ISPO 2005Annual Scientific Meeting

M Jones

Gait Analysis in Prosthetics and OrthoticsR Baker, Centre for Clinical Research Excellence

in Gait Analysis and Gait Rehabilitation, Royal Children’s Hospital, MelbourneBrand 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

• 1st 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 BachSearched 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 2 11

RT biofeedback 3 27

Other feedback 1 11

Physical & strength training

2 15

Exercise training 3 11

Service - structure 1 119

Body wt support 3 40

Alternative PT 3 68

Prosthetic 1 37

Total 19 329

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 HadeSitting procedure for

Halo Thoracic orthoses

• Slide sheets• Auto back and knee

raise• Hook arm from 45

to 90 degree sitting• Bedside poster

Shehade and LandThe 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 InclineMcIntosh, 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 TTADite, 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

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.

Non multiple fallers Multiple fallers

TUGT 16.20 +/- 5.26 25.03 +/- 6.98

Turn time 3.08 +/- 1.03 5.16 +/- 1.60

Turn Steps 5.19 +/- 1.24 6.92 +/- 1.12

4SST 17.61 +/- 8.25 32.53 +/- 10.12

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 TEC PTB Number 19 22 10

% male 68 68 90

Mean age 66 65 64

Days to 1st mob 11.5 (14) 11 (29)* Na

Days to TEC issue na 23 (33) Na

Days to 1st prosth 39 (42) 29 (30) 23 (5.1)*

Days to mob with prosthesis

71 (60) 31.5 (27) 24.5 (5.0)

Days to Independ. prosthesis

76 (67) 40 (30)* 31.5 (13)*

Days to DC 39.5 (36) 52.5 (36) 33.5 (17)

Days to definitive 152 (66) 108 (28)* 90 (36)*

% with falls 28 33 20Median (standard deviation) *significant difference to plaster

Preparing the Amputee AthleteHowells, 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 explorationChou, 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.