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

Patient History 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 ●

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 Activity Limitations Transfemoral amputation No independent walking ● ● Multiple comorbidities on varied surfaces ● CA, HTN, Obesity, Limited access to ○ ● Pharma/chemo downstairs kitchen Inability to ambulate with ● Participation Restrictions prosthetic device Limited weekend ● B hip ext & abd weakness ● getaways Reduced activity tolerance ● Limited social life with ● Reduced balance ● 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 L Test 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

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

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

Methods Highsmith et al., 2017

Data Subset Highsmith et al., 2017

Empirical Evidence Statements (Highsmith et al., 2017) Treadmill gait training Evidence statements Level of Overall evidence confidence 1 Bioenergetic efficiency improves with reduction of Low (×2), Low Moderate (×1) loading, real-time visual feedback, or a structured home-based program. Overground and/or Treadmill gait training Evidence statements Level of Overall evidence confidence 1 Overground training w/ verbal & tactile cues and Low (×4) Low treadmill training w/ body weight unloading increases ambulatory distance w/ reduced assistance 2 Gait training under skilled supervision improves Low (×5), High Moderate spatiotemporal gait parameters. (×3), High (×2) 3 Training under skilled supervision are safe and Low (×10), High Moderate effective at improving walking. (×6), High (×2)

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

Conclusion 1. Overground training with verbal and manual interventions effectively improved gait. Treadmill training was effective as a supplement to 2. overground training when augmented with visual feedback and/or body weight support. Both approaches improved sagittal and coronal plane 3. 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