Transcript UNIS Template

FUNCTIONAL PERFORMANCE IN LOWER LIMB
AMPUTEES: PAST AND FUTURE AREAS OF
RESEARCH
DR NATALIE VANICEK, SENIOR LECTURER
DISCIPLINE OF EXERCISE AND SPORT SCIENCE,
FACULTY OF HEALTH SCIENCES
MY BACKGROUND
› PhD research: Biomechanical and psychological factors that distinguish fallers
from non-fallers: A comparative study of transtibial amputees and able-bodied
individuals
› AIM: To inform the clinical recommendations for amputee rehabilitation to
reduce falls incidence and to improve falls monitoring, prevention and treatment
in physiotherapy practice
- A review of current amputee rehabilitation as it relates to falls monitoring and the use
of outcome measures to inform amputee practice
- A biomechanical comparison of level gait, stair ascent and descent and postural control
- Balance confidence and quality-of-life measures in fallers and non-fallers were
examined using psychological instruments and their relationship with functional
measures were explored
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FINDINGS 1 – REVIEW OF CURRENT PRACTICE
› No clear consensus about criteria for discharge
› Falls monitored informally and infrequently  monitoring system should be
developed
› Raise awareness about the different outcome measures  physiotherapists are
actively encouraged to reach a consensus about the use of appropriate
outcome
Percentage of
› Only 35% of physiotherapists
used psychological outcome
measures or referred patients
to a psychologist or counsellor
› Psychological tools were not
used to monitor patient
progress or inform
physiotherapy discharge
Observational measures
SIGAM mobility grade
Berg balance scale
Tinetti balance assessment tool
Mobility performance measures
TUG test
Timed 10-m walk test
6-min walk test
2-min walk test
L test of functional mobility
Psychological measures
MMSE
Self-report functional measures
LCI
SCS
Houghton scale
Self-report quality of life measures
SF-12® or SF-36®
HAD scale
PEQ
Number of
responders
(n=)
those who
used outcome
measures
(n/23)
Percentage of
total
responders
(n/29)
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3
1
70%
13%
4%
55%
10%
3%
8
4
2
1
1
35%
17%
9%
4%
4%
28%
14%
7%
3%
3%
1
4%
3%
14
2
1
61%
9%
4%
48%
7%
3%
2
2
1
9%
9%
4%
7%
7%
3%
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CLINICAL OUTCOMES
› Advocate use of following outcome measures
to inform treatment planning or to monitor
change after intervention or after discharge:
1.
ABC-UK
2.
Amputee Mobility Predictor with a
prosthesis (AMPPRO)
3.
Houghton Scale of prosthetic use in
people with lower-extremity amputations
4.
Locomotor Capabilities Index 5 (LCI-5)
5.
The Trinity Amputation and Prosthesis
Experiences Scales (TAPES)
6.
Timed Up and Go test (TUG)
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FINDINGS 2 – BIOMECHANICAL COMPARISONS
› Amputee fallers walked quickly and loaded prosthetic limb more
› Biomechanical differences between fallers and non-fallers led to the following
recommendations for increasing muscle strength:
› Eccentric control of the ankle plantarflexor muscles on the intact limb to control
the forward progression of the tibia during terminal stance
› Knee extensor eccentric strength on the affected limb should be improved to
prevent the knee from collapsing during the loading response/controlled
lowering phase
› Hip flexor eccentric control on both limbs to slow deceleration of thigh extension
during late stance
› Handrail use in stair walking and other compensatory strategies
› Intact limb should control push-off forces because the affected limb would need
to control larger accelerations during single support
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FINDINGS 3 – BIOMECHANICAL COMPARISONS
› Using computerised dynamic posturography .....
› Non-fallers bore more weight through intact vs. prosthetic limb
- Amputees should practice moving their COP rapidly towards the intact limb in dynamic
conditions
› Amputees rely more on visual input, even when input is inaccurate
- Amputees should practice postural control during quiet standing under more
challenging conditions, such as with eyes closed (no vision), or when standing on
different support surfaces (moving, flexible or uneven surfaces)
- Interpreting somatosensory feedback from the residual limb should provide important
sensory information in the absence of the biological ankle & foot and plantarflexor
muscles
› Weight distribution under the affected and intact limbs could be evaluated in a
rehabilitation setting with the use of simple scales
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FINDINGS 4 – QOL AND FUNCTION
› The TUG test, 10m walk test and MFES showed ceiling effects and were not
sensitive enough to differentiate between independently living fallers and nonfallers
- New measures may be needed to monitor function in the more able and active
amputees
› Perceived quality-of-life was related to performance on daily tasks such as
walking and the TUG test, and was considered a good indicator of overall
function
› Low scores of the functional tests were correlated with lower quality-of-life
scores
› Consequences of falling may have more negative effects on mental, rather than
physical health
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EARLY WALKING AIDS
› AIM: Using an RCT-design, to investigate the
longitudinal gait patterns of transtibial amputees
using either the AMA or PPAM aid prior to their
functional prosthesis, during rehabilitation until
discharge
PPAM
› There were no significant differences between
the PPAM and AMA groups in terms of total
rehabilitation time (days), time to receipt of
prosthesis or the total number of physiotherapy
treatments received during rehabilitation
› Both groups had improved walking, reaching an
acceptable level of walking ability, despite very
different gait patterns with the EWAs during
early rehabilitation  the most significant gait
adaptations occurred following receipt of a
functional prosthesis
AMA
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BACPAR
› British Association of Chartered Physiotherapists in Amputee Rehabilitation,
specialist group under the Chartered Society of Physiotherapists
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MY RESEARCH INTERESTS
› Broadly speaking, the underlying aim of my research is to provide evidence-based
recommendations to inform clinical standards. Through biomechanical analysis,
appropriate and targeted exercise intervention strategies that are aimed at
attenuating the loss of musculoskeletal function, reducing falls and improving quality
of life can be designed, implemented and evaluated.
› My current research interests are:
› To investigate stair walking as a more challenging locomotor task in lower limb
amputees and understand the relationship between function and quality of life
factors
› To explore the relationship between physical performance and quality of life to
develop disease-specific outcome measures
› To establish an amputee-specific database of biomechanical and psychological health
status
› To investigate whether (and how regularly) falls are monitored in current healthcare
practice and the implications of falls on a patient’s treatment programme
› To evaluate the effectiveness of a falls prevention programme on functional
performance in lower limb amputees
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MY RESEARCH INTERESTS
› WHY ? To investigate stair walking as a more challenging locomotor task in lower
limb amputees and understand the relationship between function and quality of
life factors
- WHO ? Transfemoral and transtibial amputees; vascular and traumatic cause
- WHAT ? 3D motion capture testing
- Functional tasks (e.g,. TUG & L-test, Berg balance, 10m walk test, etc ...) can be
completed during physiotherapy rehabilitation or in lab
- Questionnaires (e.g., ABC-scale, SF-36) can be completed anywhere/ anytime
- WHERE ? Participant would need to visit laboratory at UniSyd Cumberland campus in
Lidcombe
- ETHICS: NSW HREC and UniSyd ethical approval
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MY RESEARCH INTERESTS
› WHY ? To explore the relationship between physical performance and quality of
life to develop disease-specific outcome measures
- WHO ? Transfemoral and transtibial amputees; vascular and traumatic cause
- WHAT ? Functional tasks can be completed during physiotherapy rehabilitation
- Questionnaires can be completed anywhere/anytime, but before/after treatment best
practice
- WHERE ? Physiotherapy treatment
- ETHICS: NSW HREC and UniSyd ethical approval
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MY RESEARCH INTERESTS
› WHY ? To establish an amputee-specific database of biomechanical and
psychological health status
- WHO ? Transfemoral and transtibial amputees; vascular and traumatic cause
- WHAT ? Functional tasks (e.g,. TUG & L-test, Berg balance, 10m walk test, etc ...) can be
completed during physiotherapy rehabilitation
- Questionnaires (e.g., ABC-scale, SF-36) can be completed anywhere/anytime, but
before/after treatment best practice
- WHERE ? Physiotherapy treatment; sub-set of population would attend laboratory in
Lidcombe for 3D motion capture testing
- ETHICS: NSW HREC and UniSyd ethical approval
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MY RESEARCH INTERESTS
› WHY ? To investigate whether (and how regularly) falls are monitored in current
healthcare practice and the implications of falls on a patient’s treatment
programme
- WHO ? Lead physiotherapists; multi-disciplinary team
- WHAT ? Determine falls monitoring practice; influence on patient’s treatment; review of
falls education  lead to implementation of standardised monitoring system within the
AustPAR group and among the multi-disciplinary team
- WHERE ? Group meetings; phone interviews; online questionnaires  need a good
response rate representative of Sydney or NSW
- ETHICS: Need NSW HREC approval? Audit vs. Research? UniSyd ethical approval
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MY RESEARCH INTERESTS
› WHY ? To evaluate the effectiveness of a falls prevention programme on
functional performance in lower limb amputees
- Are there currently standardised prescribed home-based or supervised falls prevention
programmes that physiotherapists prescribe their patients? Has anyone evaluated
their effectiveness?
- WHO ? Transfemoral and transtibial amputees; vascular and traumatic cause
- WHAT ? Design and implement an evidence-based exercise programme
- 3D motion capture testing pre- and post-intervention
- Functional tasks (e.g,. TUG & L-test, Berg balance, 10m walk test, etc ...) can be
completed during physiotherapy rehabilitation or in lab
- WHERE ? Intervention: patient’s home or supervised exercise class
- Testing: laboratory in Lidcombe for 3D motion capture testing
- ETHICS: NSW HREC and UniSyd ethical approval
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HAND-OUT
› Please return to Naomi at the end of today’s session (or to me if you complete it
before the end of lunch)
› I am happy to discuss other possible ideas for research, so please share your
thoughts as much as possible
› Please contact me if you’d like an electronic copy of the handout or any of the
articles listed on the next slide
› Thank you
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CONTACT DETAILS
› Natalie Vanicek: [email protected]
› References:
› Barnett C, Vanicek N, Polman R. Postural responses during volitional and perturbed dynamic balance tasks in new
lower limb amputees: A longitudinal study. Gait and Posture 2012; in press.
› Barnett C, Vanicek N, Polman R. Temporal adaptations in generic and population-specific quality of life and falls
efficacy in recent lower limb amputees. Journal of Rehabilitation Research and Development 2012: accepted.
› Vanicek N, Strike S, Polman R. Falls efficacy, health status and functional performance in transtibial amputee fallers
vs. non-fallers. British Association of Chartered Physiotherapists in Amputee Rehabilitation 2012; 36: 11-19.
› Mazari FAK, Mockford KA, Barnett C, Khan JA, Brown B, Smith L, Polman R, Hancock A, Vanicek N, Chetter IC.. Hull
early walking aid for rehabilitation of transtibial Amputees - Randomised controlled Trial (HEART). The Journal of
Vascular Surgery 2010; 52: 1564-1571.
› Vanicek N, Strike S, McNaughton L, Polman R. Gait patterns in transtibial amputee fallers vs. non-fallers:
biomechanical differences during stair ascent. Prosthetics and Orthotics International 2010; 34: 399-410.
› Vanicek N, Strike S, McNaughton L, Polman R. Postural responses to dynamic perturbations in amputee fallers vs.
non-fallers: a comparative study with able-bodied subjects. Archives of Physical Medicine & Rehabilitation 2009b;
90: 1018-1025.
› Vanicek N, Strike S, McNaughton L, Polman R. Gait patterns in transtibial amputee fallers vs. non-fallers:
biomechanical differences during level walking. Gait and Posture 2009a; 29: 415-20.
› Barnett C, Vanicek N, Polman R, Hancock A, Brown B, Smith L, Chetter I. Kinematic gait adaptations in unilateral
transtibial amputees during rehabilitation. Prosthetics and Orthotics International 2009; 33: 141-53.
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