13:Visual analysis of prosthetic gait. In: Atlas of amputated and limb deficiencies: Surgical prosthetic and rehabilitation principles. Rosemont IL. p 385-394. • 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):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