Case Presentation:Case Presentation:Ms S.H. and E-kneeMs S.H. and E-knee

OutlineOutline

Background on Ms S.H.Background on Ms S.H.

E-kneeE-knee

Video of lock knee vs E-kneeVideo of lock knee vs E-knee

GoalsGoals

RehabilitationRehabilitation

Current statusCurrent status

Current goalsCurrent goals

BackgroundBackground

22ndnd year student at Sydney Uni year student at Sydney Uni Presented to A & E at RPAH on 5/10/04 Presented to A & E at RPAH on 5/10/04

with:with: RashRash Increased thirstIncreased thirst Feeling extremely unwellFeeling extremely unwell

Diagnosed with meningococcal Diagnosed with meningococcal septicaemiasepticaemia

Intubated and ventilated within 0.5 hoursIntubated and ventilated within 0.5 hours

Spent 15 days in ICU at RPAHSpent 15 days in ICU at RPAH Transferred to Concord Hospital Transferred to Concord Hospital

ICU/burns unitICU/burns unit Multiple surgeries (skin Multiple surgeries (skin

grafts/debridements), currently:grafts/debridements), currently: R TTA, without a patella or patella tendonR TTA, without a patella or patella tendon L TRAL TRA R TMCAs – incision between 1R TMCAs – incision between 1stst and 2 and 2ndnd MC to MC to

writewrite Osteomyelitis of L ankleOsteomyelitis of L ankle

Spent 9 months in hospitalSpent 9 months in hospital d/c in July ‘05d/c in July ‘05

ProstheticsProsthetics On discharge from Concord Hospital:On discharge from Concord Hospital:

R thigh-lacer with locking kneeR thigh-lacer with locking knee sensor below elbowsensor below elbow Rigid AFO for L ankleRigid AFO for L ankle

As above at 12/5/06As above at 12/5/06 July ’06: 3/12 trial of E-kneeJuly ’06: 3/12 trial of E-knee

If measurable improvement with E-knee, If measurable improvement with E-knee, then ALS would fund E-knee for then ALS would fund E-knee for subsequent prosthesessubsequent prostheses

Trial of E-KneeTrial of E-Knee

Frank Li (Burns physio at Concord) Frank Li (Burns physio at Concord) found the E-knee, manufactured by found the E-knee, manufactured by Becker Orthopaedics on the internetBecker Orthopaedics on the internet

3 letters from Dr Hawthorne (rehab 3 letters from Dr Hawthorne (rehab specialist) to the discretionary specialist) to the discretionary committeecommittee

Lobbying from S.H’s familyLobbying from S.H’s family

Dr Hawthorne and Judy Davidson Dr Hawthorne and Judy Davidson approached Becker Orthopaedic approached Becker Orthopaedic representative at ISPOrepresentative at ISPO

ALS and Becker Orthopaedic rep ALS and Becker Orthopaedic rep agreed on 3/12 trialagreed on 3/12 trial

Cost of E-knee $12,000Cost of E-knee $12,000

E-kneeE-knee Pressure sensor in heel of foot Pressure sensor in heel of foot

(like foil)(like foil) When pressure through heel, knee When pressure through heel, knee

will lockwill lock Unlocks when no pressure through Unlocks when no pressure through

heelheel 3 LEDs for locking, no lights 3 LEDs for locking, no lights

when un-locked when un-locked Locked position is the “off” Locked position is the “off”

positionposition Safety, if battery fails knee will not Safety, if battery fails knee will not

give waygive way Can check battery charge by Can check battery charge by

flicking a switch (3 lights full, 1 flicking a switch (3 lights full, 1 light low)light low)

ProblemsProblems PainPain

Ankle 2Ankle 2° to osteomyelitis (bone fragments ° to osteomyelitis (bone fragments still come out of ankle)still come out of ankle)

LBPLBP Meds: gabapentin, tramal, endoneMeds: gabapentin, tramal, endone

GaitGait Trunk SF in R stanceTrunk SF in R stance Increased R step lengthIncreased R step length Increased pelvic rotationIncreased pelvic rotation L knee hyperextensionL knee hyperextension

WeaknessWeakness Glut maxGlut max Glut medGlut med Poor control of L quadsPoor control of L quads Lumbar ext and transverse abdominusLumbar ext and transverse abdominus

Goals:Goals: Increased walking speedIncreased walking speed Independent in stair ascent (step over) Independent in stair ascent (step over)

and descentand descent Independent up and down curbsIndependent up and down curbs

→ → so that ALS would fund E-knee so that ALS would fund E-knee prosthesisprosthesis

Improve fitnessImprove fitness Decrease in LBP during gaitDecrease in LBP during gait

Rehabilitation strategiesRehabilitation strategies LBP LBP

Hip ext in prone (2 pillows under Hip ext in prone (2 pillows under abdomen)abdomen)

Arm ext in proneArm ext in prone Hip bridging on fit ball (feet on ball and Hip bridging on fit ball (feet on ball and

trunk on ball), then lifting a foot uptrunk on ball), then lifting a foot up

→ → increase back ext enduranceincrease back ext endurance

Lateral pelvic shift (glut med)Lateral pelvic shift (glut med) SLSSLS SLS with swing leg on small ball SLS with swing leg on small ball

(progressed to basketball)(progressed to basketball)

→ → small movements of leg on ball, causes small movements of leg on ball, causes contralateral activation of glut medcontralateral activation of glut med

Walking with small fit ball (progressed to Walking with small fit ball (progressed to medium then large ball)medium then large ball)

→ → moving the ball to ipsilateral stance leg causes moving the ball to ipsilateral stance leg causes trunk rotation, therefore more difficult to SF trunk rotation, therefore more difficult to SF trunktrunk

Carrying a bag with 2-4kgs and large fit Carrying a bag with 2-4kgs and large fit ballball

→ → carrying textbooks caused incr trunk SFcarrying textbooks caused incr trunk SF

FitnessFitness Stationary cycle (8.5 min = 2km)Stationary cycle (8.5 min = 2km) Walking carrying a large swiss ballWalking carrying a large swiss ball

Steps/gutter practiceSteps/gutter practice Stepping onto with R and over with L, Stepping onto with R and over with L,

with 8cm and progressed to 12.5cmwith 8cm and progressed to 12.5cm Stair ascent without ULsStair ascent without ULs Stair descent (recently) step over stepStair descent (recently) step over step

Thus far has managed 10 steps with SBAThus far has managed 10 steps with SBA Abdominal muscles (pt request) Abdominal muscles (pt request)

situpssitups Kicking a small soccer ball (novelty Kicking a small soccer ball (novelty

and pt used to play soccer)and pt used to play soccer)

12/5/0612/5/06

Lock kneeLock knee27/7/0627/7/06

E-kneeE-knee24/10/0624/10/06

E-kneeE-knee

TUAGTUAG 20.720.7 8.88.8 6.86.8

10m10m 15.915.9 6.56.5 6.16.1

stair ascentstair ascent stair stair descentdescent

2525

30301515

20208.58.5

1515

6 min walk6 min walk 193193 331331 430430

TUAG

0

5

10

15

20

25

sec

10m

0

3

6

9

12

15

18

sec

Stairs

0

5

10

15

20

25

30

35

sec stair ascent

stair descent

6 min walk

0

75

150

225

300

375

450

525

met

res

SatPro and activities scoreSatPro and activities scoreLock-kneeLock-knee

(12/5/06)(12/5/06)E-kneeE-knee

(24/10/06)(24/10/06)

SatProSatPro

(best score (best score 15)15)

35/6035/60 22/6022/60

BasicBasic

AdvancedAdvanced

TotalTotal

22/2822/28

12/2812/28

34/5634/56

28/2828/28

25/2825/28

53/5653/56

sat pro

0

10

20

30

40

50

60

satis

fact

ion

Activities Score

0

10

20

30

40

50

60

activ

ities

sco

re

BAS

AAS

TAS

Current GoalsCurrent Goals

Swimming – going to QLD in DecSwimming – going to QLD in Dec Increase fitness furtherIncrease fitness further Step over gait in descending stairsStep over gait in descending stairs Walking on uneven surfacesWalking on uneven surfaces Getting off the floorGetting off the floor

Treatment plansTreatment plans Theraband Xs for ULs on fit ballTheraband Xs for ULs on fit ball

Supine bridgingSupine bridging Prone trunk ext with arm extProne trunk ext with arm ext

Stair descent practiceStair descent practice Incr stationary cycle time to 15 min, Incr stationary cycle time to 15 min,

and incr resistance from 4Nm to 8Nmand incr resistance from 4Nm to 8Nm Pec deckPec deck Scapula retraction/rowing with Scapula retraction/rowing with

therabandtheraband