ISPO 2005 Annual Scientific Meeting

M Jones

Gait Analysis in Prosthetics and Orthotics

R Baker, Centre for Clinical Research Excellence in Gait Analysis and Gait Rehabilitation, Royal Children’s Hospital, Melbourne Brand R (1987) Can Biomechanics Contribute to clinical orthopaedic assessments, Iowa Orthopaedic Journal 9:61 64.

• • Recommends: standard video, physical exam, motion analysis, EMG and O2 consumption Clinical exam includes tone, strength, spasticity, ROM with standard form and digital video.

Gait analysis in prosthetics and orthotics

• • • • Interpretation is done by the team which includes the clinician, surgeon, PT, PO, gait analyst and bioengineer.

Routine gait analysis must be 3-D, clinical and interactive, reliable, fast and available Compare with normal or diagnostic groups, before or after intervention, or with/without prosthesis/orthosis.

The side by side comparison video is best for patient feedback.

Gait analysis in prosthetics and orthotics

• • • • • • “ Please walk normally” At what distance does patient have problem?

Is there a compensatory strategy to decrease pain?

How do other joints cope with the change in orthosis/prosthesis?

Gait analysis does not measure how the orthosis is working.

Gait analysis does not help alignment questions or interface questions.

Gait analysis in prosthetics and orthotics

• • • • 3D gait analysis costs $2K each, $260/hour.

Can this system answer a clinical question?

An MRI has an instant picture with good interpretation.

Gait Analysis creates many many graphs and is not easy to interpret. Should this become easier just as the ECG has become easier to read?

Amputation in a Disaster Setting

Cr J Crozier, Liverpool Health Service • Series of vignettes re: – – – – Rwanda 1994 PNG 1998 East Timor 1999 Bande Aceh 2004

Amputation in a Disaster Setting

• Rwanda: preplanned massacre with injuries from machete and adze – UN Health Care, Kigali Central Hosp destroyed and restored – – Early Management of Severe Trauma (resusc first) Mine Education Awareness (blast creates “umbrella” effect, needs deep debridement, secondary missiles in other limb, perineum and abdomen.)

PNG Tsunami 7.1 Earthquake

• • • • • • Healthcare workers deployed in 48 hours from Surgical team at Richmond Prepacked man-transportable boxes Triage, Resusc, OT tents, general hospital Press scrutiny Liquifactive necrosis, all wounds left open with bulky dressings for delayed closure 262 operations in 10 days

East Timor preplanned vote for Independence

• • • 1 st day deployment of 30 health care workers, tents Informed consent before any amputation Denge mosquito, bone infections.

Bande Aceh Tsunami

• • • Hospitals filled with mud If close operations prematurely, wounds liquify Tetanus

Amputation in a Disaster Setting

• Conclusion: – OH&S priority for human to human diseases, insects (no shorts, t-shirts & thongs), mine awareness, own mental health.

– – – – Consent and document all amputations (cultural After Life) Life before limb Cultural awareness Media

Prosthetic Rehabilitation Symposium

• • Dr Freijah recommended controlling the edema and protecting the stump with the most urgent being the first week post op.

– Immed post amp prosthesis Berlmont 1958 – Rigid dressing Mooney 1971, Sarmento 1972 – – RRD Wu 1979, Meuller 1982 Prosthetic liners & gel socks There is lack of uniformity in prosthetic management due to a range of overriding issues.

Prosthetic Rehabilitation Symposium

Rehabilitation prosthesis – Socket – – – Componentry Consumer expectation Agency expectation • • • • Types • POP Interim PPAM Prefab RRD Haberman Custom made (the only one that meets all the criteria)

Management of “High Risk” Foot Pathology

• • Anaesthetic feet: diabetes, neuropathy, demyelination, drug induced neuropathy, leprosy, burns on barefoot, household accidents, smoking, immunosuppressed, RA, SLE, Scleroderma, renal dysfunction, amyloidosis, polyneuropathy Diagnose with microfilament from Diabetic Educator, map the Weinstein filament pressure sense; vibration, ankle and knee jerk

Management of “High Risk” Foot Pathology

• • Advanced glycated end products: keratin, collagen, long chain protein, basement membrane thickening, joint capsule and structural changes, WBC can’t get to wound and work slower.

Windlash effect: planter fascia sheath is thicker, peroneus longus pulls down the first ray, fat pads get absorbed.

Management of “High Risk” Foot Pathology

• – – – – Ulceration is caused from – Joint changes – Increased planter pressure Callus Tissue necrosis Ulceration Osteomyelitis • Treatment – Control BSL (3-8) – Debride to release granulation factors – – – – Control infection Off load, rest Dressings should not be an additional hard lump Educate GP & pt

Management of “High Risk” Foot Pathology

• • • • Total Contact Cast Armstrong (2005) Diabetes Care 28:3:551-554 TCC bi-valved Removable Cast Walker Healing shoes • – – – – – – Which Cast shoe?

– Consent – Lower limb edema control Skin integrity Balance Neuropathic trauma Funding Lifestyle Time factors and difficulty

Management of “High Risk” Foot Pathology

• Charcot Foot – Multi fractures with deformity – Early diagnosis vital – – – – Damaged sympathetic nerve Neuropathic Brodski scale (5 levels) osteopenia • Treatment – – – – Reduce edema, cast until cool (thermal scanner), Shoes and orthotics Review regularly Upper body activity to ex and keep BSL optimal

The efficacy of amputee gait training: systematic review of the literature Pryor and Bach Searched 1966 to 2005 databases: Conchrane, Recal, Embase, AMEd, Cinahl, Medline, google, metacrawler, dissertations, web of science Key words: amputee, gait, walking, training, rehabilitation, physiotherapy/physical therapy Results: 1 RCT (Alexander and Goodrich 1978), 18 papers met secondary criteria, total n=329.

The efficacy of amputee gait training: systematic review of the literature Gait training N studies N amputees conventional RT biofeedback Other feedback 2 3 1 11 27 11 Physical & strength training Exercise training Service - structure Body wt support Alternative PT Prosthetic Total 2 3 1 3 3 1 19 15 11 119 40 68 37 329

The efficacy of amputee gait training: systematic review of the literature Conclusion: Despite our professional intuition that current gait training regimes are efficacious, there is limited evidence in the literature to support this assumption.

It will be especially valuable to conduct controlled trials of conventional training approaches, rather than those that use sophisticated biofeedback or assistive devices, as there is minimal literature in this area.

Wheeler and Hade Sitting procedure for Halo Thoracic orthoses • Slide sheets • • Auto back and knee raise Hook arm from 45 to 90 degree sitting • Bedside poster Shehade and Land The Pelvic-rib Wedge orthoses • Fitted wedge of pelite between rib and iliac crest in clients with severe neuromuscular scoliosis highly dependent on posture support systems.

The effect of Transfemoral Amputation on the attention required for a complex gait task Graham, Pryor, Bach • • • • • N=6 TFAs, n=6 control Straight line and fig 8 track, velocity measures Auditory Stroop test for the dual task No difference in response latency existed between groups (F=2.497, p=.146), however, RL increased significantly between straight line and Fig 8 walking (F=11.2, p=.007) and seated and Fig 8 walking (F=25, p=.001).

TFA walked slower than control (F=21.2, p=.001). Both groups slowed down for the complex walking task (F-182, p=.000).

Unilateral TTA gait on an Incline • • • • McIntosh, Palk, Vickers, Beatty • N=8 TTAs (6 SACH, 2 Single axis foot), n=7 control • • 7m platform at 5 degree angle Amputees walked at half the speed of the controls (ascending and descending).

Uphill prosthetic steplength longer, sound limb steplength longer downhill.

Prosthetic limb had shorter single support time Prosthetic limb reduced ROM at hip and knee Amputee lacked standard heel strike, push-off later in VGRF in both limbs, very low shear force in prosthetic limb.

Identification of Increased Fall Risk Early after Unilateral TTA

Dite, Connor, Curtis • Trips and slips have been identified as the most common cause of falling (Topper 1993) • • Up to 50% com dwelling amps fall, 49% are injured, 76% avoid activities post fall.

High risk factors: Inability to step rapidly in different directions (Dite 2002a) and to safely turn while walking (Dite 2002b).

• Tests to predict falling: Timed up and go test and Four Square Step Test, 180 degree turn test: turn time and turn steps.

Identification of Increased Fall Risk Early after Unilateral TTA TUGT Turn time Turn Steps 4SST Non multiple fallers 16.20 +/- 5.26

3.08 +/- 1.03

5.19 +/- 1.24

17.61 +/- 8.25

Multiple fallers 25.03 +/- 6.98

5.16 +/- 1.60

6.92 +/- 1.12

32.53 +/- 10.12

TTA who take longer to complete the TUGT, 180 degree turn, and 4SST would have more falls in the 6 months after discharge.

The TUGT and 4SST are performed often in ADLs and are important elements in prevention of the most common cause of falls.

A comparison of different approaches to the early prosthetic mgmt of the TTA Laux, Kohler • Aim to compare mobility outcomes and time frames of TTA with plaster temporary, TEC and PTB.

• As the DC date is dependent on the pt’s ability to mobilize with or without prosthesis and their safety in the community was expected that there would be no significant differences in the time to DC.

A comparison of different approaches to the early prosthetic mgmt of the TTA plaster 19 TEC 22 PTB 10 Number % male Mean age Days to 1 st mob Days to TEC issue Days to 1 st prosth Days to mob with prosthesis Days to Independ. prosthesis Days to DC Days to definitive % with falls 68 66 11.5 (14) na 39 (42) 71 (60) 76 (67) 39.5 (36) 152 (66) 28 68 65 11 (29)* 23 (33) 29 (30) 31.5 (27) 40 (30)* 52.5 (36) 108 (28)* 33 90 64 Na Na 23 (5.1)* 24.5 (5.0) 31.5 (13)* 33.5 (17) 90 (36)* 20 Median (standard deviation) *significant difference to plaster

Preparing the Amputee Athlete

• • • • Howells, Howells, Millons • • Weakness and inhibition from prolonged rest, surgery, pain, positioning, learned movement patterns, change in weight distribution, use of aids.

Assessment: posture, injuries, strength (include abdomen core strength and recruitment pattern), gait and sport • Re-educate gait (lateral trunk, core, hip) Inhibit overactive mm, stretch tight mm, position to stretch ant hip capsule, reduce antagonists and compensatory strategies.

Strengthening should be functional: squats with weights, STS, progress into more hip extension in stance.

Swimming: dips, kicks, rowing Theraball: push ups, lower abdomen crunch, hip stabilization

Preparing the Amputee Athlete

• Prosthesis: – Hydraulic knee only for walking, not for running – – Polycentric knee for running (post bumper, certain alignment) Sport prosthesis when physiotherapist says pt is ready: 3 mo commitment to gym, pool, track, join team and perform, then running leg.

Social and Medical Predictors of Adaptation to Amputation: a qualitative exploration Chou, Warren, Manderson • Explore social predictors of adaptation to amputation with SF-36 and qualitative narratives • • Qualitative data was analysed thematically based on priniciples of grounded theory (Glaser & Strauss1967). SF-36 data was analysed with SPSS transforming data to 8-scale health profile and summary measures. • • • Physical component yielded mean 28.5 (5.93). Self view of physical function: limited, severe role disability and high level of distress to physical body. However, this was viewed as temporary.

Mental component mean 49.3 (5.74). Low levels of social disability and high levels of social inclusion.

Interviews: social participation highly limited, dependence on formal social supports. Family members were central to rehab and impetus to continuing rehab. Prosthetic use was of significant importance in self perception of future health and well-being, return of bipedal mobility and body image.