Orthotics and Prosthetics in Rehabilitation [4 ed.] 0323609139, 9780323609135

Table of contents :
Cover
ORTHOTICS AND PROSTHETICS IN REHABILITATION
Copyright
Contributors
Preface
Acknowledgments
1
Orthotics and Prosthetics in Rehabilitation: Multidisciplinary Approach
Orthotists and Prosthetists
History
Prosthetic and Orthotic Professional Roles and Responsibilities
Disablement Frameworks
Characteristics of Rehabilitation Health Care Teams
Values and behaviors
Rehabilitation teams
Summary
References
Section I: Building Baseline Knowledge
2
Aging and Activity Tolerance: Implications for Orthotic and Prosthetic Rehabilitation
Oxygen Transport System
The Aging Heart
Cardiovascular structure
Myocardium
Valves
Coronary Arteries
Conduction System
Arterial Vascular Tree
Cardiovascular physiology
Sensitivity to β-Adrenergic Stimulation
Baroreceptor Reflex
Functional consequences of cardiovascular aging
Preload
Afterload
Left Ventricular Ejection Fraction
Pulmonary Function in Later Life
Changes within the lung and airway
Changes in the musculoskeletal system
Control of ventilation
Functional consequences of pulmonary aging
Implications for Intervention
Precautions
Estimating Workload: Heart Rate and Rate Pressure Product
Blood Pressure as a Warning Sign
Respiratory Warning Signs
Optimizing cardiopulmonary performance
Preparation for Activity and Exercise
Monitoring the cardiorespiratory response to exercise
Heart Rate and Blood Pressure
Perceived Exertion
Exercise Testing Protocols
Physical performance training
Energy Cost of Walking
Self-selected walking speed
Measuring energy costs of walking
Oxygen Rate and Oxygen Cost
Serum Lactate
Heart Rate and Physiologic Cost Index
Energy expenditure at self-selected walking speeds
Work of walking with an orthosis
Work of walking with a prosthesis
Technologic Advances Impacting Energy Demands
Summary
References
3
Motor Control, Motor Learning, and Neural Plasticity in Orthotic and Prosthetic Rehabilitation
Why Think About Motor Control, Motor Learning, or Neuroplastcity?
Theories of Motor Control
Dynamic systems perspectives
Resources of the Individual
Nature of the Task
Characteristics of the Environment
Skill acquisition models
Theories of Motor Learning
Evolution of models of motor learning
Temporal considerations
Implicit and explicit aspects of motor learning
Role of aerobic exercise in motor learning
The Importance of Practice
Appropriate level of challenge
Motivation and self-efficacy
Variability
Practice conditions: blocked, random, or serial?
Part- versus whole-task training
Relationships: practice, retention, and transfer
Intrinsic and Extrinsic Feedback
Knowledge of Performance and Knowledge of Results
How and When Should Feedback Be Used?
What Modality for Feedback Is Appropriate?
Using Normative Feedback
Mental Practice and Imagery
Role of Sleep in Motor Learning
Importance of Patient/Client-Centered Goals
Neural plasticity in motor control and motor learning
Use It or Lose It
Use It and Improve It
Specificity Is Significant
Repetition, Repetition, Repetition
Intensity Is Important
Time and Timing
Salience Is Substantial
Considering the Life Span
Transference
Interference
Task Success Reinforcement
Aerobic exercise, neuroplasticity, and neuroprotection
Application: Case Examples
Questions to consider
Functional Considerations
Motor Learning Issues
Summary
References
4
Evidence-Based Approach to Orthotic and Prosthetic Rehabilitation
What Is Evidence-Based Practice?
Process of Evidence-Based Practice
Step 1: Formulating an Answerable Clinical Question
Patient characteristics
Intervention
Defining the outcome
Step 2: Locating and Accessing the Best Evidence
Sources of evidence
Textbooks
Primary Sources: Journal Articles
Secondary Sources: Integrative and Systematic Review Articles
Secondary Sources: Clinical Practice Guidelines
Electronic resources and search strategies
Locating Citations
Executing Search Strategies
Searching for Interventions
Diagnosis as the Intervention
Natural History or Prognosis
Systematic Review
Locating full-text articles
Step 3: Critically Appraising the Evidence
Overall methodologic quality
Sample: Adequacy and Appropriateness
Outcome Measures
Step 4: Applicability to Patients and Clinical Practice
Clinical relevance
Integrating Clinical Expertise and Skill
Staying current with the literature
Summary
Appendix 4.1
Appendix 4.2
Appendix 4.3
References
5
Clinical Assessment of Gait
Normal Gait
Kinetic and Kinematic Descriptors of Human Walking
Gait Cycle
Functional task 1: Weight acceptance
Initial Contact
Loading Response
Functional task 2: Single limb support
Midstance
Terminal Stance
Functional task 3: Limb advancement
Preswing
Initial Swing
Midswing
Terminal Swing
Describing Pathological Gait
Common gait deviations observed during stance
Common gait deviations observed during swing
Gait deviations associated with abnormal muscle tone
Qualitative Gait Assessment
Instrumented Gait Analysis
Technology in gait assessment
Measuring temporal and distance parameters
Assessing the energy cost of walking
Kinematic and kinetic systems
Electromyography
Pressure-sensing technology
Choosing the Appropriate Assessment Tool
Function-Based Assessment
Functional measures
Walking Speed
Timed Up and Go
Dynamic Gait Index
Functional Ambulation Classification
Modified Gait Abnormality Rating Scale
Choosing an Assessment Strategy
Clinical Examples of Gait Deficiencies: Impact of Functional Tasks During Gait
Clinical characteristics of gait in hemiplegia
Clinical characteristics of gait in spastic diplegic cerebral palsy
Clinical characteristics of gait in children with spina bifida
Gait Patterns in Individuals With Amputation
Transtibial prosthetic gait
Studies of Transtibial Prosthetic Gait
Transtibial Alignment
Initial Contact and Loading Response
Midstance
Terminal Stance
Preswing
Swing Phase
Common gait deviations in transtibial prosthetic gait
Transfemoral prosthetic gait
Temporal Values
Transfemoral Alignment
Initial Contact and Loading Response
Midstance
Terminal Stance
Preswing
Swing Phase
Common gait deviations in transfemoral prosthetic gait
Summary
References
6
Materials and Technology
Orthotics and Prosthetics in the 20th Century
Materials
Leather
Metals
Steel
Aluminum
Titanium and Magnesium
Wood
Plastics and composites
Thermoplastics
Thermoforming
Thermosetting Materials
Composites
Processing Technologies and Composite Fabrication
Foamed Plastics
Viscoelastic Polymers
Prescription Guidelines
Orthotic prescription
Prosthetic prescription
Fabrication Process
Measurement
Negative mold
Fabricating and modifying the positive model
Fabricating the orthosis or prosthetic socket
Computer-Aided Design/Computer-Aided Manufacture
Data acquisition
Shape-manipulation software
Milling and production
Central Fabrication and Mass Production
Central fabrication facilities for custom devices
Mass production
Technologies Poised to Transform Prosthetics and Orthotics and Rehabilitation
Biosensors
Power Assistance and Actuation
Exoskeletal Robotics
3D Scanners and Shape Manipulation Software
3D Printers and Additive Manufacturing
Maintenance of Orthoses and Prostheses
Summary
References
7
Footwear: Foundation for Lower Extremity Orthoses*
Components of a Good Shoe
Sole
Upper
Heel
Reinforcements
Lasts
Enhancing function
Orthotic-related function
Proper Fitting of a Shoe: ``If the Shoe Fits´´
Determining measurements
Foot Contour
Obesity and Edema
Special Considerations
Pediatric foot
Flexible and Rigid Flatfoot
Foot during pregnancy
Foot in later life
Choosing Appropriate Footwear and Socks
Athletic shoe gear
Walking shoes
Dress shoes
Socks
Prescription Footwear, Custom-Molded Shoes, Accommodative Molded Orthoses, and Shoe Modifications
Moldable leathers
Custom-molded shoes
Plastazote shoe or sandal
Shoe modifications
Lifts for Leg-Length Discrepancy
Heel Wedging
Sole Wedging
Metatarsal Bars and Rocker Bottoms
Thomas Heels
Offset Heels and Shoe Counters
Attachments for Orthoses
Shoe Stretching
Blowout Patches and Gussets
Footwear for Common Foot Deformities and Problems
Problems in the forefoot
Metatarsalgia
Sesamoiditis
Morton Syndrome
Morton (Interdigital) Neuroma
Metatarsalgia of the Fifth Metatarsophalangeal Joint
Hallux Rigidus (Limitus)
Hallux Valgus (Bunions)
Hammertoes, Claw Toes, and Mallet Toes
Problems in the midfoot
Pes Planus
Pes Equinus
Pes Cavus
Plantar Fasciitis
Problems in the rearfoot
Arthrodesis
Achilles Tendinitis, Bursitis, and the Haglund Deformity
Diagnosis-Related Considerations in Shoe Prescription
Arthritis
Gout
Diabetes
Peripheral vascular disease
hemiplegia
Amputation and congenital deformity
Reading the Wear on Shoes
Summary
References
8
Foot Orthoses
History of the Functional Foot Orthosis
Triplanar Structure of the Foot
Talocrural joint
Rearfoot
Midfoot
Forefoot
Plantar fascia and arches of the foot
Function of the Foot in Gait
Shock absorption
Adaptation to surfaces
Propulsion
Biomechanical Examination
Non-Weight-Bearing Open Chain Examination
Examination of the rearfoot
Subtalar Neutral Position
Calcaneal Range of Motion
Talocrural Joint Range of Motion
Rearfoot Deformities
Examination of the forefoot
Neutral Forefoot Position
Mobility Testing: Locking Mechanism
Identifying Forefoot Deformities
The First Ray
The Hallux
Additional observations
Static Weight-Bearing Closed Kinetic Chain Examination
Frontal plane
Calcaneal Alignment to the Floor
Tibiofibular Alignment
Alignment of the Pelvis and Lower Leg
Sagittal plane
Knee Position
Navicular Drop
Talar Bulge and Arch Height
Transverse plane
Toe Sign
Torsional Deformities
Dynamic Gait Assessment
Functional Foot Orthoses
Criteria for abnormal pronation
Causes of abnormal foot mechanics
Structural Malalignment
Muscle Weakness or Imbalance
Compromised Joint Integrity
Goals of Orthotic Intervention
Measurement and Fabrication
Negative impression
Comparison of Negative Casting Techniques Used for Fabrication of Foot Orthotics
Direct Pressure Impression Technique
Errors in Negative Casting
Positive cast modifications
Forefoot Posting
Rearfoot Posting
The orthotic shell
Covering Materials
Managing Rearfoot Deformity
Managing Forefoot Deformity
Orthotic Checkout and Troubleshooting
Controversy With Roots Paradigm
Reliability of measurement
Subtalar position in stance
Criteria for normal alignment
Foot Type and Lower Extremity Biomechanics
Foot Type and Lower Extremity Overuse Injuries
Foot strike pattern during running and lower extremity biomechanics
Foot strike pattern during running and lower extremity injuries
Orthoses and Lower Extremity Function
Effect on rearfoot biomechanics
Effect on lower limb biomechanics
Effect of the neuromuscular system
Electromyographic and Imaging Evidence
Balance and Postural Control
Management of Overuse Injuries
Pain associated with foot deformity
Patellofemoral pain syndrome
Plantar fasciitis
Morton neuroma
Low back pain
Summary
References
Section II: Orthoses in Rehabilitation
9
Principles of Lower Extremity Orthoses
What Type of Orthosis is Best?
Determinants of Functional Gait
Rockers of Stance Phase
Prefabricated, Custom Fit, or Custom Molded?
Appropriate Footwear
Ankle-Foot Orthoses
Biomechanical principles
Static Ankle-Foot Orthoses
Solid ankle-foot orthoses
Solid Ankle-foot Orthoses Control Systems
Progression Through Stance Phase
Indications for Solid Ankle-foot Orthoses
Anterior floor reaction ankle-foot orthosis
Weight-relieving ankle-foot orthoses
Dynamic Ankle-Foot Orthoses
University of california biomechanics laboratory orthosis
Dynamic ankle-foot orthosis
Posterior leaf spring ankle-foot orthosis
Additional dorsiflexion assist options
Carbon Fiber Spring Orthoses
Functional Neuromuscular Electrical Stimulation
Commercially Available Dorsiflexion-Assist Designs
Hinged thermoplastic ankle-foot orthosis
Conventional dorsiflexion-assist ankle-foot orthosis
Ankel-foot orthosis designs, tone, and postural control
When Should a Knee-Ankle-Foot Orthosis Be Considered?
Challenges to knee-ankel-foot orthosis use
Knee function and alignment
Knee-Ankle-Foot Orthosis Design Options
Conventional knee-ankel-foot orthoses
Thermoplastic knee-ankel-foot orthoses
Carbon composite knee-ankel-foot orthoses
Controlling the ankle
Controlling the knee
Single-Axis Knee Joints
Single-Axis Locking Knee
Offset Knee Joint
Variable Position Orthotic Knee Joint
Stance-Control Orthotic Knee Joints
Medially linked bilateral knee-ankle-foot orthosis designs
KAFO Delivery and Functional Training
When Is a Hip-Knee-Ankle-Foot Orthosis Indicated?
Hip-Knee-Ankle-Foot Orthosis Design Options
Conventional hip-knee-ankle-foot orthoses
HIP guidance orthosis and parawalker
Reciprocal gait orthoses
Hybrid orthoses: functional electrical stimulation
Implications for Rehabilitation
Outcome Measures in Orthotic Rehabilitation
Walking speed
Endurance during walking
Mobility and balance while walking
Summary
Case Examples
References
10
Neurological and Neuromuscular Disease Implications for Orthotic Use
Movement Impairment in Neurological and Neuromuscular Pathology
Differential Diagnosis: Where Is the Problem?
The central nervous system
Pyramidal System
Extrapyramidal System
Coordination Systems
Somatosensory and Perceptual Systems
Visual and Visual-Perceptual Systems
Executive Function and Motivation
Consciousness and Homeostasis
Peripheral nervous system
Determinants of Effective Movement
Muscle tone and muscle performance
Hypertonus
Rigidity
Hypotonus
Flaccidity
Fluctuating Tone: Athetosis and Chorea
Postural Control
Movement and coordination
Management of Neuromuscular Impairments
Medical and surgical care
Rehabilitation
Selecting the appropriate orthosis
Summary
References
11
Orthoses for Knee Dysfunction
Introduction
Anatomy of the Knee
The tibiofemoral joint
Medial Collateral Ligament
Lateral Collateral Ligament and Iliotibial Band
Anterior Cruciate Ligament
Posterior Cruciate Ligament
Posterolateral corner of the knee
Patellofemoral joint
Biomechanics of Knee Motion
Knee Orthoses Components
Prophylactic Knee Orthoses
Biomechanical implications
Evidence of effectiveness
Recommendations
Orthoses for Anterior Cruciate Ligament Insufficiency
ACL insufficiency
Biomechanical Implications
Functional Implications
Recommendations
Postoperative acl reconstruction
Biomechanical Implications
Role in Rehabilitation
Recommendations
Orthoses for Osteoarthritis
Biomechanical implications
Evidence of effectiveness
Recommendations
Orthoses for Patellofemoral Disorders
Patellofemoral osteoarthritis
Biomechanical Implications
Conservative Management
Recommendations
Patellofemoral pain syndrome
Biomechanical Implications
Conservative Management
Recommendations
Summary
References
12
Orthoses in Orthopedic Care and Trauma
Bone Structure and Function
Bone Growth and Remodeling Over the Life Span
Orthoses in the Management of Hip Dysfunction
When are hip orthosis indicated?
Hip structure and function
Infants and children with developmental dysplasia of the hip
Incidence and etiology of developmental dysplasia of the hip
Early orthotic management of developmental dysplasia of the hip: birth to 6 months
Management of developmental dysplasia of the hip: Age 6 Months and Older
Goals of orthotic intervention for children with developmental dysplasia of the hip
Complications of orthotic management of developmental dysplasia of the hip
Orthotic management of legg-calvé-perthes disease
Etiology of Legg-Calvé-Perthes Disease
Evaluation and Intervention for Legg-Calvé-Perthes Disease
Orthotic Management in Legg-Calvé-Perthes Disease
Pediatric postoperative care
Postoperative Hip Orthoses
Management of the adult hip
Total Hip Arthroplasty
Posttrauma Care
Fracture Management
Mechanisms of fracture healing
Fracture classifications
Casts and splints
Casting and Splinting Materials
Cast Application
Lower Extremity Casts
Cast Removal
Hybrid cast braces
Fracture orthoses
Types of Fracture Orthoses
External fixation devices
Postfracture management and potential complications
Summary
References
13
Orthoses for Spinal Dysfunction*
Anatomy and Biomechanics
The Three-Column Concept
Fit and Function of the Spinal Orthosis
Regional orthoses
Cervical
Cervicothoracic and thoracic orthoses
Thoracolumbar
Lumbosacral
Cervicothoracolumbosacral
Sacroiliac Joints
Scoliosis
Prevalence and natural history
Biomechanics
Evaluation
Types of braces
Milwaukee Brace
Boston Thoracolumbosacral Orthosis
Charleston Nighttime Brace
SpineCor
Orthotic Prescription
Complications
Future directions
Summary
References
14
Orthoses in the Management of Hand Dysfunction*
Nomenclature
Articular and nonarticular orthoses
Location
Direction
Purpose of orthosis
Immobilization
Mobilization
Restriction
Examples
Design Descriptors
Choices of Orthotic Designs
Static Orthoses
Serial Static Orthoses
Dynamic Orthoses
Static Progressive Orthoses
Objectives for Orthotic Intervention
Immobilization Orthoses
Mobilization Orthoses
Restriction Orthoses
Anatomy-Related Principles
Arches of the hand
Palmar creases
Metacarpal length and mobility
Positioning the hand
Tissue precautions
Tissue Healing
Stages of tissue healing
Factors that influence tissue healing
Mechanical Principles
Levers
Stress
Angle of force application
Force application
Material and Equipment
Thermoplastic materials
Handling Characteristics
Conformability and Resistance to Stretch
Memory
Bonding
Physical Characteristics
Thickness
Perforations
Colors
Categories of Orthosis Materials
Strapping
Padding and lining
Components
Equipment
Overview of the Orthotic Fabrication Process
Summary
References
15
Orthoses in Burn Car
Burn Injury
Causes of Burns
Burn Depth
Surgical Management of Burns
Burn Size
Location of the Burn
Wound Care
Topical Agents and Wound Dressing
Psychology of Burn Injury
Rehabilitation Intervention
Wound Healing and Scar Formation
Operative Scar Management
Nonoperative Scar Management
Burn Rehabilitation Interventions
Therapeutic Exercise
Active Exercise
Gait Training
Passive Exercise and Stretching
Physical Agents
Positioning
Splinting and Orthotics
Neck
Axilla and Shoulder
Elbow and Forearm
Wrist and Hand
Trunk and Pelvis
Lower Extremity
Face and Mouth
Additional Considerations
Amputation and Prosthetics in Burn Rehabilitation
Skin Condition
Contracture
Delayed Fitting
Stabilization of Body Weight
Education
Summary
References
16
Prescription Wheelchairs: Seating and Mobility Systems*
Principles of Seating and Mobility
Principle 1: Address seating before mobility
Principle 2: Strive for optimal postural alignment
Principle 3: Apply seating solutions in a proximal to distal direction
Principle 4: Provide correction before accommodation
Principle 5: Measure accurately
The Seating System
Seating components
The Frame
The Mobility System
Manual wheelchairs
Power wheelchairs
The Seating and Mobility Assessment Process
Subjective/History
Diagnoses and related health information
Prior experience with assistive technology
Mobility-Related activities of daily living
Funding sources
Physical examination and associated considerations
Tests and measures used in seating and mobility assessments
Neuromuscular
Musculoskeletal
Cardiopulmonary
Integumentary
Comorbidities
Ordering the Wheelchair
Delivering the Wheelchair
Follow-Up
State of the Art
Summary
References
17
Etiology of Amputation
Epidemiology of Amputation
Levels of Amputation
Causes of Amputation
Diabetes and peripheral artery disease
Amputation Rates and Racial and Ethnic Populations
Outcomes of Dysvascular Conditions and Amputation
Traumatic amputation
Cancer
Congenital limb deficiencies
Rehabilitation Issues for the Person With an Amputation
Rehabilitation Environment
Summary
References
Section III: Prostheses in Rehabilitation
18
High-Risk Foot and Wound Healing
Normal Wound Healing
Assessment of the High-Risk Foot
Vascular assessment
Sensory assessment
Motor assessment
Autonomic assessment
Footwear assessment
Gait and balance
Wound Assessment
Location
Wound color
Odor
Size
Depth
Drainage
Periwound skin
Wound Management
Preparing the wound bed by eliminating the source of inflammation or infection
Providing an optimal wound-healing environment
Reducing further trauma to the wound
Total Contact Casting
Removable Cast Walkers
Instant Total Contact Cast
Wound-Healing Shoes
Other Pressure-Relieving Options
Prevention of ulceration or reulceration
Summary
References
19
Amputation Surgeries for the Lower Limb*
Introduction
Indications for Lower Extremity Amputation
Dysvascular and neuropathic disease
Prevalence and Risk Factors
Patient Assessment
Vascular Examination
Indications for Amputation Versus Revascularization
Trauma
Incidence and Patient Population
Evaluation of the Threatened Limb
Limb Salvage Versus Reconstruction
Considerations Unique to Traumatic Amputations
Neoplasm
Incidence and Patient Population
Evaluation of the Patient
Limb-Sparing Surgery Versus Amputation
Limb deficiency disorders
Surgical Principles of Amputation
Determining the level of amputation
Technical considerations
Bone
Soft Tissue and Muscle
Nerve
Vessels
Postoperative Care
Dressings
Pain management
Complications
Wound healing
Fluid collections
Heterotopic ossification
Pain
Outcomes
Amputations of the Foot and Ankle
Amputations of the toes
Ray Resection
Transmetatarsal Amputation
Amputations of the midfoot
Syme amputation
Transtibial Amputation
Modified burgess procedure
Modified bruckner procedure
Modified ertl procedure
Knee Disarticulation
Transfemoral Amputation
Hip Disarticulation and Hemipelvectomy
Future Directions
Osseointegration
Indications
Implant Fixation
Skin Implant Interface
Rehabilitation Protocol
Complications
Outcomes
Active lower limb prostheses and the human-machine interface
Neuroma Prevention and Treatment
Summary
References
20
Postoperative and Preprosthetic Care
Patient-Client Management After Amputation
Individuals with new amputation
Patient-centered care and multidisciplinary teams
Examination
Patient-client history and interview
Demographic and Sociocultural Information
Developmental Status
Living Environment
Health, Emotional, and Cognitive Status
Medical, Surgical, and Family History
Current Condition
Systems review
Test and measures
Assessing Acute Postoperative Pain
Phantom Sensation and Phantom Pain
Assessing Residual Limb Length and Volume
Assessing Integumentary Integrity and Wound Healing
Assessing Circulation
Assessing Range of Motion and Muscle Length
Assessing Joint Integrity and Mobility
Assessing Muscle Performance and Motor Control
Assessing Upper Extremity Function
Assessing Aerobic Capacity and Endurance
Assessing Attention and Cognition
Assessing Sensory Integrity
Assessing Mobility, Locomotion, and Balance
Assessing Posture, Ergonomics, and Body Mechanics
Assessing Self-Care and Environmental Barriers
Monitoring for Postoperative Complications
Process of Evaluation, Diagnosis, and Prognosis
Physical therapy diagnosis
Plan of care: prognosis
Plan of care: determining appropriate goals
Interventions for Persons With Recent Amputation
Postoperative pain management
Dealing with phantom limb sensation and phantom pain
Physical Therapy for Postoperative and Phantom Pain
Limb volume, shaping, and postoperative edema
Soft Dressings and Compression
Pressure Garments: ``Shrinkers´´
Nonremovable Rigid Dressings
Removable Rigid Dressings
Removable Polyethylene Semirigid Dressings
Zinc Oxide-Impregnated Semirigid Dressing
Pneumatic Compression for Early Ambulation
Rigid Dressing as a Base for Immediate Postoperative Prostheses
Selecting the Appropriate Compression Strategy
Skin care and scar management
Range of motion and flexibility
Muscle performance
Endurance
Postural control
Wheelchairs, seating, and adaptive equipment
Bed mobility and transfers
Ambulation and locomotion
Patient and family education: care of the remaining limb
Preprosthetic Outcome Assessment
Summary
References
21
Understanding and Selecting Prosthetic Feet
Factors in Selecting a Prosthetic Foot
Functional level
Activities of daily living, vocational, and work requirements
Body weight
Residual limb
Comorbidities
Environmental exposure and durability
Shoe choices (Heel heights and shoe shape)
Interaction with other prosthetic components
Prior prosthetic feet and gait habits
Psychological influences and personality traits
Skin tone
Cost
Bilateral limb loss
Performance Features and Appearance of Available Prosthetic Feet
Functional level 1 feet
Functional level 2 feet
functional level 3 feet
Functional level 4: high activity and specialized feet
Summary
References
22
Postsurgical Management of Partial Foot and Syme Amputation
Partial Foot Amputations
Gait characteristics after partial foot amputation
Prosthetic management
Toe Fillers and Modified Shoes
Partial Foot Inserts and Toe Fillers
Cosmetic Slipper Designs
Prosthetic Boots
Partial Foot Prostheses Incorporating an Ankle-Foot Orthosis
Chopart Prostheses
Syme Amputation
Postoperative care: Walking casts
Prosthetic management
Canadian Syme Prostheses
Medial Opening Syme Prostheses
Sleeve Suspension Syme Prostheses
Expandable Wall Prostheses
Tucker-Winnipeg Syme Prostheses
Prosthetic feet for syme prostheses
Determining the Prosthetic Clearance Value
Nonarticulating Syme Feet
Dynamic Response Syme Feet
Alignment Issues
Summary
References
23
Transtibial Prosthetics*
Evaluation for a Prosthesis
Early Management of a Prosthesis
Prescription of a Prosthesis
Socket Designs
Patellar tendon-bearing socket
Total surface-bearing socket
Interface Materials
Hard socket
Socks and sheaths
Soft inserts
Flexible inner socket
Expandable wall socket
Gel liner
Suspension
Waist belt
Joints and corset
Cuff strap
Supracondylar suspension
Supracondylar/suprapatellar
Sleeve
Suction
Locking liners
Semirigid locking liner
Elevated vacuum
Impression Techniques
Hand casting
Pressure casting
Optical scanning
Alignment
Bench alignment
Height
Dynamic alignment
Electronic alignment
Additional Features
Torque absorber
Shock absorber
Dynamic pylon
Microprocessor-Controlled Foot/Ankle Systems
Prosthetic Feet
Diagnostic sockets
Finishing Techniques
Endoskeletal considerations
Exoskeletal considerations
Deviations in Gait
Initial contact
Sagittal
Frontal
Transverse
Loading Response
Sagittal
Frontal
Transverse
Midstance
Sagittal
Frontal
Transverse
Terminal stance
Sagittal
Frontal
Transverse
Preswing
Sagittal
Frontal
Transverse
Swing phase
Sagittal
Frontal
Transverse
Troubleshooting
Specialty Prostheses
Summary
References
24
Transfemoral Prostheses
Components of the Transfemoral Prosthesis
Foot-ankle assembly
Shank
Knee Unit
Axis
Single-Axis Knee Units
Polycentric Knee Units
Stance control
Manual Locking Knee Units
Braking Mechanisms
Swing phase control
Extension Aid
Hydraulic knee units
Pneumatic knee units
Microprocessor knee units
Socket
Materials
Shape
Quadrilateral
Ischial containment
Suspension Systems
Suction
Elevated Vacuum (Subatmospheric) Suspension
Liners
Roll-on liners
Cushion Liner With Air Expulsion Valve
Shuttle Locking Liner
Lanyard
Total elastic suspension belt
Silesian belt
Pelvic belt
Osseous Integration
Transfemoral alignment
Sagittal alignment
Frontal alignment
Evaluation of the prosthesis
Base of support
Transfemoral gait
Side view
Rear view
Changing shoe heel height
Overuse
Improper donning
Inadequate suspension
Worn or loosened components
Patient innovation
Transfemoral prosthetic gait
Balance
Assessing Ability to Walk
Energy expenditure
Early stance compensations
Lateral Trunk Bending
Abducted Gait
Knee instability
Foot Slap
External Rotation of the Prosthetic Foot
Midstance to late stance compensations
Swing Phase Compensations
Excessive Knee Flexion (High Heel Rise)
Lateral and Medial Whips
Terminal Impact
Vaulting
Circumduction
Hip Hiking
Other issues
Summary
References
25
Prosthetic Options for Persons With High-Level and Bilateral Amputation*
High-Level Lower Limb Loss
Etiology
Biomechanics
Component selection
Choosing a Prosthetic Foot
Choosing a Prosthetic Knee Unit
Choosing a Prosthetic Hip Joint
Torque Absorbers
Energy consumption
Socket design
Rehabilitation outcomes after high-level amputation
Bilateral Lower Limb Loss
Energy cost
Component selection
Bilateral Transtibial Amputations
Bilateral Transfemoral Amputation
Transfemoral and Transtibial Amputation
Socket designs and suspension
Summary
References
26
Early Rehabilitation in Lower Extremity Dysvascular Amputation
Components of the Physical Therapy Examination
Patients history
Systems review
Tests and measures
The Evaluation Process
Establishing a Physical Therapy Diagnosis and Prognosis
Plan of care
Preprosthetic Interventions
Range of motion
Strength
Balance and postural control
Cardiovascular endurance
Edema control of the residual limb
Soft tissue mobility of the residual limb
Sensory status of the residual and remaining limbs
Hyposensitivity
Hypersensitivity
Phantom Limb Sensations
Phantom Limb Pain
Residual Limb Pain
Care of the sound limb
Candidacy for a prosthesis and prescription
Early Training for Use of a Prosthesis
Donning and doffing the prosthesis
Prosthetic Fit: Socket Design and Sock Use
Alignment of the prosthesis
Wearing schedule for the prosthesis
Positioning
Prevention and management of skin problems in the residual limb
Care of prosthetic equipment
Prosthetic Gait Training
Initial training
Assistive devices
Prosthetic gait
Gait training on alternate surfaces
Functional activities
Outcome assessment
Summary
References
27
Advanced Rehabilitation for People With Microprocessor Knee Prostheses
Historical Development
Overview of Non-Microprocessor Knee Prostheses
Introduction to Microprocessor Knee Prostheses
Microprocessor Knee Prostheses Control Mechanisms
Common Mobility Problems and Potential Solutions
Stance phase
Stairs and Ramps
Outcomes
Prescriptive Cases
References
28
Athletic Options for Persons With Limb Loss*
Introduction
Barriers and Motivation
Organizational Support for Sports or Recreation Participation
Disabled Sports, USA21
Amputee Coalition23
Challenged Athlete Foundation25
US and International Paralympic Committees27,28
Sport Classification29
Summer Paralympic Sports
Archery30
Badminton30
Athletics (Track and Field)30
Canoeing30
Cycling30
Equestrian30
Fencing30
Triathlon30
Powerlifting30
Rowing30
Rugby30
Sailing30
Shooting30
Swimming30
Table Tennis30
Taekwondo30
Wheelchair Tennis30
Sitting Volleyball30
Wheelchair Basketball30
Winter Paralympic Sports
Alpine Skiing30
Nordic Skiing30
Curling30
Sled (Sledge) Hockey30
Snowboarding30
Non-Paralympic Sports and Recreational Activities for Individuals With Limb Loss
Fishing32
Hunting32
Golf33
Trail Orienteering34 and Climbing35
Sky Diving36
Additional Water Sports and Activities
Prosthetic Components for Athletes With Limb Loss
Prosthetic Components for Athletes With Lower Limb Loss
Suspension and Sockets
Prosthetic Knee Joints
Lower Leg/Foot/Ankle Components
Athletes With Upper Limb Loss
Children With Limb Loss in Sport
Prosthetics in Sports: What Is Best?
References
29
Rehabilitation for Children With Limb Deficiencies
Comprehensive Considerations in Childhood
Classification and causes of limb deficiencies
Developmental milestones
Accommodating growth
Postoperative care
Psychosocial factors in habilitation and rehabilitation
Infants
Toddlers
School-age Children
Older Children and Adolescents
Rehabilitation and Prosthetic Decision Making
Rehabilitation of children with upper-limb amputation
Infants
Toddlers
School-age Children
Older Children and Adolescents
Rehabilitation of children with lower-limb loss
Infants
Toddlers
School-age Children and Adolescents
Rehabilitation of children with multiple limb amputation
Summary
References
30
Prosthetic Options for Persons With Upper Extremity Amputation
Length of the Residual Limb
Etiology of Upper Extremity Amputation
Preprosthetic Care
Prosthetic Options
No prosthesis
Prosthetic prescription
Prosthetic Socket
Passive Functional Prostheses and Restorations
Partial-Hand Prostheses
Disarticulation Considerations
Transradial and Transhumeral Considerations
Body-Powered Components
Terminal devices for body-powered prostheses
Wrists for body-powered prostheses
Elbows for body-powered prostheses
Body-Powered Control
Figure-of-eight harness for suspension and control
Figure-of-nine harness for control with self-suspending sockets
Control and suspension for bilateral prostheses
Electric Components
Electric terminal devices
Electric wrists
Electric elbows
Externally Powered Control
Myoelectric control systems
Dual-Site Control
Pattern Recognition Control
Alternative control systems
Hybrid Prostheses
Activity-Specific Prostheses
Summary
References
31
Rehabilitation for Persons With Upper Extremity Amputation*
Rehabilitation after Upper Extremity Amputation
Incidence and Causes of Upper Extremity Amputation
Classification and Functional Implications
Stages of Rehabilitation
Postoperative Care
Comprehensive Evaluation
Pain Management
Wound Healing
Edema control
Range of Motion, Flexibility, and Body Symmetry
Psychological Support
Preprosthetic training
Psychological Support
Edema Control and Limb Shaping
Enhancing Range of Motion and Strengthening
Myosite Testing and Training
Basic Training in Activities of Daily Living
Determining a Prosthetic Plan
Basic prosthetic training
Residual Limb Hygiene and Care of the Prosthesis
Wearing Schedule
Donning and Doffing the Prosthesis
Controls Training and Functional Use Training
Control and Functional Use of Body-Powered Prostheses
Control and Functional Use of the Myoelectric Prosthesis
Advanced Functional Skills Training
Current Research and Advancements in Technologies
Summary
References
Index
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
Y
Z

Citation preview

Orthotics

Prosthetics in Rehabilitation and

Kevin K. Chui, PT, DPT, PhD, GCS, OCS, CEEAA, FAAOMPT Director and Professor School of Physical Therapy and Athletic Training College of Health Professions Pacific University Hillsboro, Oregon

Milagros “Millee” Jorge, PT, MA, EdD Professor Emerita School of Physical Therapy Langston University Langston, Oklahoma

Sheng-Che Yen, PT, PhD Associate Clinical Professor Department of Physical Therapy, Movement and Rehabilitation Sciences Bouve College of Health Professions Northeastern University Boston, Massachusetts

Michelle M. Lusardi, PT, DPT, PhD, FAPTA Professor Emerita Department of Physical Therapy and Human Movement Science College of Health Professions Sacred Heart University Fairfield, Connecticut

Elsevier 3251 Riverport Lane St. Louis, Missouri 63043 ORTHOTICS AND PROSTHETICS IN REHABILITATION, FOURTH EDITION Copyright © 2020 by Elsevier, Inc. All rights reserved.

ISBN: 978-0-323-60913-5

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notice Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Previous editions copyrighted 2013, 2007, and 2000. Library of Congress Control Number: 2019943498

Content Strategist: Lauren Willis Senior Content Development Manager: Ellen Wurm-Cutter / Luke Held Senior Content Development Specialist: Sarah Vora Publishing Services Manager: Catherine Jackson Project Manager: Tara Delaney Design Direction: Patrick Ferguson Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1

Contributors Heather Appling, BSME, MSOP, CPO Program Director Department of Orthotics and Prosthetics Education School of Allied Health Professions Loma Linda University Loma Linda, California

Katherine Bendix, PT Physical Therapist Therapy Team Leader Encompass Health Rehabilitation Hospital of Braintree Clinical Services Braintree, Massachusetts; Part-Time Lecturer Department of Physical Therapy, Movement and Rehabilitation Sciences Bouve College of Health Professions Northeastern University Boston, Massachusetts

Kevin K. Chui, PT, DPT, PhD, GCS, OCS, CEEAA, FAAOMPT Director and Professor School of Physical Therapy and Athletic Training College of Health Professions Pacific University Hillsboro, Oregon

Bradley Conner, BS, CPO Orthotics and Prosthetics Virginia Prosthetics Roanoke, Virginia

Jonathan Day, MA, CPO Clinical Associate Professor Orthopedic Surgery and Rehabilitation The University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma

Donna M. Bowers, PT, DPT, MPH, PCS Clinical Associate Professor and Assistant Program Director Department of Physical Therapy and Human Movement Science Doctoral Program in Physical Therapy College of Health Professions Sacred Heart University Fairfield, Connecticut

Susan Ann Denninger, PT, DPT, PCS Physical Therapist Kidnetics Greenville Health System Greenville, South Carolina

Todd DeWees, AAS Michael Bridges, PT, DPT, BSME Assistant Professor School of Physical Therapy and Athletic Training College of Health Professions Pacific University Hillsboro, Oregon

J. Douglas Call, BS, CP President, CEO Virginia Prosthetics & Orthotics Inc. Roanoke, Virginia

Kevin Carroll, MS, CP, FAAOP(D) Vice President of Prosthetics Lower Limb Prosthetics Hanger Clinic Austin, Texas

Tzurei Chen, PT, PhD Assistant Professor School of Physical Therapy and Athletic Training College of Health Professions Pacific University Hillsboro, Oregon

Physical Therapy Assistant Prosthetist Orthotists POPS Shriner’s Hospital for Children Portland, Oregon

Carol Pierce Dionne, PT, DPT, PhD, MS, OCS, Cert MDT Associate Professor Rehabilitation Sciences University of Oklahoma Health Sciences Center; Director, Center for Human Performance Measurement Rehabilitation Sciences University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma

Joan E. Edelstein, PT, MA, FISPO Special Lecturer Columbia University New York, New York v

vi

Contributors

Eric Folmar, PT, DPT, OCS

Theresa E. Leahy, PT, MHS, PhD

Assistant Clinical Professor Department of Physical Therapy, Movement and Rehabilitation Sciences Bouve College of Health Professions Northeastern University Boston, Massachusetts

Assistant Professor Doctor of Physical Therapy Program University of Lynchburg Lynchburg, Virginia

Tabitha D. Galindo, PT, DPT Physical Therapist Adventist Health Clackamas Physical Therapy Clackamas, OR

Tamara Gravano, PT, DPT, EdD, GCS Associate Professor & Director of Survey Research Doctor of Physical Therapy Program Rocky Mountain University of Health Professions Provo, Utah

Patrick D. Grimm, MD Research Fellow & Orthopaedic Surgery Senior Resident Uniformed Services University - Walter Reed Department of Surgery Walter Reed National Military Medical Center Bethesda, Maryland

Michelle M. Lusardi, PT, DPT, PhD, FAPTA Professor Emerita Department of Physical Therapy and Human Movement Science College of Health Professions Sacred Heart University Fairfield, Connecticut

Sharidy MacCord, CPO Orthotics and Prosthetics Virginia, Prosthetics and Orthotics Lynchburg, Virginia

Kimberly Leigh Malin, PT, MS, DHSc, NCS Assistant Professor School of Physical Therapy and Athletic Training College of Health Professions Pacific University Hillsboro, Oregon

Tyler Manee, MS Jeremy E. Hilliard, PT, DPT Associate Professor & Director of Clinical Education School of Physical Therapy and Athletic Training College of Health Professions Pacific University Hillsboro, Oregon

Certified Prosthetist Orthotist Prosthetics and Orthotics Virginia Prosthetics & Orthotics Roanoke, Virginia; Chief Operating Officer Additive Orthotics & Prosthetics Charlotte, North Carolina

Ethan A. Hood, PT, DPT, MBA, GCS, NCS Assistant Professor Doctor of Physical Therapy Program DeSales University Center Valley, Pennsylvania

Heather Jennings, PT, DPT Physical Therapist Physical Medicine and Rehabilitation Department of Veterans Affairs Hospital West Roxbury, Massachusetts

Milagros "Millee" Jorge, PT, MA, EdD Professor Emerita School of Physical Therapy Langston University Langston, Oklahoma

Olfat Mohamed, PT, PhD Professor and Chair Department of Physical Therapy California State University Long Beach, California

Kelly J. Negley, PT, DPT Assistant Professor Doctor of Physical Therapy Program Marymount University; Physical Therapist Inpatient Rehabilitation Virginia Hospital Center Arlington, Virginia

Andrea Oberlander, PT, DPT Geza F. Kogler, PhD, CO Director, Master of Science in Prosthetics and Orthotics Program; Principal Investigator, Clinical Biomechanics Laboratory School of Biological Sciences Georgia Institute of Technology Atlanta, Georgia

Clinical Assistant Professor Department of Physical Therapy and Human Movement Science Doctoral Program in Physical Therapy College of Health Professions Sacred Heart University Fairfield, Connecticut

Contributors

Annemarie E. Orr, MA, OTD

Melissa Thacker, PT, DPT

Assistant Professor of Physical Medicine and Rehabilitation Uniformed Services University of Health Sciences Bethesda, Maryland; Occupational Therapist Department of Clinical Support Services Naval Medical Center San Diego San Diego, California

Assistant Professor Department of Sports and Exercise Science Cameron University Lawton, Oklahoma

Elicia Pollard, PT, MEd, PhD Dean School of Physical Therapy Langston University Langston, Oklahoma

Benjamin K. Potter, MD Director for Surgery Surgery Walter Reed National Military Medical Center; Professor Surgery Uniformed Service University of Health Sciences Bethesda, Maryland

John Rheinstein, CP, FAAOP(D) Upper and Lower Limb Prosthetic Specialist Metro New York Hanger Clinic New York, New York

Daniel A. Riddick, PT, DPT Inpatient Rehabilitation Lynchburg General Hospital Lynchburg, Virginia

Daniel H. Riddick, MD, PhD Professor (Retired) University of Vermont School of Medicine Burlington, Vermont

Julie D. Ries, PT, PhD Professor Doctor of Physical Therapy Program Marymount University Arlington, Virginia

S. Tyler Shultz, PT, DPT, OCS Assistant Professor Department of Physical Therapy Wingate University Wingate, North Carolina

Susan Spaulding, CPO, MS Senior Lecturer Department of Rehabilitation University of Washington Seattle, Washington

Eddie J. Traylor, BS, MEd, DPT Assistant Professor School of Physical Therapy Langston University Langston, Oklahoma

Susan H. Ventura, PT, MEd, PhD Associate Clinical Professor Department of Physical Therapy, Movement and Rehabilitation Sciences Bouve College of Health Professions Northeastern University Boston, Massachusetts

R. Scott Ward, PT, PhD, FAPTA Professor and Chair Department of Physical Therapy and Athletic Training University of Utah Salt Lake City, Utah

Brian J. Wilkinson, PT, DPT, CHT, CLT Assistant Professor School of Physical Therapy and Athletic Training College of Health Professions Pacific University Hillsboro, Oregon

Joshua Thomas Williams, PT, DPT Assistant Professor Department of Rehabilitation Sciences University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma

Christopher K. Wong, PT, PhD Associate Director Program in Physical Therapy Columbia University Medical Center New York, New York

Sheng-Che Yen, PT, PhD Associate Clinical Professor Department of Physical Therapy, Movement and Rehabilitation Sciences Bouve College of Health Professions Northeastern University Boston, MA

vii

Preface The twenty-first century continues to provide new advances in health care through the efforts of the many professionals working in scientific research and development. In particular the field of orthotics and prosthetics continues to make profound advancement through the dedication of scientists and clinicians at the U.S. Department of Veterans Affairs Office of Research and Development and in medical centers and private industry across the globe. The use of technology such as computer-aided design (CAD) and computer-aided engineering systems has been developed to support advances in product development that reduce the need for physical prototypes, as well as costs and fabrication time. The clinical application of assistive devices, such as those available in the field of orthotics and prosthetics, offer relief from physical impairments and reduce the activity limitations and participation restrictions presented by disease and disability to individuals of varied ages and backgrounds, including the men and women who courageously serve in the different branches of the United States Armed Forces. Advancements in the use of “smart” technology in the rehabilitation of persons using orthotic and prosthetic devices challenges health professionals such as physicians, physical therapists, occupational therapists, orthotists, prosthetists, nurses, and social workers to aspire for continuous quality improvement in service delivery models of care. Health care professionals seek to provide quality care using evidence-based best practice recommendations and clinical guidelines available in their respective fields. The need for integrated knowledge and collaborative collegial relationships among health professionals is critical for optimal delivery of health care to consumers across the life span. The 4th edition of Orthotics and Prosthetics in Rehabilitation provides clinicians, educators, and students of physical therapy, occupational therapy, prosthetics, and orthotics an updated textbook on common health conditions and available interventions for persons with physical impairments and disabilities that require the use of assistive devices such as an orthosis or prosthesis. The challenges facing health professionals who are dedicated to providing effective and efficient evidence-based rehabilitative care to individuals with conditions affecting their ability to engage in essential daily activities and participate in meaningful roles are many. These challenges include (1) the ever more rapidly advancing technology that tests our ability to remain up to date about available prosthetic and orthotic options, (2) expectations for productivity in practice reflected in the very real time constraints of daily patient care, and (3) the need to be good stewards of the health care dollar while at the same time providing the best orthosis or prosthesis and associated rehabilitation care so that the individual can meet his or her personal goals when using the device. Clearly, optimum care for these individuals and their family requires the combined expertise of health professionals from many different disciplines. The complexity of the health care delivery system, the varied options and alternatives for health care, and information available

through the internet can present challenges to health professionals and consumers alike. To address this complexity, the 4th edition of Orthotics and Prosthetics in Rehabilitation incorporates information from the perspectives of different members of the rehabilitation team. The goal of the 4th edition of Orthotics and Prosthetics in Rehabilitation is to present best available evidence for entry-level physical therapy, occupational therapy, and orthotic/prosthetic students and to provide a positive model of clinical decision making in the context of multidisciplinary and interdisciplinary care. We also intend the text to be a comprehensive and accessible reference for practicing clinicians; a resource for their person-centered examination, evaluation, intervention planning, and outcome assessment. Our contributors are professionals from the fields of orthotics and prosthetics, physical and occupational therapy, biomechanics, engineering, and medicine (including surgery). We present this text as an example of the value of collaborative and interdisciplinary patient care. Each contributor has carefully researched the developments in technology, examination, and intervention for the revised or new chapter presented in this edition. We have incorporated concepts and language of the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF) to enhance communication across disciplines. We have included case examples, posing sequential relevant questions to provoke discussion of alternatives as a model of effective clinical decision making. We have opted not to “answer” the questions posed, on the grounds that the general principles we present in the text must be adapted appropriately to meet individual needs, daring readers to work through the problem-solving process and debate the pros and cons of the various options with their peers. We seek to provide opportunity to “practice” the process of evidence-based clinical decision making, rather than present an absolute prescription or plan of care. We hope that this approach will provide a workable model, prompting the reader to appraise critically evidence from a variety of sources, integrate this material with the clinical expertise of self and others, and include the individual and family’s values and goals when making clinical decisions. As in previous editions, we have chosen purposefully to continue using “person-first” language to reflect the humanity and value of the individuals we care for. Person-first language utilizes phrases such as “person with stroke” or “person with amputation” rather than stating “stroke patient” or “amputee patient”. The use of personfirst language is the standard approach in addressing individuals with disabilities. We hope that this example assists students and clinicians using the text to embrace personcentered care. The text begins with a set of chapters that provides foundation and context for the care of persons who might benefit, in terms of function and of quality of life, from prescription of an orthosis or prosthesis. Although chapters on exercise prescription for older adults, motor learning and ix

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Preface

motor control, and evidence-based practice may not initially seem to “fit” with the remaining chapters, they are written with the intent to apply these concepts to the rehabilitation of individuals using an orthosis or prosthesis, and we trust that those who read them will recognize their relevance. The chapters on assessment of the ability to walk, the methods of fabrication and fitting, and on footwear choices have obvious relevance. The second part of the text takes us into the world of orthotic design and application, starting with orthoses for foot and lower limb, spine, and hand. We challenge our readers to think not only about selecting the most appropriate orthosis for persons with musculoskeletal or neuromuscular system problems, but also to design a rehabilitation intervention based on principles of motor learning that will facilitate the person’s use of the orthoses and ability to participate in activities most meaningful to the individual. We then consider wheelchairs and seating as an orthosis-ofsorts, designed to enhance mobility for persons when functional walking is not a viable option. The third part of the text focuses on the care of persons with amputation, beginning with consideration of why amputations are performed, care of those at risk of amputation (with prevention as a focus), how amputations are done, and postoperative/preprosthetic care. The following chapters provide an overview of prosthetic options and

alignment issues for those with partial foot, transtibial, transfemoral, transhumeral, and bilateral amputations. We then consider initial prosthetic rehabilitation, including chapters on advanced skills for community function and athletics following amputation. The chapter on children with limb deficiency prompts us to incorporate our understanding of motor, cognitive, and emotional development, as well as family dynamics, into prosthetic rehabilitation. We include chapters on prosthetic options and rehabilitation for persons with upper extremity amputation meant to provide exposure to this more specialized aspect of prosthetic and rehabilitative care. With this 4th edition of Orthotics and Prosthetics in Rehabilitation, we hope that our work will enhance collaboration, mutual respect, and communication, as well as broaden the knowledge base of health professionals involved in orthotic or prosthetic rehabilitation. It is our belief that collaborative and interdisciplinary care not only enriches clinical practice and teaching, but also insures the best possible outcomes for individuals for which we provide rehabilitative care. Kevin K. Chui, PT, DPT, PhD Milagros “Millee” Jorge, PT, MA, EdD Sheng-Che Yen, PT, PhD Michelle M. Lusardi, PT, DPT, PhD

Acknowledgments To my family, for their endless support. To Dr. Michelle Lusardi, PT, DPT, PhD, FAPTA, for believing in me. To our colleagues, for their commitment to this project. And to my Executive Dean, Dr. Ann Barr-Gillespie, PT, DPT, PhD, for her guidance. K.K.C.

To my beloved wife, Shao-Jen Cheng You have been my source of inspiration and interest for all of my scholarly work. S.Y.

To Mitchell B. Horowitz In thanksgiving for our wonderful married life together and in memory of my beloved brother William Jorge. “The way to love anything is to realize that it may be lost.”– G.K. Chesterton

To all who have served as my mentors, I as truly grateful and blessed to have followed in your footsteps. To all of the former students who have come through my classroom, what a privilege to have been part of your journey. To my beloved husband, Lawrence, and my wonderful son, Tigre, you have been the wing beneath my wings⋯

M.J.

M.M.L

xi

1

Orthotics and Prosthetics in Rehabilitation: Multidisciplinary Approach☆ MILAGROS JORGE

LEARNING OBJECTIVES

On completion of this chapter, the reader will be able to do the following: 1. Describe the role of the orthotist, prosthetist, physical therapist, and other professionals in the rehabilitation of persons with movement dysfunction. 2. Discuss the history and development of physical rehabilitation professions associated with the practice of orthotics and prosthetics in health care. 3. Identify contemporary critical factors that continue to influence the need for the use of orthotics and prosthetics in rehabilitation. 4. Apply the use of disablement frameworks in physical rehabilitation. 5. Discuss the role of health professionals in multidisciplinary and interdisciplinary rehabilitation teams. 6. Determine key attributes and attitudes that health professionals should possess to be successful members of interdisciplinary rehabilitation teams.

The author extends appreciation to Caroline Nielson, whose work in prior editions provided the foundation for this chapter. Health professionals work in health care settings to meet the physical rehabilitation needs of diverse patient populations. The current health care environment strives to be patient-centered and advocates the use of best-practice models that maximize patient outcomes and contain costs. The use of evidence-based treatment approaches, clinical practice guidelines, and standardized outcome measures provides a foundation for evaluating and determining efficacy in health care across disciplines and health conditions. The World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF)1 provides a disablement framework that enables health professionals to maximize patient/client participation and function while minimizing disability. The current complex environment of health care and evolving patterns of health care delivery require a focus on multidisciplinary and interdisciplinary approaches to the total care of the patient. For a health care team to function effectively, each member of the health care team must develop a positive attitude toward multidisciplinary and interdisciplinary collaboration. The collaborating health professional must understand the functional roles of each health care discipline within the team and must respect and value each discipline’s input in the decision-making process of the health care team. Rehabilitation, particularly when related to orthotics and prosthetics, requires an interdisciplinary approach and lends ☆ The author extends appreciation to Caroline C. Nielsen, whose work in prior editions provided the foundation for this chapter.

2

itself well to collaboration among the various health professionals involved in the management of providing physical rehabilitation. Persons with orthopedic and neurologic impairments caused by a variety of health conditions require a wide range of expert knowledge and technical skills. The physician, prosthetist, orthotist, physical therapist, occupational therapist, nurse, and social worker are important participants in the rehabilitation team who will provide the knowledge and skills necessary for effective patient management. Understanding the roles and professional responsibilities of each of these disciplines maximizes the ability of the rehabilitation team members to function effectively to provide comprehensive care for the patient. According to disability data from the American Community Survey 2017,2 12.6% of noninstitutionalized populations, male or female, of all ages and races regardless of ethnicity, reported having a disability. Nearly 24% (23.6%) of noninstitutionalized civilian veterans aged 21 to 64 years report having a Veterans Administration (VA) service–connected disability. In the 2015 US Congressional Research Service report, “A Guide to U.S. Military Casualty Statistics,”3 the US military engagements that have continuously persisted for the past 15 years in Iraq, Afghanistan, and other countries have resulted in traumatic brain injury (TBI), amputation, and physical disabilities with life-long impairments.4 The continued rise in persons with obesity has increased the number of people with diabetes. The Centers for Disease Control and Prevention 2017 Diabetes Surveillance System Report indicates 30.3 million Americans have diabetes5—1 out of every 10 persons; 84 million Americans (1 out of every 3 persons) have prediabetes (Box 1.1). Persons with diabetes are at risk for dysvascular

1 • Orthotics and Prosthetics in Rehabilitation: Multidisciplinary Approach

3

Box 1.1 Fast Facts on Diabetes

Orthotists and Prosthetists

30.3 million Americans have diabetes (1 out of every 10 persons) Diagnosed: 23.1 million people Undiagnosed: 7.2 million people 84 million Americans have prediabetes (1 out of every 3 persons)

Orthotists provide care to persons with neuromuscular and musculoskeletal impairments that contribute to functional limitation and disability by designing, fabricating, and fitting orthoses or custom-made braces. The orthotist is responsible for evaluating the patient’s functional and cosmetic needs, designing the orthosis, selecting appropriate components, and fabricating, fitting, and aligning the orthosis. The orthotist educates the patient and the care providers on appropriate use of the orthosis, care of the orthosis, and how to assess continued appropriateness of the orthosis (Figs. 1.1 and 1.2). Prosthetists provide care to patients with partial or total absence of limbs by designing, fabricating, and fitting prostheses or artificial limbs. The prosthetist creates the design to fit the individual’s particular functional and cosmetic needs; selects the appropriate materials and components; makes all necessary casts, measurements, and modifications (including static and dynamic alignment); evaluates the fit and function of the prosthesis on the patient; and teaches the patient how to care for the prosthesis (Figs. 1.3 and 1.4). According to the US Department of Labor, Bureau of Labor Statistics, in 2016, there were 7500 certified orthotists and prosthetists practicing in the United States.11 Individuals who enter the fields of orthotics and prosthetics must complete advanced education (beyond an undergraduate degree) and a residency program before becoming eligible for certification. Registered assistants and technicians in orthotics or prosthetics assist the certified practitioner with patient care and fabrication of orthotic and prosthetic devices.

Source: https://www.cdc.gov/diabetes/pdfs/data/statistics/nationaldiabetes-statistics-report.pdf.

disease, such as peripheral arterial disease (PAD),6 which often results in musculoskeletal and neuromuscular impairments to the lower extremities. Ischemic disease can cause peripheral neuropathy, loss of sensation, poor skin care and wound formation, trophic ulceration, osteomyelitis, and gangrene, which can result in the need for limb amputation. Persons coping with illness, injury, disease, impairments, and disability often require rehabilitation inclusive of special orthotic and prosthetic devices to help with mobility, stability, pain relief, and skin and joint protection. Appropriate prescription, fabrication, instruction, and application of the orthotic and prosthetic devices help persons to engage in activities of daily living as independently as possible. Orthotists and prosthetists are health care professionals who custom-fabricate and fit orthoses and prostheses. Along with other health care professionals, including nurses, physical therapists, and occupational therapists, orthotists and prosthestists are integral members of the multidisciplinary and interdisciplinary rehabilitation teams responsible for returning patients to productive and meaningful lives. The WHO ICF7 is a common framework to understand and describe functioning and disability. To make the ICF more applicable for everyday use, the WHO and ICF research branch created a process for developing core sets of data to be considered when addressing persons with disabilities. ICF categories, or ICF Core Sets,8 facilitate the description of functioning by providing lists of essential categories that are relevant for specific health conditions and health care contexts. The use of the WHO ICF disablement framework enables health professionals to evaluate and support individuals with impairments that maximize function and minimize disability. The WHO ICF disablement framework has broadened considerably the original pathology model framework in which disability was a function of a particular disease or group of diseases.9 In developing the ICF Core Sets, the WHO engages professionals from across health care disciplines to endorse a more inclusive model that uses expertise within the many sectors in rehabilitative care. A multidisciplinary approach to patient care in rehabilitation is the current standard when addressing the needs of persons with physical impairments, limitations, and disabilities. The 2016 American Heart Association (AHA)/ American College of Cardiology (ACC) clinical guideline supports an interdisciplinary approach to the management of persons with PAD.10 The AHA/ACC clinical guideline identifies a team of professionals representing different disciplines to assist in the evaluation and management of the patient with PAD. This chapter discusses the developmental history of the art and science of orthotics, prosthetics, and physical therapy as professions dedicated to rehabilitating persons with injury, impairment, and disability.

Fig. 1.1 Orthotist is evaluating the proper fit of a spinal orthosis to determine whether it meets the prescriptive goals and can be worn comfortably during functional activities or whether modifications need to be made.

4

Section I • Building Baseline Knowledge

Fig. 1.4 Prosthetist using computer-aided design in fabricating a lower-extremity prosthesis.

Fig. 1.2 Child is wearing a spinal orthosis during a physical therapy session. Orthotist is observing the child as she is engaged in therapeutic play, to assess the child’s level of support and comfort while wearing the orthosis.

Fig. 1.3 Prosthetist is assisting child in donning prosthetic limb. Prosthetist will check the prosthesis for alignment, fit, and comfort.

History The emergence of orthotics and prosthetics as health care professions has followed a course similar to the profession of physical therapy. Development of all three professions is closely related to three significant events in world history: World War I, World War II, and the onset and spread of polio in the 1950s. Unfortunately, it has taken war and disease to provide the major impetus for research and development in these key areas of rehabilitation. Although the profession of physical therapy has its roots in the early history of medicine, World War I was a major impetus to its development. During the war, female “physical educators” volunteered in physicians’ offices and Army hospitals to instruct patients in corrective exercises. After

the war ended, a group of these “reconstruction aides” joined together to form the American Women’s Physical Therapy Association. In 1922, the association changed its name to the American Physiotherapy Association and opened membership to men and aligned itself closely with the medical profession. In the late 1940s the Association had once again changed its name to the American Physical Therapy Association (APTA), as it remains at present.12 Until World War II, the practice of prosthetics depended on the skills of individual craftsmen. The roots of prosthetics can be traced to early blacksmiths, armor makers, other skilled artisans, and even the individuals with amputations, who fashioned makeshift replacement limbs from materials at hand. During the Civil War, more than 30,000 amputations were performed on Union soldiers injured in battle; at least as many occurred among injured Confederate troops. At that time, most prostheses consisted of carved or milled wooden sockets and feet. Many were procured by mail order from companies in New York or other manufacturing centers at a cost of $75 to $100 each.13 Before World War II, prosthetic practice required much hands-on work and craftsman’s skill. D.A. McKeever, a prosthetist who practiced in the 1930s, described the process: “You went to [the person with an amputation’s] house, took measurements and then carved a block of wood, covered it with rawhide and glue, and sanded it.” During his training, McKeever spent 3 years in a shop carving wood: “You pulled out the inside, shaped the outside, and sanded it with a sandbelt.”14 The development of the profession of orthotics mirrors the field of prosthetics. Early “bracemakers” were also artisans such as blacksmiths, armor makers, and patients who used many of the same materials as the prosthetist: metal, leather, and wood. By the 18th and 19th centuries, splints and braces were also mass produced and sold through catalogs. These bracemakers were also frequently known as “bonesetters” until surgery replaced manipulation and bracing in the practice of orthopedics. “Bracemaker” then became a profession with a particular role distinct from that of the physician.15

1 • Orthotics and Prosthetics in Rehabilitation: Multidisciplinary Approach

World War II and the period following were times of significant growth for the professions of physical therapy, prosthetics, and orthotics. During the war, many more physical therapists were needed to treat the wounded and rehabilitate those who were left with functional impairments and disabilities. The Army became the major resource for physical therapy training programs, and the number of physical therapists serving in the armed services increased more than sixfold.16 The number of soldiers who required braces or artificial limbs during and after the war increased the demand for prosthetists and orthotists as well. After World War II, a coordinated program for persons with amputations was developed. In 1945, a conference of surgeons, prosthetists, and scientists organized by the National Academy of Sciences revealed that little scientific effort had been devoted to the development of artificial limbs. A “crash” research program was initiated, funded by the U.S. Department of Veterans Affairs Office of Scientific Research and Development and continued by the VA. A direct result of this effort was the development of the patellar tendon–bearing prosthesis for individuals with transtibial (below-knee) amputation and the quadrilateral socket design for those with transfemoral (above-knee) amputation. This program also included educating prosthetists, physicians, and physical therapists in the skills of fitting and training of patients with these new prosthetic designs.16 The needs of soldiers injured in the military conflicts in Korea and Vietnam ensured continuing research, further refinements, and development of new materials. The development of myoelectrically controlled upper extremity prostheses and the advent of modular endoskeletal lower extremity prostheses occurred in the post–Vietnam conflict era. The US Department of Defense reports data on the casualties from military engagements in Iraq and Afghanistan, including Operation Freedom’s Sentinel; Operation Inherent Resolve; Operation New Dawn; Operation Iraqi Freedom; and Operation Enduring Freedom. Based on the 2015 Congressional Research Service report on the military casualties of war, 327,299 service men and women sustained TBI and 1645 sustained major limb amputations.17 The use of orthotics and prosthetics to support individuals with TBI and amputation is critical when seeking to reduce impairments and enhance functional abilities. The Veterans Health Administration Research Development is committed to exploring the use of new technology such as robotics, tissue engineering, and nanotechnology to design and build lighter, more functional orthoses and prostheses.18 The current term orthotics emerged in the late 1940s and was officially adopted by American orthotists and prosthetists when the American Orthotic and Prosthetic Association was formed to replace its professional predecessor, the Artificial Limb Manufacturers’ Association. Orthosis is a more inclusive term than brace and reflects the development of devices and materials for dynamic control in addition to stabilization of the body. In 1948 the American Board for Certification in Orthotics and Prosthetics19 was formed to establish and promote high professional standards. Although the polio epidemic of the 1950s played a role in the further development of the physical therapy profession, this epidemic had the greatest effect on the development of orthotics. By 1970, many new techniques and materials,

5

some adapted from industrial techniques, were being used to assist patients in coping with the effects of polio and other neuromuscular disorders. The scope of practice in the field of orthotics is extensive, including working with children with muscular dystrophy, cerebral palsy, and spina bifida; patients of all ages recovering from severe burns or fractures; adolescents with scoliosis; athletes recovering from surgery or injury; and older adults with diabetes, cerebrovascular accident, severe arthritis, and other disabling conditions. Like physical therapists, orthotists and prosthetists practice in a variety of settings. The most common setting is the private office, where the professional offers services to a patient on referral from the patient’s physician. Many large institutions, such as hospitals, rehabilitation centers, and research institutes, have departments of orthotics and prosthetics with on-site staff to provide services to patients. The prosthetist or orthotist may also be a supplier or fabrication manager in a central production laboratory. In addition, orthotists and prosthetists serve as full-time faculty in orthotic and prosthetic professional education programs. Orthotists and prosthetists also serve as residency directors and clinical educators in a variety of facilities for the yearlong residency program required before the certification examination.

Prosthetic and Orthotic Professional Roles and Responsibilities With rapid advances in technology and health care, the roles of the prosthetist and orthotist have expanded from a technologic focus to a more inclusive focus on being a member of the rehabilitation team. Patient examination, evaluation, education, and treatment are currently significant responsibilities of practitioners. Most technical tasks are completed by technicians who work in the office, in the laboratory, or at an increasing number of central fabrication facilities. The advent and availability of modifiable prefabrication systems have reduced the amount of time that the practitioner spends crafting new prostheses and orthoses. Current educational requirements reflect these changes in orthotic and prosthetic practice. Entry into professional training programs requires completion of a bachelor’s degree from an accredited college or university, with a strong emphasis on prerequisite courses in the sciences. Professional education in orthotics or prosthetics requires an additional academic year for each discipline. Along with the necessary technical courses, students study research methodology, kinesiology and biomechanics, musculoskeletal and neuromuscular pathology, communication and education, and current health care issues. Orthotics and prosthetics programs are most often based within academic health centers or in colleges or universities with hospital affiliations. On completion of the educational and experiential requirements, the student is eligible to take the certification examinations. To address the rehabilitation needs of individuals who will benefit from the art and science of the fields of prosthetics and orthotics, physical therapists,

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Section I • Building Baseline Knowledge

orthotists, prosthetists, and other members of the health care team must have discreet knowledge and skills in the management of persons with a variety of health conditions across the life span. Working as a rehabilitation team, physicians, nurses, prosthetists, orthotists, physical therapists, occupational therapists, social workers, patients, and family members seek to alleviate disease, injury, impairments, and disability by maximizing function.

Disablement Frameworks Historically, disability was described using a theoretical medical model of disease and pathology. Over time, various conceptual frameworks have been developed to organize information about the process and effects of disability.20 Disablement frameworks in the past have been used to understand the relationship of disease and pathology to human function and disability.20-23 The need to understand the impact that acute injury or illness and chronic health conditions have on the functioning of specific body systems, human performance in general, and on the typical activities of daily living from both the individual and a societal perspective has been central to the development of the disablement models. The biomedical model of pathology and dysfunction provided the conceptual framework for understanding human function, disability, and handicap as a consequence of pathological and disease processes. The Nagi model was among the first to challenge the appropriateness of the traditional biomedical model of disability.21 Nagi developed a model that looked at the individual in relationship to the pathologic condition, functional limitations, and the role that the environment and society or the social environment played. The four major elements of Nagi’s theoretical formulation included active pathology (interference with normal processes at the level of the cell), impairment (anatomic, physiologic, mental, or emotional abnormalities or loss at the level of body systems), functional limitation (limitation in performance at the level of the individual), and disability. Nagi defined disability as “an expression of physical or mental limitation in a social context.”21 The Nagi model was the first theoretical construct on disability that considered the interaction between the individual and the environment from a sociologic perspective rather than a purely biomedical perspective. Despite the innovation of the Nagi model in the 1960s, the biomedical model of disability persisted. In 1980, the WHO developed the International Classification of Impairments, Disabilities, and Handicaps (ICIDH) to provide a standardized means of classifying the consequences of disease and injury for the collection of data and the development of social policy.24 This document provided a framework for organizing information about the consequences of disease. However, it focused solely on the effects of pathologic processes on the individual’s activity level. Disability was viewed as a result of an impairment and considered a lack of ability to perform an activity in the normal manner. In 1993, the WHO began a revision of ICIDH disablement framework that gave rise to the concept that a person’s handicap was less related to the health condition that created a disadvantage for completing the necessary life roles but rather to the level of participation that the person with the health condition was able to

engage in within the environment. The concept of being handicapped was changed to be seen as a consequence of the level of participation for the person and the interaction within an environment. The Institute of Medicine enlarged Nagi’s original concept in 1991 to include the individual’s social and physical environment (Fig. 1.5). This revised model describes the environment as “including the natural environment, the built environment, the culture, the economic system, the political system, and psychological factors.” In this model, disability is not viewed as a pathologic condition residing in a person but instead is a function of the interaction of the person with the environment.25 In 2001 the ICIDH was revised to ICIDH-2 and renamed “International Classification of Functioning, Disability and Health” and is commonly referred to as ICF.26 The ICF disablement framework includes individual function at the level of body/body part, whole person, and whole person within a social context. The model helps in the description of changes in body function and structure, what people with particular health conditions can do in standard environments (their level of capacity), and what they actually do in their usual environments (their level of performance). One of the major innovations of the ICF model is the presence of an environmental factor classification that considers the role of environmental barriers and facilitators in the performance of tasks of daily living. Disability becomes an umbrella term for impairments, activity limitations, and participation restrictions. The ICF model emphasizes health and functioning rather than disability. The ICF model provides a radical departure from emphasizing a person’s disability to focusing on the level of health and facilitating an individual’s participation to whatever extent is possible within that level of health. In the ICF, disability and functioning are viewed as outcomes of interactions between health conditions (diseases, disorders, and injuries) and contextual factors (Fig. 1.6). As is stated on the ICF website,27 “To make the ICF more applicable for everyday use, WHO and the ICF Research Branch created a process for developing core sets of ICF categories, or “ICF Core Sets.”28 ICF Core Sets facilitate the description of functioning, for example, in clinical practice by providing lists of essential categories that are relevant for specific health conditions and health care contexts. These ICF categories were selected from the entire ICF following a scientific process based on preparatory studies and the involvement of a multidisciplinary group of experts. The evolution of disablement frameworks from the biomedical models to the newer, contemporary models that include the biopsychosocial domains provides theoretical constructs that guide the rehabilitation professional in clinical practice. The development of the ICF Core Sets derived from input members of the rehabilitation team is essential for clinical decision-making that addresses pathologic conditions or disease processes, impairments, functional limitations, and disabilities. Interrelationships among all four of these elements are the focus of the rehabilitation team. The physical therapist, orthotist, prosthetist, and other team members work together to create the most effective outcome for the patient by identifying and addressing pathologic processes, functional limitations, impairments, and disability. The ICF Core Sets and ICF Documentation System29 allow for data collection that can be useful in research leading to

1 • Orthotics and Prosthetics in Rehabilitation: Multidisciplinary Approach

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Health prevention strategies Promotion of health, wellness, and fitness

Biological factors Congenital conditions and genetic predispositions

Pathology/ pathophysiology of the cell or tissue

Impairment of physiological systems

Demographic factors Age, gender, education, and income

Functional limitation Activity limitation of the individual

Disability Participation restriction in social roles

Psychological attributes, motivation, expectations, coping, sense of safety, and social support

Comorbidities, health habits, and lifestyle behaviors

Physical and social/psychological environments

Medical care

Medications/therapies

Rehabilitation

Health-related quality of life Overall quality of life

Fig. 1.5 The revised Institute of Medicine/Nagi model of the disablement process considers the impact of pathologic conditions and impairment, as well as intraindividual and extraindividual factors, that may influence functional limitation and disability affecting health-related and overall quality of life. (Modified from Guccione AA. Arthritis and the process of disablement. Phys Ther. 1994;74[5]:410, the Nagi Model.)

improved patient interventions, assessment of patient outcomes, and development of health and social policies.

Health condition Disorder or disease

Body functions Body structures

Activity Execution of tasks by the individual

Environmental factors Social attitudes/expectations, health care and legal systems, social structures, family and support systems, climate and terrain, and architectural characteristics

Participation Involvement in life situations

Personal factors Gender, age, economic status, coping styles, expectations, social background, education/ intellect, past and current experience, and overall behavior patterns

Contextual factors Fig. 1.6 World Health Organization International Classification of Functioning, Disability and Health Framework. (Modified from World Health Organization. Towards a Common Language for Functioning, Disability and Health. Geneva: World Health Organization; 2002: 9–10.)

Characteristics of Rehabilitation Health Care Teams The complexity of the health care arena and the level of care required by individuals in rehabilitation care settings require the collaboration of many health care practitioners with varied professional skills who can form multidisciplinary, interdisciplinary, and transdisciplinary teams as needed.30-32 The multidisciplinary rehabilitation team is composed of the different health professionals such as the physician, nurse, physical therapist, occupational therapist, prosthetist, orthotist, and social worker. Each professional operates with an area of specialization and expertise. The members of the multidisciplinary team work parallel to one another, and the medical record is the collecting source for the information gleaned and shared. Interdisciplinary teams also include the representatives of a variety of health disciplines, but there is interdependence among the professionals. In the interdisciplinary team process, there is structure and organization that promotes program planning to support patient-centered care through effective communication and effective clinical management. Clinical practice guidelines that seek to promote best practices for

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Section I • Building Baseline Knowledge

Table 1.1 AHA/ACC Clinical Guidelines for Management of Patients With Lower-Extremity Peripheral Artery Disease

▪ Nurses ▪ Orthopedic surgeons and podiatrists ▪ Endocrinologists ▪ Internal medicine specialists ▪ Infectious disease specialists ▪ Radiology and vascular imaging specialists ▪ Physical medicine and rehabilitation clinicians ▪ Orthotics and prosthetics specialists ▪ Social workers or exercise physiologists ▪ Physical and occupational therapists ▪ Nutritionists/dieticians Recommendations for interdisciplinary care team members include: Vascular medical and surgical specialists (i.e., vascular medicine, vascular surgery, interventional radiology, interventional cardiology). ACC, American College of Cardiology; AHA, American Heart Association. From Gerhard-Herman MD, et al. 2016 AHA/ACC Lower Extremity PAD Guideline. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease. A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology. 2017;69(11):1465-1508.

specific health conditions often include information on the interdisciplinary team.33 Table 1.1 provides an example of the suggested composition of an interdisciplinary team for the management of patients with PAD. The interdisciplinary team members work to establish goals for the team that drive the rehabilitation process for the patient. Interdisciplinary teams traditionally follow a patient-centered approach to goal setting. Establishing the patient as the focus of the work for the team, the interdisciplinary team members collaborate to execute the goals and meet the desired outcomes. Most team processes in rehabilitation centers strive for an interdisciplinary team approach that promotes patient-centered care. Each discipline works within its scope of practice to optimize care through coordinated efforts. Transdisciplinary teams are comprised of the same professional members identified in the multidisciplinary and interdisciplinary teams; however, the team members in the transdisciplinary model function differently in that they share clinical responsibilities and overlap in duties and responsibilities. In the transdisciplinary model of team building, the professional roles and responsibilities are so familiar to the team members that there is an interchange of tasks and functions.34 Transdisciplinary teams engage in release of professional roles typical to the discipline in an effort to have the patient receive the interventions needed within a context that is supportive of the learning and the practice. The transdisciplinary model is operational in the management of infants and toddlers who receive early intervention rehabilitation services and have an Individualized Family Service Plan (IFSP).35 Two major issues emerging in health care that affect health care professionals include (1) the need for health care professionals with advanced education and training in specialty and subspecialty areas and (2) the need for collaboration among health practitioners to ensure efficiency of patient management that results in best practice and improves patient outcomes. The information explosion in health care, particularly in rehabilitation, has led to increasing specialization and subspecialization in many fields. The

multidisciplinary, interdisciplinary, or transdisciplinary health care team concept has evolved, in part, because no single individual or discipline can have all the necessary expertise and specialty knowledge required for high-quality care, especially the care of patients with complex disorders. Rehabilitation health care teams provide patient care management approaches that capitalize on clinical expertise by engaging members from diverse medical and rehabilitation professions working together, collaborating, and communicating closely to optimize patient care.36 Collaboration is defined as a joint communication and decision-making process with the goal of meeting the health care needs of a particular patient or patient population. Each participant on the rehabilitation team brings a particular expertise, and leadership is determined by the particular rehabilitation situation being addressed. The rehabilitation team has the opportunity to meet and engage in “asking the answerable questions” that are critical in current clinical practice when engaging in an evidence-based model of practice. According to Strauss and colleagues,37 evidencebased practice is the integration of the best research evidence, clinical expertise, and patient values. Evidence-based practice and clinical decision-making enhance the role of the rehabilitation team professionals as they share their clinical insights supported by historical and current evidence. Rehabilitation teams that are diverse in professional representation can bring a wide perspective of expertise on particular rehabilitation issues. With this perspective, clinical decision-making becomes a more inclusive process. The role of the health care professional on a rehabilitation team begins during professional education. Rehabilitation sciences health professionals must work at understanding, evaluating, and analyzing the many facets of health care that require specialized professionals who will work to meet the goals and objectives of the specialty and of health care delivery on the whole. The formation of a rehabilitation team provides a cohort of professionals who individually and collectively strive for effective and efficient management of patients. The team process allows for a deeper understanding of and appreciation for the contributions of the other rehabilitation disciplines in the assessment and treatment of the patient and management of patient problems. In addition to discipline-specific skills and knowledge, health professionals must be aware of the interrelationships among health care workers. One of the major barriers to effective team functioning is a lack of understanding or misconception of the roles of different disciplines in the care of the whole patient.38 A clear understanding of the totality of the health care delivery system and the role of each professional within the system increase the potential effectiveness of the health care team. A group of informed, dedicated health professionals working together to set appropriate goals and initiate patient care to meet these goals uses a model that exceeds the sum of its individual components. Almost all current rehabilitation health care is provided in a team setting using a patient-centered approach. This integrated approach facilitates appreciation of the patient as a person with individual strengths and needs rather than as a dehumanized diagnosis or problem. The diverse perspectives and knowledge that are brought to the rehabilitation process by the members of the interdisciplinary team provide insight into all aspects of the patient’s concerns

1 • Orthotics and Prosthetics in Rehabilitation: Multidisciplinary Approach

Nurse Physical therapist

Orthotist

Physician

Patient

Occupational therapist

Prosthetist

Social worker Dietitian

Fig. 1.7 Patient-centered rehabilitation teams. Key components of the successful health care team are a clear understanding of the role, responsibilities, and unique skills and knowledge of each member of the rehabilitation team, combined with open and effective communication.

factors, which are often less obvious but equally influential on group process, include working relationships among team members; power networks within and external to the group; and the values, beliefs, and goals of individuals within the group. Team-building initiatives are often focused on the formal, or visible, areas, but informal communication, values, and norms play key roles in the functioning of the health care team. A variety of characteristics and considerations also enhance the effectiveness of the interdisciplinary health care team. In addition to having strong professional backgrounds and appropriate skills, team members must appreciate the diversity within the group, taking into account age and status differences and the dynamics of individual professional subgroups.42 The size of the team is also important: the most capable and effective teams tend to have no more than 12 members. Team members who know each other and are aware of and value each other’s skills and interests are often better able to set and achieve goals. Clearly defined goals and objectives about the group’s purpose and primary task, combined with a shared understanding of each member’s roles and skills, increase the likelihood of effective communication. Values and behaviors that facilitate the collaborative team care model include the following:

▪ ▪

(Fig. 1.7). Conceptually, all members of the health care team contribute equally to patient care. The contribution of each is important and valuable; otherwise, quality of patient care and efficacy of intervention would be diminished. Although one member of the team may take an organization or management role, decision-making occurs by consensus building and critical discussion. Professionals with different skills function together with mutual support, sharing the responsibility of patient care. Effective team-based health care assumes that groups of health care providers representing multiple disciplines can work together to develop and implement a comprehensive, integrated treatment plan for each patient. Much of our understanding of team function is drawn from organization and management research literature, the theories of which provide insight and information on how interdisciplinary teams operate and the factors that facilitate or inhibit their effectiveness. A number of factors are important influences on health professionals’ perception of team membership that can be positive or negative to the team process.

VALUES AND BEHAVIORS Some of the factors that tend to limit the effectiveness of a work group are large group size, poor decision-making practices, lack of fit between group members’ skills and task demands, and poor leadership.39-41 Other factors that influence team dynamics are classified as formal (tangible or visible) and informal (submerged). Formal factors include the policies and objectives of the group or its parent organization, the systems of communication available to the group, and the job descriptions of its members. Informal

9

▪ ▪ ▪ ▪ ▪

Trust among members that develops over time as members become more familiar with each other Knowledge or expertise necessary for the development of trust Shared responsibility for joint decision-making regarding patient outcomes Mutual respect for all members of the team Two-way communication that facilitates sharing of patient information and knowledge Cooperation and coordination to promote the use of skills of all team members Optimism that the team is indeed the most effective means of delivering quality care

In the early stages of development, it is essential that the team spend time developing goals, tasks, roles, leadership, decision-making processes, and communication methods. In other words, the team needs to know where it is going, what it wants to do, who is going to do it, and how it will get done. One of the most important characteristics of an effective health care team is the ability to accommodate personal and professional differences among members and to use these differences as a source of strength. The well-functioning team often becomes a means of support, growth, and increased effectiveness and professional satisfaction for the physical therapist and other health professionals who wish to maximize their strengths as individuals while participating in professional responsibilities.

REHABILITATION TEAMS The interdisciplinary health care team has become essential in the rehabilitation of patients whose body function and level of participation in the tasks of daily living could be enhanced by assistive technology such as an orthosis or prosthesis. The complexity of the rehabilitation process and the multidimensional needs of patients frequently

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Section I • Building Baseline Knowledge

require the expertise of many different professional disciplines. The rehabilitation team is often shaped by the typical needs and characteristics of the patient population that it is designed to serve. The individuals most often represented on the rehabilitation team include one or more physicians with specialties in rehabilitation medicine, orthopedics, vascular surgery or neurology; nurses; prosthetists and/or orthotists; physical therapists; occupational therapists; dietitians; social workers; and vocational rehabilitation counselors, as well as patients and caregivers (see Fig. 1.7). Each member of the interdisciplinary team has an important role to play in the rehabilitation of the patient. Patient education is often one of the primary concerns of the team. Imparting information regarding the health condition, etiology, treatment, progression, management, and prognosis helps patients to become active partners in the rehabilitation process rather than passive recipients of care. Patient education addresses prevention and treatment strategies; patients and their families are able to identify their needs and concerns and communicate them to the team members. Each member of the team has the responsibility for contributing to patient education so that patients have the information needed for an effective partnership and positive outcome of rehabilitation efforts. Research studies across a wide variety of medical conditions and health disciplines contain evidence that patients who feel prepared and informed are most likely to invest in and comply with recommended interventions and often have the most positive health outcome. Ideally, patient education about amputation and prosthetics begins in advance of, or at least immediately after, the amputation surgery.43 The Department of Veterans Affairs has instituted a system of care for US veterans with limb amputations, using outcome measures. The Amputation System of Care (ASoC) was introduced in 2008 with a goal of providing “lifelong care for service members with combat-related amputations from military conflicts in Iraq and Afghanistan and for veterans with amputations from diseases such as diabetes and peripheral vascular disease.” The ASoC provides coordinated care that enables persons with amputation to receive the prosthetic technology and rehabilitation management that will maximize function and independence.44 Coordinated patient-centered care by an interdisciplinary rehabilitation team is just as essential for effective

rehabilitation of children as it is for adults. For children with myelomeningocele or cerebral palsy, the broad knowledge base available through team interaction provides a stronger foundation for tailoring interventions to the ever-changing developmental needs of the child and family. Initially, the optimal delivery of care for children is best provided in a comprehensive health care setting in which the various specialists can provide a truly collaborative approach. Orthopedic surgeons, neurologists, orthotists, prosthetists, physical therapists, occupational therapists, nurses, dietitians, social workers, psychologists, and special education professionals may all be involved in setting goals and formulating and carrying out plans for intervention and outcomes assessment. The concept of a multidisciplinary pediatric clinic team was formulated as World War II came to an end.45 This structure has evolved further over the years and is particularly effective for the more complex orthotic and prosthetic challenges. A “mini-team” consisting of the patient’s physician, a physical therapist, and a prosthetist or orthotist can usually be assembled, even in a small town with few facilities. Regardless of its size, an effective team views the child and family from a holistic perspective, with the input from each specialty being of equal value. Under these circumstances, the setting of treatment priorities, such as whether prosthetic fitting or training in single-handed tasks is most appropriate at a child’s current age or developmental level, is made on the basis of the particular needs of the individual. Children with orthotic and prosthetic needs are followed in the community and within the school setting. As appropriate, a child may receive rehabilitation or habilitation services under the Individuals with Disabilities Education Act (IDEA).46 The rehabilitation/educational team is a diverse group of health care professionals, educators, family, and caregivers, each with essential skills necessary to address the needs of the child that encourage maximum participation in tasks of daily living. Each member of the team works in a collaborative manner with the family and caregivers and with the child’s teachers and other health professionals to ensure that the goals of the IFSP or the Individualized Education Plan (IEP) are addressed and met. Clear and frequent communication is essential for the team to function effectively and to achieve the desired outcomes for the child.

Case Example 1.1 Interdisciplinary Teams P.G. is a 23-year-old man admitted to a level 3 trauma center 2 weeks ago after sustaining severe crush injuries to both lower extremities and a closed-head injury in an accident involving a motorcycle and a sport utility vehicle. Initially unconscious with a Glasgow Coma Scale score of 8, P.G. was placed on life support in the emergency department. Radiographs revealed a severely comminuted fracture of the distal right femur and displaced fractures of the left tibia and fibula at midshaft. Examination revealed partial-thickness “road burn” abrasions on the left anterior thorax and thigh; these were thoroughly cleaned and covered with semipermeable dressings. A computed tomography scan of his cranium and brain revealed a subdural hematoma over the left Sylvian fissure and moderate contusion of the anterior pole and undersides of the frontal lobes. Arteriography indicated rupture of the right femoral

artery 4 inches above the knee. Given the extent of the crush injuries, the trauma team determined P.G. was not a candidate for reconstructive surgery to salvage his right limb. P.G. was taken to the operating room, where a standardlength transfemoral amputation was performed on the right lower extremity. Simultaneously, orthopedic surgeons performed an open-reduction internal fixation with an intramedullary rod in the tibia and used surgical plates and screws to repair the fibula. Neurosurgeons drained the subdural hematoma through a burr hole in his skull. P.G. was started on high-dose broadspectrum antibiotics in the operating room. He was transferred to the surgical intensive care unit for postoperative care. P.G. was weaned from the ventilator and is now functioning at a Rancho Los Amigos Scale level of 7. He is able to follow oneand two-step commands but becomes easily confused and

1 • Orthotics and Prosthetics in Rehabilitation: Multidisciplinary Approach

Case Example 1.1

Interdisciplinary Teams (Continued)

angry in complex environments and when fatigued. His postoperative pain is currently being managed with Tylenol #3 as needed. His right lower extremity has been managed with soft dressings and elastic bandages; his residual limb is moderately bulbous, with resolving ecchymosis from the accident and surgery. Moderate serosanguineous drainage continues from the medial one third of the suture line. Although most of the skin abrasions show signs of regranulation, one area on his left thigh is red and hot, with yellowish drainage. When transferred (maximum assist of two) into a bedside recliner, P.G. tolerates 30 minutes in a 45- to 60-degree reclined position. He becomes lightheaded and has significant pain when sitting upright with his left lower extremity dependent. He has been referred to physical therapy for evaluation of rehabilitation potential and initiation of mobility activities. Before his accident, P.G. was a graduate student in physics at a nearby university. He lived in a third-floor walk-up apartment with his fianc
e and his golden retriever. Besides his motorcycle, his interests and hobbies included long-distance running and mountain climbing. His mother and father have traveled to be with him during the acute hospital stay.

Case Example 1.2

QUESTIONS TO CONSIDER ▪ Who are the clinical specialists and health professionals needed to address the medical needs of the patient? ▪ What are the priorities, specific roles, and responsibilities for each potential member of the team? What team structure do you envision? ▪ How are the roles and responsibilities similar or different across the team? ▪ What external influences will affect team formation and functioning in a busy level 3 trauma center? ▪ What factors might facilitate team development? ▪ What factors might challenge the effectiveness of the team? ▪ As P.G. recovers from his injuries, how might the roles and responsibilities of the various team members change or evolve? ▪ When and how would you apply the International Classification of Functioning (ICF) disablement model for P.G.? ▪ Is there an ICF Core Set that applies to this clinical situation? ▪ Are there recommended clinical practice guidelines that apply to the management of this patient?

Interdisciplinary Teams

E.L. is a 73-year-old woman with a 10-year history of type 2 diabetes mellitus. She is insulin dependent. Two weeks before her most recent hospitalization, she and her husband (who is in the early stages of Alzheimer disease) moved from their home of 50 years to an assisted-living complex in a neighboring town. Although the furniture is set up and functional, they have not had the chance to fully unpack and make the apartment their own. Over the past 3 years, E.L. has been monitored by her team of physicians for progressive polyneuropathy of diabetes and for moderate peripheral vascular disease. She had a transmetatarsal amputation of her right forefoot 8 months ago because of nonhealing recurrent neuropathic ulcer. Despite wearing custom-molded shoes and accommodative orthoses, another ulcer of her first metatarsal head developed on the left foot 2 months ago. This new ulcer did not heal with conservative care and progressed to osteomyelitis 2 weeks ago. When vascular studies suggested inadequate circulation to heal the ulcer, she received arterial revascularization intervention, but the ischemia persisted and E.L. underwent an elective transtibial amputation of her left lower extremity. Despite a short bout of postoperative delirium thought to be related to pain management with morphine, E.L. (5 days postoperatively) was adamant about returning to her new assisted-living apartment, using a wheelchair for mobility, and receiving home care until her residual limb is healed and ready for prosthetic fitting. Currently she is able to ambulate two lengths of 15-foot-long parallel bars before needing to rest and has begun gait training with a “hop-to” gait pattern with a standard walker. She is able to transfer from sitting on a firm seating surface with armrests to standing with standby guarding and verbal cueing and needs minimal assistance from low and soft seats without armrests. She believes that she and her husband will be able to manage at home because her bathroom has grab bars on the toilet, and a tub seat and handheld shower head are available from the “loaner closet” at her assisted-living facility. At discharge, the suture line had one small area of continued moderate drainage, requiring frequent dressing changes. She is

unable to move her residual limb into a position for effective visual self-inspection of the healing surgical wound without significant discomfort. Her husband, although attentive, becomes confused with the routine of wound care. E.L.’s postoperative limb volume and edema are being managed with a total contact cast, which she is able to don and doff independently. She had one late evening fall, when she awoke from a sound sleep having to go to the bathroom and was surprised when her left limb “wasn’t really there” to stand on when she tried to get out of bed. Since her amputation, E.L.’s insulin dosages have had to be adjusted frequently because of unpredictable changes in her serum glucose levels. She has lost 20 pounds (half of which can be attributed to her amputation) since admission. QUESTIONS TO CONSIDER ▪ Who are the health care professionals likely to be involved in her care? ▪ Which team approach is most desirable for patient-centered care: multidisciplinary, interdisciplinary, or transdisciplinary? Why? ▪ What are the major challenges facing the team of care providers involved in the postoperative, preprosthetic care of E.L and her husband? How are these similar to or different from challenges and issues the trauma center team considered before her amputation? ▪ What strategies are currently in place or must be developed to ensure that E.L.’s care at home is comprehensive and coordinated? ▪ How will the roles and responsibilities of the team members evolve and change as she recovers from her surgery and is ready to begin prosthetic use? ▪ When and how would you apply the International Classification of Functioning (ICF) disablement model for E.L.? ▪ Is there an ICF Core Set that applies to this clinical situation? ▪ Are there recommended clinical practice guidelines that apply to the management of this patient?

11

12

Section I • Building Baseline Knowledge

Case Example 1.3 Interdisciplinary Teams M.S. is a 12-year-old girl with myelomeningocele (spina bifida) who uses a wheelchair for mobility. In the past year, she has developed significant thoracolumbar scoliosis believed to be associated with a growth spurt. Concerned about the rate of increase in her S-shaped thoracolumbar curve, her parents sought the advice of an orthopedic surgeon who has been involved as a consultant in her care since birth. The surgeon recommends surgical stabilization of M.S.’s spine with Harrington rods and bony fusion to (1) prevent further progression of the curve and rib hump so that secondary impairment of the respiratory system will be minimized as she grows and (2) provide more efficient upright sitting posture for wheelchair propulsion in the years ahead. M.S. currently attends classes in her neighborhood middle school where she receives related health services including physical therapy. Until 2 years ago, she ambulated for exercise by using a reciprocal gait orthosis during gym periods at school, but with recent spurts in growth the use of a manual wheelchair is more efficient for mobility (to keep up with her classmates). She is also followed up on a regular basis by a neurologist who monitors the operation of her ventriculoperitoneal shunt (commonly used in the management of hydrocephalus associated with myelomeningocele). In addition to their concerns about the risk of the surgical procedure, M.S.’s parents are quite concerned about how the anticipated 4-month postoperative immobilization in a thoracolumbosacral orthosis will affect her capacity for self-care and

Summary Patient-centered care, whether in tertiary care medical centers, in-patient rehabilitation facilities, skilled nursing facilities, or ambulatory community settings, currently relies on interdisciplinary rehabilitation teams that function to address the patient goals and maximize patient outcomes. The use of rehabilitation teams has evolved in part because no one person or discipline has the expertise in all the areas of specialty knowledge required for the established standards of care. The success of the rehabilitation team process requires health professionals to work together in a collaborative and cooperative manner. The rehabilitation team professional must demonstrate attitudes and attributes that foster collaboration, including: 1. Openness and receptivity to the ideas of others 2. An understanding of, value of, and respect for the roles and expertise of other professionals on the team 3. Value interdependence and acceptance of a common commitment to comprehensive patient-centered care 4. Willingness to share ideas openly and take responsibility This chapter introduces the topic of orthotics and prosthetics in rehabilitation and advocates for a multidisciplinary and interdisciplinary approach to patient-centered care. There is a burgeoning demand for the use of orthotics and prosthetics, based on several varying health concerns for the population, including limb loss associated with US service men and women military duties; traumatic injuries sustained by US service men and women involved in military conflicts; and on the projected rise in the number

independent wheelchair mobility. They are also concerned about how the surgery and postoperative period will potentially interrupt the effective bowel and bladder management routine for which M.S. has just begun to assume responsibility. As witnesses to their daughter’s deconditioning and loss of stamina over the past 6 months, they are concerned that she might not be “physically ready” for the surgery and postoperative rehabilitation. They are also asking questions about whether this spinal surgery will ultimately improve the prognosis of a successful return to ambulation with her reciprocal gait orthosis. QUESTIONS TO CONSIDER

▪ Who are the members of the rehabilitation team? ▪ What is the structure of the team that will best address the needs of the patient?

▪ What are the priorities, roles, and responsibilities of the

health professionals involved in the care of this child and her family? ▪ How is the composition of M.S.’s rehabilitation team similar to or different from that of P.G.’s and E.L.’s teams? ▪ How will the health and education professionals support M.S. and her family through the postoperative recovery process? ▪ When and how would you apply the International Classification of Functioning disablement model to M.S.?

of persons with chronic health conditions such as obesity, type 2 diabetes, and vascular disease. The overarching goal is to rehabilitate persons to the highest level of functional independence which is possible for the individual. The WHO ICF is the current disablement framework endorsed by 191 countries. Rehabilitation professionals including orthotists, prosthetists, and physical and occupational therapists will apply the ICF disablement model to maximize strategies for patient participation in the tasks of daily living through enhancement of environmental factors such as providing appropriate, cost-effective assistive technology including orthoses and prostheses. A rehabilitation model of patient-centered care that uses a multidisciplinary or interdisciplinary team approach to enhance communication, address goals and objectives, apply best practice, and improve patient outcomes is the current standard of care for persons in rehabilitation settings. Collaboration, mutual respect, and an understanding of the roles and responsibilities of colleagues engender productive teamwork and improved outcomes for the rehabilitation patient.

References 1. How to Use the ICF—A Practical Manual for Using the International Classification of Function http://www.who.int/classifications/ drafticfpracticalmanual2.pdf Accessed on December 27, 2017. 2. Erickson W, Lee C, von Schreder S. Disability Statistics from the American Community Service (ACS). Ithaca, NY: Cornell University YangTan Institute (YTI). Retrieved from Cornel University Disability Statistics Website: www.disabilitystatistics.org Accessed December 1, 2017. 3. 2015 U.S. Congressional Research Report, A Guide to U.S. Military Casualty Statistics: Operation Freedom’s Sentinel, Operation Inherent Resolve, Operation New Dawn, Operation Iraqi Freedom, and Operation

1 • Orthotics and Prosthetics in Rehabilitation: Multidisciplinary Approach

4. 5.

6.

7. 8. 9.

10.

11. 12. 13.

14. 15.

16. 17.

18. 19. 20. 21. 22.

Enduring Freedom. Hannah Fischer August 2015 https://fas.org/sgp/ crs/natsec/RS22452.pdf Accessed December 1, 2017. DeBruyne Nese F. American War and Military Operations Casualties: Lists and Statistics. April 2017, https://fas.org/sgp/crs/natsec/RL32492.pdf. Accessed 8 January 2018. Centers for Disease Control and Prevention (CDC) National Diabetes Statistics Report 2017 https://www.cdc.gov/diabetes/pdfs/data/ statistics/national-diabetes-statistics-report.pdf. Accessed on December 26, 2017. Gerhard-Herman MD, et al. AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease 2016. CIR.0000000000000471; Originally published. 2016;(November 13, 2016); A Report of the American College of Cardiology/American Hear. (Marie D. Gerhard-Herman, Heather L. Gornik, Coletta Barrett, Neal R. Barshes, Matthew A. Corriere, Douglas E. Drachman, Lee A. Fleisher, Francis Gerry R. Fowkes, Naomi M. Hamburg, Scott Kinlay, Robert Lookstein, Sanjay Misra, Leila Mureebe, Jeffrey W. Olin, Rajan A.G. Patel, Judith G. Regensteiner, Andres Schanzer, Mehdi H. Shishehbor, Kerry J. Stewart, Diane Treat-Jacobson, M. Eileen Walsh). WHO Towards a Common Language for Functioning. Disability and Health. ICFGeneva2002. http://www.who.int/classifications/icf/ icfbeginnersguide.pdf?ua¼1. Accessed 8 January 2018. Bickenbach J, Cieza A, Rauch A, Stucki G. (Eds.) ICF Core Sets Manual for Clinical Practice. Hogrefe, G€ottingen 2012 http://www.icf-core-sets. org/ Accessed January 8, 2018. Nagi SZ. Disability concepts revisited: implications for prevention. In: Pope AM, Tarlov AR, eds. Institute of Medicine Disability in America: Toward a National Agenda for Prevention. Washington, DC: National Academy Press; 1991. Gerhard-Herman MD, et al. AHA/ACC Lower Extremity PAD Guideline 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation; 2016: CIR.0000000000000471; Originally published. 2016;(November 13, 2016). U.S Bureau of Labor Statistics Occupational Employment Statistics For Orthotists and Prosthetists May 2016. https://www.bls.gov/oes/ current/oes292091.htm Accessed January 8, 2018. American Physical Therapy Association (APTA) History http://www. apta.org/History/ Accessed January 8, 2018. Wilson BA. History of amputation surgery and prosthetics. In: Bowker JH, Michael JW, eds. Atlas of Limb Prosthetics: Surgical, Prosthetic and Rehabilitation Principles. St. Louis: Mosby–Year Book; 1992:3–15. Retzlaff K. AOPA celebrates 75 years of service to O&P. Orthotics and Prosthetics Almanac. 1992. (Nov):45. Wilson BA. History of amputation surgery and prosthetics. In: Bowker JH, Michael JW, eds. Atlas of Limb Prosthetics: Surgical, Prosthetic and Rehabilitation Principles. St. Louis: Mosby–Year Book; 1992:3–15. Hazenhyer IM. A history of the American Physiotherapy Association. Part IV: maturity, 1939-1946. Phys Ther Rev. 1946;26:174–184. 2015 U.S. Congressional Research Report. A Guide to U.S. Military Casualty Statistics: Operation Freedom’s Sentinel, Operation Inherent Resolve, Operation New Dawn, Operation Iraqi Freedom, and Operation Enduring Freedom. Hannah Fischer August 2015 https:// fas.org/sgp/crs/natsec/RS22452.pdf Accessed December 1, 2017. Webster JB, Poorman CE, Cifu DX. Department of Veterans Affairs Amputation System of Care: 5 Years of Accomplishments and Outcomes. JRRD. 2014;51(4):vii–xvi. American Board of Certification in Orthotics, Prosthetics & Pedorthics, Inc. Serving the OP & P Profession since 1948. Practitioner Book of Rules and Candidate Guide; 2017. Masala C, Donatella RP. From disablement to enablement: conceptual models of disability in the 20th century. Disabil Rehabil. 2008;30(7): 1233–1244. Nagi S. Some conceptual issues in disability and rehabilitation. In: Sussman M, ed. Sociology and Rehabilitation. Washington, DC: American Sociological Association; 1965:100–113. Bornman J. The World Health Organisation’s terminology and classification: application to serve disability. Disabil Rehabil. 2004;26(3): 182–188.

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23. Rimmer J. Use of the ICF in identifying factors that impact participation in physical activity/rehabilitation among people with disabilities. Disabil Rehabil. 2006;28(17):1087–1095. 24. WHO Towards a Common Language for Functioning. Disability and Health. Geneva: ICF; 2002. http://www.who.int/classifications/icf/ icfbeginnersguide.pdf?ua¼1 Accessed January 8, 2018. 25. Nagi SZ. Disability concepts revisited: implications for prevention. In: Pope AM, Tarlov AR, eds. Institute of Medicine Disability in America: Toward a National Agenda for Prevention. Washington, DC: National Academy Press; 1991. 26. World Health Organization. Towards a Common Language for Functioning, Disability and Health. In: Geneva: 2002. 27. WHO ICF Research Branch. www.icf-research-branch.org. Accessed 1 December 2017. 28. Bickenbach J, Cieza A, Rauch A, Stucki G. (Eds.) ICF Core Sets Manual for Clinical Practice. Hogrefe, G€ottingen 2012 http://www.icf-core-sets. org/ accessed January 8, 2018. 29. WHO ICF Research Branch –Documentation Form https://www.icfresearch-branch.org/component/content/article/120-external-links/ 456-icf-based-documentation-form.html. 30. Sullivan EE, Ibrahim Z, Ellner AL, Giesen LJ. Management Lessons for High-Functioning Primary Care Teams. J Healthcare Management Nov/ Dec. 2016;61(6):449–466. 31. Erwin C. Perspectives on Multidisciplinary Team Processes Among Healthcare Executives: Processes that facilitate team effectiveness. Journal of Health and Human Services Administration Winter. 2015;38 (3):350–380. 32. Bewer V. Transdisciplinarity in Health Care:A Concept Analysis.2017 Wiley Periodicals, Inc. Nursing Forum Volume 52, No. 4, OctoberDecember 2017; 339–347. 33. Gerhard-Herman MD, et al. AHA/ACC Lower Extremity PAD Guideline 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation; 2016: CIR.0000000000000471; Originally published. 2016;(November 13, 2016). 34. Bewer V. Transdisciplinarity in Health Care:A Concept Analysis.2017 Wiley Periodicals, Inc. Nursing Forum Volume 52, No. 4, OctoberDecember 2017; 339–347. 35. Early Intervention Programs for Infants and Toddlers with Disabilities. https://sites.ed.gov/idea/ Accessed January 8, 2018. 36. Zafiropoulous G, Byfield D. Multidisciplinary meeting (MDM) can provide education and reinforcement of inter-professional development. Academic Journals. 2016;11(2):78–86. 37. Strauss SE, Richardson WS, Glasziou P, Hayes RB. Evidence Based Medicine. 4th ed. Elsevier Churchill Livingston; 2011. 38. Zafiropoulous G, Byfield D. Multidisciplinary meeting (MDM) can provide education and reinforcement of inter-professional development. Academic Journals. 2016;11(2):78–86. 39. Hackman JR. Groups That Work (& Those That Don’t): Creating Conditions for Effective Team Work. San Francisco: Jossey-Bass; 1990. 40. Goodman PS, Devadas RA, Hughson TLG. Groups and productivity: analyzing the effectiveness of self-managing teams. In: Campbell JP, Campbell JR, eds. Productivity in Organizations. San Francisco: JosseyBass; 1988:295–327. 41. Van Norman G. Interdisciplinary Team Issues. Ethics in Medicine. http:// depts.washington.edu/bioethx/topics/team.html Accessed January 8, 2018. 42. Goodman PS, Devadas RA, Hughson TLG. Groups and productivity: analyzing the effectiveness of self-managing teams. In: Campbell JP, Campbell JR, eds. Productivity in Organizations. San Francisco: JosseyBass; 1988:295–327. 43. Fitzgerald R. The Diabetic Foot—“Being DRRAFTED.” Podiatry Management. 102–108. 44. Webster JB, Poorman CE, Cifu DX. Deparment of Veterans Affairs Amputation System of Care: 5 Years of Accomplishments and Outcomes. JRRD. 2014;51(4):vii–vxi. 45. Wiart L, Darrah J. Changing philosophical perspectives on the management of children with physical disabilities: their effect on the use of powered mobility. Disabil Rehabil. 2002;24(9):492–498. 46. U.S. Department of Education–IDEA. https://sites.ed.gov/idea/. Accessed January 8, 2018. References from 3rd Edition.

2

Aging and Activity Tolerance ETHAN A. HOOD, KEVIN K. CHUI, and MICHELLE M. LUSARDI

IMPLICATIONS FOR ORTHOTIC AND PROSTHETIC REHABILITATION LEARNING OBJECTIVES

On completion of this chapter, the reader will be able to do the following: 1. Describe the role of the cardiopulmonary and cardiovascular systems as “effectors” for goal-driven functional motor activity. 2. Define the key components of the cardiopulmonary and cardiovascular systems as they relate to energy expenditure during functional activity. 3. Describe the functional consequences of age-related change in cardiopulmonary and cardiovascular structures, especially with respect to exercise and activity tolerance. 4. Apply principles of cardiopulmonary/cardiovascular conditioning to rehabilitation interventions for older and/or deconditioned individuals who will be using a prosthesis or an orthosis. 5. Weigh the benefits and limitations with respect to energy cost and facilitation of daily function in selecting an appropriate orthosis or prosthesis for an older or deconditioned individual. 6. Appreciate technologic advances in prosthetics and orthotics and their role in activity tolerance.

Many individuals who rely on orthotic or prosthetic devices to walk or to accomplish functional tasks have impairments of the musculoskeletal or neuromuscular systems that limit the efficiency of their movement and increase the energy cost of their daily and leisure activities. The separate and interactive effects of aging, inactivity, and cardiac or pulmonary disease can also compromise the capacity for muscular “work,” tolerance of activity, and ability to function. Consider this example: a 79-year-old woman with insulincontrolled type 2 diabetes has been referred for physical therapy evaluation after transfemoral amputation following a failed femoral-popliteal bypass. She has been on bed rest for several weeks because of her multiple surgeries. The physical effort required in undergoing rehabilitation and prosthetic training may initially feel overwhelming to this woman. In her deconditioned state, preprosthetic ambulation with a walker is likely to increase her heart rate (HR) close to the upper limits of a safe target HR for aerobic training. What, then, is her prognosis for functional use of a prosthesis? What are the most important issues to address in her plan of care? What intensity of intervention is most appropriate given her deconditioned state? In what setting and for how long will care be provided? These questions have no simple answers. The physical therapist, orthotist, and prosthetist must recognize factors that can be successfully modified to enhance performance and activity tolerance when decisions about prescription and intervention strategies are being made. Aerobic fitness should be a key component of the rehabilitation program for those who will be using a prosthesis or orthosis for the first time. It is vitally important that rehabilitation professionals recognize and respond to the warning signs of significant cardiopulmonary or cardiovascular dysfunction during treatment and training sessions. 14

Although the anatomic and physiologic changes in the aging cardiopulmonary system are important to our discussion, our focus is on the contribution of cellular and tissuelevel changes to the performance of the cardiopulmonary and cardiovascular systems and, consequently, on the individual’s ability to function. This view provides a conceptual framework for answering four essential questions:

▪ ▪ ▪ ▪

Is this individual capable of physical work? If so, what is the energy cost of doing this work? Is it possible for this individual to become more efficient or more able to do physical work? What impact does the use of an orthosis or prosthesis have on energy use and cost during functional activities for this person?

Oxygen Transport System The foundation for the functional view of the cardiopulmonary system is the equation for the oxygen transport system (Fig. 2.1). Aerobic capacity (VO2max) is the body’s ability to deliver and use oxygen (maximum rate of oxygen consumption) to support the energy needs of demanding physical activity. VO2max is influenced by three factors: the efficiency of ventilation and oxygenation in the lungs, how much oxygen-rich blood can be delivered from the heart (cardiac output, or CO) to active peripheral tissues, and how well oxygen is extracted from the blood to support muscle contraction and other peripheral tissues during activity (arteriovenous oxygen difference, or AVO2diff).1–4 Aerobic capacity can be represented by the following formula: VO2 max ¼ CO  AVO2 max

2 • Aging and Activity Tolerance

Central Lungs

15

Peripheral Heart

Pulmonary vein

Arteries & arterioles Left atrium

Left ventricle

Aorta

O2 exchange Mitral valve Pulmonic valve

Aortic valve

Capillary bed

Tricuspid valve

CO2 exchange Pulmonary artery

Right ventricle Right atrium

Oxygenation

Vena cava Veins & venules

Delivery

Extraction

Fig. 2.1 Functional anatomy and physiology of the cardiorespiratory system. After blood has been oxygenated in the lungs, the left side of the heart contracts to deliver the blood, through the aorta and its branches, to active tissues in the periphery. Oxygen must be effectively extracted from blood by peripheral tissues to support their activity. Deoxygenated blood, high in carbon dioxide, returns through the vena cava to the right side of the heart, which pumps it to the lungs for reoxygenation. Aerobic capacity (VO2max) is the product of how well oxygen is delivered to cardiac output (CO) and extracted by arterial-venous oxygen difference (AVO2diff) active tissues. HR, Heart rate; SV, stroke volume.

The energy cost of doing work is based on the amount of oxygen consumed for the activity, regardless of whether the activity is supported by aerobic (with oxygen) or anaerobic (without oxygen) metabolic mechanisms for producing energy. VO2max provides an indication of the maximum amount of work that can be supported.1–4 CO is the product of two elements. The first is the HR, the number of times that the heart contracts (or beats) per minute. The second is stroke volume (SV), the amount of blood pumped from the left ventricle with each beat (measured in milliliters or liters). CO is expressed by the following formula (measured in milliliters or liters per minute): CO ¼ HR  SV As a product of HR and SV, CO is influenced by four factors: (1) the amount of blood returned from the periphery through the vena cava, (2) the ability of the heart to match its rate of contraction to physiologic demand, (3) the efficiency or forcefulness of the heart’s contraction, and (4) the ability of the aorta to deliver blood to peripheral vessels. The delivery of oxygen to the body tissues to be used to produce energy for work is, ultimately, a function of the central components of the cardiopulmonary system.1–4 The second determinant of aerobic capacity, the AVO2diff, reflects the extraction of oxygen from the capillary by the surrounding tissues. The AVO2diff is determined by subtracting the oxygen concentration on the venous (postextraction) side of the capillary bed (CvO2) from that of the arteriole (preextraction) side of the capillary bed (CaO2), according to the formula: AVO2 max ¼ CaO2  CvO2 The smaller vessels and capillaries of the cardiovascular system are involved in the process of extraction of oxygen from the blood by the active tissues. Extraction of oxygen from the blood to be used to produce energy for the work

of the active tissues is a function of the peripheral components of the cardiopulmonary system.1–4 During exercise or a physically demanding activity, CO must increase to meet the need for additional oxygen in the more active peripheral tissues. This increased CO is the result of a more rapid HR and a greater SV: As the return of blood to the heart increases, the heart contracts more forcefully and a larger volume of blood is pumped into the aorta by the left ventricle. Chemical and hormonal changes that accompany exercise enhance the peripheral shunting of blood to the active muscles, and oxygen depletion in muscle assists transfer of oxygen from the capillary blood to the tissue at work.1,4,5 The efficiency of central components, primarily of CO, accounts for as much as 75% of VO2max. Peripheral oxygen extraction (AVO2diff) contributes the remaining 25% to the process of making oxygen available to support tissue work.6 In healthy adults under most conditions, more oxygen is delivered to active tissues (muscle mass) than is necessary.4,6 During exercise in healthy adults, CO may increase five times, allowing for oxygen to be available to working muscles.1 For those who are significantly deconditioned or who have cardiopulmonary or cardiovascular disease, the ability to deliver oxygen efficiently to the periphery as physical activity increases may be compromised. With normal aging, there are age-related physiologic changes in the heart itself that limit maximum attainable HR. Because of these changes, it is important to assess whether and to what degree SV can be increased effectively if rehabilitation interventions are to be successful.

The Aging Heart The ability to plan an appropriate intervention to address cardiovascular endurance and conditioning in older adults who may need to use a prosthesis or orthosis is founded on

16

Section I • Building Baseline Knowledge

an understanding of “typical” age-related changes in cardiovascular structure and physiology as well as on the functional consequences of these changes.

CARDIOVASCULAR STRUCTURE Age-related structural changes in the cardiovascular system occur in five areas: myocardium, cardiac valves, coronary arteries, conduction system, and coronary vasculature (i.e., arteries) (Table 2.1).7–10 Despite these cellular and tissue-level changes, a healthy older heart can typically meet energy demands of usual daily activity. Cardiovascular disease, quite prevalent in later life, and a habitually sedentary lifestyle coupled with unhealthy lifestyle choices can, however, significantly compromise activity tolerance.11,12

Myocardium In advanced age, cells of the myocardium show microscopic signs of degeneration, including increases in myocardial fat content (i.e., storage of triglyceride droplets within cardiomyocytes); however, the relationship between the quantity of fat and disease severity remains unclear.13 Unlike aging skeletal muscle cells, there is minimal atrophy of cardiac smooth muscle cells. More typically, there is hypertrophy of the left ventricular myocardium, increasing the diameter of the left atrium.12,14–16 These changes have been attributed to cardiac tissue responses to an increased systolic blood pressure (SBP) and to reduced compliance of the left ventricle; they are associated with an increase in the weight and size of the heart.15–19 Valves The four valves of the aged heart often become fibrous and thickened at their margins as well as somewhat calcified.20 Calcification of the aorta at the base of the cusps of the aortic valve (aortic stenosis) is clinically associated with the slowed exit of blood from the left ventricle into the aorta.21 Such aortic stenosis contributes to a functional reduction in CO. A baroreflex-mediated increase in SBP attempts to compensate for this reduced CO.22,23 Over time, the larger residual of blood in the left ventricle after each beat (increased end systolic volume, or ESV) begins to weaken the left ventricular muscle.24 This muscle must work harder to pump the Table 2.1

blood out of the ventricle into a more resistant peripheral vascular system.25,26 Calcification of the annulus of the mitral valve can restrict blood flow from the left atrium into the left ventricle during diastole. As a result, end-diastolic volume (EDV) of blood in the left ventricle is decreased because the left atrium does not completely empty. Over time, this residual blood in the left atrium elongates the muscle of the atrial walls and increases the diameter of the atrium of the heart.25–27

Coronary Arteries Age-related changes of the coronary arteries are similar to those in any aged arterial vessel: an increase in the thickness of the vessel walls and tortuosity of the vessel’s path.28 These changes tend to occur earlier in the left coronary artery than in the right.29 When coupled with atherosclerosis, these changes may compromise the muscular contraction and pumping efficiency and effectiveness of the left ventricle during exercise or any activity of high physiologic demand.3,4,30 Conduction System Age-related changes in the conduction system of the heart can have a substantial impact on cardiac function. The typical 75-year-old person has less than 10% of the original number of pacemaker cells of the sinoatrial node.31,32 Fibrous tissue builds within the internodal tracts as well as within the atrioventricular node, including the bundle of His and its main bundle branches.31,32 As a consequence, the ability of the heart to coordinate the actions of all four of its chambers may be compromised.31 Arrhythmias are pathologic conditions that become more common in later life; they are managed pharmacologically or with implantation of a pacemaker/defibrillator.33 Rehabilitation professionals must be aware of the impact of medications or pacemaker settings on an individual’s ability to physiologically respond to exercise and to adapt to the intervention accordingly, whether it be a conditioning program or early mobility after a medical/surgical event.34 Arterial Vascular Tree Age-related changes in the arterial vascular tree, demonstrated most notably by the thoracic aorta and eventually

Age-Related Changes in the Cardiovascular System

Structure

Change

Functional Consequences

Heart

Deposition of lipids, lipofuscin, and amyloid within cardiac smooth muscle Increased connective tissue and fibrosity Hypertrophy of left ventricle Increased diameter of atria Stiffening and calcification of valves Fewer pacemaker cells in sinoatrial and atrioventricular nodes Fewer conduction fibers in bundle of His and branches Less sensitivity to extrinsic (autonomic) innervation Slower rate of tension development during contraction

Less excitability Diminished cardiac output Diminished venous return Susceptibility to dysrhythmia Reduction in maximal attainable heart rate Less efficient dilation of cardiac arteries during activity Less efficient left ventricular filling in early diastole, leading to reduced stroke volume Increased afterload, leading to weakening of heart muscle

Blood vessels

Altered ratio of smooth muscle to connective tissue and elastin in vessel walls Decreased baroreceptor responsiveness Susceptibility to plaque formation within vessel Rigidity and calcification of large arteries, especially the aorta Dilation and increased tortuosity of veins

Less efficient delivery of oxygenated blood to muscle and organs Diminished cardiac output Less efficient venous return Susceptibility to venous thrombosis Susceptibility to orthostatic hypotension

2 • Aging and Activity Tolerance

the more distal vessels, can disrupt the smooth or streamlined flow (i.e., laminar flow) of blood from the heart toward the periphery.33,35,36 Altered alignment of endothelial cells of the intima creates rough or turbulence flow (i.e., nonlaminar flow), which increases the likelihood of deposition of collagen and lipid.37 Fragmentation of elastic fibers in the intima and media of larger arterioles and arteries further compromises the functionally important “rebound” characteristic of arterial vessels.38 Rebound normally assists directional blood flow through the system, preventing the backward reflection of fluid pressure waves of blood. This loss of elasticity increases vulnerability of the aorta, which, distended and stiffened, cannot effectively resist the tensile force of left ventricular ejection. Not surprisingly, the incidence of abdominal aortic aneurysms rises sharply among older adults, and stiffness (distensibility) of the ascending aorta is associated with the severity of coronary artery disease.39,40

CARDIOVASCULAR PHYSIOLOGY Although the physiologic changes in the cardiovascular system are few, their impact on the performance of the older adult can be substantial. The nondiseased aging heart continues to be an effective pump, maintaining its ability to develop enough myocardial contraction to support daily activity. The response of cardiac muscle to calcium (Ca2+) is preserved and its force-generating capacity maintained.41 Two aspects of myocardial contractility do, however, change with aging: the rate of tension development in the myocardium slows, and the duration of contraction and relaxation becomes prolonged.42,43

Sensitivity to β-Adrenergic Stimulation One of the most marked age-related changes in cardiovascular function is the reduced sensitivity of the heart to sympathetic stimulation, specifically to the stimulation of β-adrenergic receptors.43,44 Age-related reduction in β-adrenergic sensitivity includes a decreased response to norepinephrine and epinephrine released from sympathetic nerve endings in the heart as well as a decreased sensitivity to any of these catecholamines circulating in the blood.44,45 Normally, norepinephrine and epinephrine are potent stimulators of ventricular contraction. An important functional consequence of the change in receptor sensitivity is less efficient cardioacceleratory response, which leads to a lower HR at submaximal and maximal levels of exercise or activity.46 The time for HR rise to the peak rate is prolonged, so more time is necessary to reach the appropriate HR level for physically demanding activities. A further consequence of this reduced βadrenergic sensitivity is less than optimal vasodilation of the coronary arteries with increasing activity.44,47 In peripheral arterial vessels, β-adrenergic receptors do not appear to play a primary role in mediating vasodilation in the working muscles.48 Baroreceptor Reflex Age-related change in the cardiovascular baroreceptor reflex also contributes to prolongation of cardiovascular response time in the face of an increase in activity (physiologic demand).43 The baroreceptors in the proximal aorta appear to become less sensitive to changes in blood volume

17

(pressure) within the vessel. Normally any drop in proximal aortic pressure triggers the hypothalamus to begin a sequence of events that leads to increased sympathetic stimulation of the heart. Decreased baroreceptor responsiveness may increase an older individual’s susceptibility to orthostatic (postural) and postprandial (after eating) hypotension or may compromise his or her tolerance of the physiologic stress of a Valsalva maneuver associated with breath holding during strenuous activity.49–51 Clinically this is evidenced by lightheadedness when rising from a lying or sitting position, especially after a meal, or if one tends to hold one’s breath during effortful activity. The effects of age-related physiologic changes on the cardiovascular system can often be managed satisfactorily by routinely using simple lower extremity warmup exercises before position changes. Several repetitions of ankle and knee exercises before standing up, especially after a prolonged time sitting (including for meals) or lying down (after a night’s rest), help maximize blood return to the heart (preload), assisting cardiovascular function for the impending demand. In addition, taking a bit more time in initiating activities and progressing their difficulty may help the slowed cardiovascular response time reach an effective level of performance. Scheduling physical therapy or physical activity at a distance from mealtimes might also be beneficial for patients who are particularly vulnerable to postprandial hypotension. Fortunately many of the aging effects on the cardiovascular system can be minimized or reversed with exercise training.1

FUNCTIONAL CONSEQUENCES OF CARDIOVASCULAR AGING What are the functional consequences of cardiovascular aging for older adults participating in exercise or rehabilitation activities? This question can best be answered by focusing on what happens to the CO (Fig. 2.2). The age-related structural and physiologic changes in the cardiovascular system give rise to two loading conditions that influence CO: cardiac filling (preload) and vascular impedance (afterload).4,22

Preload Cardiac filling/preload determines the volume of blood in the left ventricle at the end of diastole. The most effective ventricular filling occurs when pressure is low within the heart and relaxation of the muscular walls of the ventricle is maximal.1,2,6 Mitral valve calcification, decreased compliance of

Strength of contraction

Stroke End diastolic volume volume

CARDIAC OUTPUT

Heart rate

Instrinsic rhythmicity Autonomic regulation

Fig. 2.2 Factors affecting cardiac output are influenced by the aging process. If strength of contraction decreases and end-diastolic volume increases, stroke volume is reduced. Coupled with alterations in heart rate response to increasing workload, activities that were submaximal in intensity at a younger age may become more physiologically demanding in later life.

18

Section I • Building Baseline Knowledge

the left ventricle, and the prolonged relaxation of myocardial contraction can contribute to less effective filling of the left ventricle in early diastole.52 Doppler studies of the flow of blood into the left ventricle in aging adults demonstrate decreased rates of early filling, an increased rate of late atrial filling, and an overall decrease in the peak filling rate.6,24,52 When compared with healthy 45- to 50-yearold adults, the early diastolic filling of a healthy 65- to 80-year-old is 50% less.6,24,53 This reduced volume of blood in the ventricle at the end of diastole does not effectively stretch the ventricular muscle of the heart, thus compromising the Frank-Starling mechanism and the myocontractility of the left ventricle.54 The functional outcome of decreased early diastolic filling and the reduced EDV is a proportional decrease in SV, one of the determinants of CO and, consequently, work capacity (VO2max).6,23,43

Afterload High vascular impedance and increased afterload disrupt the flow of blood as it leaves the heart and moves toward the peripheral vasculature. Increased afterload is partly a function of age-related stiffness of the proximal aorta, an increase in systemic vascular resistance (elevation of SBP, hypertension), or a combination of both.43,55 Ventricular contraction that forces blood flow into a resistant peripheral vascular system produces pressure waves in the blood. These pressure waves reflect back toward the heart, unrestricted by the stiffened walls of the proximal aorta. The reflected pressure waves, aortic stiffness, and increased systemic vascular resistance collectively contribute to an increased afterload in the aging heart.42,55 Increased afterload is thought to be a major factor in the age-associated decrease in maximum SV, hypertrophy of the left ventricle, and prolongation of myocardial relaxation (e.g., slowed relaxation in the presence of a persisting load on the heart).7,8,10 An unfortunate long-term consequence of increased afterload is weakening of the heart muscle itself, particularly of the left ventricle. Restricted blood flow out of the heart results in a large residual volume (RV) of blood in the heart at the end of systole, when ventricular contraction is complete. Large ESVs gradually increase the resting length of ventricular cardiac muscle, effectively weakening the force of contraction.3,7,8,10,24,56 Left Ventricular Ejection Fraction Left ventricular ejection fraction (LVEF) is the proportion of blood pumped out of the heart with each contraction of the left ventricle, which is expressed by the following equation: LVEF ¼ ðEDV  ESVÞ + EDV At rest, the LVEF does not appear to be reduced in older adults. Under conditions of maximal exercise, however, the rise in LVEF is much less than that in younger adults.23,57,58 This reduced rise in the LVEF with maximal exercise clearly illustrates the impact that functional cardiovascular age-related changes in preload and afterload have on performance. A substantial reduction in EDV, an expansion of ESV, or a more modest change in both components may account for the decreased LVEF of the exercising older adult:

Reserve capacity

Age-related loss

Age-related loss

Age-related loss

Reserve capacity

Impact of inactivity

Impact of inactivity

Reserve capacity

Impact of disease Reserve capacity

ADLs

ADLs

ADLs

ADLs

At rest

At rest

At rest

At rest

Healthy young adult

Healthy older adult

Sedentary older adult

Older adult with disease

Fig. 2.3 Comparison of the effects of aging, inactivity, and cardiopulmonary disease on functional reserve capacity, expressed as cardiac output (CO in L/min). At rest, the heart delivers between 4 and 6 L/min of blood to peripheral tissues. This may double during many activities of daily living (ADLs). In a healthy young person, the CO may increase to as much as 24 L/min to meet the metabolic demands of sustained exercise. This reserve capacity decreases to approximately 18 L/min in healthy, fit adults after the age of 60 years. A sedentary lifestyle decreases functional reserve capacity further. Superimposed cardiopulmonary disease further limits the ability to do physical work, in some cases approaching or exceeding cardiopulmonary reserve capacity. ADLs, Activities of daily living. (Modified from Irwin SC, Zadai CC. Cardiopulmonary rehabilitation of the geriatric patient. In Lewis CB, ed. Aging: the health care challenge. Philadelphia: F.A. Davis; 1990:190.)

# EDV ¼# LVEF " ESV ¼# LVEF When going from resting to maximal exercise conditions, the amount of blood pumped with each beat for young healthy adults increases by 20% to 30% from a resting LVEF of 55% to an exercise LVEF of 80%. For a healthy older adult, in contrast, LVEF typically increases less than 5% from rest to maximal exercise.57,59 The LVEF may actually decrease in adults who are 60 years of age and older.57,60 As LVEF and CO decrease with aging, so does the ability to work over prolonged periods (functional cardiopulmonary reserve capacity) because the volume of blood delivered to active tissue decreases (Fig. 2.3). Functional reserve capacity is further compromised by the long-term effects of inactivity and by cardiopulmonary pathology.23,30,61,62 The contribution of habitual exercise to achieving effective maximum exercise LVEF is not well understood, but the decline may not be as substantial for highly fit older adults.23

Pulmonary Function in Later Life Several important age-related structural changes of the lungs and of the musculoskeletal system have a significant impact on pulmonary function.63 These include change in the tissues and structures making up the lungs and airways, alteration in lung volume, reduced efficiency of gas exchange, and a mechanically less efficient ventilatory pump related to changes in alignment and posture

2 • Aging and Activity Tolerance

19

Table 2.2 Summary of Age-Related Changes in the Cardiopulmonary System and Functional Consequences Anatomic Changes

Physiologic Changes

Consequences

Change in Lung Function Tests

Rearrangement and fragmentation of elastin fibers Stiffened cartilage in compliant articulation of ribs and vertebrae Increasing stiffness and compression of annulus fibrosus in intervertebral disks Reduction of strength and endurance of respiratory musculature

Less elastic recoil for expiration Greater compliance of lung Decreased vital capacity, forced More rigid thoracic cage Decreased volume of maximum voluntary ventilation and maximum sustained ventilatory capacity Greater mismatch between ventilation and perfusion within lung

Greater airspace within alveoli, less surface area for O2/CO2 exchange thoracic cage Increased work of breathing Less force during inspiration Less efficient cough Diminished exercise tolerance Reduced resting PaO2

Increased functional residual capacity and residual volume tissue Shorter, less vital capacity, and forced expiratory volume in 1 s (FEV1) Decreased maximum inspiratory pressure, maximum expiratory pressure, and maximum voluntary ventilation

(Table 2.2).64,65 Although a healthy adult at midlife uses only 10% of the respiratory system’s capacity at rest, aging of the pulmonary system, especially when accompanied by chronic illness or acute disease, negatively affects the ability of the lungs to respond to increasing demands of physical activity (Fig. 2.4).66 Age-related changes in the pulmonary and musculoskeletal systems also contribute to an increase in the physiologic work of breathing.

CHANGES WITHIN THE LUNG AND AIRWAY The production of elastin, which is the major protein component of the structure of the lungs, decreases markedly in late life. The elastic fibers of the lung become fragmented, and, functionally, the passive elastic recoil or rebound important for expiration becomes much less efficient. The elastic fibers that maintain the structure of the walls of Young adults

6

Older adults

5

Volume in liters

IRV 4

IRV FVC

3

TLC

FVC TV

TV 2

TLC ERV

ERV

1 RV

RV

RV

RV

0 Fig. 2.4 Changes in the distribution of air within the lungs (volume) have an impact on an older adult’s efficiency of physical work. Loss of alveoli and increasing stiffness of the rib cage result in a 30% to 50% increase in residual volume (RV) and a 40% to 50% decrease in forced vital capacity (FVC). FVC includes three components: inspiratory reserve volume (IRV) and expiratory reserve volume (ERV) tend to decrease with aging, whereas resting tidal volume (TV), the amount of air in a normal resting breath, tends to be stable over time. Total lung capacity (TLC) and inspiratory capacity (IRV + TV) also tend to decrease. Over time, the physiologic consequences of these changes make the older adult more vulnerable to dyspnea (shortness of breath) during exercise and physically demanding activity.

the alveoli also decrease in number. This loss of elastin means loss of alveoli and consequently a less surface area for the exchange of oxygen as well as an increase in RV associated with more “dead space” within the lung, where air exchange cannot occur.64–66 There may be as much as a 15% decrease in the total number of alveoli per unit of lung volume by the age of 70 years.67 With aging, there is also an increase in diameter of major bronchi and large bronchioles as well as a decreased diameter of smaller bronchioles, often leading to a slight increase in resistance to airflow during respiration.67 This contributes to greater physical work of breathing as age advances. Starting at midlife and continuing into later life, there tends to be a growing mismatch between lung area ventilated with each breath and lung area perfused by pulmonary arterioles and capillaries, which is attributed to alteration in alveolar surface, vascular structures, and posture.68 This mismatch compromises the efficiency of diffusion of oxygen across the alveoli into the capillary bed (i.e., decreasing arterial oxygen tension) within the lung becomes less efficient from midlife into later life.64,68 However, fit elderly can produce levels of maximum oxygen consumption that match those of untrained middle-aged men. This suggests that pulmonary rehabilitation can play a large role in improving exercise tolerance in the elderly.65,69–71

CHANGES IN THE MUSCULOSKELETAL SYSTEM The decreasing elastic recoil and alveolar surface area for oxygen exchange may be further compounded by increased stiffness (loss of flexibility); “barreling” of the thoracic rib cage, which houses the lungs; and a decrease in height as intervertebral disks narrow and stiffen.72 Much of this stiffness is attributed to changes in the articulation between ribs and vertebrae as well as decreased elasticity of intercostal muscle and soft tissue.73 Although the stiffened rib cage may be as much a consequence of a sedentary lifestyle as of advancing age, lack of flexibility compromises inspiration and also decreases the elastic recoil of expiration.65,74 In addition, the forward head and slight kyphosis that tend to develop with aging alter the position of both ribs and diaphragm, thus decreasing the mechanical efficiency of inspiration.66,72,74 The net effect of a stiffer thoracic cage is an increase in the work of taking a breath, since muscles of respiration must work harder during inspiration to counteract the stiffness.66

20

Section I • Building Baseline Knowledge

The striated muscles of respiration are composed of a combination of type I (slow twitch and fatigue resistant, for endurance) and type II (fast twitch, for power) fibers and are susceptible to the same age-related changes in strength and endurance that have been observed in muscles of the extremities.75 Normally type I muscle fibers are active during quiet breathing, whereas recruitment of type II fibers is triggered by increasing physiologic demand as activity increases. Age-related decrements in the strength and efficiency of the diaphragm, intercostals, abdominal muscles, and other accessory muscles of respiration affect the effectiveness and work of breathing.66,76 Altered posture and higher RV within the lung also contribute to an increased work of breathing; when the diaphragm rests in less than optimal position and configuration for contraction, accessory muscles become active sooner as physiologic demand increases. Oxygen consumption in respiratory muscles, as in all striated muscle, decreases linearly with age, making older muscle more vulnerable to the effects of fatigue in situations of high physical demand, especially in the presence of lung disease or injury.64

CONTROL OF VENTILATION The rate of breathing (breaths per minute) is matched to physiologic demand by input from peripheral mechanoreceptors in the chest wall, lungs, and thoracic joints, as well as centers in the brain stem of the central nervous system (CNS) and peripheral aortic and carotid bodies that are sensitive to concentration of CO2, O2, and hydrogen ions (pH) in the blood.77 With aging, stiffness of the thorax tends to reduce the efficiency of mechanoreceptors, and the CNS and peripheral nervous system (PNS) centers that monitor CO2, O2, and pH to detect hypoxia during activity slowly begin to decline.65 Gradual loss of descending motor neurons within the CNS also occurs, with less efficient activation of neurons innervating muscles of respiration via the phrenic nerve to the diaphragm for inspiration and of spinal nerves to intercostals for expiration.68 These three factors combine to compromise the individual’s ability to quickly and accurately respond to increasing physiologic demand and increase the likelihood of dyspnea during activity.

range of the length-tension curve, and the energy cost of the muscular work of breathing rises.66 Functionally, the amount of air inhaled per minute (minute ventilation) is a product of the frequency of breathing and the tidal volume (volume of air moving into and out of the lungs with each usual breath). In healthy individuals, the increased ventilatory needs of low-intensity activities are usually met by an increased depth of breathing (i.e., increased tidal volume).78 Frequency of breathing increases when increased depth alone cannot meet the demands of activity, typically when tidal volume reaches 50% to 60% of the VC.78 For the older adult with reduced VC who is involved in physical activity, tidal volume can quickly exceed this level so that the frequency of breathing increases much earlier than would be demonstrated by a young adult at the same intensity of exercise.79 Because the energy cost of breathing rises sharply with the greater respiratory muscle work associated with an increased respiratory rate, an important consequence of increased frequency of breathing is fatigue.80 This early reliance on an increased frequency of breathing combined with a large RV and its higher CO2 concentration in lung air results in a physiologic cycle that further drives the need to breathe more frequently. Overworked respiratory muscles are forced to rely on anaerobic metabolism to supply their energy need, resulting in a buildup of lactic acid. Because lactic acid lowers the pH of the tissues (acidosis), it is also a potent physiologic stimulus for increased frequency of breathing.80–82 The older person can be easily forced into a condition of rapid, shallow breathing (shortness of breath) to meet the ventilatory requirements of seemingly moderateintensity exercise.

Implications for Intervention Rehabilitation professionals must consider two questions about the implications of age-related changes in the cardiovascular and cardiopulmonary systems on an older person’s ability to do physical work. First, what precautions should be observed to avoid cardiopulmonary and cardiovascular complications? Second, what can be done to optimize cardiopulmonary and cardiovascular function for maximal physical performance?

FUNCTIONAL CONSEQUENCES OF PULMONARY AGING

PRECAUTIONS

With less recoil for expiration and reduced flexibility for inspiration, the ability to work is compromised in two ways (see Fig. 2.4). First, vital capacity (VC), the maximum amount of air that can be voluntarily moved in and out of the lungs with a breath, is decreased by 25% to 40%. Second, RV, the air remaining in the lungs after a forced expiration, is increased by 25% to 40%.64 This combination of reduced movement of air with each breath and increased air remaining in the lung between breaths leads to higher lung-air carbon dioxide content and, eventually, lower oxygen saturation of the blood after air exchange. The increase in RV also affects the muscles of inspiration: the dome of the diaphragm flattens and the accessory respiratory muscles are elongated. As a result of these length changes, the respiratory muscles work in a mechanically disadvantageous

Because of the combined effects of the age-related changes in the cardiovascular and cardiopulmonary systems, the high incidence of cardiac and pulmonary pathologies in later life, and the deconditioning impact of bed rest and inactivity, older patients who require orthotic or prosthetic intervention may be vulnerable if exercise or activity is too physiologically demanding. The clinician must also consider whether the intervention is occurring after a recent major surgery, which may compound these age-related changes. High-complexity patients with a prolonged hospitalization that have undergone multiple procedures may demonstrate compromised airway protective responses to clear the airway and may be susceptible to diaphragmatic fatigue, which complicates mechanical ventilation weaning and overall recovery from surgery.83,84 Although most

2 • Aging and Activity Tolerance

older adults can tolerate exercise and respond to it positively, exercise is not appropriate in a number of circumstances (Table 2.3).

Estimating Workload: Heart Rate and Rate Pressure Product One of the readily measurable consequences of the reduced response of the heart to sympathetic stimulation in later life is a reduction in the maximal attainable HR.42,77,85 This reduction in maximal HR also signals that an older person’s HR reserve, the difference between the rate for any given level of activity and the maximal attainable HR, is limited as well. For older patients involved in rehabilitation programs, the difference between resting and maximal HR is narrowed. One method of estimating maximal (max) attainable HR is the following6: Max HR ¼ 220  Age For healthy individuals, the recommended target HR for aerobic conditioning exercise is between 60% and 80% of maximal attainable HR. For many older adults, especially those who are habitually inactive, resting HR may be close to the recommended range for exercise exertion.86 Consider an 80-year-old individual with a resting HR of 72 beats per

21

minute. His maximal attainable HR is approximately 140 beats per minute (220–80 years). A target HR for an aerobic training level of exertion of 60% of maximal HR would be 84 beats per minute. His resting HR is within 12 beats of the HR for aerobic training. Functionally this means that an activity as routine as rising from a chair or walking a short distance on a level surface may represent physical work of a level of exertion equated with moderate- to high-intensity exercise. Because of the reduction in maximal attainable HR with age, older adults may be working close to their VO2max range even in usual activities of daily living (ADLs).86,87 Because HR essentially signals the work of the heart, with each beat representing ventricular contraction, increased HR relates closely to increased heart work and increased oxygen consumption by the myocardium.85 Given that afterload on the heart increases with age, the overall work of the heart for each beat is likely greater as well.23,41–43 A more representative way to estimate the work of the heart during activity for older adults is the rate pressure product (RPP),88–90 using HR and SBP as follows: RPP ¼ HR  SBP The linear relationship between VO2max and HR for younger adults actually levels off for older adults.91 Because of

Table 2.3 Signs and Symptoms of Exercise Intolerance Category

Cautionary Signs/Symptoms

Contraindications to Exercise

Heart rate

130 bpm at rest Little HR increase with activity Excessive HR increase with activity Frequent arrhythmia

Prolonged at maximum activity

ECG

Any recent ECG abnormalities

Prolonged arrhythmia or tachycardia Exercise-induced ECG abnormalities Second or third-degree heart block

BP

Resting SBP >165 mm Hg Resting DBP >110 mm Hg Lack of SBP response to activity Excessive BP response to activity

Resting SBP >210 mm Hg Resting DBP >110 mm Hg Drop in SBP >10 mm Hg in low level exercise Drop in DBP during exercise

Angina

Low threshold for angina

Resting or unstable angina New jaw, shoulder, or left arm pain

Respiratory rate

Dyspnea >35 breaths/min

Dyspnea >45 breaths/min

Blood gas values

O2 saturation 100°F Aortic stenosis Recent mental confusion Abnormal electrolytes (potassium) Known left main coronary artery disease Idiopathic hypertrophic subaortic stenosis Compensated heart failure

Any acute illness Digoxin toxicity Overt congestive heart failure Untreated second- or third-degree heart block Acute pericarditis 220 lbs). Persons with cognitive impairment may not be able to comprehend how to safely use or maintain a SC-KAFO; SC options must be used with caution when cognitive ability and judgment are impaired. The positive impact of SC knee joints on kinematics of walking is well documented. In addition to improving selfselected walking speed, cadence, and stride length, use of these orthotic knee joint improves symmetry of gait, reduces compensatory movement, and allows safer management of inclines and obstacles when compared with KAFOs with locked knees.97-100 Persons who have used traditional KAFOs with locked knees for long periods before adopting SC designs benefit from additional functional training to be able to take full advantage of the mobility that a SC-KAFO provides.104 The few studies that have examined wearers’ experience with SC-KAFOs indicate better acceptance and general satisfaction with the devices in terms of effectiveness in improving mobility, dependability, and performance of the device and enhancing the wearer’s sense of well-being.105,106 The major concerns raised by wearers include ease of donning and doffing, weight of the orthosis, and cosmesis.105,106

systems, the linkage system limits abnormal abduction of the limbs during gait. Preparation for swing limb advancement begins with an exaggerated lateral lean for weight

MEDIALLY LINKED BILATERAL KNEE-ANKLE-FOOT ORTHOSIS DESIGNS For persons with mid to low thoracic and lumbar SCI, several options have been developed to link a pair of conventional KAFOs in an effort to allow reciprocal gait without having to brace about the hip in a conventional HKAFO (Fig. 9.22). The Walkabout Orthosis and the Moorling Medial Linkage Orthosis, both of which use a single-axis hinge between the two medial uprights of the KAFOs, are most effective for individuals with some residual volitional hip flexion who have sufficient thoracolumbar spinal mobility, especially into lateral flexion.107-109 In both of these

Fig. 9.22 Themoplastic hip-knee-ankle-foot orthoses (HKAFOs), typically lighter in weight than conventional HKAFOs, also have a pelvic band and orthotic hip and knee joints. Because they distribute forces over a wider thigh and calf band, an anterior knee stabilization pad may not be necessary. Many incorporate a solid or articulating ankle-foot orthosis design, fitting inside the shoe rather than in an external stirrup.

246

Section II • Orthoses in Rehabilitation

shift onto the stance limb; the wearer then initiates swing using residual hip hiking or hip flexion ability. When compared with reciprocal gait HKAFO (see later), medially linked KAFOs provided better ability (less assistance required) to accomplish sit-to-stand transitions, but walking speed tended to be slower, management of inclines more problematic, and performance on measures of balance somewhat less effective.110,111 In addition, persons with SCI who wore both devices over a 3-month period reported that both were useful for standing and there was no functional advantage of medially linked KAFOs over reciprocal gait HKAFOs in terms of mobility.112 Hybrid systems, consisting of medially linked KAFOs and FES, have also been used as an approach to improve the ability to walk for persons with SCI.113

KAFO Delivery and Functional Training Once fabrication is completed, the orthotist inspects the KAFO to ensure that selected components work as intended, that finish work of plastic edges and metal components are effective, that the placement and contours are appropriate to the individual’s limbs, and that orientation of the axis of the orthotic ankle and knee match anatomic joint axis. This initial fitting process not only identifies the fit of the orthosis in its intended functional upright and weight-bearing positions but also closely examines potential for soft tissue irritation in vulnerable areas of the person’s skin. Length of the uprights and position and alignment of components are carefully inspected. The goal is a comfortable standing position with no discomfort or skin irritation. If minor problems are identified, the orthotist often makes simple adjustments of fit and alignment before functional training. The team then evaluates the ability of the orthosis to meet the functional goals of the orthotic prescription. If the team determines that fit is acceptable and that orthotic goals (a combination of joint protection, structural stability, especially in stance, and functional mobility) have been met, functional training then begins. In most cases, especially if a patient is new to the use of an orthosis, a wearing schedule is developed, tailored to the patient’s specific needs and physical condition, in which the patient gradually increases to full-time wear. Whether the orthosis is of conventional KAFO design or is an SC-KAFO, physical therapy programs should include:

▪ ▪ ▪ ▪ ▪ ▪ ▪

exercises to strengthen muscle groups and improve control of hip, knee, and core (trunk) musculature to maximize ability to use the device; practice donning/doffing the device; rising to standing and returning to sitting; activities to facilitate anticipatory and reactionary postural control and balance; gait training under various task-environment conditions practice on stairs, uneven surfaces, and inclines; functional training in variety of environments

Training should also focus on developing a clear understanding of the fit of the orthosis on the limb, proper

adjustment of stabilizing straps, education about appropriate footwear, and management of the locking mechanisms and function of the knee unit. Wearers and their caregivers must understand the care and maintenance of the orthosis, which is a mechanical device with moving parts that requires regular cleaning and occasional lubrication of its mechanical parts.

When Is a Hip-Knee-Ankle-Foot Orthosis Indicated? There is much less evidence available in the clinical research literature to guide prescription and selection of HKAFOs than for selecting AFOs and KAFOs. Because HKAFOs encompass the hip, pelvis, and sometimes the trunk, they tend to be much more cumbersome to use, more challenging to don and doff, more expensive to fabricate, and require more maintenance than AFOs and KAFOs. HKAFOs only partially restore functional mobility, often with high energy cost. The additional control of joint motion achieved by moving proximally with a hip joint and pelvic band or an attached lumbosacral orthosis must be balanced against the practical challenges that the wearer will face when using the device. Persons who use HKAFOs for standing and for the limited mobility that they provide typically have much more neuromotor system impairment that those who use AFOs and KAFOs. These orthoses are most often prescribed for children with neurologic involvement and individuals with SCI but may also be appropriate for those with progressive neuromuscular disorders—in effect, for any person for whom the ability to stand may not only enhance function for some functional tasks but also contribute to bone health, skin integrity, efficacy of digestion, urinary and bowel health, respiratory capacity, cardiovascular fitness and exercise response, and the psychological benefit that comes from being upright when interacting with peers.114 Children, with their lower center of mass, may not be quite as concerned about the consequences of a fall, but for adults, upright standing in HKAFOs may be made more challenging by concerns about the potential to fall and related consequences.115

Hip-Knee-Ankle-Foot Orthosis Design Options As in the case of AFOs and KAFOs, HKAFOs can be fabricated with many different materials (e.g., metals, thermoplastics, carbon composites) and with orthotic ankle, knee, and hip components. Historically, during the years immediately following the polio epidemic until the mid to late 1980s, orthotists fabricated HKAFOs by adding a hip joint and pelvic band to conventional KAFOs. To better meet the developmental and educational needs of children with neurologic conditions, conventional HKAFO designs evolved into standing frames, parapodiums, and swivel walkers. Building on this, a number of HKAFOs specifically designed

9 • Principles of Lower Extremity Orthoses

to mechanically facilitate reciprocal gait were developed to meet the needs of persons with SCI.

CONVENTIONAL HIP-KNEE-ANKLE-FOOT ORTHOSES Fig. 9.22 illustrates the configuration of conventional HKAFOs. These devices are designed to hold both lower extremities in a stable extended position for upright standing; persons wearing this orthosis use either a hop-to gait with walkers or a swing-through gait with a pair of crutches for ambulation. Typically, HKAFOs require an assistive device to use upper extremity and trunk compensatory mechanisms to advance the orthosis. On rare occasions, a single HKAFO might be used for persons with neuromuscular or musculoskeletal impairment affecting one lower extremity. Even after the incorporation of lightweight thermoplastic or carbon composite materials, the energy cost of ambulation with conventional HKAFOs is significant and often functionally prohibitive. The most distal component of the HKAFO is usually a solid or dorsiflexion assist articulating AFO. These are typically set in a few degrees of dorsiflexion to direct the tibia forward enough that the individual’s weight line falls anterior to the knee and posterior to the hip when in a tripod standing position with crutches or a walker. Traditionally, the orthotic knee joint is locked into extension, although for persons with incomplete SCI capable of reciprocal gait, a SC knee joint might be considered. Thermoplastic thigh cuffs are effective in resisting torsional forces that would otherwise act on the limb in standing. A variety of commercially available orthotic hip joints include various single axis designs that can be used in locked position, allow free motion when unlocked, or allow motion only within a limited range. The axis of motion (center) of the orthotic hip joint must be positioned just proximal and anterior to the greater trochanter to best match the anatomic axis of motion of the hip. Because orthotic hip joints are fixed to the pelvic band and to lateral uprights of the thigh section, they effectively restrict abduction/adduction and rotation of the limb as well. Single-axis hip joints meet the needs of most individuals who require HKAFOs to stand and to ambulate. There are also several types of dual-axis hip joints with separate mechanical control systems for flexion/extension and for abduction/adduction. The proximal pelvic band is positioned between the trochanter and iliac crest. The pelvic band provides solid support from a position slightly medial to the anterior superior iliac spines (ASIS) and around the posterior pelvis. The pelvic band can be fabricated from metal, laminated components, or thick thermoplastic and is typically closed anteriorly by a belt or webbing with a Velcro fastener. For stability in standing, the individual typically stands in a tripod position, with crutch tips diagonally 12 to 18 inches forward and a slightly exaggerated lumbar lordosis. This position ensures that the individual’s center of gravity (weight line) falls posterior to the hip joint, creating an extension moment at the hip, achieving stability by alignment. To achieve forward motion, the individual uses the “head-hips” principle with shoulder joints acting as a fulcrum (Fig. 9.23A to F). A quick forceful “pike” (chin tuck and forward inclination of the trunk) while pushing

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downward through the handles of the assistive device elevates the lower extremities from the ground. This is immediately followed by head, neck, and back extension to “throw” the lower extremities forward for the next initial contact. As soon as the feet contact the ground, the individual quickly advances the crutches to once again reach the stable “tripod” position. To effectively use HKAFOs, hip and knee joints of the lower extremity must be flexible enough to be positioned in extension. Although exaggerated lumbar lordosis may compensate for mild hip flexion contracture in achieving upright position, over time and with repeated forceful loading of swing through gait, this lordosis will likely contribute to development of disabling low back pain. Prevention of flexion contracture or deformity of the hips and knees is a key component of physical therapy intervention, especially for growing children with neurologic conditions.

HIP GUIDANCE ORTHOSIS AND PARAWALKER The hip guidance orthosis (HGO) and the Orthotic Research and Locomotor Assessment Unit (ORLAU) Parawalker allow individuals with impaired muscle performance (those unable to accomplish the lifting of body weight needed for swing through gait pattern with crutches) to “walk” with crutches with a lateral weight shift. The HGO and Parawalker require the use of an ambulatory assistive device; training usually begins in the parallel bars and progresses to over ground level surfaces using a rolling walker or bilateral Lofstrand crutches. The HGO orthotic hip joint is stable when weight is borne through the lower extremity during stance but allows a pendular swing of the unweighted extremity for swing clearance. This occurs because of the rigid support that the HGO provides during single limb stance, keeping the limbs parallel in the coronal plane, which enhances swing limb clearance as the opposite limb advances.116 In the original evaluation of the HGO prescribed for children with myelomeningocele, the ability to sit unsupported (hands free) for extended periods was the best predictor of successful use of the HGO.117 The Parawalker, similar in design, provides more proximal support to the thorax and trunk (making it even more rigid) and uses a smaller orthotic hip joint. Because of its higher proximal trim line, the Parawalker can be used for standing and limited mobility (i.e., therapeutic walking) for persons with SCI at upper thoracic levels.118-120

RECIPROCAL GAIT ORTHOSES The reciprocal gait orthosis (RGO), originally designed for children with myelomeningocele and currently used for adults with SCI, extends a pair of thermoplastic KAFOs upward to include a pelvis and thoracic bands; providing rigid stability for stance, it uses a cable-coupling system to provide hip joint motion for swing phase (Fig. 9.24).121,122 Its dual cable system operates by reinforcing extension of the stance limb as the swing limb flexes forward when unloaded by lateral weight shift. This reciprocal dual cable also reduces risk of “jack-knifing” during ambulation by preventing both hips from flexing at the same time. Like the HGO and Parawalker, the RGO requires the person

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Fig. 9.23 Illustration of the head-hips principle in swing through gait using bilateral knee-ankle-foot orthoses and Lofstrand crutches, with shoulder joints acting as the fulcrum for movement. (A) Resting position is a stable hips forward, shoulders back posture, with a tripod formed by the individual’s feet and the tips of the crutches. (B) Mobility is initiated with a quick and forceful chin tuck that (C) is combined with downward pressure through the crutches to unweight the feet. (D) A backward head movement then propels the lower body forward until (E) the hips are forward and shoulders are back to once again assume a stable inverted tripod position. Finally (F) the individual quickly propels off of the crutches to move them anteriorly to the stable starting position. (From Mulcahey MJ. Managemenr of the upper limb in individuals with tetraplegia. In Sisto SA, Sliwinski MM [eds]. Spinal Cord Injuries: Management and Rehabilitation. St. Louis: Mosby; 2009: 388.)

to use an assistive device (rolling walker, bilateral Lofstrand crutches, bilateral canes), relying on upper extremity motor control and muscle performance to a large degree to operate the system. The advanced RGO (ARGO) is an adaptation of the design, using a single cable, and engineered to allow standing with unilateral or no upper extremity support.123,124 A prototype for an adjustable AGRO has been described; this would provide opportunity for a trial of ambulation with ARGO during rehabilitation to assist decisionmaking about capacity to use the device before a custom ARGO is fabricated.125 There is some evidence that persons with neuromuscular conditions who consistently use an RGO or ARGO for therapeutic walking are less likely to develop significant secondary complications (i.e., contractures, decubitus ulcers, and/or scoliosis) than those with similar conditions who do not.126

HYBRID ORTHOSES: FUNCTIONAL ELECTRICAL STIMULATION The most recent investigations of reciprocal orthoses for persons with upper motor neuron SCI have added FES to HGO/Parawalker and RGO/ARGO designs.127,128 SC orthotic knee joints (described in the section on KAFOs) have also been incorporated in hybrid RGO-FES systems to afford a more natural pattern of swing limb advancement.129 The major benefit of hybrid RGO-FES systems appears to be in greater distance covered, lower energy cost (as measured by physiologic cost index), and somewhat faster walking speed.125,127,128 It is important to note that, although such hybrid systems are promising, they do not fully restore the ability to walk at preinjury levels. Walking speeds with hybrid devices have been reported to be

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(eventually) don and doff the orthosis without substantial assistance. They must understand the design of the orthosis and the function of its components enough to recognize when maintenance, adjustment, or repair is necessary. This is quite a bit to commit to; it is often wise to have the person interested in pursuing use of such an orthosis interact with someone else who has successfully used one to get a clear sense of what is required and what the potential outcomes are.

Outcome Measures in Orthotic Rehabilitation How do the health care team, the individual using an orthosis and their caregivers, and the payers of the health care system determine successful use of a lower extremity orthosis, whether it be as simple as a UCBL insert for a child with mild diplegic cerebral palsy, an adult using an articulating AFO, a person with postpolio syndrome using a SC-KAFO, or a person with SCI using an ARGO? Initial criteria to consider might include:

Fig. 9.24 The reciprocal gait orthosis uses a dual cable system to couple flexion of one hip with extension of the other. This coupling assists forward progression of the swing limb while ensuring stability of the stance limb.

between 0.20 and 0.45 m/s, whereas limited community walking becomes possible when walking speed is greater than 0.6 m/s, and usual waking speed for healthy adults ranges from 1.0 to 1.3 m/s, depending on height.128-130

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Implications for Rehabilitation The costs and benefits need to be carefully weighed when considering whether an orthosis that would facilitate therapeutic reciprocal walking would be appropriate for an individual with paralysis. The individual and/or the caregivers must clearly understand that these devices cannot fully restore the ability to walk at what would be considered community level. They must explore and embrace the goals of therapeutic walking: enhancement of bone health, cardiovascular conditioning, and digestive and urinary health, among others. For many individuals, gaining the motor skills necessary for safe use of the device may require substantial time and effort; training times reported in the literature range from 45 to 80 hours over a period of weeks to months. They must be ready to adhere to stretching protocols to ensure sufficient range of motion at the hip, knee, and ankle so that the device will both fit and operate optimally. They must be prepared to work to improve muscle performance and postural control of trunk and upper extremities so that they can use the orthosis most effectively. They must be willing to maintain a stable weight so that the orthosis will fit over many months or years. They must have the postural control necessary to

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Can the person don and doff the orthosis independently? Does the person understand how the orthosis should fit on the limb, and can the person recognize signs that fit may not be appropriate (especially for growing children and for adults with peripheral or central sensory impairment)? Can the person transition from sitting to standing and back to sitting safely, independently, and with reasonable effort? Does the person have sufficient postural control to use the device not only on level nonresistant surfaces (e.g., tile or wood floors) but also on other surfaces (e.g., carpet, grass, inclines, stairs), which are likely to be encountered in the course of daily life? Children often play on the floor, and adults are often concerned with risk of falls. Can the person transition from the floor to standing safely, independently, and with reasonable effort? If not, can the person direct those who would offer assistance? Does the person know how to manage his or her body and assistive devices in case of a fall? Does the person understand the care and maintenance requirements of the device?

These questions, while ensuring that the individual is able to use the orthosis safely, do not sufficiently address the efficacy of the orthosis in enhancing the individual’s ability to walk. Although observational gait analysis might allow the orthotist and physical therapist to evaluate changes an orthosis effects at each subphase of the gait cycle, this description of the quality of walking is not enough evidence to justify orthotic intervention. A variety of outcome measures must be used to address efficacy of an orthosis and the physical therapy intervention that facilitates its use.

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WALKING SPEED Probably the most robust indicator of the ability to walk is walking (gait) speed. Although technology such as motion analysis and the GAITRite system provide precise data about gait velocity, walking speed can be quickly and easily captured using a stopwatch over a known distance.130,131 There is clear evidence for validity, reliability, and responsiveness of walking speed (measured over a 10-m distance), as well as information about typical walking performance values, correlations with fall risk and criteria for limited versus full community ambulation ability for most of the medical diagnoses in which a lower extremity orthosis may be prescribed (stroke, SCI, cerebral palsy, traumatic brain injury, among others).130,132-140 Documenting comfortable and maximum walking speed at intervals without and with the orthosis at time of delivery and change in walking speed over the course of physical therapy intervention, along with discussion of the change in walking speed with respect to age-base and disease-reference norms, provide powerful information about efficacy of intervention.

ENDURANCE DURING WALKING The ability to sustain walking over a period of time is also a key outcome of orthotic and physical therapy intervention. The most frequently used measure of endurance while walking is the 6-minute walk test (6 MWT), in which the distance that an individual walks during a 6-minute period is measured. Also valid is a 2-minute walking test. Clinometric properties of the 6 MWT have been evaluated for persons with stroke, SCI, cerebral palsy, traumatic brain injury, myelomeningocele, and chronic poliomyelitis.141-146 A self-report indicator of effort of physical activity that has also been used extensively in the clinical research literature is Rating of Perceived Exertion (RPE). In his original work, Borg presented a scale ranging from 6 (no effort) to 20 (maximum effort)147; a modified version, which uses a 1 to 10 scale (for adults) or color-coded schematic pictures of the face (for children and those with cognitive dysfunction) may be more interpretable for patients.148,149 The question that use of RPE scale addresses is, “Does the orthosis reduce the perceived work (effort) of walking?” RPE scales have been used to assess efficacy of therapeutic intervention for persons with stroke, brain injury, SCI, and cerebral palsy.128,150,151

MOBILITY AND BALANCE WHILE WALKING The ability to change direction and transition between surfaces (i.e., sit to stand) is also a key aspect of successful use of a lower extremity orthosis. During the TUG test, an individual must rise from a seated position, walk forward over a 3-m distance, turn around, walk back to the chair, and return to sitting, either at a usual pace or as quickly and safely as able.152 Because most lower extremity orthoses constrain joint movement, and many of those who use them have neuromuscular impairments that place them at risk for falling, the TUG may provide a snapshot of dynamic postural control during walking with an orthosis. The TUG has been successfully used to assess functional status and predict outcomes in persons with neurologic and orthopedic

conditions.143,153-159 Self-reported measures, such as the Falls Efficacy Scale and Activities-Specific Balance Confidence (ABC) Scale, can supplement performance-based outcomes to measure the change in a patient’s fear of falling pre- and post-bracing.160-163

Summary This chapter explores the biomechanical design and component options of lower extremity orthoses used to facilitate the ability to walk for persons with a variety of neuromuscular impairments and at various ages and developmental stages of the life span. We have discovered that no orthosis can make walking “normal,” although an appropriate orthosis can make walking more functional and less energy costly. We currently can evaluate how an orthosis will impact each of the rockers of stance phase, as well as the ability to clear the limb during swing phase. We currently have ideas about how footwear, such as an athletic shoe that provides a cushion heel and a rocker bottom, may compensate if an orthosis limits forward progression over the foot during stance. We have discovered that the selection of an appropriate orthosis involves input from many members of the rehabilitation team, not the least being the person who will wear the orthosis and his or her caregivers. We certainly have gained an appreciation that there is no “one size fits all” when it comes to choosing an orthosis but that orthotic prescription requires thoughtful deliberation about both the functional benefits and tradeoffs, as well as the financial cost of the device. We have learned that using an orthosis effectively requires much more than simply putting it on; there must be adequate time filled with appropriately challenging activities so that motor practice can build skill, postural control, and endurance necessary for functional walking. Finally, we have begun to consider strategies to assess outcomes of orthotic and physical therapy interventions for persons who require an AFO, KAFO, or HKAFO to accomplish their mobility goals.

Acknowledgments The authors recognize professional colleagues Robert S. Lin, CPO (Director of Pediatric Clinical Services and Academic Programs, Hanger Orthopedic Group at the Connecticut Children’s Medical Center, Hartford, CT.), Thomas V. DiBello, BS, CO (President, Dynamic Orthotics and Prosthetics, Inc., Houston, TX), and James H. Campbell, PhD, CO (Director of Research and Development, Engineering and Technical Services, Becker Orthopedic, Troy MI), whose excellent chapters on ankle-foot orthoses, knee-ankle-foot orthoses, and hip-knee-ankle-foot orthoses in the previous editions of this text provided a solid foundation for the this integrative chapter.

Case Examples Recommendations are intended as ideas and guides for the clinician, not an all-inclusive or complete answer.

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Case Example 9.1 P.M. is a 7-year-old child with a primary diagnosis of spastic diplegic cerebral palsy. He is anxious to keep up with his nonimpaired peers at school, but his moderate “crouch gait” (despite using Lofstrand crutches as assistive devices) limits his mobility and endurance. He is referred by his neurologist for evaluation in the interdisciplinary “brace clinic” at the local children’s medical center. On physical examination, P.M. is found to have moderate tightness and soft tissue shortening of his plantarflexors, distal hamstrings, adductors, and hip flexors. Although he exhibits moderate extensor-pattern spasticity in both lower extremities, sagittal and coronal plane motions of his hip, knee, and ankle are within 10 degrees of normal. Structurally, he exhibits 25 degrees of femoral anteversion and 15 degrees of internal tibial torsion. However, upon barefoot weight bearing, his foot progression angles appear to be normal, at approximately 10 degrees external (outward) angle. QUESTIONS TO CONSIDER ▪ What are the most likely gait problems in each subphase of gait that might be effectively addressed by an AFO? ▪ What musculoskeletal (alignment and flexibility) and neuromuscular (control) impairments or characteristics, as well as developmental issues, will have to be considered by the team as they sort through orthotic options for this child? ▪ Which of the orthotic options (static vs. dynamic) might you choose for this child? What are the possible benefits and tradeoffs of each? ▪ How might you assess if the orthosis chosen is accomplishing the desired outcomes? RECOMMENDATIONS OF THE TEAM Given the finding of dynamic pes planus and valgus deformity and the boy’s propensity to crouch during stance, the team

recommends bilateral polypropylene SAFO be custom molded for P.M. When P.M. receives his AFOs, he attends several sessions of outpatient gait training. His gait pattern demonstrates improved plantarflexion–knee extension couples, with virtually all of the preorthosis knee persistent knee flexion eliminated. Subtalar joint alignment is also improved, with an effective support of the medial longitudinal arch. FOLLOW-UP CARE Three weeks later, the patient’s mother schedules a follow-up visit because she observes, “The AFO is causing P.M.’s feet to turn in.” On this return visit, observational gait assessment reveals an apparent 30-degree internal (inward) foot progression bilaterally. This is causing difficulty with clearance of the advancing limb during swing phase. Examination of the fit and alignment of the AFOs reveal appropriate design and fit, with effective subtalar neutral position. The team recommends computerized gait analysis to be performed to determine the underlying factors leading to this significant change in foot progression angle despite appropriately fit and designed SAFO. The team suspects that this altered foot progression angle is most likely the result of underlying musculoskeletal deformities (tibial torsion and femoral anteversion) unmasked when compensatory motion of the subtalar and midtarsal joints during stance is restricted by the AFOs. In effect, when foot alignment is well supported by the AFO, the effect of excessive tibial torsion and femoral anteversion during gait become more evident. It is not possible for an AFO to effectively address or control gait problems arising from existing underlying transverse plane (rotational) deformity. The team and family begin to consider the possibility of femoral/tibial derotation osteotomy as a solution to the gait problems that have emerged.

Case Example 9.2 A 40-year-old man presented to the emergency department with severe shooting back pain radiating down both legs (right greater than left) weakness of the feet, saddle anesthesia, and urinary incontinence for 2 to 3 weeks with worsening over the past 4 days. Magnetic resonance imaging revealed multilevel degenerative disease with severe central canal stenosis at L2-L3 and L3-L4, thoracic spine spondylosis with severe stenosis, and spinal cord compression C3-C7. He underwent C3-C7 and L2-L5 laminectomies. Persistent weakness and foot drop bilaterally postoperatively. Past Medical History: remote history of motor vehicle accident with severe right knee trauma. Social history: Patient lives with fiance in second-floor apartment with one flight of outdoor stairs with a single railing to enter plus one flight of stairs without a railing to the thirdfloor bedroom and bathroom. Prior to injury, patient was independent with activities of daily living, instrumental activities of daily living, and mobility. Patient goals: To walk. To return to his apartment. To resume his studies to complete his undergraduate degree including mobility on campus.

He is now admitted to the acute rehabilitation spinal cord injury unit for functional retraining. Present examination findings include: Sensation: Intact light touch, localization throughout bilateral lower extremities Proprioception: Impaired right great toe and ankle. Intact left great toe and ankle. Integumentary: Intact Range of motion: Right ankle dorsiflexion (DF) to neutral. Left ankle DF -6 degrees. Strength MMT: Hip grossly 2-3/5. Knee extension 4/5. Knee flexion 2/5. Ankle 0/5 in all planes except left plantarflexion 1/5. Gait: 40 feet with bilateral Lofstrand crutches with excessive knee flexion during weight acceptance, hyperextension thrust at early to midstance transition, excessive knee extension and genu varus during midstance and terminal stance phase, excessive plantarflexion throughout swing phase causing reduced foot clearance, excessive forward pelvic rotation and hip hike bilaterally during swing phase, Continued on following page

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Case Example 9.2

(Continued)

B Trendelenburg hip drop, with step lengths short with swing heel landing near stance toe. ▪ What are the critical phases of gait where the patient’s body structure/function impairments are evident? ▪ Which of these gait abnormalities could be supported/ reduced through the use of an orthosis? ▪ What are the positive outcomes expected when using an orthosis for this patient (i.e., how will it improve mobility and gait, influence tone, or protect a limb or body segment)? ▪ How might you assess whether the orthosis chosen is accomplishing the desired outcomes? TEAM RECOMMENDATIONS Weakness is evident during weight acceptance as demonstrated by excessive knee flexion and again during midstance as hyperextension thrust is a compensation to lock the knee into a stable position due to the inability to effectively use strength to stabilize tibia advancement. Weakness is also negatively affecting

swing limb advancement reflexed in excessive plantarflexion and need for hip hike compensation. An orthosis could stabilize the distal limb during stance, improving weight acceptance and reducing abnormal knee forces during forward progression. It could assist with functional shortening of the limb by limiting excessive plantarflexion, which could reduce the need for hip hiking and pelvic rotation compensations to clear the limb in swing. An orthosis can be expected to reduce excessive biomechanical forces from abnormal foot and tibial position, as well as improve gait efficiency, reducing energy consumption and allowing further ambulation tolerance and greater independence. Valid and highly recommended outcome measures for a patient with spinal cord injury that could be used to assess the patient’s outcomes with the orthoses include the following: Walking Index for Spinal Cord Injury II (WISCI II), 10-meter walk test, Timed Up and Go, 6-minute walk test (Neuro EDGE SCI incomplete).

Case Example 9.3 An 81-year-old man presented to the hospital with weakness and was diagnosed with Guillain-Barre syndrome. He was treated with intravenous immunoglobulin/prednisone. His course was complicated by limb and bulbar weakness and aspiration pneumonia. He was transferred to an acute rehabilitation hospital for functional retraining. Past Medical History: Hypertension, hyperlipidemia, prostate cancer s/p prostatectomy, small left rotator cuff tear Social history: Patient lives at home with wife in a two-level home plus basement. There are three steps to enter with a railing from the garage or three steps to enter the front entrance with no railing. The bedroom is located on the first floor as is the bathroom; however, the shower has a 6-inch lip to enter. There is one flight of 8 + 8 steps with railing to access the patient’s second-floor home office. Prior to injury, the patient was independent with ADLs, IADLs, and mobility. He was playing tennis 3 days per week and bicycling during warm-weather months. Patient’s goals: To get in and out of bed independently. To walk. To negotiate stairs to his second-floor office. To return to tennis. Present examination findings include: Sensation: Absent to diminished throughout bilateral lower extremities Proprioception: Absent at bilateral great toe and ankles Spasticity: 0/4 (modified Ashworth Scale) Integumentary: Intact Range of motion: Hamstring muscle lengths limited to approx. 80 degrees bilaterally via straight leg raise. Strength MMT: Right hip grossly 1/5. Left hip flexion 1/5 otherwise left hip 0/5. Bilateral knee extension 1/5. Bilateral hip flexion 2-/5. Right ankle DF 0/5. Left ankle DF 1/5. Bilateral ankle plantarflexion 1/5. Upper extremity strength is grossly 3/5 except hand function is limited to 2/5 bilaterally with impairments in fine motor control. Bed mobility: Supine to sit with maximal assist of one person Transfers: Sit to stand dependent via standing frame or maximal assist of two persons

▪ What type of orthosis is most appropriate to consider for early standing and gait training with this patient?

▪ What are the positive outcomes expected when using an

orthosis for this patient (i.e., how will it improve mobility and gait, influence tone, or protect a limb or body segment)? ▪ What are the expected disadvantages or tradeoffs that may be associated with use of an orthosis (i.e., the ways in which it may complicate daily activity, mobility, or preferred activities; the energy cost associated with its use; the relative expense of the device)? ▪ What are the indications that the orthosis may be useful to the patient (i.e., the match between the person’s characteristics and needs and what the orthosis will provide)? ▪ Considering the prognosis for recovery with this patient, how might the patient’s orthosis be progressed/changed as his motor control improves? TEAM RECOMMENDATIONS Prognostic indicators for patients with Guillain-Barre syndrome suggest that 80% are able to ambulate within 6 months and 84% are able to ambulate at 1 year. Therefore the SAFO can progress with the patient by adding a hinged or articulating ankle joint to allow tibial progression during stance or by cutting back the trim lines to lessen stability. Factors impacting the decision for early orthosis include significant muscle weakness, absent sensation and proprioception, and no tone present. Given lower extremity muscle strengths grossly in the absent (0) to poor (1) range, this patient will need a highly stable orthosis to maintain the ankle and knee in position to effectively stand. His upper extremities are also weak, limiting the patient’s ability to rely on them for support in standing further, indicating the need for a highly stable brace. With no tone present, the patient will not be able to rely on tone to substitute for lack of strength. There do not need to be any considerations for a brace that will minimize spasticity. The absence of sensation and proprioception suggests that the brace must be well fitting to reduce pressure and shear forces that could occur during mobility.

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Considerations for bracing selection could range from, at simplest, a custom-molded solid AFO to a more complex KAFO. In the interest of selecting the least restrictive prescriptive orthoses, a solid AFO would be an appropriate initial brace to provide stability to the ankle and knee by limiting tibia mobility, thus stabilizing the leg in standing. A solid AFO will provide two primary patient benefits: stability in stance and assistance with clearance in swing. The ankle ROM restrictions will provide distal stability to the limb in stance, limiting the degrees of freedom and allowing the patient and therapist to focus on proximal stability training at

the core and trunk. The fixed ankle position will assist with swing limb clearance by limiting excessive plantarflexion during swing phase. There may be increased caregiver burden for donning and doffing due to upper extremity weakness and impaired fine motor control. The patient is unable to stand without an external standing device or two-person assist. Stabilizing the distal limb by orthoses may allow the patient increased standing tolerance and increased frequency of standing if it can be reduced to the assistance of a single caregiver.

Meythaler JM. Rehabilitation of Guillain-Barr e syndrome. Arch Phys Med Rehabil. 1997;78(8):872–879; Rajabally YA, Uncini A. Outcome and its predictors in Guillain-Barre syndrome. J Neurol Neurosurg Psychiatry. 2012;83(7):711–718.

Case Example 9.4 A 70-year-old man presented to the hospital with left leg pain of 3 months’ duration and weakness over the past several weeks due to diabetic amyotrophy now with worsening of right leg weakness. Past Medical History: arteriosclerosis, diabetes mellitus, umbilical hernia (repaired), bradycardia Social history: Patient lives with his wife in a two-story home with 15 steps to enter from the garage level to the first floor. He has an additional flight of stairs to the second floor, where his bedroom and full bathroom are. On the first floor are a small living area, couch, and bathroom with shower stall. Patient has been staying on the couch on the first floor due to 11 falls in the past month on stairs. A few months prior to presentation, patient was regularly hiking on weekends and working as a homeland security agent. One month prior to injury he began using a right AFO short solid AFO due to foot drop and a cane. More recently he also began using a rolling walker. Patient goals: To get his legs strong and to not have any more falls. Present examination findings include: Sensation: Absent light touch to bilateral feet, diminished light touch and localization throughout bilateral lower extremities distal to knee left worse than right. Proprioception: Absent bilateral hallux. Diminished bilateral ankles. Integumentary: Intact Range of motion: Within functional limits but noted bilateral hamstring muscle length limitations. Strength MMT: Left lower extremity grossly 2-/5 except knee extension 1/5. Right hip flexion, adduction, and extension 4/5. Right hip abduction 3-/5. Right knee 3/5. Ankle dorsiflexion and plantarflexion 0/5. Gait: 250 ft with rolling walker with minimal assistance except minimal to moderate assistance to recover when knees buckle. Patient wearing Right personal short semisolid AFO and left loaner Allard ToeOFF (carbon fiber) AFO. Gait is remarkable for left knee buckling when center of mass is

anterior to the left foot during terminal stance, similar but less severe presentation of right knee. Decreased left heel strike at initial contact, absent foot clearance on left. ▪ Which of these gait abnormalities could be supported/ reduced through the use of an orthosis? ▪ What are the positive outcomes expected when using an orthosis for this patient? (i.e., how will it improve mobility and gait, influence tone, or protect a limb or body segment). ▪ What are the expected disadvantages or tradeoffs that may be associated with use of an orthosis? (i.e., the ways in which it may complicate daily activity, mobility, or preferred activities; the energy cost associated with its use; the relative expense of the device)? ▪ Considering the prognosis for recovery with this patient, how might the patient’s orthosis be progressed/changed as his motor control improves? TEAM RECOMMENDATIONS Given the patient’s continued buckling with an AFO and his degree of weakness, a KAFO may be the most appropriate device to effectively assist with foot clearance and heel strike by stabilizing the ankle in near neutral while also providing limitations of tibial advancement and knee flexion during stance phase. Use of an orthosis will allow control of knee and ankle joint range during weight bearing in stance phase. Limiting the range of both joints will prevent significant knee buckling, improving the patient’s ability to ambulate safely, build confidence, and reduce fall risk. Use of a KAFO is more complex for the patient to don and doff as part of activities of daily living. It is less cosmetically appealing compared with a less significant brace, such as an AFO. The brace will limit ROM during sitting tasks. The KAFO has more bulk and weight than an AFO, only which can increase energy demands during gait. The prognosis for recovery of strength is fair to good for persons with diabetic amyotrophy; therefore, as the patient’s motor control improves, the KAFO can be progressed to an AFO, providing more degrees of freedom for movement, reduced energy demand, and a less cumbersome donning/doffing process.

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Case Example 9.5 A 69-year-old man presented to outpatient rehabilitation clinic with gait abnormalities in the setting of multiple sclerosis. Past Medical History: hypertension, neurogenic bladder, rotator cuff syndrome, dyslipidemia, low back pain, osteoarthritis of the knee Social history: Patient lives with his wife in a two-level home with stair slide to access the second floor. He is able to ambulate independently with a rolling walker. He has a manual wheelchair for community distances but rarely uses it. Patient goals: To walk better. To walk in the community more. Present examination findings include: Sensation: Present but diminished light touch and localization in bilateral lower extremities distal to the knee. Proprioception: Present bilateral ankle and hallux. Integumentary: Intact Range of motion: Within functional limits except bilateral ankle dorsiflexion limited to neutral. Spasticity: 1 + bilateral ankle plantarflexors; 1 + bilateral hip adductors via modified Ashworth Scale. Strength MMT: Lower extremities are grossly 2 to 3/5 throughout via functional observation except bilateral ankle dorsiflexion 2-/5 and bilateral ankle plantarflexion 2/5. Unable to formally manual muscle test due to inability to isolate single plane movement during testing in setting of increased lower extremity tone. Gait: 40 ft with rolling walker and close supervision. Gait is remarkable for bilateral excessive plantarflexion during swing phase resulting in toe drag throughout; bilateral hip adduction with narrow base of support; short step lengths bilaterally; limited knee flexion during midswing phase and excessive knee extension, even hyperextension during stance phase. ▪ What are the critical phases of gait where the patient’s body structure/function impairments are evident? ▪ Which of these gait abnormalities could be supported/ reduced through the use of an orthosis? ▪ What are the positive outcomes expected when using an orthosis for this patient (i.e., how will it improve mobility and gait, influence tone, or protect a limb or body segment)? ▪ What are the expected disadvantages or tradeoffs that may be associated with use of an orthosis (i.e., the ways in which it may complicate daily activity, mobility, or preferred activities; the energy cost associated with its use; the relative expense of the device)? ▪ Considering this patient’s diagnosis, how might the patient’s orthosis be progressed/changed over time? TEAM RECOMMENDATIONS The patient’s dorsiflexion weakness is evident during swing limb advancement. Plantarflexor spasticity may also be a contributing

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factor to the excessive plantarflexion seen during swing phase. Both of these body structure/function impairments result in a functionally long limb. Combined with weakness of the more proximal limb muscles and adductor tone, the patient has insufficient foot clearance. Ankle dorsiflexion can be easily supported through the use of an orthosis. One option for this patient could be a neuroprosthesis such as Bioness 300 or WalkAid. Peripheral nerve integrity should be intact given the patient’s diagnosis with an upper motor neuron disease process. Stimulation applied to the common peroneal nerve/anterior tibialis timed with swing phase can increase functional strength of ankle dorsiflexion and potentially reduce effects of antagonist spasticity. This will in effect make the limb shorter and easier to clear during swing, as well as provide a more normal heel strike at initial contact. If adductor tone and proximal muscle weakness are limiting his ability to achieve hip and knee flexion during swing, a thigh component such as the Bioness L300+ can be added to the hamstring to cause knee flexion during swing phase, further shortening the limb and allowing improved swing limb advancement. It is important to note that hamstring flexion during swing phase is not normal muscle activity during gait, rather hamstrings would normally only be active eccentrically as the patient approaches terminal swing. In this case, the neuroprosthesis is being used as a compensatory strategy to reduce the energy associated with foot clearance and reduce risk of falls from inability to clear the limb. Use of a neuroprosthesis will provide improved gait efficiency by reducing effort for swing limb advancement, reduce fall risk by improving limb clearance, and possibly provide functional strength recovery with continued stimulation use. Neuroprostheses are associated with greater cost than more traditional bracing styles and therefore likely require a higher level of documentation of medical necessity and possibly greater advocacy on the part of the patient to obtain clinic/insurance coverage. In addition, the maintenance requirements are higher for battery life and electrode life, and some require the pad to be damp, which could require the patient to redampen midday. The patient’s cognition and sensation should be monitored over time. The use of a neuroprosthesis requires greater insight of the patient to ensure proper maintenance and wear and skin integrity checks. This patient has a degree of impaired sensation. This is not a contraindication for use of a neuroprosthesis but must be considered with other factors to ensure the patient maintains a healthy integumentary system. If the patient’s sensation decreases, it will require greater cognitive awareness to monitor skin regularly. If the patient’s cognition declines, he may require assistance from a caregiver for skin checks or require another type of brace if he cannot individually manage it.

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after spinal cord injury: a case study. Neuromodulation. 2005;8 (4):264–271. Fritz S, Lusardi M. White paper: "walking speed: the sixth vital sign". J Geriatr Phys Ther. 2009;32(2):46–49. Turner-Stokes L, Turner-Stokes T. The use of standardized outcome measures in rehabilitation centres in the UK. Clin Rehabil. 1997;11 (4):306–313. Carvalho C, Sunnerhagen KS, Willen C. Walking speed and distance in different environments of subjects in the later stage post-stroke. Physiother Theory Pract. 2010;26(8):519–527. Bowden MG, Balasubramanian CK, Behrman AL, Kautz SA. Validation of a speed-based classification system using quantitative measures of walking performance poststroke. Neurorehabil Neural Repair. 2008;22(6):672–675. Jackson AB, Carnel CT, Ditunno JF, et al. Outcome measures for gait and ambulation in the spinal cord injury population. J Spinal Cord Med. 2008;31(5):487–499. van Hedel HJ, Group ES. Gait speed in relation to categories of functional ambulation after spinal cord injury. Neurorehabil Neural Repair. 2009;23(4):343–350. van Hedel HJ, Wirz M, Curt A. Improving walking assessment in subjects with an incomplete spinal cord injury: responsiveness. Spinal Cord. 2006;44(6):352–356. Martin L, Baker R, Harvey A. A systematic review of common physiotherapy interventions in school-aged children with cerebral palsy. Phys Occup Ther Pediatr. 2010;30(4):294–312. Kurz MJ, Stuberg W, DeJong SL. Body weight supported treadmill training improves the regularity of the stepping kinematics in children with cerebral palsy. Dev Neurorehabil. 2011;14(2):87–93. van Loo MA, Moseley AM, Bosman JM, de Bie RA, Hassett L. Interrater reliability and concurrent validity of walking speed measurement after traumatic brain injury. Clin Rehabil. 2003;17(7):775–779. Moseley AM, Lanzarone S, Bosman JM, et al. Ecological validity of walking speed assessment after traumatic brain injury: a pilot study. J Head Trauma Rehabil. 2004;19(4):341–348. Fulk GD, Echternach JL, Nof L, O’Sullivan S. Clinometric properties of the six-minute walk test in individuals undergoing rehabilitation poststroke. Physiother Theory Pract. 2008;24(3):195–204. Ditunno Jr JF, Barbeau H, Dobkin BH, et al. Validity of the walking scale for spinal cord injury and other domains of function in a multicenter clinical trial. Neurorehabil Neural Repair. 2007;21(6):539–550. van Hedel HJ, Wirz M, Dietz V. Assessing walking ability in subjects with spinal cord injury: validity and reliability of 3 walking tests. Arch Phys Med Rehabil. 2005;86(2):190–196. Thompson P, Beath T, Bell J, et al. Test-retest reliability of the 10metre fast walk test and 6-minute walk test in ambulatory schoolaged children with cerebral palsy. Dev Med Child Neurol. 2008;50 (5):370–376. Hassan J, van der Net J, Helders PJ, Prakken BJ, Takken T. Six-minute walk test in children with chronic conditions. British journal of sports medicine. 2010;44(4):270–274. Gylfadottir S, Dallimore M, Dean E. The relation between walking capacity and clinical correlates in survivors of chronic spinal poliomyelitis. Arch Phys Med Rehabil. 2006;87(7):944–952. Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc. 1982;14(5):377–381. Lamb KL, Eston RG, Corns D. Reliability of ratings of perceived exertion during progressive treadmill exercise. Br J Sports Med. 1999;33 (5):336–339. Groslambert A, Hintzy F, Hoffman MD, Dugue B, Rouillon JD. Validation of a rating scale of perceived exertion in young children. Int J Sports Med. 2001;22(2):116–119. Eng JJ, Chu KS, Dawson AS, Kim CM, Hepburn KE. Functional walk tests in individuals with stroke: relation to perceived exertion and myocardial exertion. Stroke. 2002;33(3):756–761. Kelly S. Oxygen cost, walking speed, and perceived exertion in children with cerebral palsy when walking with anterior and posterior walkers. Pediatr Phys Ther. 2002;14(3):159–161. Podsiadlo D, Richardson S. The timed "Up & Go": a test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society. 1991;39(2):142–148. Ng SS, Hui-Chan CW. The timed up & go test: its reliability and association with lower-limb impairments and locomotor capacities in people with chronic stroke. Arch Phys Med Rehabil. 2005;86(8): 1641–1647.

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154. Erel S, Uygur F, Engin Simsek I, Yakut Y. The effects of dynamic anklefoot orthoses in chronic stroke patients at three-month follow-up: a randomized controlled trial. Clin Rehabil. 2011;25(6):515–523. 155. Andersson AG, Kamwendo K, Seiger A, Appelros P. How to identify potential fallers in a stroke unit: validity indexes of 4 test methods. J Rehabil Med. 2006;38(3):186–191. 156. Gan SM, Tung LC, Tang YH, Wang CH. Psychometric properties of functional balance assessment in children with cerebral palsy. Neurorehabil Neural Repair. 2008;22(6):745–753. 157. Katz-Leurer M, Rotem H, Keren O, Meyer S. Balance abilities and gait characteristics in post-traumatic brain injury, cerebral palsy and typically developed children. Dev Neurorehabil. 2009;12(2):100–105. 158. Williams EN, Carroll SG, Reddihough DS, Phillips BA, Galea MP. Investigation of the timed ’up & go’ test in children. Dev Med Child Neurol. 2005;47(8):518–524.

159. van Hedel HJ, Wirz M, Dietz V. Standardized assessment of walking capacity after spinal cord injury: the European network approach. Neurol Res. 2008;30(1):61–73. 160. Dewan N, MacDermid JC. Fall Efficacy Scale-International (FES-I). J Physiother. 2014;60(1):60. 161. Powell LE, Myers AM. The Activities-specific Balance Confidence (ABC) Scale. J Gerontol A Biol Sci Med Sci. 1995;50A(1):M28–M34. 162. Zissimopoulos A, Fatone S, Gard S. The effect of ankle-foot orthoses on self-reported balance confidence in persons with chronic poststroke hemiplegia. Prosthet Orthot Int. 2014;38(2):148–154. 163. van Vliet R, Hoang P, Lord S, Gandevia S, Delbaere K. Falls efficacy scale-international: a cross-sectional validation in people with multiple sclerosis. Arch Phys Med Rehabil. 2013;94(5):883–889.

10

Neurological and Neuromuscular Disease Implications for Orthotic Use☆ DONNA M. BOWERS and KEVIN K. CHUI

LEARNING OBJECTIVES

On completion of this chapter, the reader will be able to do the following: 1. Describe the contribution of the major components of the central nervous system (CNS) and the peripheral nervous system (PNS) to functional, goal-directed movement. 2. Describe the impact of CNS and PNS pathologies commonly encountered in physical therapy and their implications for orthotic practice. 3. Explain the interaction of muscle tone and muscle performance on goal-directed, functional movement. 4. Describe the characteristics of muscle tone in the CNS and PNS pathologies most commonly encountered in physical therapy and implications for orthotic practice. 5. Describe the contributions of various CNS and PNS components to, and key determinants of, effective postural control. 6. Describe the contributions of various CNS components to, and key determinants of, mobility and coordination during functional activity. 7. Discuss the roles of orthopedic and neurosurgical procedures, central and peripherally acting pharmacological agents, and various orthotic options for the management of hypertonicity. 8. Plan a strategy for examination and evaluation of persons with CNS and PNS dysfunction to determine the need for an orthosis or adaptive equipment. 9. Describe strategies for orthotic use to reduce the risk of developing secondary musculoskeletal impairments in persons with hypertonicity. 10. Describe strategies for orthotic and adaptive equipment use to support postural control in persons with hypotonicity.

Movement Impairment in Neurological and Neuromuscular Pathology Pathologic conditions of the neuromuscular system manifest in a sometimes confusing array of clinical signs and symptoms. To select the most appropriate therapeutic interventions, be it exercise to promote neuroplasticity and neurorecovery, functional training, or the use of various orthoses and assistive devices to accommodate for impairment of a body system or structure, the clinician must develop a strategy to “classify” the movement disorder that has produced the observed impairments and functional limitations.1 The clinician must understand the medical prognosis and potential progression of the disease process, as well as the lifestyles and risk factors that might contribute to secondary impairments that limit function over time (even if the disease is “nonprogressive”) and their impact on the individual’s growth and development. ☆

The authors extend appreciation to Michelle M. Lusardi, whose work in prior editions provided the foundation for this chapter.

The context of a person’s impairments, physical activity limitations, and desire to participate in chosen pursuits must be accounted for in deciding a course of physical therapy interventions, including the use of orthotics1–3 Health professionals use a number of organizational strategies as frameworks for decision making during rehabilitation of individuals with pathologic conditions leading to neuromuscular dysfunction. Many neurologists use a medical differential diagnosis process to determine that the lesion is located within the central nervous system (CNS) or involving structures of the peripheral nervous system (PNS) or the muscle itself.4 They do this by triangulating evidence gathered through focused patient histories, which leads to examination of tone, deep tendon reflexes, observation of patterns of movement, postural control, and specific types of involuntary movement.4–6 They may also interpret results of special tests such as nerve conduction studies, electromyography (EMG), computed tomography (CT), and magnetic resonance imaging (MRI).7,8 These tests might pinpoint areas of denervation, ischemia, or demyelinization and help the health professionals arrive at a medical diagnosis. In collaboration with neurologists, rehabilitation professionals are most interested in the functional consequences 259

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associated with the various neuromotor conditions. They examine the ways in which the resultant altered motor control (from the neurological pathologic condition) affects postural control, mobility and locomotion, and coordination (error control) during functional activities.9,10 Rehabilitation professionals are not only concerned about function at the present time but also consider the long-term impact of neuromotor impairment on the person’s joints and posture, especially in children who are growing with abnormal tone and postures.11,12 This chapter considers the ways that key components of the CNS and PNS contribute to functional movement. We explore the concepts of muscle tone and muscle performance, considering how their interaction influences an individual’s ability to move. We investigate how abnormalities of tone resulting from CNS and PNS pathologic conditions are described in clinical practice. We consider the determinants of postural control and of coordination and how CNS and PNS pathologic conditions might lead to impairments of balance and movement. We provide an overview of the ways that commonly encountered CNS pathologic conditions impact muscle tone, muscle performance, postural control, movement, and coordination as a way of understanding how an orthosis or adaptive equipment might help improve an individual’s ability to walk and use their arms/hands for functional movement in order to participate in meaningful activities and roles.2 We consider how the physical therapy examination contributes to the determination of a need for an orthosis or adaptive equipment. We also explore the clinical decision-making process by asking key questions about how an orthosis might help (or hinder) function. Finally, we apply what we have learned using five clinical cases to develop orthotic prescriptions.

Differential Diagnosis: Where Is the Problem? Most neurological and neuromuscular diseases affect either the CNS or the PNS; only a few diseases, such as amyotrophic lateral sclerosis, affect both CNS and PNS. Diseases of the CNS and of the PNS may contribute to motor or sensory impairment; however, there are patterns and characteristics of dysfunction that are unique to each. Selection of the appropriate orthosis, seating/wheelchair system, or assistive devices is facilitated when the therapist, orthotist, members of the rehabilitation team, patient, and patient’s family understand the typical function and consequences of the disease process of the neurological subsystem that is affected.

THE CENTRAL NERVOUS SYSTEM The CNS is a complex of dynamic and interactive subsystems that mediates purposeful movement and postural control, vital autonomic vegetative and physiological functions, and learning of all types.13 Readers are encouraged to refer to a recent neuroanatomy or neuropathology textbook to refresh their understanding of CNS structure and function. Knowledge of the roles of various CNS structures and their interactions (for perception, problem solving, motor planning, and coordination) is foundational for evidenced-based clinical decision making when considering orthoses for individuals with neuromuscular dysfunction.

Some diseases affect a single CNS system or center (e.g., Parkinson disease affects the function of the basal ganglia in regulating agonist/antagonist muscle activity; a lacunar stroke in the internal capsule may interrupt transmission only within the pyramidal/corticospinal pathway) leading to a specific array of signs/symptoms characteristic of that system or center. Other pathologic conditions disrupt function across several systems: a thromboembolic stroke in the proximal left middle cerebral artery may disrupt volitional movement and sensation of the right side of the body, as well as communication and vision. Several exacerbations of multiple sclerosis may lead to plaque formation in the cerebral peduncles/pyramidal system, superior cerebellar peduncle/error control system, restiform body/balance system, and fasciculus gracilis/lower extremity sensation; in this case, it can be challenging but imperative to sort through the various types of impairments that may result in order to select the most appropriate therapeutic or orthotic intervention for the individual.

Pyramidal System The pyramidal system is responsible for the initiation of volitional movement and plays a major role in the development of skilled and manipulative activities.14 The cell bodies of pyramidal neurons are located in the postcentral gyrus/primary motor cortex. The motor cortex in the left cerebral hemisphere influences primarily the right side of the body (face, trunk, and extremities); the right cortex influences the left body. The axons of pyramidal neurons form the corticobulbar and corticospinal tracts, projecting toward alpha (α) motor neurons in cranial nerve nuclei and anterior horn of the spinal cord. To reach their destination, these axons descend through the genu and posterior limb of the internal capsule, the cerebral peduncles, the basilar pons, the pyramids of the medulla, and finally the opposite lateral funiculus of the spinal cord. A lesion at any point in the pyramidal system has the potential to disrupt volitional movement. The degree of disruption varies with the extent and functional salience of the structures that are damaged, manifest on a continuum from mild weakness (paresis) to the inability to voluntarily initiate and direct movement (paralysis).14 Immediately following insult or injury of the pyramidal system, during a period of neurogenic shock, there may be substantially diminished muscle tone and sluggish or absent deep tendon reflexes.14 As inflammation from the initial insult subsides, severely damaged neurons degenerate and are resorbed, while minimally damaged neurons may repair themselves and resume function.15,16 The more neurons that are destroyed, the greater the likelihood that hypertonicity will develop over time due to the altered balance of descending input of pyramidal and extrapyramidal systems. As the recovery period continues, individuals may begin to move in abnormal synergy patterns whenever volitional movement is attempted.17,18 When the damage to the system is less extensive, individuals may eventually recover some or all volitional motor control; the more extensive the damage to the system, the more likely there will be residual motor impairment.15,18 Extrapyramidal System The extrapyramidal system is made up of several subcortical subsystems that influence muscle tone, organize patterns of

10 • Neurological and Neuromuscular Disease Implications for Orthotic Use

movement from among the many possible movement strategies, and make both feedforward adjustments (in anticipation of movement) and refining feedback adjustments (in response to sensations generated as movement occurs) during performance of functional tasks.19 The motor planning subsystem is a series of neural loops interconnecting the premotor and accessory motor cortices in the frontal lobes, the nuclei of the functional basal ganglia (caudate, putamen, globus pallidus, substantia nigra, subthalamus), and several nuclei of the thalamus. Damage to the premotor and accessory motor cortex leads to apraxia, the inability to effectively sequence components of a functional task and to understand the nature of a task and the way to use a tool in performance of the task.20 If there is damage to the caudate and putamen (also called the corpus striatum), underlying muscle tone may fluctuate unpredictably (athetosis) and involuntary dancelike movements (chorea) are likely to occur.21 Damage to the subthalamic nuclei can lead to forceful, often disruptive, involuntary movement of the extremities (ballism) that interrupts purposeful activity.22 Damage to the substantia nigra characteristically leads to resting tremor, rigidity of axial and appendicular musculature (hypertonicity in all directions), and bradykinesia (difficulty initiating movement, slow movement with limited excursion during functional tasks), which are most commonly seen in persons with Parkinson disease.23 Motor impairments resulting from damage to the ventral anterior nucleus and related thalamic nuclei are less well understood but may contribute to less efficient motor planning, especially when the individual is learning or performing novel tasks.24 Extrapyramidal structures influence muscle tone and readiness to move via a network of interconnections among motor centers in the brainstem. The reticulospinal tracts, originating in the lower pons and medulla, are thought to influence tone by acting on gamma (γ) motor neurons and their associated muscle spindles. They play a major role in balancing the stiffness required for antigravity position and the flexibility necessary for movement of the limbs through space during functional activity and are likely the effectors for tonic hindbrain reflexes.19,25 The vestibulospinal tracts, also originating from the pons and medulla, influence anticipatory postural adjustment in preparation for movement and reactionary postural adjustments as movement occurs. These tracts are thought to be the “effectors” for postural control and balance.19,26 The tectospinal tracts, originating in the collicular nuclei of the dorsal midbrain, influence linkages between the head and extremities (especially arms and hands) so that the visual and auditory systems can be used effectively to orient the head and body during tasks that require visual (eye-hand) and auditory (ear-hand) guidance.16,26

Coordination Systems The error control, or coordination subsystem, has several interactive components.27,28 Feedforward information (how movement is likely to occur) from the forebrain’s motor cortex is relayed through the thalamus to the deep nuclei of the cerebellum via the middle cerebellar peduncle (brachium pontis). Feedback information generated during movement (“in flight”) travels from the muscle spindle and anterior horn of the spinal cord via the inferior cerebellar peduncle (restiform body), as does sensory information from

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static and dynamic vestibular receptors (head position and movement in space) and the vestibular nuclei in the brainstem. Through the interaction of Purkinje cells in the cerebellar cortex and neurons in the deep cerebellar nuclei, the cerebellum judges how “in sync” these various types of information are (essentially asking the questions, “Did the movement occur as planned? Was the outcome of the movement as intended?”) and suggests refinements for more precise and coordinated movement.29 These adjustments are relayed to the red nucleus in the midbrain via the superior cerebellar peduncle (brachium conjunctiva) and are forwarded back to the thalamus and the motor cortex, as well as to the spinal cord via the rubrospinal tract. The rubrospinal tract is thought to be essential for refinement and correction of direction and control of movement as it occurs.29

Somatosensory and Perceptual Systems The somatosensory system is composed of a set of ascending pathways, each carrying a specific sensory modality from the spinal cord and brainstem to the thalamus and postcentral gyrus of the cerebral cortex, reticular formation, or cerebellum. The anterolateral (spinothalamic) system carries exteroceptive information from mechanoreceptors that monitor protective senses (e.g., pain, temperature, irritation to skin and soft tissue).25,30 This tract originates in the dorsal horn (substantia gelatinosa) of the spinal cord and the spinal trigeminal nucleus, crosses the midline of the neuraxis to ascend in the lateral funiculus of the spinal cord to the contralateral ventral posterior thalamus, and then continues to the postcentral gyrus. The dorsal column/medial lemniscus carries information from encapsulated receptors that serve as internal monitors of body condition and motion.25,31 This tract ascends from the spinal cord to reach the nuclei gracilis and cuneatus in the medulla of the brainstem, then crosses midline to ascend to the contralateral ventral posterior thalamus and on to the posterior central gyrus. The postcentral gyrus (somatosensory cortex) is organized as a homunculus, with each region of the body represented in a specific area.25,32 Sensation from the lower extremities (lumbosacral spinal cord) is located at the top of the gyrus near the sagittal fissure. Moving downward toward the lateral fissure, the next area represented is the trunk (thoracic spinal cord), followed by upper extremities and head (cervical spinal cord), and finally face, mouth, and esophagus (trigeminal nuclei) just above the lateral fissure. A lesion such as a multiple sclerosis (MS) plaque in one of the ascending pathways may result in a discrete area of loss of exteroception or of conscious proprioception in one area of the body; a lesion on the somatosensory cortex can lead to a more profound, multimodality impairment on the opposite side of the body. Although sensory information is logged in at the postcentral gyrus, the location of the somatosensory cortex, interpretation and integration of this information occurs in the somatoperceptual system in the parietal association areas, with specialization in the right hemisphere.30,32 These association areas give meaning to the sensations that are generated as people move and function in their environments. This is where people understand the relationships among their various extremities and trunk (body schema), as well as their relationship to and position within our physical environment. Damage to the parietal lobes leads to problems ranging from left-right confusion to the inability to

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recognize and monitor the condition of a body part (neglect, agnosia), depending on how much of the association area is involved.33,34

Visual and Visual-Perceptual Systems The visual system begins with processing of information gathered by the rods and cones in the multiple layers of specialized neurons in the retina, located in the posterior chamber of the eye. Axons from retinal ganglion cells are gathered into the optic nerve, which carries information from that eye toward the brain. At the optic chiasm there is reorganization of visual information, such that all information from the left visual field (from both eyes) continues in the right optic tract, and that from the right field continues in the left tract. This information is relayed, through the lateral geniculate body of the thalamus, via the optic radiations, to the primary visual cortex on either side of the calcarine fissure of the midsagittal occipital lobe.35 Damage to the retina or optic nerve results in loss of vision from that eye. Damage to the optic chiasm typically leads to a narrowing of the peripheral visual field (bitemporal hemianopsia); a lesion of one of the optic tracts or radiations leads to loss of part or all of the opposite visual field (homonymous hemianopsia). Damage to the visual cortex can result in cortical blindness, in which visual reflexes may be intact but vision is impaired.36 Visual information is interpreted in the visual association areas in the remainder of the occipital lobe.37 The visual association areas in the left hemisphere are particularly important to interpretation of symbolic and communication information, while spatial relationships are of more interest in the right hemisphere. Specific details about the environment, especially about speed and direction of moving objects with respect to the self and of the individual with respect to a relatively stationary environment, are important contributors to functional movement and to the development of skilled abilities.38 Interconnections between the parietal and occipital association areas serve to integrate visual and somatic/kinesthetic perception and provide important input to motor planning and motor learning systems.39 Effective visual information processing is founded on three interactive dimensions: visual spatial orientation, visual analysis skills, and visual motor skills.40 Developmentally, visual spatial orientation includes spatial concepts used to understand the environment, the body, and the interaction between the body and environment that are part of functional activity (e.g., determining location or direction with respect to self, as well as respect to other objects or persons encountered as people act in their environment). Visual analysis skills allow people to discriminate and analyze visually presented information, identify and focus on key characteristics or features of what people see, use mental imagery and visual recall, and respond or perceive a whole when presented with representative parts. The visual motor system links what is seen, to how the eyes, head, and body move; allowing one to use visual information processing skills during skilled, purposeful activities. This also provides the foundation for movements requiring eye-hand coordination, both large upper extremity movements such as throwing, and fine movement skills such as typing or manipulation of objects.37

Executive Function and Motivation The ability to problem solve, consider alternatives, plan and organize, understand conceptual relationships, multitask, set priorities, and delay gratification, as well as the initial components of learning, are functions of the frontal association areas of the forebrain.10,41,42 These dimensions of cognitive function are often described by the phrase higher executive function. Quantitative and other analytical skills are thought to be primarily housed in the frontal association areas of the left hemisphere, while intuitive understanding and creativity may be more concentrated in the right hemisphere. Most people tap the resources available in both hemispheres (via interconnections through the corpus callosum) during daily life, although some may fall toward one end or another of the analytical–intuitive continuum. Individuals with acquired brain injury involving frontal lobes often exhibit subtle deficits that have a significant impact on their ability to function in complex environments, as well as under conditions of high task demand; difficulty in these areas certainly compromises functional efficiency and quality of life.43,44 The neuroanatomical structures that contribute to the motivational system include the nuclei and tracts of the limbic system, prefrontal cortex, and temporal lobes; all play major roles in managing emotions, concentration, learning, and memory.45 The motivational system not only has an important impact on emotional aspects of behavior but also influences autonomic/physiological function, efficacy of learning, interpretation of sensations, and preparation for movement (Fig. 10.1).46 Dimensions of limbic function that influence motivation and the ability to manage challenges and frustration include body image, self-concept, and selfworth as related to social roles and expectations, as well as the perceived relevance or importance (based on reward or on threat) of an activity or situation.47,48 Central set is a phrase used to describe the limbic system’s role as a motivator and repository of memory on readiness to move or act.46 Central set helps people predict movement needs relevant to a given situation or circumstance (considering both the physical and affective dimensions of the environment in which they are acting) from past experience.49 Consciousness and Homeostasis The ability to be alert and oriented when functioning in a complex environment is the purview of the consciousness system and is a function of interaction of the brainstem’s reticular formation, the filtering system of thalamic nuclei, and the thought and problem solving that occur in the association areas of the telencephalon, especially in the frontal lobes.50 The reticular activating system, found in the inferior mesencephalon and upper pons of the brainstem, is the locus of sleep-wake and level of alertness.51 The thalamus and the reticular formation help people habituate to repetitive sensory stimuli while they focus on the type of sensory information that is most germane to the task at hand.52 The frontal association areas add content to one’s consciousness: the ability to reason and to adapt to challenges encountered as one moves through daily life.53 Alteration in quality and level of consciousness and behavior are indicators of evolving problems within the CNS.54 Increasing intracranial pressure, the result of an expanding mass

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Interconnections Between Sensory, Limbic, and Motor Systems Limbic System Motivational Centers

Olfactory cortex Septal area Entorhinal

Auditory Visual association association Brodmann’s (18,19) Wernicke’s (40,42) Angular gyri (39) Angular gyri (39)

Somatosensory association Parietal lobe (5,7)

Olfactory pathway

Visual pathway Auditory path Visual cortex (17) Auditory cortex (41)

Somatic sensory pathways Postcentral gyrus (3,1,2) VPL & VPM

Olfactory tract Olfactory bulb

Optic radiations LGB Optic tract Optic chiasm Optic nerve Retina

Anterior-lateral MGB Spinothalamic Inferior colliculus (exteroception) Lateral lemniscus SC lat. Superior olive nucleus Funiculus D & V cochlear nuclei 8th CN & cochlea

Sensory stimulus Information from environment Information generated by movement

Motor centers Primary motor cortex (4)

Red nucleus Cerebellum

Med Vestibular nuc. Lemniscus 8th CN N Gracilis (LE) SSC, S&U N Cuneus (UE) DSCT (actual) Dorsal columns VSCT (intended) Muscle spindle

Task-specific motor behaviors

Amygdala & Hypothalamus

Motor planning cortex (6) & Functional basal ganglia

Pyramidal system

Extrapyramidal systems Reticulospinal tracts (tone)

Brainstem Parasympathetic

Corticospinal tracts

Vestibulospinal tracts (equilibrium/postural control)

Thoracic Sympathetic

Apha motor neurons (esp. distal extremity)

Rubrospinal tracts (error control)

Lumbosacral Parasympathetic

Tectospinal tracts (head-body coordination) Gamma motor neurons

Peripheral Autonomic ganglia

Muscle

Intrafusal muscle activation Extrafusal muscle activation Smooth muscle behavior

Fig. 10.1 A conceptual model of the interactions and interconnections among sensory, limbic, and motor systems that influence functional movement. CN, Cranial nerve; D, dorsal; DSCT, dorsal spinocerebellar tract; N Cuneus, nucleus cuneus; N Gracilis, nucleus gracilis; S&U, saccule & utricle DB; SC lat, spinal cord lateral; SSC, somatosensory cortex; V, ventral; VPL, ventral posterolateral nucleus; VPM, ventral posteromedial nucleus; VSCT, ventral spinocerebellar tract.

or inflammatory response following trauma or ischemia, may be initially manifest by confusion or agitation; progression into a state of lethargy, stupor, or unresponsiveness (coma) indicates deteriorating compromise of the CNS structures.55 Homeostasis and the ability to respond to physiological stressors are functions of the components of the autonomic nervous system.56 The nuclei of the hypothalamus serve as the command center for parasympathetic and sympathetic nervous system activity via projections to parasympathetic cranial nerve nuclei in the brainstem, the sympathetic centers of the intermediate horn in the thoracic spinal cord, and the parasympathetic centers in the lumbosacral spinal cord. The hypothalamus has extensive interconnections with the limbic system, bridging physiological and emotional/psychological aspects of behavior and activity.57 The hypothalamus also integrates neural-endocrine function through interconnections with the pituitary gland.58 Clearly, this relatively small area of forebrain plays a substantial integrative role in physiological function of the human body. Damage or dysfunction to this area therefore has significant impact on physiological stability and stress response.

PERIPHERAL NERVOUS SYSTEM The PNS serves two primary functions: to collect information about the body and the environment and to activate muscles during functional activities. Afferent neurons

collect data from the various sensory receptors distributed throughout the body and transport this information to the spinal cord and brainstem (sensory cranial nerves) for initial interpretation and distribution to CNS centers and structures that use sensory information in the performance of their various specialized roles.25,33 The interpretation process can have a direct impact on motor behavior at the spinal cord level (e.g., deep tendon reflex) or along any synapse point in the subsequent ascending pathway (e.g., righting and equilibrium responses) as sensory information is transported toward its final destination within the CNS.59 Efferent neurons (also described as lower motor neurons or, more specifically, α and γ motor neurons) carry signals from the pyramidal (voluntary motor) and extrapyramidal (supportive motor) systems to extrafusal/striated and intrafusal (within muscle spindle) muscle fibers that direct functional movement by enacting the CNS’s motor plan.26,60,61 The cell bodies of these α and γ motor neurons live in the anterior horn of the spinal cord and in cranial nerve somatic motor nuclei. In the spinal cord, α and γ axons project through the ventral root, are gathered into the motor component of a spinal nerve, and (in cervical and lumbosacral segments) are reorganized in a plexus before continuing toward the targeted muscle as part of a peripheral nerve. In the brainstem, α and γ axons project to target muscles via motor cranial nerves (oculomotor, III; trochlear, IV; motor trigeminal, V; abducens, VI; facial, VII; glossopharyngeal, IX; spinal accessory, XI; hypoglossal, XII).62 When α

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and γ axons reach their target set of muscle fibers (motor unit), a specialized synapse—the neuromuscular junction—triggers muscular contraction.63 Pathologic conditions of the PNS can be classified by considering two factors: the modalities affected (only sensory, only motor, or a combination of both) and the anatomical location of the problem (at the level of the sensory receptor, along the neuron itself, in the dorsal root ganglion, in the anterior horn, at the neuromuscular junction, or in the muscle itself).64,65 Poliomyelitis is the classic example of an anterior horn cell disease; Guillain-Barr
e syndrome is a demyelinating infectious-autoimmune neuropathy that impairs transmission of electrical impulses over the length of motor and sensory nerves. The polyneuropathy of diabetes (affecting motor, sensory, and autonomic fibers) is the classic example of a metabolic neuropathy. Radiculopathies (e.g., sciatica) result from compression or irritation at the level of the nerve root, while entrapment syndromes (e.g., carpal tunnel) are examples of compression neuropathies over the more distal peripheral nerve. Myasthenia gravis, tetanus, and botulism alter function at the level of the neuromuscular junction. Myopathies and muscular dystrophies are examples of primary muscle diseases.65

Determinants of Effective Movement

Effectiveness of purposeful movement is determined by the interaction of underlying muscle tone and muscle performance. Muscle tone can be conceptualized as the interplay of compliance and stiffness of muscle, as influenced by the CNS. Ideally the CNS can set the neuromotor system to be stiff enough to align and support the body in functional antigravity positions (e.g., provide sufficient baseline postural tone). At the same time, it allows the system to be compliant enough in the limbs and trunk to carry out smooth and coordinated functional movement, and effectively respond to changing environmental conditions or demands as daily tasks are carried out.66,67 In the tone continuum of stiffness to compliancy, the interplay of stiffness and compliance is optimal at the center, such that motor performance is well supported (Fig. 10.2, horizontal continuum). At the lowtone end of the continuum, where there is low stiffness and high compliance, individuals are challenged by inadequate postural control and inability to support antigravity movement, and by the inability to support proximal joints for effective use of limbs, particularly in antigravity motions. At the high tone end of the continuum, where there is high stiffness and low compliance, freedom and flexibility of movement are compromised. Among individuals, postural tone varies with level of consciousness, level of energy or fatigue, and perceived importance (salience) of the tasks they are involved with at the time.26,68

Excessive power but with difficulty adapting or dampening force

Quick, imprecise movement Burst of power with difficulty sustaining force

Optimal Muscle Performance

Optimal Muscle Tone

Excessive force production

Excessive fluidity

EFFECTIVE MOVEMENT

Difficulty generating adequate force Difficulty with eccentric and isometric control Tendency to move only within a shortened range

“All or nothing” force with ballistic tendency Poor accuracy and precision

Optimal Muscle Performance Inadequate force production

Optimal Muscle Tone

Inadequate Hyperkinetic (Problematic)

MUSCLE TONE AND MUSCLE PERFORMANCE

Excessive extensibility

Tendency to move through the extremes of range

Inadequate Hypokinetic (Problematic)

MUSCLE PERFORMANCE CONTINUUM

Regardless of the underlying neurological or neuromuscular disease, rehabilitation professionals seek to understand the impact of the condition on an individual’s underlying muscle tone and motor control (ability to initiate, guide, sustain, and terminate movement), muscle performance (strength, power, endurance, speed, accuracy, fluidity),

and postural control and balance (ability to stay upright, to anticipate how to make postural adjustment during movement, and to respond to unexpected perturbations) in order to move effectively during goal-directed, functional movement necessary for daily life.

Slow movement Difficulty with segmentation (dissociation) and fluidity Poor eccentric control Tendency to move within a shortened range

MUSCLE TONE CONTINUUM Low Tone Low Stiffness High Compliance (Problematic)

High Tone High Stiffness Low Compliance (Problematic)

Fig. 10.2 A conceptual model of the interrelationship of muscle tone and muscle performance as they interact to influence functional movement. The muscle tone ranges from excessively compliant (easily extensible on passive movement) to excessively stiff (resistant to passive movement). The muscle performance continuum ranges from hypokinetic (exhibiting minimal movement during task activity) to hyperkinetic (exhibiting excessive movement during task activity). Movement is most effective at the intersection of optimal muscle tone (with balanced stiffness and compliance) and optimal muscle performance (with appropriate force production and adaptability of speed and power).

10 • Neurological and Neuromuscular Disease Implications for Orthotic Use

Effective purposeful movement occurs when muscle performance meets the demands of the movement task. The components of muscle performance are the ability to (1) produce sufficient force (strength); (2) produce at the rate of contraction required for the task at hand (speed); (3) sustain the concentric, holding/isometric, or eccentric contraction necessary to meet task demands (muscle endurance); (4) ramp up or dampen force production in response to task demands (accuracy and power); and (5) coordinate mobility and stability of body segments to complete the task (fluidity).69 Muscle performance can also be conceptualized as having a continuum with optimal control of its components around the center and inadequate control on either side: hypokinesis (little movement) at one extreme, and hyperkinesis (excessive movement) at the other (see Fig. 10.2, vertical continuum). While muscle tone and muscle performance are distinct contributors to movement, they are certainly interactive.70,71 Movement is most effective and efficient if an individual’s resources fall within the center of each continuum. A problem with muscle tone, muscle performance, or a combination of both leads to abnormal and less effective and efficient movement. Consider what will happen if there is a combination of low tone and inadequate hypokinetic muscle performance: individuals will have difficulty with postural control and proximal support for limb movement, force production, power, and eccentric and isometric control, such that movement tends to occur in shortened ranges, and for short periods of time (less sustainability of contraction/endurance). For example, an infant with Down syndrome (with low tone) struggles to sustain adequate support of the shoulder girdle in prone on elbows in order to lift one arm to reach for a toy (hypokinesis). In the presence of low tone and hyperkinetic muscle performance, movement is fast but imprecise, with bursts of power that cannot be sustained. For example, a toddler with Down syndrome (with low tone) who is beginning to walk takes rapid and inconsistent steps (hyperkinesis). In contrast, the presence of high tone and hypokinetic muscle performance, movement is slow and stiff, with inadequate force production, compromised segmentation, impaired eccentric control (difficulty letting go), and constrained range. For example, an individual with Parkinson disease takes short steps and has little reciprocal arm swing when walking. In the presence of high-tone and hyperkinetic muscle performance, there tends to be “all or nothing” force production, with somewhat ballistic and inaccurate movement occurring between the extremes of ranges. For example, a child with spastic quadriplegic cerebral palsy (CP) rising from sitting to standing often employs rapid mass extension (lower extremity and trunk), compromising his or her ability to move toward flexion in order to effectively rise; the child would also have difficulty lowering back into sitting without collapsing. Although muscle performance, especially the ability to generate force, does tend to decline with aging, the impact of inactivity is even more profound; all aspects of muscle performance can improve with appropriate training, even in the very old.72–74 Traditionally, an individual’s muscle tone has been described clinically as hypertonic or spastic, rigid, hypotonic or low, flaccid, or fluctuating.

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Hypertonus Hypertonus is a term used to describe muscles that are influenced to be too stiff or are excessively biased toward supporting antigravity function. Spasticity is a type of hypertonus that typically occurs when there is damage to one or more CNS structures of the pyramidal motor system and is encountered as a component of many neuromuscular pathologies.26,75–79 Decrements in underlying tone and muscle performance, in bipedal humans with impairment of the pyramidal system, most often occurs in a decorticate pattern: The upper extremity is typically biased toward flexion, such that the limb can be easily moved into flexion but not into extension (decreased compliance of flexors). The lower extremity is biased toward extension, such that the impaired compliance of extensors makes movement into flexion difficult (Fig. 10.3).80 In persons with severe acquired brain injury the entire body may be biased toward extension, a condition or posture described as decerebrate pattern spasticity (Sherrington originally described this phenomenon as decerebrate rigidity).80 Both decorticate and decerebrate conditions are unidirectional in nature; there is an increase of muscle stiffness and resistance to passive elongation (impaired compliance) in one group of muscles (agonists) with relatively normal functioning of opposing muscle groups (antagonists). Spasticity is a velocity-dependent phenomenon. Under conditions of rapid passive elongation, spastic muscle groups “fight back” with increased stiffness, a result of a hypersensitive deep tendon reflex loop (Fig. 10.4). This has been described as clasp-knife spasticity, in which the spastic limb

A

B

Fig. 10.3 Hypertonicity following cerebrovascular accident. (A) The extensor pattern hypertonus in the affected lower extremity precludes swing-limb shortening normally accomplished by hip and knee flexion; instead, the individual uses an abnormal strategy such as pelvic retraction and hip hiking to advance the involved limb; swing is assisted by the ankle-foot orthosis (AFO) to prevent plantarflexion at the ankle. (B) The affected upper extremity shows a flexed posture. Although the extensor bias in the lower extremity may cause hyperextension at the knee, the AFO provides a counter force to allow knee flexion.

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Peripheral nerve

DRG Ia

␣MN

␥MN

Pyramidal tracts Quadriceps muscle

Muscle spindle annulospiral ending

Anterior horn Patellar tendon Extrapyramidal tracts

Condyle of femur

A Dorsal root ganglion

Descending pyramidal tracts

Descending extrapyramidal tracts

␣MN Ia afferent ␣MN ␥MN

Muscle spindle (enlarged)

B Fig. 10.4 Diagram of the deep tendon reflex loop: stimulation of the annulospiral receptor within muscle spindle of the quadriceps (A) and biceps brachii (B) (via “tap” on the patellar tendon with a reflex hammer) activates 1a afferent neurons, which in turn assist motor neurons in the anterior horn of the spinal cord. These motor neurons project to extrafusal muscle fibers in the quadriceps, which contract, predictably, as a reflex response. Sensitivity of muscle spindle (threshold for stimulation) is influenced by extrapyramidal input, reaching γ motor neurons (γMNs) in the anterior horn, which project to intrafusal muscle fibers within the muscle spindle itself. αMN, αMotor neuron; DRG, dorsal root ganglion.

10 • Neurological and Neuromuscular Disease Implications for Orthotic Use

“gives” after an initial period of resisting passive movement in the way that a pocket knife initially resists opening when near its initially closed position but then becomes more compliant once moved past a threshold position as it is opened. Growing evidence indicates that the stiffness encountered during passive movement has both neurological (spasticity) and musculoskeletal (changes in muscle and associated soft tissue) components that combine to increase the risk of contracture development.81,82 Given the unidirectional nature of severe hypertonus, it is common for persons with severe hypertonus to develop chronic atypical postures. The limb or body segment assumes an end-range position that the limb would not normally be able to assume (e.g., equinovarus with marked supination in an individual with severe acquired brain injury, equinovalgus with marked pronation in a child with CP).80,81 If persistent, these fixed postures are associated with a significant likelihood of secondary contracture development.83 Hypertonicity is also associated with deficits in muscle performance, most notably diminished strength (force production), diminished ability to produce power (force production with increased speed), diminished ability to effectively isolate limb and body segments (segmentation), diminished excursions of movements within joints (i.e., moving within a limited range of motion [ROM]), and inefficiency with altering force production or timing of contractions to meet changing (fluid) demands of tasks (accuracy and functionality).84–86 Muscle performance deficits can contribute to an imbalance of forces around a joint that leads to habitual abnormal patterns of movement. These habitual patterns are often biomechanically inefficient and, over time, contribute to the development of secondary musculoskeletal impairments such as adaptive shortening or lengthening of muscles and malalignment of joints.83 Strengthening exercises can have a positive impact on function, even in the presence of hypertonicity.85–87 Orthotics and adaptive equipment play a crucial role to position and support trunk, limbs, and joints to prevent or minimize development of contractures in individuals with hypertonicity.

Rigidity Individuals with Parkinson disease and related neurological disorders often demonstrate varying levels of rigidity: a bidirectional, co-contracting hypertonicity in which there is resistance to passive movement of both agonistic and antagonistic muscle groups.23,88 Co-contraction of flexor and extensor muscles of the limbs and trunk creates a bidirectional stiffness that interferes with functional movement. Rigidity is often accompanied by slowness in initiating movement (bradykinesia), decreased excursion of active ROM, and altered resting postures of the limbs and trunk (Fig. 10.5). The rigidity of Parkinson disease can be overridden under certain environmental conditions: Persons with moderate to severe disease can suddenly run reciprocally if they perceive danger to themselves or a loved one; once this initial limbic response has dissipated, they will resume a stooped and rigid posture, with difficulty initiating voluntary movement, limited active ROM, and bradykinesia. Because rigidity creates a situation of excessive stability of the trunk and limbs, orthoses are not typically a component in the plan of care for persons with Parkinson disease.89

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Fig. 10.5 A person with Parkinson disease showing typical standing posture; note the forward head, kyphotic and forward flexed trunk, and flexion at hip and knees. The upper extremities are held in protraction with flexion. The altered position of the body’s center of mass, when combined with rigidity and bradykinesia, significantly decreases the efficacy of anticipatory postural responses during ambulation, as well a response to perturbation.

Hypotonus Hypotonus (low muscle tone) describes a reduced stiffness of muscle that does not effectively support upright posture against gravity or to produce adequate force during contraction; as a result, hypotonic muscles are more compliant than they are stiff.90 In children, hypotonia can arise from abnormal function within the CNS (approximately 75%) or from problems with peripheral structures (peripheral nerve and motor units, neuromuscular junction, the muscle itself, or unknown etiology).91 Hypotonia can be congenital (seen as “floppy” infants), transient (e.g., in preterm infants), part of the clinical presentation of CP, Down syndrome and other genetic disorders, as well as autism spectrum disorders.91–96 Hypotonic muscles are considerably more compliant on rapid passive elongation (i.e., less resistant to passive stretch) than muscles with typical tone, as well as those with hypertonus/spasticity. Because their postural muscles are less stiff, individuals with hypotonicity often have difficulty when assuming and sustaining antigravity positions.97 To compensate for their reduced postural tone, individuals with hypotonicity may maintain postural alignment by relying on ligaments and connective tissue within joint capsule and muscle to sustain upright posture. With overreliance on ligaments in extreme ends of range, further degradation to joint structures often occurs. Additionally, individuals may rely on the upper extremities for postural support, such as a child who uses arms to aid in floor sitting or an adult who holds onto a table when standing. This reliance on upper extremities diminishes the ability to use those extremities for functional tasks. This has implications for

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to minimize degradation. For example, a child with hypotonia may use bilateral supramalleolar orthotics to provide improved postural support of the foot and ankle.91

Fig. 10.6 Postural control is often inefficient in children (and adults) with hypotonicity or low tone. This 18-month-old child has insufficient muscle tone to maintain her trunk in an upright position; note the curvature of the thoracic and lumbar spine, with weight bearing on the sacrum (sacral sitting with kyphosis). This leads to shortening of the hamstrings over time, note right knee flexion.

seating and standing systems, or orthotic use to provide external support that will allow individuals to use their upper limbs for play, work, and daily activities91 (Fig. 10.6). In addition to postural control dysfunction, individuals with hypotonia often have difficulty with coordination of movements. This may be due to the decreased efficacy of afferent information collected by a lax muscle spindle during movement execution.90 Children with hypotonia often have impaired control of movements at midrange of muscle length, suggesting that kinesthetic information is not being used efficiently to guide movement or that the ability to regulate force production throughout movements is compromised. In either case, muscle performance is notably less efficient, especially in activities that require eccentric control (e.g., controlled lowering of the body from a standing position to sitting on the floor).91,97 Individuals with hypotonia have difficulty regulating force production and collaboration between agonists and antagonists is not well coordinated.97 Immediately after an acute CNS insult or injury there is often a period of neurogenic shock in which the motor system appears to shut down temporarily, with apparent loss of voluntary movement (paralysis) and markedly diminished or absent deep tendon reflex responses.98–100 This phenomenon is observed following cervical or thoracic spinal cord injury and early on following significant stroke. During this period, individuals with extreme levels of hypotonus are sometimes (erroneously) described as having flaccid paralysis. Most individuals with acute CNS dysfunction will, within days to weeks, begin to show some evidence of returning muscle tone; over time, many develop hyperactive responses to deep tendon reflex testing and other signs of hypertonicity.99 If they continue to have difficulty activating muscles voluntarily for efficient functional movement, these individuals are described as demonstrating spastic paralysis. Orthotics can be used to support joints in individuals with hypotonia

Flaccidity The term flaccidity is best used to describe muscles that cannot be activated because of interruption of transmission or connection between lower motor neurons and the muscles they innervate.60,101 True flaccidity is accompanied by significant atrophy of muscle tissue, well beyond the loss of muscle mass associated with inactivity; this is the result of loss of tonic influence of lower motor neurons on which muscle health is based.102 The flaccid paralysis seen in persons with myelomeningocele (spina bifida) occurs because incomplete closure of the neural tube during the early embryonic period (soon after conception) prevents interconnection between the primitive spinal cord and neighboring somites that will eventually develop into muscles of the extremities.103 The flaccid paralysis observed in persons with cauda equina level spinal cord injury is the result of damage to axons of α and γ motor neurons as they travel together as ventral roots to their respective spinal foramina to exit the spinal column as a spinal nerve.104 After acute poliomyelitis, the loss of a portion of a muscle’s lower motor neurons will lead to marked weakness; the loss of the majority of a muscle’s lower motor neurons will lead to flaccid paralysis.65 In Guillain-Barr
e syndrome, the increasing weakness and flaccid paralysis seen in the early stages of the disease are the result of demyelination of the neuron’s axons as they travel toward the muscle in a peripheral nerve.105 After injection with botulinum toxin, muscle tone and strength are compromised because of the toxin’s interference with transmitter release from the presynaptic component of the neuromuscular junction.106 Orthotics and adaptive equipment play a critical role in providing antigravity support for upright positioning and locomotion in individuals with flaccidity. Additionally, orthotics are used to prevent contracture in joints with unbalanced muscle activity. This allows individuals to participate in desired activities in the home, school, or community. For example, a child with a thoracic level myelomeningocele may require adaptive seating for school, while a child with lumbar level myelomeningocele may require orthotics for lower extremity support for ambulation, and a positioning device to prevent contractures of the hip adductors.103 Fluctuating Tone: Athetosis and Chorea Athetosis is the descriptor used when an individual’s underlying muscle tone fluctuates unpredictably.107 Athetosis is characterized by random changes in postural tone, with variations from hypertonus to hypotonus. Athetosis, although less common than spastic CP, can have as significant (and often more pronounced) an impact on daily function.108 Although etiology of athetosis is not well understood, it is most frequently described as a type of basal ganglia or thalamic dysfunction associated with bilirubin toxicity or significant perinatal anoxia.107 Persons with athetosis typically demonstrate truncal hypotonia, with fluctuating levels of hypertonus in antigravity musculature and the extremities. In some individuals, movements appear to have a writhing dancelike quality (choreoathetosis) in addition to the tonal influences. Others may compensate

10 • Neurological and Neuromuscular Disease Implications for Orthotic Use

for postural instability by assuming end-range positions, relying on mechanical stability of joints during functional activity. Although persons with athetosis are less likely to develop joint contracture than those with long-standing hypertonicity, they are more likely to develop secondary musculoskeletal complications that compromise stability of joints, a result of extreme posturing, imbalance of forces across joint structures, and the need to stabilize in habitual postural alignment patterns for function.109 Orthotic usage in individuals with athetosis must be evaluated carefully to consider the balance of supportive versus restrictive influences of the device.

POSTURAL CONTROL Postural control has three key dimensions: (1) Static postural control is defined as the ability to hold antigravity postures at rest; (2) dynamic anticipatory postural control is the ability to sustain a posture during movement tasks that shift (internally perturb) the center of mass (COM); and (3) dynamic reactionary postural control is the ability to be able to withstand or recover from externally derived perturbations without loss of balance.110 One has functional postural control if the COM can be maintained within one’s base of support (BOS) under a wide range of task demands and environmental conditions. This requires some level of ability across the triad of static, anticipatory, and reactionary control. The key interactive CNS systems involved in postural control include extrapyramidal and pyramidal motor systems, visual and visual-perceptual systems, conscious (dorsal column/medial lemniscal) and unconscious (spinocerebellar) somatosensory systems, the vestibular system, and the cerebellar feedback/feedforward systems.111,112 Clinical measures used to assess efficacy of static postural control include timing of sitting or standing activities and measures of center of pressure excursion in quiet standing.113 The Clinical Test of Sensory Interaction and Balance sorts out the contribution of visual, vestibular, and proprioceptive systems’ contribution to balance, as well as the individual’s ability to select the most relevant sensory input when there is conflicting information collected among these systems.114 Measures of anticipatory postural control consider how far the individual is willing to shift his or her COM toward the edge of his or her sway envelope.115,116 Clinically, anticipatory postural control is often quantified by measuring reaching distance in various postures.117–120 Measures of dynamic reactionary postural control consider the individual’s response to unexpected perturbations (e.g., when pushed or displaced by an external force, when tripping/slipping in conditions of high environmental demand).119–121 Although these three dimensions of postural control are interrelated, competence in one does not necessarily ensure effective responses in the others.122 Many individuals with neuromuscular disorders demonstrate inefficiency or disruption of one or more of the CNS subsystems necessary for effective postural control and balance.123 An individual with mild to moderate hypertonicity or spasticity often has difficulty with anticipatory and reactionary postural control, especially in high task demand situations within a complex or unpredictable open environment.124 Difficulty with muscle performance, such as

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impairment of control of force production or the imbalance of forces acting across a joint, might constrain anticipatory postural control in preparation for functional tasks such as reaching or stepping. Impairment of the ability to segment trunk from limb or to individually control joints within a limb may affect the individual’s ability to react to perturbations in a timely or consistent manner.125 Persons with hypotonicity, on the other hand, often have difficulty with sustaining effective postural alignment in antigravity positions such as sitting and standing. They are likely to demonstrate patterns of postural malalignment such as excessive lumbar lordosis and thoracic kyphosis.97 Because of difficulty with muscle force production (especially in midrange of movement), individuals with hypotonia also have difficulty with anticipatory postural control.90 A lack of on-demand motor control contributes to difficulty moving within one’s postural sway envelope; this may be observed as a tendency to stay in one posture for long periods of time, with infrequent alterations in position during tasks.94 Reactionary control may also be altered, particularly with respect to the use of equilibrium reactions and the reliability of protective responses. Individuals with hypotonia have difficulty when a task requires them to absorb small-amplitude perturbations; they must use equilibrium or balance strategies more frequently than persons with adequate muscle tone.90 Additionally, a lack of stability in joints, from both tonal and ligamentous laxity, contributes to an inability to safely stop an accelerating body part as it comes into contact with a surface during a loss of balance episode.94

MOVEMENT AND COORDINATION Many functional activities require us to move or transport the entire body (e.g., mobility or locomotion) or a segment of the body (e.g., using one’s upper extremity to bring a cup toward the mouth to take a drink) through space.126,127 The locomotion task that receives much attention in rehabilitation settings is bipedal ambulation—the ability to walk. For full functional ability, individuals must be able to manage a variety of additional locomotion tasks: running, skipping, jumping, and hopping.128 To fully understand an individual’s functional ability, therapists and orthotists must also consider the environmental context in which ambulation is occurring.129 What are the physical characteristics of the surface on which the individual needs to be able to walk or traverse? Is it level, unpredictably uneven, slippery or frictional, or structurally unstable? Is the ambulation task occurring where lighting is adequate for visual data collection about environmental conditions? Does it involve manipulation of some type of object (e.g., an ambulatory assistive device, a school backpack, shopping bags, suitcases)? Is it occurring in a familiar and predictable environment (e.g., at home) or in a more unpredictable and challenging open environment such as a busy school, supermarket, mall, or other public space? The task demands of locomotion in complex and challenging environments create more demand on the CNS structures involved in motor control (perceptual-motor function, motor planning, cerebellar error control), as well as on the musculoskeletal effectors (muscles and tendons, joints, ligaments, and bones) that enact the motor plan necessary for successful completion of the task that relies on body transport. Individuals with neurological and neuromuscular system problems related to

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muscle tone, muscle performance, and postural control are typically less efficient, less adaptable, and more prone to fall when walking, especially if there are competing task demands and the environment is complex and challenging.130 The use of a limb segment can also be defined by the nature of the task and the circumstances in which the movement is performed. Upper extremity functional tasks can involve one or more components: reaching, grasping, releasing, manipulating, or any combination of these four purposes.126 Upper extremity tasks can also be defined by considering the function to be accomplished by the movement: grooming, dressing, meal preparation, self-care, or writing. Many upper extremity mobility tasks are founded on effective postural control (e.g., making appropriate anticipatory postural adjustments as the COM shifts while throwing, lifting, lowering, or catching an object).126 Complex mobility tasks require simultaneous locomotion and segmented use of extremities (e.g., reaching for the doorknob while ascending the steps toward the front door, throwing or catching a ball while running during a football or baseball game). For individuals with neurological and neuromuscular system dysfunction, the ability to safely and efficiently perform complex mobility tasks is often compromised due to abnormal muscle tone, impaired muscle performance, and poor postural control.130 Coordination can be thought of as the efficacy of execution of the movement necessary to complete a task. A well-coordinated movement requires effective simultaneous control of many different dimensions of movement: the accuracy of a movement’s direction and trajectory; the timing, sequencing, and precision of muscle activation; the rate and amplitude of force production; the interaction of agonistic and antagonistic muscle groups; the ability to select and manage the type of contraction (concentric, holding, or eccentric) necessary for the task; and the ability to anticipate and respond to environmental demands during movement.131 Coordination can be examined by considering the individual’s ability to initiate movement, sustain movement during the task or activity, and terminate movement according to task demands.132 For movement and coordination to be functional, one must have muscle performance that is flexible/adaptable to varying demands.133 Mobility or transport tasks cannot be performed independently (safely) unless the individual

is able to (1) transition into and out of precursor positions (e.g., getting up from the floor into a standing position, rising from a chair), (2) initiate or begin the activity (e.g., take the first step), (3) sustain the activity (control forward progression with repeated steps), (4) change direction as environmental conditions demand (e.g., step over or avoid an obstacle), (5) modulate speed as environmental conditions demand (e.g., increase gait speed when crossing the street), and (6) safely and effectively stop or terminate the motion, returning to a precursor condition or position (quiet standing, return to sitting).133 For individuals with neuromuscular disorders who have difficulty with muscle performance, abnormal underlying tone, or impaired postural control, coordination of functional movement can be compromised in several ways. In order to approach and complete a movement task, the individual might rely on abnormal patterns of movement with additional effort and energy cost.134 Many individuals with hypertonicity initiate movement with strong bursts of muscle contractions but have difficulty sustaining muscle activity and force of contraction through the full ROM necessary to perform a functional movement.98,108 Deficits in timing and sequencing of muscle contractions, as well as difficulty with dissociation of limb and body segments, also contribute to difficulty with performance of functional tasks.135 An adult with hemiplegia following a cerebrovascular accident may be able to initiate a reach toward an object but not be able to bring the arm all the way to the target.136 The same individual may have difficulty with timing and segmentation, leading to inability to open the hand before reaching the target in preparation for grasping the object.137,138 The muscle performance of many children with CP is compromised by inappropriate sequencing of muscle contractions when activation of synergists and antagonists happens simultaneously.84,108 Conversely, an individual with hypotonus who has difficulty with stabilization often moves quickly with diminished accuracy and coordination.90 The following tables provide an overview of incidence/ prevalence, etiology and risk factors, clinical presentation, and impact on muscle tone, muscle performance, postural control, and movement for of the most common pathologies that might include use of an orthosis: stroke (Table 10.1), CP (Table 10.2), spina bifida (Table 10.3), MS (Table 10.4), and spinal cord injury (Table 10.5).

Table 10.1 Stroke Also known as

Brain attack, cerebrovascular accident

Incidence

Approximately 795,000/year in the United Statesa
610,000 are first attacks.
185,000 are recurrent attacks

Prevalence

2.7% of total US population have had strokea Prevalence of stroke by age and sex: 20–39 years: Males ¼ 0.3%, Females ¼ 0.6% 40–59 years: Males ¼ 1.8%, Females ¼ 2.4% 60–79 years: Males ¼ 6.5%, Females ¼ 6.1% 80+ years: Males ¼ 13.8%, Females ¼14.9%

ETIOLOGY AND RISK FACTORS Ischemic Stroke (87%) Thrombus

Hypertension, high blood cholesterol and other lipids, diabetes, overweight and obesity, smoking/tobacco use, nutrition, physical inactivity, family history/genetics, chronic kidney disease, sleep apnea, psychosocial factors

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Table 10.1 Stroke (Continued) Embolism

Disorders of heart rhythm (e.g., atrial fibrillation), atherosclerosis in carotid/vertebral arterial systems; previous embolic stroke

Hemorrhagic Stroke (10%) Intracranial hemorrhage

Uncontrolled hypertension, ruptured aneurysm

STROKE SYNDROMES (BY ARTERY) Middle cerebral (most common)

Contralateral hemiparesis/hemiplegia, lower face, UE > LE Contralateral sensory loss of lower face, UE > LE Contralateral homonymous hemianopia (optic tract) Possible dysarthria and dysphagia R hemisphere: visual-spatial or somatic perceptual impairment L hemisphere: communication impairment (various aphasias)

Lenticulo-striate (lacunar MCA)

Contralateral hemiparesis/hemiplegia, lower face, UE ¼ LE Cortical functions (perception, communication) intact

Anterior cerebral

Contralateral hemiparesis/hemiplegia LE > UE Sensation often intact or only mildly impaired (contralateral) Incontinence “Alien hand” syndrome (involuntary/unintended movement) Motor (nonfluent/Broca) aphasia may occur

Posterior cerebral

Contralateral homonymous hemianopsia (optic radiations) Visual inattention L hemisphere: alexia (unable to read), with ability to write preserved

Thalamogeniculate (lacunar PCA)

Contralateral sensory loss, often severe Sensory ataxia (uncoordinated movement due to lack of proprioception) Thalamic pain and hyperpathia syndrome

Basilar (complete)

Loss of consciousness, coma High mortality

Superior cerebellar

Ipsilateral ataxia, falling to side of lesion Intention tremor Contralateral loss of pain temperature sensation from body Contralateral loss of proprioception Ipsilateral Horner syndrome (meiosis, ptosis, anhidrosis)

Anterior-inferior cerebellar

Ipsilateral facial paralysis (both upper and lower face) Ipsilateral loss of pain and temperature of entire face Contralateral loss of pain and temperature from body Loss of taste sensation, loss of corneal reflex, ipsilateral hearing loss, nystagmus, vertigo, nausea Ataxia and incoordination of limb movement Ipsilateral Horner syndrome (meiosis, ptosis, anhidrosis)

Vertebral

Contralateral loss of pain, temperature sensation from body

Posterior-inferior cerebellar (Wallenberg syndrome) (lateral medullary syndrome)

Ipsilateral loss of pain and temperature sensation from face Ipsilateral Horner syndrome (meiosis, ptosis, anhidrosis) Dysphonia, dysphagia, dysarthria, diminished gag reflex Nystagmus, diplopia, vertigo, nausea Ipsiversive falling (toward side of lesion), incoordination, ataxia

PROGNOSIS

Ischemic: severity depends on site of occlusion within arterial tree and the size of the area that is without blood flow Embolic: risk of recurrence is higher than in thrombosis; risk of hemorrhage at site of embolism Hemorrhagic: highest morbidity and mortality Static event, with evolving symptoms in weeks/months following initial damage, due to initial inflammatory response and subsequent tissue remodeling/healing.

MUSCLE TONE

Initial hypotonus (sometimes appearing to be flaccid) due to neurogenic shock. Some individuals remain hypotonic, most develop various levels of hypertonus in weeks/months following event. Hyperactive deep tendon reflexes evolve over time

MUSCLE PERFORMANCE

Upper extremity often biased toward flexion, with lower extremity biased toward extension. Impaired force production, speed and power, eccentric/isometric control, accuracy, and fluidity

POSTURAL CONTROL

Frequently impaired, especially if lesion included gray matter of R hemisphere, with perceptual dysfunction

MOBILITY AND COORDINATION

Asymmetry in ability to use trunk, limbs during functional activity; tendency to move in abnormal “synergy” (flexion UE, extension LE). Frequently require AFO and ambulatory device

AFO, Ankle/foot/orthosis; L, left; LE, lower extremity; MCA, middle cerebral artery; PCA, posterior cerebral artery; R, right; UE, upper extremity. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics—2017 update: a report from the American Heart Association. Circulation. 2017;135(10): e146–e603.

a

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Table 10.2 Cerebral Palsy Prevalence in the United States

1 in every 323 children born in the United Statesa

Prevalence in developed countries worldwide

2.0–2.5 per 1000 birthsb

Etiology

Associated with prenatal (34%), perinatal (43%), and postnatal (6%) events of hypoxia, infection, ischemia, or trauma affecting the brainb

Risk factors

Collection of multiple risk factors rather than one event; cerebral vascular accidents within a neonate’s first 28 days most significant cause; premature birth contributes to one half or fewer of cases; low birth weight, perinatal or neonatal respiratory distress/anoxia, uterine or placental pathologiesb

CLASSIFICATION OF CEREBRAL PALSY

a

Topographic distributions:b Diplegia Hemiplegia or hemiparesis Quadriplegia or tetraplegia

Lower extremities affected more than upper extremities Unilateral upper and lower extremities All four extremities

Movement disorder distributions:b Spastic (77.4%)a,b

Involvement of motor cortex and sensorimotor cortical tracts (gray and white matter). Spasticity and hyperreflexia contribute to impaired posture and movement

Dyskinetic (5%–10%)a (dystonic or athetonic)

Involvement of the basal ganglia. Contributes to atypical posture and involuntary and sometimes stereotypical movement

Ataxic/cerebellar (5%)

Involvement of the cerebellum. Contributes to instability and altered posture, uncoordinated and imprecise movements

Mixed

Elements of spasticity and dyskinesia

GROSS MOTOR FUNCTION CLASSIFICATION SYSTEMb,c

Standard for describing motor disability in children with cerebral palsy. Includes Levels I through V in children between 6th and 12th birthday and children between 12th and 18th birthday

Children Between 6th and 12th Birthdays

Level I Walk at home, school, outdoors, and in the community. Can navigate stairs. Can run and jump. Difficulty with speed, balance, and coordination Level II Walk in most settings and navigate stairs with railing. May have difficulty with long distances, uneven terrain, inclines, obstacles, or crowded spaces. May need physical assistance, hand-held mobility device, or wheeled mobility for long distances. Minimal ability to run and jump. May need adaptations for recreational activities Level III Walk with a hand-held mobility device in indoor settings, navigate stairs with rail and assistance. Use wheeled mobility for long distances. Need adaptations for recreational activities Level IV Mobility requires physical assistance or powered mobility in most settings. Require adaptive seating and body support walker for home and school activities. For community activities, require transportation in manual or powered wheelchair Level V Require transportation in manual wheelchair, adaptive seating and standing systems. Require full assist for transfers and self-care

Children Between 12th and 18th Birthdays

Level I Walk at home, school, outdoors, and in the community. Can navigate stairs and curbs. Can run and jump. Difficulty with speed, balance, and coordination Level II Walk in most settings; environmental factors and personal preference influence mobility choices. May require hand-held mobility device for safety and assistance or rail for stairs. May use wheeled mobility for long distances in community. May need adaptations for sports and recreational activities Level III Walk with hand-held mobility device; need assistance or rail for stairs. Need physical assistance or upper extremity support for transfers. At school may use self-propelled manual wheelchair or powered mobility. In community are transported in manual chair or powered mobility Level IV Use wheeled mobility in most settings. Physical assist required (one to two persons) for transfers. Indoors may walk with assistance or body support walker. Outdoors are transported in manual chair or powered mobility Level V Transported in manual chair in all settings. Require adaptive seating and standing systems. Self-mobility is severely limited even with assistive technology

Centers for Disease Control and Prevention. Cerebral palsy. http://www.cdc.gov/ncbddd/cerebralpalsy/facts.html. Accessed 15.06.18. Wright M, Wallman L. Cerebral palsy. In: Campbell SK, Palisano RJ, Orlin MN, eds. Physical Therapy for Children. 4th ed. St. Louis: Elsevier; 2012:577–627. Palisano R, Rosenbaum P, Bartlett D, Livingston M. Content validity of the expanded and revised Gross Motor Function Classification System. Dev Med Child Neurol. 2008;50(10):744–750.

b c

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Table 10.3 Spina Bifida Prevalence

Prevalence for babies born with spina bifida is highest in babies born to women of Hispanic decent: 3.80 per 10,000 births; Next non-Hispanic white: 3.09 per 10,000 births; and last Black or African American: 2.73 per 10,000 birthsa

Etiology

Unknown; genetics and environmental factors may play rolea

Risk factors

Folic acid deficiency in early pregnancya,b,c Maternal alcohol intake during pregnancy (occurs with fetal alcohol syndrome) Use of valproic acid for seizure management during pregnancyb,c Having high temperatures early in pregnancy

TYPES OF SPINA BIFIDAa,b,c Occulta

Abnormal formation of lumbar or sacral vertebrae, with intact spinal cord and spinal nerves, and full skin coverage. May be a progressive deterioration of function in late childhood into adulthood

Meningocele

Vertebral defect such that meninges and cerebrospinal fluid protrude but spinal cord, cauda equina, and spinal nerves remain within the spinal column. Vertebral defect may or may not be covered by skin. Often associated with minor to mild impairment of motor and sensory function

Myelomeningocele

Defect such that meninges and incompletely closed spinal cord protrude; associated with lower motor neuron dysfunction (flaccid paralysis) and complete sensory loss below level of lesion; may have spasticity of muscles innervated by spinal nerves just proximal to level of lesion. Urinary and fecal incontinence common, risk of neuropathic wounds high; risk of osteoporosis of lower extremities high

PROGNOSIS

Incomplete closure of neural tube soon after conception; leading to flaccid paralysis and total sensory impairment of all structures innervated at and below level of lesion. May be concurrent with hydrocephalus, often managed by ventriculoperitoneal shunt. Associated with multiple secondary musculoskeletal deformities including hip dysplasia, hip dislocation, knee valgus or varus, rearfoot valgus, forefoot equinovarus, scoliosis and kyphosis, osteoporosis, overuse injuries of upper extremities.c Static, nonprogressive condition; however postural impairments and decreasing levels of mobility occur with aging, particularly in adolescence and young adulthood. Depending on level of lesion, voluntary bladder and bowel control may also be impaired or absent

MUSCLE TONE

Typically flaccid paralysis below the segmental level of the lesion.c 9%–25% may have spasticity associated with central nervous system abnormalities

MOBILITY AND COORDINATION

Ranges from bipedal ambulation to wheeled mobility and may change depending on setting and mobility needs. Ambulation distances typically assessed by home, school, or community needs. Orthoses range from ankle/foot orthotic to reciprocating gait orthoses (hip/knee/ankle/foot orthotic). May or may not need assistive device. Wheeled mobility often needed for long distances including school and community venues Evaluation criteria to determine feasibility for ambulation and/or wheelchair mobilityc: Household distances—evaluate for endurance; effectiveness of transfers; directionality; management of obstacles including doors; thresholds; efficiency/speed; safety; accessibility to all rooms/areas of house School distances—evaluate for endurance; effectiveness of transfers; stairs; curbs; ramps; indoor and outdoor surfaces; management of obstacles including classroom furniture, cafeteria furniture; doors and thresholds; efficiency/speed; safety; accessibility to all rooms/areas of school including bathrooms, special classrooms such as auditoriums, stages, art rooms, computer rooms, gymnasium, and playground Community distances—evaluate for endurance and sufficient speed for public places including medical offices, stores; entertainment and recreational venues; parks and outdoor spaces; effectiveness of transfers; stairs, curbs, and ramps; indoor and outdoor surfaces; management of obstacles including structures, furniture, and people; efficiency/speed; safety; accessibility to all areas of public buildings including bathrooms, lobbies, and parking areas

a

Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/spinabifida/data.html. Accessed 17.06.18. Murray CB, Holmbeck GN, Ros AM, Flores DM, Mir SA, Varni JW. A longitudinal examination of health-related quality of life in children and adolescents with spina bifida. J Pediatr Psychol. 2015;40(4):419–430. c Hinderer KA, Hinderer SR, Shurtleff DB. Myelodysplasia. In: Campbell SK, Palisano RJ, Orlin MN, eds. Physical Therapy for Children. 4th ed. St. Louis: Elsevier; 2012:703–755. b

Table 10.4 Multiple Sclerosis Incidence

10,000 new cases of MS are diagnosed yearly in the United Statesa

Prevalence


400,000 people living with MS in the United States,b,d but it may be close to 1,000,000c Nationally, 90 per 100,000b to 149.2 per 100,000d Varies by location: 110–140 per 100,000 above the 37th parallel and 57–78 per 100,000 below the 37th parallelc Varies by gender: 224.2 per 100,000 for females and 149.2 per 100,000 for malesd Varies by region: 192.1 per 100,000 in the East, 111.6 per 100,000 in the South, 165.0 per 100,000 in the Midwest, and 110.7 per 100,000 in the Westd

Etiology

Unknown; CNS demyelinating disease affecting CNS subsystem Continued on following page

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Table 10.4 Multiple Sclerosis (Continued) Risk factors

May be exposure to slow virus, environmental toxin, possible autoimmune components, risk higher among siblings (genetic predisposition), more common in women than men, more common among persons in northern latitudes; more common among Caucasians. Most commonly diagnosed in early to mid-adulthood

CLASSIFICATIONS OF MSc Possible MS

An individual experiences a clinically isolated syndrome (CIS): a single neurologic episode that lasts at least 24 hours, and is caused by inflammation/demyelination in one or more sites in the CNS, especially if lesions are present on MRI

Relapsing remitting (85%)

Cycle of exacerbations (new signs/symptoms) followed by partial to complete recovery during which there is no apparent worsening of the disease process

Progressive

Steadily worsening of symptoms from time of diagnosis, with incomplete recovery between exacerbations

PROGNOSIS

Unpredictable exacerbations result from inflammation and destruction of myelin around pathways within the CNS. Residual impairments are the consequence of slowed transmission of neural impulses across plaques interrupting connections between CNS structures May impact on any subsystem within CNS (voluntary motor, postural control, coordination, memory, perception, sensation) Definitive diagnosis made if there have been at least two different episodes of impairment, involving two different neurological subsystems, affecting two different parts of the body, at two different periods of time Variable course, with many different types of impairment accruing over time with repeated exacerbations Typically, onset of initial symptoms in young and mid-adulthood. Often diagnosis by exclusion; when neurological signs/ symptoms cannot be attributed to other disease processes

MUSCLE TONE

Varies, depending on location and size of residual plaque. Some individuals may exhibit normal tone and deep tendon reflexes, in the presences of perceptual, postural, or coordination impairment. Others may demonstrate hypertonus and hyperactive reflexes is various muscles. Others may have hypotonus and impaired muscle performance

MUSCLE PERFORMANCE

Varies, depending on the location of MS plaque. If in pyramidal system, may have weakness, impaired muscle endurance, poor eccentric control, among others. If in cerebellar systems, may demonstrate ataxia, intention tremor, among others

POSTURAL CONTROL

Postural control and equilibrium responses may be impaired due to a combination of pyramidal and/or extrapyramidal motor system impairment, sensory impairment or somatosensory, spinocerebellar, or visual pathways, or damage of major integrative while matter structures such as the corpus callosum, or medial longitudinal fasciculus

MOBILITY AND COORDINATION

Mobility and locomotion may be impaired, along with postural control, depending on location of lesion. Some individuals with impaired muscle performance benefit from AFOs (for support and positioning of lower extremity in gait) associated with weakness or hypertonicity. Many choose to use ambulatory aides and assistive devices for function and safety. Some with significant multisystem impairment benefit from seating and wheeled mobility systems

Note that the US government does not track or report the incidence and prevalence of MS (https://www.nationalmssociety.org/About-the-Society/MSPrevalence). AFO, Ankle/foot orthosis; CNS, central nervous system; MRI, magnetic resonance imaging; MS, multiple sclerosis. a Rumrill PD. Multiple sclerosis: medical and psychosocial aspects, etiology, incidence, and prevalence. J Vocat Rehabil. 2009;31(2):75-78. b Cleveland Clinic—Center for Continuing Education. http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/neurology/multiple_sclerosis/. Accessed 08.08.18. c National Multiple Sclerosis Society. https://www.nationalmssociety.org/About-the-Society/News/Preliminary-Results-of-MS-Prevalence-Study. Accessed 08.08.18 d Dilokthornsakul P, Valuck RJ, Nair KV, et al. (2016). Multiple sclerosis prevalence in the United States commercially insured population. Neurology. 2016;86:1014–1021.

Table 10.5 Spinal Cord Injury Incidence


17,730 new cases in the United States per year,
5.4 per 100,000a

Prevalence


291,000 persons in the United States are living with SCI (range ¼ 249,000 to 363,000)a

Etiology

Usually traumatic (e.g., vehicle crashes [39.3%], falls [31.8%], violence - primarily gunshot wounds [13.5%], sports/recreation activities [8%]), sometimes infectious (e.g., transverse myelitis) or ischemic (e.g., complication of abdominal aortic aneurysm repair)

Risk factors

Young age, male gender (
78%), drunk driving, participation in extreme sports, all-terrain vehicle accidents, military injury

SCI SYNDROMES Complete UMNa 12.3% Complete quadriplegia 19.6% Complete paraplegia

Quadriplegia (cervical cord injury) or paraplegia (thoracic cord injury) with spastic paralysis Consequence of compression, contusion, or ischemia of spinal cord as a result of vertebral fracture or dislocation sustained in fall, collision, diving, gunshot wound, or other high-impact event Exacerbated by resultant inflammatory process Spinal cord below level of lesion survives but is unhooked from brain and brainstem, only able to operate reflexively (e.g., neurogenic bladder and bowel function)

Incompletea 47.6% Incomplete quadriplegia 19.9% Incomplete paraplegia

Similar mechanism of injury but with sparing of one or more areas of spinal cord such that there is some volitional motor function and sensation along with more typical UMN (for cervical and thoracic vertebral lesions) or LMNs (for lumbosacral vertebral

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Table 10.5 Spinal Cord Injury (Continued) lesions) (e.g., central cord syndrome: upper extremity involvement > lower extremity involvement, often with preserved volitional bladder and bowel function) Becoming more common with advances in emergency care on newly injured persons Paraplegia consequence of compression, contusion of lumbosacral nerve roots (cauda equina) within the lower spinal canal, resulting in flaccid paralysis and sensory loss below the level of lesion Prognosis

Improved emergency and acute medical management often result in incomplete lesion, with varying combinations of return of function and spastic paralysis

MUSCLE TONE Complete UMN

Initial hypotonicity during period of neurogenic shock. Many develop significant hypertonicity in the months after injury; some may have muscle spasm needing pharmacological intervention. Sudden increase in resting tone may signal unrecognized skin irritation, bladder distention or infection, or bowel impaction. At risk of secondary musculoskeletal deformity (contracture) due to longstanding abnormal tone and limited mobility

Incomplete

Also may demonstrate hypotonicity in the days immediately following injury. Some volitional muscle function may be apparent early on; spasticity may develop in other muscles over time. Muscles with spasticity similar to complete UMN injury

Complete LMN

Considered a lower motor neuron lesion with flaccid paralysis and absence of deep tendon reflexes at and below level of lesion

MUSCLE PERFORMANCE Complete UMN

Impaired and inadequate; reflexive function only

Incomplete

Muscles that remain innervated often initially weak; responsive to interventions to enhance force production, muscle endurance, power

Complete LMN

No muscle function and areflexic below level of lesion

POSTURAL CONTROL Complete UMN

Disconnection of lower motor neuron pool below level of lesion results in loss of volitional movement, as well as automatic postural responses, despite hypertonus. Deep tendon reflexes are often brisk, sometimes resulting in sustained clonus

Incomplete

Varies from significantly impaired to minimally impaired, depending on location and extent of lesion

Complete LMN

Postural control of trunk intact, although flaccid paralysis of lower extremities limit stability in standing without external support of orthoses

MOBILITY AND COORDINATION All types

May temporarily use spinal orthosis (CO, CTO, TLSO) until surgical stabilization of damaged vertebrae is well healed. Often require seating and wheelchair systems for mobility Persons with cervical level lesions may require upper extremity splints and adaptive equipment for activities of daily living, or resting splints or orthoses to manage abnormal tone and prevent contracture

Complete LMN

Persons with low thoracic and lumbosacral lesions may use AFO, KAFO, or HKAFO along with assistive device (rolling walker, crutches) for ambulation, either as part of rehabilitation or of fitness program; energy cost of ambulation for community distances often high enough to be impractical

AFO, Ankle/foot orthosis; CO, cervical orthosis; CTO, cervical thoracic orthosis; HKAFO, hip/ankle/foot orthosis; KAFO, knee/ankle/foot orthosis; LMN, lower motor neuron; SCI, spinal cord injury; TLSO, thoraco/lumbo/sacral orthosis; UMN, upper motor neuron. a National Spinal Cord Injury Statistical Center, Facts and Figures at a Glance. Birmingham, AL: University of Alabama at Birmingham, 2019. Accessed 03.11.19.

When considering an upper or lower extremity orthosis or an adaptive equipment system to support the trunk for individuals with neurological or neuromuscular dysfunction, the rehabilitation team must clearly define what they hope the orthosis will accomplish and consider the needs of the individual and family. Goals for orthosis and adaptive equipment usage include provision of stability for trunk, limb segment, or specific joint for postural control; provision of stability for improved efficiency of movement, reduction of the influence of hypertonicity on movement, minimization/prevention of the development of contractures, and increasing participation in desired activities of the individual. There is no perfect orthosis or adaptive equipment piece that will address all dimensions of movement dysfunction; there are always trade-offs that must be taken into account.

Management of Neuromuscular Impairments Effective care of persons with movement dysfunction secondary to neurological and neuromuscular pathologies requires collaboration of health professionals from many disciplines: neurologists, orthopedist, physiatrists, physical and occupational therapists, and orthotists, among others.139–141 Physicians and surgeons manage spasticity and correct orthopedic deformity with medication and surgery. Nurses are involved in wellness care, as well as medical and surgical management. Rehabilitation professionals facilitate return of function after an acute event and provide functional training and postoperative rehabilitation for individuals across the spectrum of neurological and

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neuromuscular pathologies. Orthotists contribute their knowledge of orthotic options to improve gait and function. The multidisciplinary approach leads to greater satisfaction with care and less risk of abandonment of orthoses and assistive devices by the person for which they were made.142

MEDICAL AND SURGICAL CARE Medical management of CNS dysfunction often includes prescription of pharmacological agents. Physicians can select from a range of centrally acting tone-inhibiting medications (e.g., baclofen [Lioresal]) or pharmacological interventions that target lower motor neurons, peripheral nerves, or muscle (e.g., botulinum toxin injection, intrathecal baclofen) for individuals with significant hypertonicity.143–149 A host of medications have become available to reduce the likelihood of exacerbation, delay disease progression, and manage fatigue for persons with MS.150,151 Many individuals with CNS disorders also must cope with seizure management; many antiepileptic drugs affect tone, arousal, and ability to learn.152 It is important for physical therapists and orthotists to be aware of the potential impact of neuroactive

medications on an individual’s ability to concentrate and learn, overall health status, and neuromotor control.153,154 A summary of pharmacological agents used in the management of hypertonicity resulting from CNS disease in the management of MS and for seizure disorders is presented in Table 10.6. Alternatively, physicians may recommend various neurosurgical procedures and orthopedic surgeries to correct deformity, improve flexibility, or reduce level of abnormal tone, with the goal of enhancing mobility and improving performance of functional tasks. Neurectomy and neurotomy, for example, may be used to manage severe equinovarus and upper extremity spasticity after stroke and for children with CP.155–159 Selective dorsal rhizotomy effectively reduces problematic hypertonicity for children with CP but does not seem to reduce the future risk of developing deformity, which would then require orthopedic surgery.160–162 Intrathecal baclofen pumps have been used as a strategy to manage severe spasticity in persons with traumatic brain injury, stroke, spinal cord injury, and CP.163–165 Despite pharmacological and positioning interventions, musculoskeletal deformities can still develop, particularly

Table 10.6 Pharmacological Interventions for Individuals With Neurological and Neuromuscular System Impairments Trade Names

Generic Name (Class)

Administration

Indications

Adverse Effects a

MANAGEMENT OF DYSTONIA AND CENTRAL NERVOUS SYSTEM-RELATED SPASM NeuroBloc botulinum B toxin Intramuscular Facial spasm, spasmodic torticollis, Myobloc (neurotoxin) blepharospasm

Pain at injection site, ptosis, eye irritation, weakness of neck muscles, dysphagia, dry mouth, heartburn

MANAGEMENT OF HYPERTONICITY, CLONUS, AND TICSa Botox Dysport

botulinum A toxin (neurotoxin)

Intramuscular or perineural injection, intrathecal

Chronic severe spasticity or dystonia

Pain or bruising at injection site, muscle weakness, tiredness, drowsiness, nausea, anxiety

Catapres

clonidine (antihypertensive)

Oral or transdermal

Spasticity in MS

Dry mouth, gastrointestinal disturbances, fatigue, headache, nervousness, insomnia, skin irritation (transdermal)

Ceberclon Klonopin Rivotril Valpax

clonazepam (benzodiazepine)

Oral

Spasticity in CP, dystonic, chorea, akathisia (also for seizures, panic attacks)

Sedation, dizziness, unsteadiness, incoordination, memory problems, muscle or joint pain, blurred vision, frequent urination

Dantrium

dantrolene sodium (skeletal muscle relaxant)

Oral or injection

Chronic severe spasticity of UMN origin

Drowsiness, dizziness, generalized weakness, malaise, fatigue, nervousness, headache

Ethanol

ethyl alcohol (neurotoxin)

Intramuscular or perineural injection

Severe spasticity, with serial casting followup

Neuritis, hyperesthesia, or paresthesia

Lioresal

baclofen (skeletal muscle relaxant)

Oral, injection, or intrathecal

Chronic severe spasticity for conditions including SCI, ABI, MS; not effective in CP

Sedation, confusion, hypotension, dizziness, ataxia, headache, tremor, nystagmus, paresthesia, diaphoresis, muscular pain or weakness, insomnia, behavioral changes

Neurontin

gabapentin

Oral

Adjunct to other antispasticity medications for SCI and MS

Drowsiness, dizziness, ataxia, fatigue, nystagmus, nervousness, tremor, diplopia, memory impairment

Phenol

phenol

Intramuscular or perineural injection

Severe lower limb spasticity (with serial casting follow-up) pain control

Damage to other neural structures

Robaxin

methocarbamol

Oral or injection

Short-term relief of muscle spasm or spasticity

Sedation, drowsiness, lightheadedness, fatigue, dizziness, nausea, restlessness

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Table 10.6 Pharmacological Interventions for Individuals With Neurological and Neuromuscular System Impairments (Continued) Trade Names

Generic Name (Class)

Administration

Indications

Adverse Effects

Valium

diazepam

Oral or injection

Short-term relief of muscle spasm or spasticity

Sedation, drowsiness, fatigue, ataxia, confusion, depression, diplopia, dysarthria, tremor

Zanaflex Sirdalud

tizanidine (skeletal muscle relaxant)

Oral

Spasticity from MS or SCI

Sedation, drowsiness, fatigue, dizziness, mild weakness, nausea, hypotension, GI irritation

Trigeminal neuralgia, pelvic pain, intense episodic/lancinating/burning pain, pins/ needles, cramping, dysesthetic extremity pain, tonic spasms, other neurogenic pain, nocturnal spasms

See Seizure Medications

Oral

Chronic neurogenic pain (e.g., dysesthetic extremity pain such as burning, tingling)

Drowsiness, blurred vision, dizziness, GI and urinary disturbances, tachycardia, hypotension, weight gain, fatigue, headache

MANAGEMENT OF SEIZURESc Amytal amobarbital (barbiturate)

Intravenous

Status epilepticus

Sedation, nystagmus, ataxia, vitamin K and folate deficiency

Ativan

lorazepam (benzodiazepine)

Intravenous

Status epilepticus

Sedation, ataxia, changes in behavior

Atretol Convline Epitol Macrepan Tegretol

carbamazepine (iminostilbene)

Oral

Complex partial seizures, tonic-clonic seizures, trigeminal neuralgia, bipolar disorder

Ataxia, diplopia, drowsiness, fatigue, dizziness, vertigo, tremor, headache, nausea, dry mouth, anorexia, agitation, rashes photosensitivity, heart failure

Celontin

methsuximide (succinimide)

Oral

Alternative to ethosuximide for absence seizures

Nausea, vomiting, headache, dizziness, fatigue, lethargy, dyskinesia, bradykinesia

Cerebyx

fosphenytoin (hydantoin)

Intravenous

Status epilepticus

GI irritation, confusion, sedation, dizziness, headache, nystagmus, ataxia, dysarthria

Depacon

Sodium valproate (carboxylic acid)

Oral or injection

All types of seizures

Ataxia, tremor, sedation, nausea, vomiting, hyperactivity weakness, incoordination, risk of hepatotoxicity

Depakene

valproic acid (carboxylic acid)

Oral

Absence seizures, as adjunct for other seizure types

Nausea, sedation, ataxia headache nystagmus, diplopia, asterixis, dysarthria, dizziness, incoordination, depression, hyperactivity, weakness, risk of hepatotoxicity

Depakote

divalproex sodium (carboxylic acid)

Oral

Complex partial seizures, absence seizures, as adjunct for other seizure types

Headache, asthenia, nausea, somnolence, tremor, dizziness diplopia, risk of hepatotoxicity

Diamox

acetazolamide (sulfonamide)

Oral

Absence seizures, myoclonic seizures

Drowsiness, dizziness

Dilantin Diphen Diphentoin Dyantoin Phenytex

phenytoin (hydantoin)

Oral or injection

Status epilepticus, tonic-clonic seizures, simple complex seizures

Ataxia, slurred speech, confusion, insomnia, nervousness, hypotension, nystagmus diplopia, nausea, vomiting

Felbatol

felbamate (2nd generation)

Oral

Partial seizures, absence seizures Used for severe seizure disorders unresponsive to other medications

Aplastic anemia, liver failure, insomnia, headache, dizziness, loss of appetite, nausea, vomiting

MANAGEMENT OF DYSESTHESIA/NEUROPATHIC PAINb Carbatrol carbamazepine Oral Epitol phenytoin Tegretol gabapentin Dilantin zonisamide Neurontin desipramine Zonegran (anticonvulsants) Norpramin Adapin Sinequan Triadapin Zonalon Elavil Imavate Janimine Tofranil Vivactil

doxepin amitriptyline imipramine protriptyline (tricyclic antidepressants)

Continued on following page

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Table 10.6 Pharmacological Interventions for Individuals With Neurological and Neuromuscular System Impairments (Continued) Trade Names

Generic Name (Class)

Administration

Indications

Adverse Effects

Gabitril

tiagabine (2nd generation)

Oral

Partial seizures

Generalized weakness, dizziness, tiredness, nervousness, tremor, distractibility, emotional lability

Keppra

levetiracetam (2nd generation)

Oral

Adjunct for partial seizures in adults

Sedation, dizziness, generalized weakness

Klonopin Rivotril

clonazepam (benzodiazepine)

Oral or injection

Myoclonic seizures, absence seizures, kinetic seizures

Drowsiness, dizziness, ataxia, dyskinesia, irritability, disturbances of coordination, slurred speech, diplopia, nystagmus, thirst

Lamictal

lamotrigine (2nd generation)

Oral

Partial seizures, tonic-clonic seizures

Dizziness, headache, ataxia, drowsiness, incoordination, insomnia, tremors, depression, anxiety, diplopia, blurred vision, GI disturbances, agitation, confusion, rash

Luminol Solfoton

phenobarbital (barbiturate)

Oral or injection

Status epilepticus, all seizure types except absence seizures

Drowsiness, lethargy, agitation, confusion, ataxia, hallucination, bradycardia, hypotension, nausea

Mebaral

mephobarbital (barbiturate)

Oral

Tonic-clonic seizures, simple and complex partial seizures

Drowsiness, sedation, nystagmus, ataxia, folate and vitamin K deficiency

Mesantoin

mephenytoin (hydantoin)

Oral

Partial seizures, tonic-clonic seizures used if Dilantin is not effective

Similar to Dilantin, but more toxic

Milontin

phensuximide (succinimide)

Oral

Alternative to Zarontin for absence seizures

Nausea, vomiting, headache, dizziness, fatigue, lethargy, bradykinesia, dyskinesia

Mysoline

primidone (barbiturate)

Oral

All seizure types except absence seizures, essential tremor

Ataxia, vertigo, drowsiness, depression, inattention, headache, nausea, visual disturbances

Nembutal

pentobarbital (barbiturate)

Intravenous

Tonic-clonic seizures, simple and complex partial seizures

Sedation, nystagmus, ataxia, vitamin K and folate deficiency

Neurontin

gabapentin (2nd generation)

Oral

Partial seizures in adults and children older than 3 years, neuropathic pain

Drowsiness, dizziness, ataxia, fatigue, nystagmus, nervousness, tremor, diplopia, memory impairment

Peganone

ethotoin (hydantion)

Oral

Tonic-clonic seizures; used if Dilantin is not effective

Similar to Dilantin, but more toxic

Seconal

secobarbital (barbiturate)

Intravenous

Tonic-clonic seizures, partial seizures

Sedation, nystagmus, vitamin K and folate deficiency

Topamax

topiramate (2nd generation)

Oral

Partial seizures, adjunct to tonic-clonic seizures

Ataxia, confusion, dizziness, fatigue, paresthesia, emotional lability, confusion, diplopia, nausea

Thosutin Zarontin

ethosuximide (succinimide)

Oral

Absence seizures

Drowsiness, headache, fatigue, dizziness, ataxia, euphoria, depression, myopia, nausea, anorexia

Tranxene

clorazepate (benzodiazepine)

Oral

Adjunct for partial seizures

Sedation, ataxia, changes in behavior

Trileptal

oxcarbazepine (iminostilbene)

Oral

Partial seizures, tonic-clonic seizures

Ataxia, drowsiness, nausea, dizziness, headache, agitation, memory impairment, asthenia, ataxia, confusion, tremor, nystagmus

Valium Valrelease

diazepam (benzodiazepine)

Injection

Status epilepticus, severe recurrent seizures

Drowsiness, fatigue, ataxia, confusion, depression, dysarthria, syncope, tremor, vertigo

Zonegran

zonisamide (2nd generation)

Oral

Adjunct for partial seizures in adults

Sedation, ataxia, loss of appetite, fatigue

ABI, Acquired brain injury; CP, cerebral palsy; GI, gastrointestinal; MS, multiple sclerosis; NMJ, neuromuscular junction; SCI, spinal cord injury; UMN, upper motor neuron. a Ciccone CD. Skeletal muscle relaxants. In: Ciccone CD, ed. Pharmacology in Rehabilitation. 5th ed. Philadelphia: FA Davis; 2016:179–197. b Jensen T, Madsen C, Finnerup N. Pharmacology and treatment of neuropathic pains. Curr Opin Neurol. 2009;22(5):467–474. c Ciccone CD. Antiepileptic drugs. In: Ciccone CD, ed. Pharmacology in Rehabilitation. 5th ed. Philadelphia: FA Davis; 2016:115–130.

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in the growing child. Surgical interventions are used to correct musculoskeletal defaults of the spine and limbs, realign joints for better mechanical advantage, improve ease of caregiving and hygiene management, promote cosmesis, or reduce and prevent pain. Tendon lengthenings or transfers are commonly used to correct contractures and provide greater functional ROM to improve the ability to walk in children with CP.84,166–169 Derotation osteotomies are another option that have traditionally been used to improve or correct deformity and improve walking ability in children with CP.170–173 Because children with CP and acquired brain injury who have significant hypertonicity are at risk for developing neuromuscular scoliosis, various spinal surgeries are used to improve spinal alignment and reduce pelvic obliquity, to improve physiological and daily function, and to reduce caregiver burden.174–176 Rather than subject children with CP to multiple surgeries over time, many centers perform multiple procedures at the same time.177,178 To achieve maximum benefit, rehabilitation is a necessary component following any of these surgeries.84,179–181 Individuals with significant spasticity are commonly managed with a combination of these strategies to most effectively diminish the impairment, improve the functional ability, and help them participate in activities that are important to them.182–184 Increasingly, instrumented gait analysis is being used inform clinical decision making in selecting the most appropriate intervention or combination of interventions for ambulatory individuals with functional limitation secondary to neuromuscular pathologies and their associated secondary impairments.185–188

REHABILITATION Rehabilitation professionals use a variety of examination strategies to determine the nature and extent of dysfunction across systems that are associated with a particular pathological condition. The components of a complete evaluation when considering orthotic or equipment decisions include asking specific history questions, a biomechanical analysis of the limb(s)/segment(s), examination of neuromotor status, motor control, functional movement ability, integumentary integrity, sensory processing, cognitive function, and psychosocial factors. See Table 10.7 for an example.9,189 The physical therapist evaluates this information to (1) determine an appropriate movement-related physical therapy diagnosis, (2) predict potential outcomes (prognosis), and (3) structure an appropriate plan of care.189–191 Physical therapists use adaptive equipment, orthoses, and seating as key components of an effective plan of care for persons with neuromotor/neurosensory system dysfunction.192–196 Consideration of the use of an orthotic or other equipment must be made in the context of the patient’s activity needs/desires and participation in life activities that contribute to quality of life.197 Orthoses are used to: 1. align or position limb segments to enhance voluntary limb movement and improve function (e.g., an anklefoot orthosis [AFO] to provide prepositioning of the foot during swing limb advancement and stability during the stance phase of gait); 2. minimize the influence of abnormal tone on posture and movement (tone-inhibiting designs);

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3. provide individuals with a variety of comfortable and safe positions in which they can sleep, eat, travel, work, or play; 4. promote joint alignment and minimize risk of contracture development and other secondary musculoskeletal sequelae (especially in growing children); 5. protect a limb following orthopedic surgery performed to correct deformity or instability; 6. enhance alignment following pharmacological intervention with botulinum toxin; and 7. provide alternative methods for mobility. The risk for developing secondary musculoskeletal impairments is high in the presence of hypertonicity.108,197–200 Passive stretching programs alone are generally ineffective as a management strategy for reducing risk for contracture development.201,202 Prolonged positioning for several hours a day is a critical adjunct to stretching.203–205 Adaptive equipment can be used to provide structural alignment for prolonged periods of time to maintain extensibility of muscles, decrease the effect of muscle imbalance across joints, and provide postural support, particularly to increase effectiveness in daily activities such as feeding and play.206–208 An adaptive seating system, for example, would provide upright postural support for sitting; maintain spinal alignment and pelvic positioning; support optimal hip, knee, and ankle positions; and promote the best position for upper extremity function.206–210 Positioning devices for supported standing are often used to maintain extensibility of muscles, to promote bone mineral density through weight bearing, and to promote musculoskeletal development such as acetabular depth in a developing child with hypertonicity (Fig. 10.7).211–213 Other examples of positioning devices include prone, supine, and sidelyer systems, bathing and toileting seating systems, and a variety of mobility alternatives such as gait trainers.214–217 Although there are many options for adaptive equipment designed to assist function and caregiving for persons with neurological and neuromuscular dysfunction, knowledge about options and limitations in funding limit access for many who might otherwise benefit from such devices.218–221 Serial corrective casts have long been used as a primary intervention for individuals with significant hypertonus to provide a prolonged elongation of soft tissue over a long time period. They increase the length of a contracted muscle and its supportive tissues and reset the threshold for response to stretch reflex.155–160,203 Some splints or dynamic orthoses are used primarily at night to provide 8 or more hours of stretch on a regular basis; others can be worn during daily activities to provide a longer period of stretch (Fig. 10.8).222–226 More recently, serial casting and dynamic splinting have been used in conjunction with pharmacological interventions for the management of spasticity in both children and adults with severe hypertonicity (Fig. 10.9).203,222,227,228 Although the pharmacological agent may reduce the degree of spasticity in hypertonic muscles, concomitant shortening of the muscles and tendons must be addressed while the neurological influence is altered, as should concomitant deficits in other dimensions of muscle performance and motor control.229–231 A young child with CP—spastic diplegia, for example—may receive botulinum injections to the gastrocnemius and soleus muscles to reduce the severity of spasticity as an alternative to early orthopedic surgery.232,233

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Table 10.7 Elements of a Physical Therapy Examination in Consideration for Prescription/Use of Orthoses, Adaptive Equipment, or Serial Casting Examination Element

Examination Strategies

Implications for Orthosis, Equipment or Cast

Chief complaint: What is the MOVEMENT PROBLEM that brings the individual to physical therapy?

Interview of individual and caregivers

Ambulation/gait dysfunction—consider need for LE orthosis. Reach, grasp, manipulation dysfunction— consider need for UE orthosis

History of current illness, past medical history: How did the MOVEMENT PROBLEM develop or evolve? Explore duration of the presenting problem; previous and concurrent pharmacological management; previous and concurrent orthopedic or neurosurgical management; previous orthotic management; Current health status; Comorbidities and their management

Review of medical record Interview with individual and caregivers Consultation with clinical colleagues

Consider what strategies are currently working or not. Consider combination of strategies that might be possible. For example, hypertonicity reduction medication coupled with an orthosis

Biomechanical evaluation: ROM, flexibility (especially of multijoint muscles), muscle length, alignment of joints, pelvis, and spine, torsional/rotational deformity of hip, femur, tibia,

Goniometric measurement; Evaluation of muscle length (e.g., Thomas test, straight-leg raise); integrity of ligaments and supportive structures; radiograph; inclinometer

Consider strategies for contracture management. For example, Botox injection followed by serial casting or orthosis. If contracture may be “permanent” or severe, consider accommodation needs for positioning. For example, heel wedge to accommodate fixed plantarflexion contracture

Postural alignment in sitting and standing

Spatial relationships of head, upper trunk/limb girdle, mid trunk, lower trunk/pelvic girdle, extremity symmetry

Consider seating or standing adaptations and/or seating/standing systems

Anthropomorphic characteristics

Height, weight, limb length, limb girth, body mass

Implications for sizing

Neuromotor status: Muscle tone (compliance vs. stiffness) Deep tendon reflex testing Antigravity stiffness/postural tone Involuntary movement

Resistance to passive movement at various speeds Palpation tone scales (e.g., modified Ashworth), descriptive category (hypertonic/spastic, rigid, hypotonic, fluctuating, flaccid) amplitude of response, pattern of response (distal-proximal), symmetry of response

Consider strategies and combination of strategies to manage hypertonicity

Motor control: Recruitment/adaptation of contractions Segmentation of limbs, joints within a limb

Ability to move between concentric, eccentric, and holding contractions during functional activity Ability to initiate, sustain, and terminate contraction and movement. Influence of abnormal synergy or abnormal developmental reflexes

Determine if trunk or extremities require positioning or orthosis to provide control (minimize tonal influence, support body structure)

Muscle performance: Strength Speed/power Accuracy Timing Fluidity Muscle endurance Relationship of agonist/antagonist

Observation of antigravity movement Manual muscle testing, dynamometer Isokinetic testing Description: hypokinetic, functional, hyperkinetic Control for concentric, eccentric, isometric contractions, repetitions to test endurance

Consider postural support requirements for UE tasks; trunk and LE support requirements for LE tasks

Postural control

Static balance tests (e.g., timed single limb stance) Anticipatory balance tests (e.g., reach distances, ability to change direction) Reactionary balance test: perturbation

Consider postural support requirements for UE tasks; trunk and LE support requirements for LE tasks

Functional movement ability, functional task abilities ADL

Ability to adapt movement strategies in different environmental conditions and to different task demands. Observation of movement during task Self-report of individual or caregiver Various ADL scales Ability to don/doff orthosis

Consider orthoses to improve efficiency, effectiveness of movement. Consider equipment that may assist in task completion

10 • Neurological and Neuromuscular Disease Implications for Orthotic Use

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Table 10.7 Elements of a Physical Therapy Examination in Consideration for Prescription/Use of Orthoses, Adaptive Equipment, or Serial Casting (Continued) Examination Element

Examination Strategies

Implications for Orthosis, Equipment or Cast

Dexterity, coordination, agility

Observation of performance during functional activity Special tests Developmental scales and profiles

Consider orthoses to improve efficiency, effectiveness of movement

Transitional movements and transfers To/from floor Sit to stand Bathroom transfers Car transfers

Assistance required Level of difficulty Task analysis to identify where in movement difficulty occurs and contributors to difficulty

Consider LE orthosis for standing and movement needs; consider seating needs, wheelchair usage. Consider mechanical lift needs

Mobility and locomotion

Observational gait analysis, with and without orthosis Gait speed, other kinematic measures Use of assistive devices Level of assistance required Gait lab kinetic measures (moments, torques, force plate, activity via video, and EMG analysis

Consider orthosis needs for gait cycle impairments. Consider assistive device needs

UE function and use of hands

Observation during various fine and gross UE motor tasks

Consider UE orthosis needs

Cardiovascular endurance

Heart rate, blood pressure, oxygen saturation during activity Ratings of perceived exertion during tasks 6-Minute walk test Fatigue scales

Consider orthosis for efficiency, to decrease energy expenditure

Environmental assessment (home, work, school, leisure)

Environmental safety checklists Interview with individual and caregivers about characteristics of environments in which individual must function

Consider environmental adaptations

Integumentary integrity Skin condition

Inspection for neuropathic, dysvascular, or traumatic wounds Document callus and scarring Document pressure sensitive areas Document protective sensation, insensate weight-bearing areas

Consider protection of vulnerable areas; consider custom fit to minimize/prevent wound development

Sensory organization and processing Sensory integrity

Adequacy of vision (acuity, peripheral vision, tracking, visual field loss) Screening for exteroception, proprioception ability Document insensate areas, especially of hands/feet Document paresthesia and dysesthesia

Consider protection of vulnerable areas; consider custom fit to minimize/prevent wound development

Perceptual function Visual spatial perception Awareness of position in space Awareness of body parts

Observation of movement during functional tasks Developmental tests, measures Special perceptual tests, measures

Consider workstation, home adaptations

Cognitive function: Ability to learn and remember Ability to problem solve Motivation Distractibility/focus Ability to manage frustration, uncertainty

Reports of teachers, clinicians; neuropsychological testing; Observation when presented with challenge; Self-report of individual and caregivers

Consider ability to manage orthosis, cleaning and maintenance of devices. Consider ability to don/doff orthosis. Consider ability to know if fit feels wrong and ability to seek appropriate assistance

Communication

Adequacy of hearing and auditory processing; Ability to understand language; Ability to use language; Oral-motor function (dysarthria); Impact of position on voice

Consider ability to understand and follow instructions for proper fit, wearing schedules

Psychosocial factors Desired participation in leisure or play activities, school or work-related activities. Family and caregiver Quality of life

Typical activities and roles: demands and barriers encountered for activities. Availability and capacity of others to assist with respect to use of orthosis Self-efficacy scales Patient/caregiver satisfaction with orthosis/device

Consider use of orthosis, adaptive equipment for different environments. Consider training of caregiver if needed

ADL, Activities of daily living; EMG, electromyographic; LE, lower extremity; ROM, range of motion; UE, upper extremity. Truman H, Racette W. Orthotics: evaluation, intervention, and prescription. In: Umphred DA, ed. Neurological Rehabilitation. 6th ed. St. Louis: Mosby; 2013:1037–1052.

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SELECTING THE APPROPRIATE ORTHOSIS Rehabilitation professionals play an active role in deciding what type of orthosis would be most appropriate for an individual with neuromuscular impairment. A number of factors contribute to the decision-making process; the

Fig. 10.7 Example of adaptive equipment (stander) available to assist appropriate alignment and function in the presence of impairment of muscle tone, muscle performance, postural control, or difficulty with movement and coordination.

A

B

collective wisdom of physical and occupational therapists, orthotists, physicians, family, and the patient who might benefit from orthotic intervention is necessary for appropriate and effective casting or orthotic intervention.192,234,235 The primary goal of orthotic or adaptive equipment prescription is to select the device and components that will best improve function, given the individual’s pathologic condition and prognosis, desired activities, and participation needs, both in the immediate situation and over time. To do this, the cast, splint, or orthosis might provide external support, control or limit ROM, optimally position a limb for function, reduce the risk of secondary musculoskeletal complications, or provide a base for adaptive equipment that would make function more efficient. What evidence is available to support clinical decision making with respect to orthotic prescription? Although many professionals rely on expertise gained by working with persons with neuromotor impairment over years of clinical practice, a growing number of articles on orthotic design for particular patient populations in the rehabilitation and orthotic research literature are available to guide decision making not only for individuals with hypertonicity but also for those with spinal cord injury, myelomeningocele, and muscular dystrophy.195,234–241 Evaluation of the effectiveness of the orthotic intervention is becoming increasingly important in clinical decision making. Several articles related to specific outcome measures for effectiveness of orthotic use and patient satisfaction have recently been published.242–245 This chapter has discussed general orthotic and adaptive equipment usage; however, lower extremity orthotics are often a significant component of physical therapy practice, particularly for ambulation and gait dysfunction. When the primary goal of orthotic intervention is to improve safety and functionality during ambulation, it is imperative to identify where in the gait cycle abnormal tone or muscle performance is impaired (refer to Chapter 5 for more information on critical events in each subphase of gait, as well as detailed information about strategies to examine gait). Systematic consideration of

C

Fig. 10.8 Example of knee/ankle/foot orthosis (KAFO) with knee extension stop. (A) Front view. (B) Back view. (C) Side view.

10 • Neurological and Neuromuscular Disease Implications for Orthotic Use

Fig. 10.9 Examples of ankle/foot orthoses (AFO). (A) Pictured on the left is a custom molded solid AFO and pictured on the right is a custom molded hinged AFO. (B) Pictured on the left is a carbon fiber floor reaction AFO and pictured on the right is a custom molded posterior leaf spring AFO.

A

a series of questions can help identify where within the gait cycle (considering both stance and swing phases) problems occur.246–248 Rehabilitation professions must recognize that no orthosis will normalize gait for persons with neurologically based gait difficulties. Whenever an external device is placed on a limb, it is likely to solve one problem while at the same time creating other constraints on limb function. The therapist, orthotist, and patient collectively problem solve during the orthotic prescription phase to prioritize the difficulties the individual is having during gait and then select the design and components that will allow the person to be most functional while walking, with the least additional constraint on other mobility and functional tasks. The rehabilitation team at Rancho Los Amigos National Rehabilitation Center has developed an algorithm that is particularly useful in guiding clinical decision making and sorting through possible orthotic options for adults with neuromotor impairment (ROADMAP: Recommendations for Orthotic Assessment, Decision Making, and Prescription).192 When considering orthotic interventions for persons having difficulty with ambulation, this team suggests asking the following questions: 1. Is there adequate ROM in the lower extremities to appropriately align or position limb segments in each subphase of gait? 2. Does the individual have the motivation and cognitive resources necessary to work toward meeting the goal of ambulation? 3. Does the individual have enough endurance (cardiovascular and cardiopulmonary resources) to be able to functionally ambulate? If endurance is not currently sufficient, might it be improved by a concurrent conditioning program? 4. Does the individual have adequate upper extremity, trunk, and lower extremity strength; power; motor

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B

control; and postural control for ambulation (with an appropriate assistive device, if necessary)? If these dimensions of movement are not currently sufficient, might they be improved with concurrent rehabilitation intervention? 5. Is there sufficient awareness of lower limb position (proprioception, kinesthesia) for controlled forward progression in gait? If not, might alternative sensory strategies be learned or used to substitute for limb position sense? If the answers to most of these questions are “yes,” the individual is considered to be a candidate for orthotic intervention. The next determinant is knee control and strength: If the individual has antigravity knee extension with the ability to respond to some resistance (manual muscle testing grade of 3 + strength), even if there is impaired proprioception in the involved limb, then an AFO may be appropriate. If there is impairment of strength or of proprioception (or both), then the team is more likely to recommend a knee/ankle/foot orthosis (KAFO). Box 10.1 is an example of a decision tree used to guide the selection of components. Especially important is that the individual who will use the orthosis and caregivers, as appropriate, are actively involved in the decision-making process. To make an informed decision, the person needing an orthosis must understand both the benefits and constraints associated with the orthotic designs and components being considered. He or she must be able to consider the range of orthotic options, as well as medical/surgical intervention and additional rehabilitation interventions that might affect his or her ability to walk. The entire team must consider what the individual who will be wearing the orthosis wants to accomplish, as well as the preferences he or she might have in terms of ease of donning/doffing, wearing schedule, and cosmesis of the device being recommended. Beginning with a trial orthosis, perhaps

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Box 10.1 Decision Tree for Orthotic Options Is a KAFO Indicated?

▪ Is there at least antigravity with some resistance (MMT 3+/5 strength) in quadriceps bilaterally?

▪ Is proprioception intact bilaterally? If yes: continue with the assessment for ankle-foot orthosis (AFO) If no: KAFO may improve gait—continue assessment process Which KAFO Components Are the Most Appropriate?

▪ Is there at least antigravity with some resistance (MMT 3+/5 strength) in one lower extremity?

▪ Is proprioception intact in at least one lower extremity? If no: consider trial of bilateral KAFOs or a reciprocal gait orthosis If yes: unilateral KAFO may be indicated—continue assessment to determine if knee locking mechanism is necessary

Which AFO Design and Components Are the Best Option?

▪ Does impaired strength hamper foot position in stance or swing? ▪ Does impaired proprioception hamper foot placement in stance or swing?

▪ Does hypertonicity/spasticity hamper foot position in stance or swing?

If no: consider adjustable articulating ankle joint (allows full DF and PF) If yes: consider limiting or blocking ankle motion and continue assessment process Is There More Than Minimal Impairment of Static and Dynamic Postural Control in Standing?

▪ Is there significant spasticity? ▪ Is proprioception significantly impaired?

If no: consider KAFO with knee lock If yes: consider KAFO with variable knee mechanism and continue assessment

If no: consider adjustable articulating ankle joint that blocks PF beyond neutral ankle position and continue assessment If yes: consider solid-ankle AFO or adjustable articulating ankle that is fully locked (consider rocker bottom shoe)

Is There at Effective Active Control of Knee Extension During Stance?

▪ Is there also plantarflexion strength  MMT 4 in standing? ▪ Is there also excessive knee flexion and dorsiflexion during

Can the Knee Be Fully Extended, Without Pain, During Stance?

If no: consider stance control knee mechanism If yes: consider free motion knee mechanism. Continue with AFO decision tree to determine appropriate ankle control strategy Is an AFO Indicated?

▪ Is there impairment of ankle strength? ▪ Is there impairment of proprioception? ▪ Is there hypertonicity of plantarflexors? ▪ Is there a combination of all of the above? If no: may not require lower extremity orthosis If yes: lower extremity orthosis may improve gait—continue assessment process

stance?

▪ Is there also excessive plantarflexion with knee hyperextension during stance?

If no: consider adjustable articulating ankle joint with PF stop, and continue assessment If yes: consider adjustable articulating ankle joint with PF stop and limited DF excursion, and continue assessment

▪ Is there also dorsiflexion strength 4 in standing? If no: consider adjustable articulating ankle with PF stop, limited DF excursion instance, no DF assist necessary If yes: consider adjustable articulating ankle with PF stop, limited DF excursion, and DF assist for effective swing phase

DF, Dorsiflexion; KAFO, knee-ankle-foot orthosis; MMT, manual muscle testing; PF, plantarflexion.

a prefabricated or multiadjustable version would be helpful before finalizing the orthotic prescription, especially if it is unclear whether ambulation will eventually be possible. Certainly, most individuals with neuromuscular conditions that compromise their ability to walk benefit from a chance to experience what ambulation with an orthosis requires, given their individual constellation of impairments. Some may decide that using orthoses and an appropriate assistive device for functional ambulation throughout the day meets their mobility needs. Others may opt, because of the energy cost of walking with knee-ankle-foot orthoses or hip-knee-ankle-foot orthoses, to use a wheelchair for primary mobility and reserve the use of orthoses to exercise bouts aimed at building cardiovascular endurance. Some may decide that orthotic intervention will not meet their needs and pursue other avenues to address mobility and endurance issues. Once a decision is made and the orthosis or adaptive equipment has been procured, education and practice are key components to successful adoption and usage of the device. The patient and the family/caregiver need specific training for each device including don/doff,

putting patient into or out of the device, visual inspection for proper fit, and wear/use schedules. Additionally, training must include the assessment of skin integrity after use. Following trail usage and time for practice with the device for a period of time, the rehabilitation team must assess the patient/family/caregiver satisfaction with the product. Education, time, and practice with the product are the best indicators of long-term usage with functional benefits.242–245

Summary This chapter reviews several factors that influence the need for orthotics and adaptive equipment usage in the presence of neurological and neuromuscular disorders. The factors discussed include the functions and roles of structures and systems in both the CNS and the PNS; the impairments that are likely to occur when particular structures or systems are damaged by injury or disease process; abnormalities of tone and muscle performance; influence of impaired motor control on an individual’s ability to move effectively and

10 • Neurological and Neuromuscular Disease Implications for Orthotic Use

efficiently (including ambulation); the likelihood of developing secondary musculoskeletal impairments; and some of the pharmacological and surgical options available to manage hypertonicity and correct deformity that may develop over time. Strategies to determine gait cycle dysfunction in an individual with various neuromotor impairments are explored, as well as the orthotic options that might best address those limitations that the individual faces. This chapter provides a strong foundation for physical therapy examination and considerations for orthotic/equipment prescription. Next, the reader should consider physical

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therapy interventions that follow orthotic acquisition. The following case examples provide an opportunity for readers to focus on wearing, using, and caring for the prescribed orthosis, including (1) strategies to enhance motor learning when a new ambulatory aid (orthosis and/or assistive device) is introduced, (2) practice using the device under various environmental conditions (surfaces, obstacles, people moving within the environment), and (3) the ability to use the orthosis and ambulatory assistive device during functional activities, beyond walking, at comfortable gait speed.

Case Example 10.1 A Young Child With Spastic Diplegic Cerebral Palsy T.H. is a 4-year-old child who was born prematurely at 32 weeks’ gestation and was diagnosed with spastic diplegic cerebral palsy (CP) at 10 months of age. She is being evaluated for potential botulinum A injection as a strategy to manage significant extensor hypertonicity that is increasingly limiting her ability to ambulate as she grows. At present she uses bilateral articulating ankle-foot orthoses with a plantarflexion stop and a posterior rolling walker for locomotion at home and at preschool. Her articulating orthoses allow her to move into some dorsiflexion as she transitions to and from the floor during play. She has difficulty pushing to stand from half-kneel secondary to poor force production of hip and knee extensors. Muscle endurance is impaired, contributing to a crouch gait position, especially as she tires after a full day of activity. She falls frequently when she tries to run. She has been monitored in a CP clinic at the regional children’s hospital; the team is concerned that she is developing rotational deformity of the lower extremities, as well as plantarflexion contracture and forefoot deformity due to her longstanding hypertonicity. QUESTIONS TO CONSIDER

▪ In which subphases of the gait cycle is function or safety

compromised when T.H. ambulates without her orthoses?

▪ In what way does T.H.’s hypertonicity contribute to her

▪ In what ways does T.H.’s inadequate muscle performance

contribute to her difficulty with floor mobility and ambulation? What are the most likely dimensions of muscle performance that are impaired, given her diagnosis of spastic diplegia? ▪ Are there primary or secondary musculoskeletal impairments that are influencing her function and safety during ambulation? How do her age and future growth influence her risk for developing secondary impairments? ▪ Given her constellation of impairments, how can ambulation become more efficient and effective? ▪ What orthotic options (design, components) are available to address T.H.’s impairment of locomotion and related functional limitations? What are the pros and cons of each? ▪ What alternative or concurrent medical (surgical/pharmacological) interventions might assist improvement in safety and function for T.H.? ▪ What additional rehabilitation interventions might assist improvement in function and safety for T.H.? ▪ How do you anticipate T.H.’s orthotic needs might change as she develops and grows? ▪ What outcome measures are appropriate to assess efficacy of orthotic, therapeutic, pharmacological, or surgical intervention for T.H.?

difficulty with floor mobility and ambulation?

Case Example 10.2 A Child With Spastic Quadriplegic Cerebral Palsy J.T. is an 11-year-old boy with significant spastic quadriplegic cerebral palsy (CP) who is in the midst of a preadolescent growth spurt. He currently uses a custom seating system in a wheelchair for assisted mobility at school and in the community. At home he divides his time between an adaptive seating system and using a ceiling-mounted tracking system for assisted standing and mobility. J.T.’s mom reports that it is becoming increasingly difficult to transfer him in and out of the chair and help him with self-care activities because of upper extremity flexor tightness, increasing hip and knee flexion contractures, plantarflexion tightness, and his growing size. In addition, when supine, J.T.’s resting position is becoming more obviously “windswept,” with excessive right hip external rotation and excessive left hip internal rotation, causing a pelvic obliquity and rotation in his spine. He receives physical therapy at school several times each week to help him with functional abilities in the classroom and around school, with additional outpatient visits focusing on improving postural control and muscle performance. Both of his therapists are becoming

concerned about his increasing limitation in range of motion (ROM), as well as the risk for increasing hip rotational deformity and spinal deformity as he grows. His outpatient therapist accompanies J.T. and his mother to the CP orthotics clinic at the regional children’s medical center to explore the possibility of functional bracing or dynamic orthoses, or both, to manage the musculoskeletal complications that are developing because of his spasticity. They also have questions about surgical and pharmacological intervention. QUESTIONS TO CONSIDER

▪ In what way does J.T.’s hypertonicity contribute to his difficulty with mobility/locomotion and other functional activities? ▪ In what ways does J.T.’s impaired muscle performance contribute to his difficulty with functional activities? ▪ In what ways does J.T.’s impaired postural control contribute to his difficulty with locomotion/ambulation? What are the

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Case Example 10.2 A Child With Spastic Quadriplegic Cerebral Palsy (Continued) most likely dimensions of his impairment in postural control, given his diagnosis of spastic quadriplegic CP? ▪ Are any primary or secondary musculoskeletal impairments influencing J.T.’s function and safety during mobility and transfer tasks? ▪ Given his constellation of impairments, what compensatory strategies is J.T. likely to use to accomplish his functional tasks at school and at home? ▪ Which of J.T.’s anticipated or observed impairments are remediable? Which will require accommodation? ▪ What orthotic options (design, components) are available to address J.T.’s impairments and functional limitations? What are the pros and cons of each? ▪ What adaptive equipment options are available to address J.T.’s impairments and functional limitations? What are the pros and cons of each?

▪ Given the pelvic obliquity and spinal rotation, what sec-

ondary musculoskeletal complications need to be monitored as J.T. grows? How might these concerns be addressed by seating or orthoses? ▪ What alternative or concurrent medical (surgical/pharmacological) interventions might assist improvement in safety and function for J.T.? ▪ What additional rehabilitation interventions might assist improvement in function and safety for J.T.? ▪ How do you anticipate J.T.’s orthotic and equipment needs might change as he develops and grows? ▪ What outcome measures are appropriate to assess efficacy of orthotic, equipment, therapeutic, pharmacological, or surgical intervention for J.T.?

Case Example 10.3 A Young Adult With Acquired Brain Injury and Decerebrate Pattern Hypertonicity P.G. is a 17-year-old girl who sustained significant closed-head injury in a motor vehicle accident 3 weeks ago. She was admitted to the brain injury unit at the regional rehabilitation hospital earlier this week. Now functioning at a Rancho Los Amigos Cognitive Level 5 (confused and inappropriate), P.G. exhibits significant decorticate posturing whenever she attempts to move volitionally (right greater than left). She has marked limitations in passive range of motion (ROM) at the elbow and wrist, as well as equinovarus at the ankle, both of which are limiting her ability to stand and effectively propel her wheelchair. While sitting, she falls when she tries to throw a ball to her therapist. Her gait is characterized by large range ballistic extensor thrust throughout stance, which impedes forward progression. She is most focused and responsive to intervention when involved in ambulation-oriented activities. Currently, her hypertonicity is being managed with oral baclofen (Lioresal). However, her therapists are concerned that contracture formation continues. During rehabilitation rounds, the physiatrist, neurologists, and therapists agree that a trial of serial casting should be added to her regimen to enhance her rehabilitation. QUESTIONS TO CONSIDER

▪ In which subphases of the gait cycle is function or safety compromised when G.P. attempts to ambulate?

▪ In what way does G.P.’s hypertonicity contribute to her difficulty with postural control and locomotion/ambulation?

▪ In what ways does G.P.’s impaired muscle performance

contribute to her difficulty with postural control and

locomotion/ambulation? What are the most likely dimensions of her impairment in muscle performance, given her diagnosis of acquired brain injury? ▪ Are any primary or secondary musculoskeletal impairments influencing her function and safety during ambulation? What do you think is likely to develop as she recovers from her head injury? ▪ Given her constellation of impairments, what compensatory strategies is G.P. likely to use to accomplish the task of locomotion? ▪ Which of G.P.’s anticipated or observed impairments are remediable? Which will require accommodation? ▪ What orthotic options (design, components) are available to address G.P.’s impairment of locomotion and related functional limitations? What are the pros and cons of each? ▪ What orthotic options (design, components) are available to address G.P.’s impairment of specific joints? What are the pros and cons of each? ▪ What alternative or concurrent medical (surgical/pharmacological) interventions might assist improvement in safety and function for G.P.? ▪ What additional rehabilitation interventions might assist improvement in function and safety for G.P.? ▪ How do you anticipate G.P.’s orthotic needs might change as she recovers over the next year? ▪ What outcome measures are appropriate to assess efficacy of orthotic, therapeutic, pharmacological, or surgical intervention for G.P.?

Case Example 10.4 Two Individuals With Recent Stroke You work in the short-term rehabilitation unit associated with the regional tertiary care hospital in your area. This week two gentlemen recovering from stroke sustained 3 days ago were admitted to the unit for a short stay in preparation for discharge home. Both indicate that their primary goals at this time are to be able to walk functional distances within their homes, manage stairs to enter/leave the house, and get to bedrooms on the second floor. You anticipate that they will receive intensive

rehabilitation services for 5–8 days, with home care for follow-up after discharge. M.O., 73 years old with a history of hypertension, mild chronic obstructive pulmonary disease, and an uncomplicated myocardial infarction 2 years ago, has been diagnosed with a lacunar infarct within the left posterior limb of internal capsule. On passive motion, he has been given modified Ashworth scores of 3 in his right upper extremity and 2 in his right lower

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Case Example 10.4 Two Individuals With Recent Stroke (Continued) extremity. When asked to bend his knee (when supine), he demonstrates difficulty initiating flexion, and when he finally begins to move, his ankle, knee, and hip move in a mass-flexion pattern; he is unable to isolate limb segments. When asked to slowly lower his leg to the bed, he “shoots” into a full lower extremity synergy pattern. He rises from sitting to standing with verbal and tactile cueing, somewhat asymmetrically, relying on his left extremities. Once upright, he can shift his center of mass (COM) to the midline, holding an effective upright posture, but feels unsteady when shifted beyond midline to the right. With encouragement and facilitation, he can shift weight toward his right in preparation for swing-limb advancement of the left lower extremity, and he is pleased to have taken a few steps, however short, in the parallel bars. Before his infarct, he was an avid golfer and enjoyed bowling. He is fearful that he will never be able to resume these activities. E.B. is a 64-year-old recently retired car mechanic with an 8-year history of diabetes mellitus previously controlled by diet and oral medications who has required insulin since his stroke. Magnetic resonance imaging indicates probable occlusion in the right posteroinferior branch of the middle cerebral artery, with ischemia and resultant inflammation in the parietal lobe. Because E.B. has been afraid of hospitals for most of his life, he resisted seeking medical care as his symptoms began, arriving at the emergency department 12 hours after the onset of hemiplegia. He currently displays a heavy, hypotonic, somewhat edematous left upper extremity. He is unusually unconcerned about the fact that he has had a stroke and tells you that he should be able to function “well enough” when he returns home to his familiar environment. On examination, he demonstrates homonymous hemianopsia, especially of the lower left visual field, and impaired kinesthetic awareness of his left extremities. You observe that he appears to be unaware when his lower upper extremity slips off the tray table of his wheelchair and his fingers become entangled in the spokes of the wheel as he propels forward using his right leg. When assisted to standing in the parallel bars, he does not seem to be accurately aware of his upright position, requiring moderate assistance to keep him from falling to the left. When asked to try to walk forward a few paces, he repeatedly advances his right lower extremity, even when prompted to consider the position and activity of his lower left extremity.

QUESTIONS TO CONSIDER

▪ In what ways are the stroke-related impairments observed in

these two gentlemen similar or different? How can you explain these differences? ▪ In what subphases of the gait cycle is function or safety compromised when each of these gentleman attempts to ambulate? ▪ In what way does each gentleman’s abnormal tone contribute to his difficulty with postural control and locomotion/ ambulation? ▪ In what ways does each gentleman’s impaired muscle performance contribute to his difficulty with postural control and locomotion/ambulation? What are the most likely dimensions of each man’s impairment in muscle performance, given his etiologic condition and location of stroke? ▪ Are any primary or secondary musculoskeletal impairments influencing each man’s function and safety during ambulation? How does each man’s age and concomitant medical conditions influence his risk for developing secondary impairments? ▪ Given each gentleman’s constellation of impairments, what compensatory strategies are likely to be used to accomplish the task of locomotion in each man? ▪ Which of each gentleman’s anticipated or observed impairments are remediable? Which will require accommodation? ▪ What orthotic options are available to address each gentleman’s impairment of locomotion and related functional limitations? What are the pros and cons of each? ▪ What alternative or concurrent medical (surgical/pharmacological) interventions might help improve in safety and function for each individual? ▪ What additional rehabilitation interventions might help improve function and safety for M.O. and E.B.? ▪ How do you anticipate each gentleman’s orthotic needs, which might change as he recovers from central nervous system damage? ▪ What outcome measures are appropriate to assess the efficacy of orthotic, therapeutic, pharmacological, or surgical intervention for each gentleman?

Case Example 10.5 A Young Adult With Incomplete Spinal Cord Injury Z.C. is a 23-year-old man who sustained an incomplete C7 spinal cord injury 3 weeks ago when he lost control and crashlanded during a failed acrobatic stunt during a half-pipe snowboard competition at a local ski resort. After being stabilized on site, he was quickly airlifted to a regional spinal cord injury/ trauma center. Methylprednisolone was administered within 1.5 hours of injury, and his cervical fractures were repaired by fusion (C5 through T1) the day after injury; he now wears a Miami J cervical orthosis. He was admitted to your rehabilitation center 5 days ago. He demonstrates no activity of triceps brachii bilaterally but reports dysesthesia in the C7 and C8 dermatomes and can point his index finger on the left. He is aware of lower limb position in space and can activate toe flexors and extensors, plantarflexors, knee extensors, and hip flexors and abductors at 2 +/5 levels of strength. Deep tendon reflex at the Achilles heel is brisk bilaterally, whereas more proximal lower extremity reflexes are diminished. He demonstrates

positive Babinski reflex bilaterally. Biceps and wrist extensor deep tendon reflexes, initially diminished, are now rated 2 +; the triceps reflex, initially diminished, is now quite brisk. He requires moderate assistance of 1 to come to sitting from supine but can hold a static posture in sitting, demonstrating a limited sway envelope when attempting to shift his weight anteriorly, posteriorly, and mediolaterally. He requires moderate assistance of 1 to rise from seated in his wheelchair to a standing position in the parallel bars. He is determined to “walk” out of the facility on discharge, which is anticipated after 3 more weeks of rehabilitation. QUESTIONS TO CONSIDER

▪ Given Z.C.’s history and present point in recovery from spinal

cord injury, what is the anticipated prognosis concerning his functional performance and ability to ambulate? Continued on following page

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Case Example 10.5 A Young Adult With Incomplete Spinal Cord Injury (Continued)

▪ In what subphases of the gait cycle is function or safety likely to be compromised when Z.C. attempts to ambulate? ▪ In what way does Z.C.’s abnormal tone contribute to his difficulty with postural control and locomotion/ambulation? What strategies would be useful in documenting/assessing the severity and type of his abnormal tone? ▪ In what ways does Z.C.’s impaired muscle performance contribute to his difficulty with postural control and locomotion/ambulation? What are the most likely dimensions of his impairment in muscle performance, given his etiologic condition and level of injury? ▪ Are any primary or secondary musculoskeletal impairments likely to influence Z.C.’s function and safety during ambulation? How do Z.C.’s age and concomitant medical conditions influence his risk for developing secondary impairments? ▪ Given Z.C.’s constellation of impairments, what compensatory strategies is he likely to use to accomplish the task of locomotion?

▪ Which of Z.C.’s anticipated or observed impairments are remediable? Which will require accommodation?

▪ What orthotic options (design, components) are available to

address Z.C.’s difficulty with locomotion and related functional limitations? What are the pros and cons of each? ▪ What alternative or concurrent medical (surgical/pharmacological) interventions might assist improvement in safety and function? ▪ What additional rehabilitation interventions might assist improvement in function and safety for Z.C.? ▪ How do you anticipate Z.C.’s orthotic needs might change as he recovers from his spinal cord injury? ▪ What outcome measures are appropriate to assess the efficacy of orthotic, therapeutic, pharmacological, or surgical intervention for Z.C.?

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Disabilities: A Structural Equation Modeling Analysis. Archives Of Physical Medicine & Rehabilitation [serial online]. January 2018;99 (1):1–8. Weinstein M, Lloyd M, Finch K, Laszacs A. Underappreciated challenges to pediatric powered mobility - Ways to address them as illustrated by a case report. Assistive Technology [serial online]. June 2018;30(2):74–76. Canning B. Innovations in practice. Funding, ethics, and assistive technology: should medical necessity be the criterion by which wheeled mobility equipment is justified? Topics In Stroke Rehabilitation [serial online] Summer. 2005;12(3):77–81. Gulley SP, Rasch EK, Chan L. The complex web of health: relationships among chronic conditions, disability, and health services. Public Health Rep. 2011;126(4):495–507. O’Neil ME, Costigan TE, Gracely EJ, et al. Parents’ perspectives on access to rehabilitation services for their children with special healthcare needs. Pediatr Phys Ther. 2009;21(3):254–260. Effectiveness of intermittent serial casting on spastic wrist flexion deformity in children with cerebral palsy treated by botulinum toxin-A. Developmental Medicine & Child Neurology [serial online]. 59:35. Jain S, Mathur M, Joshi JR, et al. Effect of serial casting in spastic cerebral palsy. Indian J Pediatr. 2008;75(10):997–1002. McNee AE, Will E, Lin JP. The effect of serial casting on gait in children with cerebral palsy: preliminary results from a crossover trial. Gait Posture. 2007;25(3):463–468. Romeiser L. Rehabilitation techniques to maximize spasticity management. Top Stroke Rehabil. 2011;18(3):203–211. Marshall S, Teasell R, Bayona N. Motor impairment rehabilitation post acquired brain injury. Brain Inj. 2007;21(2):133–160. Yaşar E, Tok F, Safaz I, et al. The efficacy of serial casting after botulinum toxin type A injection in improving equinovarus deformity in patients with chronic stroke. Brain Inj. 2010;24(5):736–739. Canavese F, Botnari A, Dubousset J, et al. Serial elongation, derotation and flexion (EDF) casting under general anesthesia and neuromuscular blocking drugs improve outcome in patients with juvenile scoliosis: preliminary results. European Spine Journal [serial online]. February 2016;25(2):487–494. Izquierdo G. Multiple sclerosis symptoms and spasticity management. new data Neurodegenerative Disease Management [serial online]. November 2, 2017;7:7–11. Hughes C, Howard I. Spasticity management in multiple sclerosis. Physical Medicine & Rehabilitation Clinics Of North America [serial online]. November 2013;24(4):593–604. Karri J, Mas M, Francisco G, Sheng I. Practice patterns for spasticity management with phenol neurolysis. Journal Of Rehabilitation Medicine (Stiftelsen Rehabiliteringsinformation)[serial online]. July 2017;49(6):482–488. McGuire J. Intrathecal baclofen for the management of spasticity after a traumatic brain injury. Brain Injury Professional [serial online]. June 2011;8(2):18–20. Management of spasticity with botulinum toxin for patient with stroke – based on ICF framework. Journal Of Rehabilitation Medicine (Stiftelsen Rehabiliteringsinformation) [serial online]. June 2, 2012;47.

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234. Fatone S. Orthotic management in stroke. In: Stein J, Harvey R, Macko R, et al. Stroke Recovery & Rehabilitation. New York: Demos Medical Publishing; 2009:515–530. 235. Lannin NA, Ada L. Neurorehabilitation splinting: theory and principles of clinical use. NeuroRehabilitation. 2011;28(1):21–88. 236. Webster JB, Miknevich MA, Stevens P, et al. Lower extremity orthotic management in neurologic rehabilitation. Crit Rev Phys Rehabil Med. 2009;21(1):1–23. 237. Rehabilitation with Isocentric Reciprocating Gait Orthosis on Functional Ambulation in Patients with Spinal Cord Injury. Journal Of Prosthetics & Orthotics (JPO) [serial online]. April 2017;29 (2):80–87. 238. Arazpour M, Gholami M, Bahramizadeh M, Sharifi G, Bani M. Influence of Reciprocating Link When Using an Isocentric Reciprocating Gait Orthosis (IRGO) on Walking in Patients with Spinal Cord Injury: A Pilot Study. Topics In Spinal Cord Injury Rehabilitation [serial online] Summer2017. 2017;23(3):256–262. 239. Malas BS. What variables influence the ability of an AFO to improve function and when are they indicated? Clin Orthop Relat Res. 2011;469(5):1308–1314. 240. Shipley JS, Shipley RW. Orthotic considerations for pediatric pathologies. J Nurse Life Care Planning. 2010;10(1):213–217. 241. Skalsky A, McDonald C. Prevention and management of limb contractures in neuromuscular diseases. Physical Medicine & Rehabilitation Clinics Of North America [serial online]. August 2012;23 (3):675–687. 242. Swinnen E, Lefeber N, Kerckhofs E, et al. Male and female opinions about orthotic devices of the lower limb: A multicentre, observational study in patients with central neurological movement disorders. Neurorehabilitation [serial online]. January 2018;42(1):121–130. 243. Swinnen E, Lafosse C, Van Nieuwenhoven J, Ilsbroukx S, Beckw
ee D, Kerckhofs E. Neurological patients and their lower limb orthotics: An observational pilot study about acceptance and satisfaction. Prosthetics & Orthotics International (Sage Publications, Ltd.) [serial online]. February 2017;41(1):41–50. 244. Yasukawa A, Malas B, Martin P. Caregiver Satisfaction for Orthotic Management of a Severely Involved Child with Cerebral Palsy Seen at Age 7 Years and 19 Years. Journal Of Prosthetics & Orthotics (JPO)[serial online]. April 2016;28(2):78–82. 245. Fisk J, DeMuth S, Fise T, et al. Suggested Guidelines for the Prescription of Orthotic Services, Device Delivery, Education, and Follow-up Care: A Multidisciplinary White Paper. Military Medicine [serial online]. 181:11–17. 246. Moon Y, Sung J, An R, Hernandez M, Sosnoff J. Gait variability in people with neurological disorders: A systematic review and meta-analysis. Human Movement Science [serial online]. 47:197–208. 247. B€ohm H, Matthias H, Braatz F, D€oderlein L. Effect of floor reaction ankle–foot orthosis on crouch gait in patients with cerebral palsy: What can be expected? Prosthetics & Orthotics International (Sage Publications, Ltd.)[serial online]. June 2018;42(3):245–253. 248. Samadian M, Arazpour M, Ahmadi Bani M, Pouyan A, Bahramizadeh M, Hutchins S. The influence of orthotic gait training with an isocentric reciprocating gait orthosis on the walking ability of paraplegic patients: a pilot study. Spinal Cord [serial online]. October 2015;53(10):754–757.

11

Orthoses for Knee Dysfunction☆ S. TYLER SHULTZ

LEARNING OBJECTIVES

On completion of this chapter, the reader will be able to do the following: 1. Describe the various types and classifications of knee orthoses. 2. Appreciate normal knee function. 3. Identify common knee conditions for which bracing is a component of conservative intervention. 4. Compare and contrast the purposes, indications, and limitations of prophylactic, functional, and rehabilitative knee orthoses. 5. Apply current research evidence to clinical decision making with regard to knee bracing as an intervention, including biomechanical and functional implications. 6. Use evidence of effectiveness to select the most appropriate knee orthosis to a given patient scenario. 7. Provide clinical rationale for utilizing knee orthoses as an intervention for impairments at the tibiofemoral and patellofemoral joints.

Introduction Knee orthoses are used as a common intervention in orthopedic and physical therapy practice, not only for the treatment of knee impairments, but also for injury prevention. The clinical goals of using knee orthoses include pain reduction, joint protection, functional or recreational improvement, and injury prevention. However, the effectiveness of bracing to meet these clinical goals by providing joint unloading, external stability, or patellofemoral tracking is not universally accepted by clinicians.1 Knee orthoses can be organized by their intended function: prophylactic, functional, and rehabilitative knee braces. Prophylactic knee braces are designed and used to protect athletes from sustaining debilitating injuries, usually ligamentous, without inhibiting overall knee function and mobility.2 Prophylactic bracing continues to be used despite inconclusive evidence supporting brace ability to protect the user from injury.2,3 Clinically, these braces tend to be used with individuals who are deemed to be at high risk for knee injury, based on their chosen sport and individual history of previous knee dysfunction. Functional knee orthoses (FKOs) attempt to provide external support and biomechanical stability to the joint. FKOs can be further categorized based on impairment or limitation in knee structure with which they are intended to help. FKOs that are designed for individuals who have ligamentous instability, for example, provide external support that would limit the same knee motion as the ligament. These braces can also serve a rehabilitative function, as seen with patients who have suffered anterior cruciate ligament (ACL) rupture and have undergone surgical repair. ☆

The author extends appreciation to Anthony E. “Toby” Kinney and Ellen Wetherbee, whose work in prior editions provided the foundation for this chapter.

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Furthermore, rehabilitative braces function to provide protection and progressive range of motion (ROM) to the joint (Fig. 11.1). Rehabilitative braces include unloading braces and patellofemoral braces. These braces are used to decrease joint load across the tibiofemoral and patellofemoral joints and reduce pain in the arthritic joint. Orthoses for patellofemoral disorders are rehabilitative braces that often attempt to correct patellar tracking (Fig. 11.2). Each of these different types of braces can be custom-designed for patients or prefabricated. This chapter will describe in further detail the design, function, effectiveness, and clinical decision making involved with the use of these knee orthoses. In order for a clinician to select and prescribe the appropriate knee orthoses for a patient, a patient-centered approach must be used. The clinician needs not only to understand the purpose for bracing, but also to have an underlying mastery of normal knee structure and function. For example, the knee brace prescribed to an individual following a tear of the ACL would be different than the brace used to treat medial knee osteoarthritis (OA). The implications of a pathologic condition of the knee, as well as the functional goals of braces, will be presented. Indications for bracing in the management of patients with knee injury and dysfunction are also discussed. Clinical scenarios will be presented to assist in developing clinical decision-making regarding brace use in different patient presentations.

Anatomy of the Knee The articulations at the tibiofemoral joint and the patellofemoral joint form the knee complex. An understanding of the anatomy and biomechanics of each respective joint is critical in knowing the potential stresses and implications of pathologic conditions of the knee that can occur at the knee complex.

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G

F A

E D

B

C

Fig. 11.1 Example of a common style of postoperative brace. Notice the longer areas of support to the thigh and calf areas. The sidebars are connected with a hinge that allows for limiting or progressing range of motion available at the joint. (Courtesy Breg. Retrieved from https:// www.breg.com/wp-content/uploads/product_images/Post_Op.png.)

Fig. 11.2 Example of an open patella neoprene knee sleeve. (Courtesy of DonJoy)

THE TIBIOFEMORAL JOINT The knee joint is a hinge-like articulation between the medial and lateral condyles of the femur and the medial and lateral tibial plateau (Fig. 11.3). Because of the shape and asymmetry of the condyles, the instantaneous axis of knee flexion/extension motion changes through the arc of motion. As the knee moves from extension to flexion, the instant center pathway moves posteriorly.4 In open chain movements (non–weight-bearing activities), the tibia rotates around the femoral condyles. In closed chain movements (weight-bearing activities), an anatomical locking mechanism is present in the final degrees of extension as

Fig. 11.3 In this view of the surface of the tibia, we can identify the medial collateral ligament (A), the C-shaped medial meniscus on the large medial tibial plateau (B), the posterior cruciate ligament with the accessory anterior and posterior meniscofemoral ligaments (C), the tendon of the popliteus muscle (D), the circular lateral meniscus on the smaller lateral tibial plateau (E), the anterior cruciate ligament as it twists toward the inside of the lateral femoral condyle (F), and the transverse ligament (G). (From Greenfield BH. Rehabilitation of the Knee: A Problem Solving Approach. Philadelphia: FA Davis; 1993.)

the longer medial femoral condyle rotates medially on the articular surfaces of the tibia. Consequently, if the instant center of pathway changes, it will alter the optimal joint mechanics and therefore result in abnormal knee stressors. The alignment between an adducted femur and relatively upright tibia creates a vulnerability to valgus stress in many weight-bearing activities. The capsule that encases the knee joint is reinforced by the collagen-rich medial and lateral retinaculum. The medial and lateral menisci rest on the tibial plateau. They are fibrocartilaginous, nearly ring-shaped disks that are flexibly attached around the edges of the tibial plateau (see Fig. 11.3). These menisci increase the concavity of the tibial articular surface, enhancing congruency of articulation with the femoral condyles to facilitate normal gliding and distribute weight-bearing forces within the knee during gait and other loading activities.5 The menisci also play an important role in nutrition and lubrication of the articular surfaces of the knee joint. Stability to the tibiofemoral joint is provided by sets of ligaments. The medial (tibial) collateral ligament (MCL) and the lateral (fibular) collateral ligament (LCL) are extrinsic ligaments. The collateral ligaments counter valgus and varus forces that act on the knee. In addition, two intrinsic ligaments of the tibiofemoral joint, the ACL and the posterior cruciate ligaments (PCL) check translatory forces that displace the tibia on the femur. The location of attachments makes each of these ligaments most effective at particular points in the knee’s normal arc of motion.5 Additionally, contraction of the quadriceps and knee flexor muscle groups produce compressive forces that help stabilize the knee. Muscles of the hip and lower leg also make contributions to the mechanics of the femur and tibia, respectively, which impact the movements of the knee complex.

Medial Collateral Ligament The MCL is a strong, flat membranous band that overlays the middle portion of the medial joint capsule (Fig. 11.4).

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Intercondylar notch

Iliopatellar band

Biceps femoris

Medial collateral ligament

A

Iliotibial band

Lateral collateral ligament

Anterior

Posterior

cruciate

cruciate Medial

Lateral

collateral

collateral

ligament

ligament

Transverse

B

Fig. 11.4 (A) A medial view of the right knee showing structures that provide medial support to the right knee. (B) A lateral view of the right knee illustrating structures that give lateral support to the knee. (Reprinted with permission from Levangie PK, Norkin CC. The knee. In: Joint Structure and Function: A Comprehensive Analysis, 3rd ed. Philadelphia: FA Davis; 2017.)

ligament of meniscus

A

It is most effective in counteracting valgus stressors when the knee is slightly flexed to fully extended. Approximately 8 to 10 cm in length, it originates at the medial epicondyle of the femur and attaches to the medial surface of the tibial plateau. The MCL can be subdivided into a set of oblique posterior fibers and anterior parallel fibers. A bundle of meniscotibial fibers, also known as the posterior oblique ligament, runs deep to the MCL, from the femur to the midperipheral margin of the medial meniscus and toward the tibia. These fibers connect the medial meniscus to the tibia and help form the semimembranosus corner of the medial knee. Additionally, the medial patellar retinacular fibers play a reinforcing role.6

Lateral Collateral Ligament and Iliotibial Band The LCL resists varus stressors and lateral rotation of the tibia and is most effective when the knee is slightly flexed. The LCL runs from the lateral femoral condyle (the back part of the outer tuberosity of the femur) to the proximal lateral aspect of the fibular head (see Fig. 11.4). The tendon of the popliteus muscle and the external articular vessels and nerves pass beneath this ligament. Another lateral structure that acts on the knee complex is the iliotibial band (ITB). The ITB is positioned slightly anterior to the LCL and is taut in all ranges of knee motion. Its lateral position allows it to stabilize against varus forces along with the LCL. Anterior Cruciate Ligament The ACL runs at an oblique angle between the articular surfaces of the knee joint and prevents forward shift and excessive medial rotation of the tibia as the knee moves toward extension (Fig. 11.5). The ACL attaches to the tibia in a fossa just anterior and lateral to the anterior tibial spine and to the femur in a fossa on the posteromedial surface of the lateral femoral condyle. The ACL’s tibial attachment is somewhat wider and stronger than its femoral attachment. Some authors divide the fasciculi that make up the broad, somewhat flat ACL into two or three distinct bundles. The ligament’s anteromedial band, with fibers running from the

Posterior

Anterior

cruciate

cruciate Lateral collateral

Medial

ligament

collateral ligament

B Fig. 11.5 (A) Anterior view of the tibiofemoral joint in 90 degrees of knee flexion showing the menisci and the ligamentous structures that stabilize the knee. (B) Posterior view of the knee in extension. (Reprinted with permission from Antich TJ. Orthoses for the knee; the tibiofemoral joint. In: Nawoczenski DA, Epler ME, eds. Orthotics in Functional Rehabilitation of the Lower Limb. Philadelphia: Saunders; 1997.)

anteromedial tibia to the proximal femoral attachment, is most taut in flexion and relatively lax in extension. The posterolateral bulk (PLB), which begins at the posterolateral tibial attachment, is most taut in extension and relatively lax in flexion. An intermediate bundle of transitional fibers between the anteromedial band and PLB tends to tighten when the knee moves through the midranges of motion. This arrangement of fibers ensures tension in the ACL throughout the entire range of knee motion. The ACL is most vulnerable to injury when the femur rotates internally on the tibia when the knee is flexed and the foot is fixed on the ground during weight-bearing activities.7

Posterior Cruciate Ligament The PCL restrains posterior displacement of the tibia in its articulation with the femur, especially as the knee moves

11 • Orthoses for Knee Dysfunction

toward full extension.5 The PCL is shorter and less oblique in orientation than the ACL; it is the strongest and most resistant ligament of the knee. PCL fibers run from a slight depression between articular surfaces on the posterior tibia to the posterolateral surface of the medial femoral condyle (see Figs. 11.3 and 11.5). Like the ACL, the PCL can be divided into anterior and posterior segments. The larger anterior medial band is most taut between 80 and 90 degrees of flexion and is relatively lax in extension. The smaller PLB travels somewhat obliquely across the joint, becoming taut as the knee moves into extension. The PCL plays a role in the locking mechanism of the knee as tension in the ligament produces lateral (external) rotation of the tibia on the femur in the final degrees of knee extension. The PCL may also assist the collateral ligaments when varus or valgus stressors are applied to the knee.5 Coursing along with fibers from the MCL is the meniscofemoral ligament, which stretches between the posterior horn of the lateral meniscus and the lateral surface of the medial femoral condyle. The anterior meniscofemoral band (ligament of Humphry) runs along the medial anterior surface of the PCL and may be up to one third its diameter. The posterior meniscofemoral band (ligament of Wrisberg) lies posterior to the PCL and may be as much as one half its diameter. The meniscofemoral ligaments pull the lateral meniscus forward during flexion of the weight-bearing knee to maintain as much articular congruency as possible with the lateral femoral condyle.

POSTEROLATERAL CORNER OF THE KNEE The lateral meniscus is somewhat more mobile than the medial meniscus because of the anatomy of the posterolateral corner of the knee. The arcuate complex and posterolateral corner run from the styloid process of the fibula, joining the posterior oblique ligament on the posterior aspect of the femur and tibia. The arcuate ligament is firmly attached to the underlying popliteus muscle and tendon. The tendon of the popliteus muscle separates the deep joint capsule from the rim of the lateral meniscus.

PATELLOFEMORAL JOINT The patella, a sesamoid bone embedded in the tendon of the quadriceps femoris, is an integral part of the extensor mechanism of the knee. The patella functions as an anatomical pulley, increasing the knee extension moment created by contraction of the quadriceps femoris by as much as 50%. It also guides the forces generated by the quadriceps femoris to the patellar ligament, protects deeper knee joint anatomy, protects the quadriceps tendon from frictional forces, and increases the compressive forces to which the extensor mechanisms can be subjected.5 Although the anterior surface of the patella is convex, the posterior surface has three distinct anatomical areas: a lateral, medial, and odd facet. The lateral and medial facets are separated by a vertical ridge. The odd facet articulates with the medial condyle at the end range of knee extension (Fig. 11.6). The posterior patellar surface is covered with hyaline articular cartilage, except for the distal apex, which is roughened for the attachment of the patellar tendon. Pressure between the patella and trochlear groove of the femur increases substantially as the knee flexes. During knee

297

Patella

Femur Lateral

Medial

A Superior Vertical ridge

Medial

Lateral Odd facet

B

Inferior

Fig. 11.6 (A) The normal position of the patella in the intercondylar groove of the distal femur. (B) Underside of the patella with its three facets and vertical ridge. (Reprinted with permission from Belyea BC. Orthoses for the knee: the patellofemoral joint. In: Nawoczenski DA, Epler ME, eds. Orthotics in Functional Rehabilitation of the Lower Limb. Philadelphia: Saunders, 1997.)

flexion, the patella moves in a complex but consistent three-dimensional pattern of flexion/extension rotation, medial/lateral rotation, medial/lateral tilt, and a medial/lateral shift relative to the femur.8,9 These motions occur biomechanically in the X, Y, and Z planes. The stability of the patella is derived from the patellofemoral joint’s static structural characteristics and dynamic (muscular) control. Static stability is a product of the anatomy of the patella – the depth of the intercondylar groove, and the prominent and longer lateral condyle of the femur. The sulcus angle, formed by the sloping edges of the condyles, is normally between 114 and 120 degrees; however, it can vary significantly from person to person.10 Wiberg11 divides the patellofemoral joint into six types based on the size and shape of facets (Table 11.1). The depth of the patellar trochlea and the facet pattern are important in patellar stability. Dynamic stability of the patellofemoral joint is derived primarily from activity of the quadriceps femoris as well as from the tensile properties of the patellar ligament (Fig. 11.7). The four components of the quadriceps muscle act together to pull the patella obliquely upward along the shaft of the femur, whereas the patellar ligament anchors it almost straight downward along the anatomical axis of the lower leg. The tibial tubercle is typically located at least 6 degrees lateral to the mechanical axis of the femur.

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Table 11.1 Classification of Patellar Types, Listed From Most to Least Stable Patellar Type

Description

I

Equal medial and lateral facets, both slightly concave

II

Small medial facet, both facets slightly concave

II/III

Small, flat medial facet

III

Small, slightly convex medial facet

IV

Very small, steeply sloped medial facet with medial ridge

V (Jagerhut)

No medial facet, no central ridge

Major guiding forces acting on the patella Overall line of force of the quadriceps

MEDIAL DIRECTED FORCES

LATERAL DIRECTED FORCES

Vastus medialis (oblique fibers)

Iliotibial band

Raised lateral facet of the trochlear groove

Bowstringing force on the patella Lateral patellar retinacular fibers

Medial patellar retinacular fibers

Patellar tendon force

Fig. 11.7 A schematic diagram of structures that act on the patella. (Reprinted with permission from Neumann DA. Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation. 3rd ed. St. Louis: Mosby Elsevier, 2017.)

Because the structure of the patellofemoral articulation and the muscular/ligamentous forces that act on the patella are complex, patellar dynamics involve much more than simple cephalocaudal repositioning as the knee is flexed or extended. Van Kampen and Huiskes9 describe the threedimensional motions of the patella as flexion rotation, medial rotation, wavering tilt, and lateral shift. All of these patellar movements (except flexion) are influenced by the rotation of the tibia and the dynamic stabilization of the muscles that act on the patella.

Biomechanics of Knee Motion Although it is beyond the scope of this chapter to comprehensively cover the biomechanics of knee motion, it is important to have a basic foundation of knee biomechanics to understand the use of knee orthoses as an intervention for pathologic conditions of the knee. Evaluating and managing injuries of the knee requires an in-depth understanding of the biomechanical characteristics of the knee joint. The kinematics of the knee describe its motion in terms of the type

and location and the magnitude and direction of the motion. The kinetics of the knee describe the forces that act on the knee, causing movement.5 Kinetic forces are classified as either external forces that work on the body (e.g., gravity) or as internal body-generated forces (e.g., friction, tensile strength of soft tissue structures, muscle contraction). Motion in the tibiofemoral joint can be best understood by separating the motion into its physiological and accessory components. Physiological motion can be controlled consciously, most often through voluntary contraction of muscle. Osteokinematic (bone movement) and arthrokinematic (joint surface motion) are examples of physiological motion. Accessory motion occurs without conscious control and cannot be reproduced voluntarily. Joint play, which is elicited by passive movement during examination of a joint, is an example of an accessory motion. The magnitude and type of accessory motion possible are determined by the characteristics of a particular articulation and the properties of the tissues that surround it. The arthrokinematics of the tibiofemoral joint will vary depending upon whether the lower extremity is in a weight-bearing or loaded position. For example, with tibial-femoral extension the tibia moves anteriorly relative to the femur, and with femoral-tibia extension the femoral condyles slide from anterior to posterior, while rolling anteriorly.6 One of the important accessory component motions of the tibiofemoral joint is its screw home or locking mechanism. In the final degrees of knee extension, the tibia continues to rotate around the large articular surface of the medial femoral condyle. This motion cannot be prevented or changed by volitional effort; it is entirely the result of the configuration of the articular surfaces. When the knee is flexed to or beyond 90 degrees, however, conscious activation of muscles can produce physiological (osteokinematic) external (lateral) or internal (medial) rotation of the tibia on the femur. Three osteokinematic motions are possible at the tibiofemoral joint. Knee flexion/extension occurs in the sagittal plane around an axis in the frontal plane (x-axis). Internal/external rotation of the tibia on the femur (or vice versa) occurs in the transverse plane around a longitudinal axis (y-axis). Abduction and adduction occur in the frontal plane around a horizontal axis (z-axis). The arthrokinematic movements of the tibiofemoral joint are rolling, gliding, and sliding (Fig. 11.8). It is important to note that the roll-glide ratio is not constant during tibiofemoral joint motion: Approximately 1:2 in early flexion, the roll-glide ratio becomes almost 1:4 in late flexion.12 Rolling and gliding occur primarily on the posterior portion of the femoral condyles. In the first 15 to 20 degrees of flexion, a true rolling motion of the femoral condyles occurs in concert with the tibial plateau. As the magnitude of flexion increases, the femur begins to glide posteriorly on the tibia. Gliding becomes more significant as flexion increases. From a kinematic standpoint, the ACL and PCL operate as a true gear mechanism controlling the roll-glide motion of the tibiofemoral joint. With rupture of either or both of the cruciate ligaments, the gear mechanism becomes ineffective, and the arthrokinematic motion is altered. In an ACL-deficient knee, the femur is able to roll beyond the posterior half of the tibial plateau, increasing the likelihood of damage or tear of the posterior horn of the medial or lateral meniscus.

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11 • Orthoses for Knee Dysfunction

Posterior rolling

Fig. 11.8 Diagram of femoral motion on a fixed tibia. (A) As the knee flexes, the femoral condyles roll posteriorly (curved arrow) while gliding/sliding forward (straight arrow). (B) As the knee extends, the condyles roll forward (curved arrow) while gliding posteriorly (straight arrow). (From Hartigan E, Lewek M, SnyderMackler L. The knee. In: Levangie PK, Norkin CC [eds], Joint Structure and Function: A Comprehensive Analysis, 5th ed. Philadelphia: David, 2011, p. 355.)

Anterior rolling

Femur

Anterior sliding

Posterior sliding

Tibia fixed

A

Motion of the femoral condyles during flexion

Because the knee has characteristics of a hinge joint and an arthrodial joint, two types of motion (translatory and rotatory) can occur in each plane of motion (sagittal, frontal/coronal, transverse). For this reason, knee motion is described as having six degrees of freedom. The three translatory motions of the knee include anteroposterior translation of 5 to 10 mm, mediolateral translation of 1 to 2 mm, and compression-distraction motion of 2 to 5 mm. The three rotatory motions occur in flexion/extension, varus/valgus, and internal (medial)/external (lateral) rotation.5,12

Motion of the femoral condyles during extension

B

B

2

A

Knee Orthoses Components Commercially available knee orthoses are comprised of different components, depending on the purpose of the brace (Fig. 11.9). Braces to unload or protect the joint will likely have some type of sidebar support and connect with either a freely moving hinge or one that can be set to limit knee ROM (see Fig. 11.1). Sidebars can be constructed of plastic, metal, or a composite substance. Sidebars can prevent varus and valgus motion at the joint. Straps are provided to help secure the brace to the lower extremity, often utilizing hookand-loop closure. Other orthoses may include components that rest on the anterior or posterior aspect of the lower leg to limit anterior or posterior translation of the tibia, an important treatment consideration following cruciate ligament injury.

Prophylactic Knee Orthoses Knee injuries are extremely common, accounting for at least 60% of sporting injuries.1 Among knee injuries in athletes, soft tissue injury to knee ligaments are of particular concern. Ligamentous injury often results in extensive lost playing time and cost due to surgical repair and rehabilitation. Prophylactic knee orthoses (PKOs) are knee braces that are designed to mitigate or altogether prevent soft tissue injury, usually ligamentous, to the healthy knee (Fig. 11.10). However, the use of these braces for injury

1

D

3

C

Fig. 11.9 The components of most commercially available rehabilitation knee orthoses include open cell foam interface that encases the calf and thigh (A); a nonelastic adjustable Velcro strap for closures (B); lightweight metal, composite, or plastic sidebars (C); and single-axis or polycentric hinge that can be locked or adjusted to allow or restrict motion (D) within the therapeutically desired range of motion. The force systems of these orthoses apply a pair of anteriorly directed forces at the proximal posterior thigh (1) and distal posterior calf (3), against a posteriorly directed force (2) applied over or on either side of the patella. Varus and valgus stressors are resisted by the sidebars. (Reprinted with permission from Redford JB, Basmajian JV, Trautman P. Lower limb orthoses. In: Orthotics: Clinical Practice and Rehabilitation Technology. New York: Churchill Livingstone, 1995;195:230.)

prevention purposes continues to be debated in scientific literature.1 PKOs are nonadhesive devices that are external to the joint itself. Usually worn by athletes, these braces are designed to prevent injury to the soft tissue structures of the knee from contact or noncontact injuries. It is important to note that there is significant variation in brace design

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Fig. 11.10 CTi Custom Knee Brace from Ossur. Example of a custom fit PKO. This brace is custom fabricated for a more precise fit. This brace can be further individualized based on the physical activity require€ ments of the patient. (© Ossur.)

among manufacturers, but the basic goal of ligament protection remains the same despite design. To prevent injury to the MCL or LCL, a brace would need to limit the amount of valgus or varus force, respectively, that the joint receives. For ACL protection, the PKO needs to limit anterior tibial translation forces. For clinicians, understanding the design and intended purpose of a brace in conjunction with the physical demands of the athlete’s sport is critical to prescribing an appropriate PKO.

BIOMECHANICAL IMPLICATIONS The application of a PKO can have effects on joint kinetics and kinematics, proprioception of the knee joint, as well as muscle activation, limb stiffness, and athletic performance. Specific brace design may have an impact on any or all of these factors in a healthy knee.13 Noncontact ligamentous knee injuries often occur when an athlete makes a cutting maneuver or lands on a hard surface after jumping, such as with a basketball rebound. Ewing et al.14 examined the effects of simulating a jump landing from various heights on lower extremity joint kinetics among healthy athletes with and without prophylactic bracing. The results indicate that bracing altered hip flexion angle at initial contact and peak dorsiflexion angle, notably more in female athletes than in male athletes. These results are significant, as the hip and ankle have been shown to play a crucial role in decelerating the center of mass and protecting the knee during landing. The increase in hip flexion angle observed in this study could serve to protect the ACL during landing, especially in female athletes. The authors observed that ground reaction forces (GRFs) were not altered by the use of a PKO. Other significant observations included increases in peak hip extension moment,

peak hip negative power, and hip negative work that were observed with PKO use. Sinclair et al.3 examined the effects of PKO use on knee joint kinetics and kinematics during netball specific movements. Netball is physically demanding and is characterized by high-level athletic movements such as jumping and cutting performed on a hardwood surface. The authors examined joint kinetics during running, jumping, and cutting maneuvers in athletes with and without PKO. They found that joint kinetics showed no significant change in braced or unbraced conditions. They did however observe significant reduction in transverse plane kinematics—internal and external rotation ROM—when wearing the brace during all maneuvers. Less significantly, the test subjects reported increased perceived knee stability. Mortaza et al.2 examined the isokinetic force production of knee flexion and extension in healthy subjects wearing a PKO, neoprene sleeve, or no brace. The authors reported no effect of bracing on the subject’s muscle strength and power during flexion and extension movements. Although the PKO did not enhance muscle performance, the finding that the PKO did not diminish muscle performance is significant. Baltaci et al.13 found that across five different types of PKOs, maximal muscle force was enhanced. It is believed that the reduction in ROM produced by these braces allowed for an increase in maximal force production. The differences in muscle performance reported by the Mortaza and Baltaci studies may be due to the difference in assessment method. Whereas Mortaza et al.2 examined muscle performance with isokinetic testing, Baltaci et al.13 examined force produced during closed chain knee extension force production only. One proposed model for how PKOs can provide stability to the knee is by increasing lower limb muscle stiffness. Ewing et al.15 found an increase in active stiffness of the hamstrings and vasti muscles during landing procedures in healthy individuals. Hobara et al.16 found that PKO use increased lower limb stiffness during hopping as compared with no brace but not significantly different than when individuals used an ankle brace. These findings suggest that muscle activation patterns are not altered with brace use but decrease lower limb muscle stiffness.15,16 The connection between lower limb muscle stiffness and ligament protection is not well understood at this time. Proprioception is highly complex and involves the coordination of multiple receptors found in the joint capsule, ligaments, and skin with the central nervous system. Lack of proprioception is thought to be related to episodes of instability and joint injury.17,18 Increasing proprioception of a joint through the use of a brace may reduce injury risk by improving overall joint control.17 A review by Dargo et al.19 found that the addition of neuromuscular and proprioceptive exercises to a prevention program decreased the incidence of knee injury and ACL rupture. The addition of proprioceptive and neuromuscular exercises to an ACL rehabilitation program can help prevent injury recurrence.20 Bottoni et al.17 tested proprioception by comparing athletes’ ability to determine movement at the knee without a brace, with a PKO, and with a neoprene sleeve. This repeated-measures study found that the use of a PKO or a neoprene sleeve had no influence, either positively or

11 • Orthoses for Knee Dysfunction

negatively, on the proprioception of the knee. However, the test subjects were not tested in a weight-bearing position; applying these findings to closed chain or athletic movements is difficult. Baltaci also examined proprioception in healthy individuals wearing PKOs, however they tested in a weight-bearing position. The authors report an enhancement in knee proprioception with five different PKOs compared with an unbraced condition.13 In a systematic review and meta-analysis performed by Ghai et al.,21 the effects of PKOs on joint proprioception and stability were reported. The authors report that conflicting evidence exists to support the notion that PKOs have an effect on joint proprioception. Several high-quality studies report enhancements in proprioception, whereas negligible effects were reported in others. These results speak to the impact that different PKO designs can have on knee function.

EVIDENCE OF EFFECTIVENESS When considering the use of a PKO in a healthy patient population, it is important to consider that there is no published data available on the role of bracing in preventing ligamentous injury in healthy knees.22 As previously discussed, the effects these braces have on joint kinematics, proprioception, and muscle performance should not hinder a healthy athlete’s performance, so any additional ligamentous protection gained from brace use would be beneficial. However, the use of bracing has been advocated in athletes who are determined to be at high risk for ligamentous knee injury or in those individuals who are ACL deficient or have ACL reconstructed knees. Intrinsic risk factors include a narrow intercondylar notch, weak ACL, generalized joint laxity, lower extremity alignment, and gender—with women being more at risk than men.23 Extrinsic risk factors include quadriceps and hamstring strength imbalances, altered neuromuscular control, and the athlete’s playing style and surface.23 In a systematic review by Bodendorfer et al.,1 several factors for identifying at-risk population are identified: being between the ages of 13 and 18, and participating in pivoting and jumping sports (basketball, football, soccer, and skiing among others). The authors conclude that this population may benefit from prophylactic bracing but recognize the limitation in available data at this time. In individuals who are ACL deficient, bracing can be an effective way to prevent further injury that could be sustained for extra anterior tibial translation. Bracing following ACL reconstruction and its efficacy is further discussed later in the chapter. Two large scale epidemiological studies have examined the injury rates among football players wearing PKOs.24,25 Both studies found that bracing can be effective in preventing MCL injury in football players. Sitler et al.25 found that although the brace may reduce MCL injury rate, it did not significantly affect severity when an injury was sustained. The Albright et al.24 study also supported prophylactic bracing for MCL injury prevention in football players, especially in linemen and linebackers. These individuals would be considered at high risk based on the criteria set forth by Bodendorfer et al.1 A more recent systematic review by Salata et al.26 found that bracing did not have a significant effect on MCL injury rate in football players, and cited a lack of evidence to support PKO use in the healthy population.

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Potential negative effects of PKO use are not fully understood. An older study by Highgenboten et al.27 found increased metabolic demand in individuals wearing knee braces, which was related to the weight of the brace. Brace design has continued to evolve in response, using more light-weight materials to reduce the metabolic demands associated with brace use. Further research to determine the metabolic demands of newer, lightweight braces is warranted. Additionally, healthy patients who wear PKOs often report an increased sense of security.3 This sense of security may be false, as the ability for these braces to prevent injury in healthy individuals is not fully understood.

RECOMMENDATIONS In some individuals, brace use may increase not only muscle performance, but also increase lower limb stiffness and knee proprioception without significantly changing joint kinetics.2,3,13-15 Currently, there is a lack of current research to suggest that PKOs significantly reduce knee function, or reduce ligamentous injury risk. In a normal healthy population, PKO use is not warranted based on the available literature at this time. However, in those individuals identified as high risk for ACL injury, bracing may offer a viable way to reduce injury risk and should be recommended. Clinicians should recognize individuals who are high risk and prescribe an appropriate PKO in an effort to mitigate injury risk.

Orthoses for Anterior Cruciate Ligament Insufficiency The anterior and posterior cruciate ligaments function to provide stabilization of the knee joint in multiple directions. The ACL attaches superiorly to the femur on the posterior medial aspect of the lateral condyle. Distally, the ACL attaches anteriorly and laterally to the intercondylar notch of the tibia. The primary role of the ACL is to limit anterior translation of the tibia on the femur, and the PCL functions to limit posterior translation of the tibia on the femur.28 Additionally, the ACL provides some stability in the transverse and frontal planes, limiting both tibial rotation and abduction.28 Besides these mechanical functions, the ACL also plays an important role in knee joint proprioception.29 The critical function of the cruciate ligaments from a mechanical and proprioceptive perspective is complex, and beyond the scope of this chapter. However, a basic understanding of the joint mechanics is necessary to appreciate the design and function of orthoses, as well as prescribing appropriate devices to individuals with ACL injury. As discussed previously in this chapter, the purpose of a PKO is to prevent injury to the soft tissue structures of the knee from contact or noncontact injuries. In the event that an injury to the ligamentous support structures of the knee does occur, an FKO is often prescribed (Fig. 11.11A). The purpose of an FKO is to provide the mechanical stabilization that is usually provided by intact support structures. For example, a patient who has suffered an ACL rupture may be provided with a brace to prevent anterior translation of the tibia. Utilizing an FKO can serve two main purposes: First, it may be used to protect the joint from further injury

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Fig. 11.11 (A) Axiom Elite Ligament Knee Brace by Breg. Example of a knee brace that could be used for either prophylactic purposes or following collateral ligament repair. The rigid metal frame and dual hinges provide support and protection. (B) Rebound ACL Brace by Ossur. Example of a knee brace that is used for nonsurgical treatment of ACL rupture or following surgery for ACL reconstruction. (A, Courtesy Breg. Retrieved from: https://www. € breg.com/wp-content/uploads/product_images/Axiom_Elite_Standard_Straight-001-705x705.png. B, © Ossur.)

that may occur due to the lack of ligamentous support. The chronic instability and altered kinematics may lead to increased injury risk of other ligaments, the meniscus, or the articular cartilage.6 Secondly, an FKO can be used to protect a surgical repair of a ligament or other support structure in the knee while it heals or during athletic activities.

ACL INSUFFICIENCY ACL injuries are the most common ligamentous knee injuries.1,29 Due to the complex role of the ACL in mechanical stabilization and proprioception, individuals who are ACL deficient often report symptoms of instability and “giving way” in the knee. Although many individuals elect to undergo surgical repair of the ACL, there is a subset of the population that is able to return to previous levels of function without an intact ACL. This group is collectively known as “copers,” whereas those with continued reports of instability are deemed non-copers. FKO use in copers would serve the purpose of protecting the joint from further injury by providing an external mechanical force to the joint to replicate the normal function of the ACL (see Fig. 11.11B). Several studies have explored the ability of an FKO to replicate those normal functions.

Biomechanical Implications Giotis et al.30 examined the effects of bracing on tibial rotation during high load activities in ACL patients. By comparing the ACL intact knee to the ACL-deficient knee during several different tasks, the authors were able to determine if excessive tibial rotation was occurring and if bracing could potentially limit those effects. Subjects were tested during stair descent with pivoting, and a drop landing followed

by a pivot. The results of this analysis reveal that there is increased tibial rotation in the ACL-deficient knee compared with the intact knee, and that bracing the deficient knee resulted in a significant decrease in tibial rotation. Jalali et al.31 used video fluoroscopy to examine the effect that knee bracing has on anterior tibial translation during lunging in individuals who are ACL deficient. In this study, the braces used were custom fabricated but were characteristic of an FKO. No significant differences were reported for anterior tibial translation in braced and unbraced conditions. This lack of findings is significant as often the purpose of an FKO is to provide the anterior stability of the knee lost by ACL rupture. Additionally, one might assume that a custom fabricated FKO would be superior in providing this support as compared to an off-the-shelf brace. Pierrat et al.32 also examined the ability of FKOs to reduce anterior tibial translation in individuals who are ACL deficient. Contrary to the Jalali et al.31 study, the authors examined the amount of anterior translation during low grade loads and used off-the-shelf braces. They found that at a low force, which resulted in low anterior displacement, an FKO can replace the mechanical role of the ACL.32 However, they determined that an FKO cannot fully replace the role of the ACL, as braces generally reach a firm “stop” in a linear manner, whereas the intact ACL increases stiffness as load increases in a nonlinear manner. It is likely that these braces are not effective for higher knee loads or activities that produce higher levels of anterior tibial displacement, although further research is necessary.

Functional Implications Palm et al.29 studied the effect of ACL deficiency on knee joint proprioception and postural control. They reported a

11 • Orthoses for Knee Dysfunction

significant difference in overall postural stability between injured and noninjured knees, with injured knees having less stability. Fernandes et al.33 also found decreased postural control in ACL-deficient athletes during static and dynamic activities. The Palm et al. study examined the effect of a commercial knee sleeve, which consisted mainly of a compressive sleeve with patellar pads. After application of the sleeve, the authors noted an increase in overall postural stability by nearly 22%, finding that this increased postural control to a level similar to that of the uninjured knee.29 Clinically, a bulkier FKO is often used to manage patients who have isolated ACL deficiency. The results of this study indicate that a simple sleeve can improve the overall stability and postural control in these individuals and may be sufficient when compared with bulkier FKOs. Mortaza et al.34 examined the effect that FKOs have on the isokinetic muscle performance and functional performance in individuals who have ACL-deficient knees. Functional tests included single-leg crossover hopping distance and vertical jump height. The results indicated that FKO use did not have any positive or negative effect on knee performance in either of the examined groups. However, small effects of the brace on peak knee extension torque and power were measured. The authors conclude that although not statistically significant, these findings have rehabilitation implications in reducing muscle function asymmetry during the rehabilitation process.

Recommendations Although these studies demonstrate that an FKO does not limit the anterior tibial translation that often causes a feeling of joint instability, they may still be helpful by increasing postural stability and proprioception.29,31,32 Additionally, they may also be helpful for low-load activities or when limiting tibial rotation to avoid further injury is the main goal of use.1,32,35 It is important to remember an FKO cannot match the nonlinear stiffening exhibited by the healthy ACL as demand is increased.32 Therefore it is important for the clinician to consider the use of FKOs in the rehabilitation of ACLdeficient individuals. For example, if an individual is planning to undergo ACL repair, and the goal is to limit the subjective feeling of instability, a brace may be useful to increase postural stability and proprioception. In the preoperative ACL patient, a simple sleeve can often provide this support without the bulkiness of a traditional FKO.29 In those individuals who elect to not have surgery to repair the ACL, bracing can provide support for low-level activities, but likely not enough external support for high loading activities.

POSTOPERATIVE ACL RECONSTRUCTION Immediately after surgery for ACL reconstruction, current practice is to provide bracing to protect the quadricepsinhibited knee from a sudden flexion moment in weight bearing.36,37 For this reason many surgeons opt to prescribe an FKO for the purpose of protecting the surgical repair from re-rupture. Over the course of rehabilitation, bracing may serve the additional purpose of providing more stability as the patient progresses to more intense exercise or sport specific training.37 Despite being common practice, FKO use during the rehabilitation phase following ACL repair has become more controversial over the past years as more

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information is gathered about the effect bracing has on the ACL-reconstructed knee.36

Biomechanical Implications In an in vivo, prospective controlled study, Giotis et al.30 collected data on the amount of tibial rotation present during high-loading activities in ACL-reconstructed knees. Tibial rotation was measured during immediate pivoting after stepping down from a stair and immediate pivoting after landing from a jump down from a step. The researchers measured tibial rotation in both the operative and nonoperative knees, with a knee sleeve, a knee orthosis, and no bracing. It was determined that excessive tibial rotation remains during dynamic pivoting maneuvers following ACL reconstruction, and bracing can reduce this rotation, but does not restore normative function. This study protocol was used to examine the same effects in individuals who are ACL deficient and found similar results.35 It is important to consider that this study used only male participants who had bone-patellar tendon-bone graft, and who were on average 26 months postoperative.30 It may be difficult to apply these findings to females or other graft types, however, it is important to consider the long-term effects on tibial rotation following ACL injury. In a follow-up study, Giotis et al.38 examined the same outcomes in individuals who underwent ACL repair with a hamstring tendon graft. Again, only male patients who were a minimum of 24 months postoperative were examined. In this population a similar finding was reported; tibial rotation during high-level dynamic activities was reduced when wearing a brace but not to the extent of a healthy ACL. In both graft types, using an orthosis resulted in superior outcomes as compared to the knee sleeve, and the knee sleeve was superior to the unbraced condition.30,38 Limiting anterior tibial translation in addition to tibial rotation to reduce stress on the repaired ACL may also be a theoretic reason for bracing in the postoperative population. Multiple studies have shown that bracing is not an effective way to replicate the physiologic function of an intact ACL in this regard.31,32 Due to this, excessive tibial translation has not been extensively studied in a postoperative population. LaPrade et al.39 examined the differences between dynamic and static braces on the posteriorly directed forces from the brace on the proximal tibia during open and closed chain knee movements in healthy individuals. Dynamic braces were found to be superior to static braces, most closely matching physiological ACL function. As previously reported, the ACL stiffens in a nonlinear way during active knee ROM, and dynamic bracing attempts to match this phenomenon.32 Role in Rehabilitation Common impairments following ACL reconstruction include pain, effusion, muscle weakness, and ROM loss, among others. The use of bracing during the rehabilitation phase following ACL repair is generally not supported in the literature to reduce these impairments.37,40,41 In a review by Nyland et al.,37 the authors conclude that the evidence supporting postsurgical brace use tends to decrease across the healing continuum following ACL repair. A systematic review by Kruse et al.40 found that bracing after ACL repair is neither necessary nor beneficial and may actually

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increase the cost of the procedure. Additionally, the review found that bracing did not result in significant benefits in ROM or laxity. In a long-term prospective study, Mayr et al.41 found that postoperative bracing showed no advantage in regard to anteroposterior laxity or visual analog pain scale among those individuals who used a postoperative brace, with pain levels being less in those who did not use a brace. Postoperative bracing has also been found to have no effect on joint effusion.42 During gait in adolescent patients, bracing had no effect on altered kinematic and kinetic asymmetries between surgical and noninjured limbs.43 A review by Sugimoto et al.44 found inconsistent evidence that bracing provided improvements in joint position sense in this population. Despite these findings, there may be patients who would benefit from brace use. One such population is those with kinesiophobia, or fear of re-injury.45,46 Harput et al.45 found that bracing provided a reduction in kinesiophobia, allowing patients to have improved knee function and return to preinjury levels when compared with kinesiology taping or no brace conditions. A systematic review by Lowe et al.46 suggests using a brace following ACL reconstruction after return to sport for ligament protection and to reduce kinesiophobia. It is the role of the clinician to recognize those individuals who demonstrate kinesiophobia and may benefit from complementary brace use in addition to comprehensive rehabilitation following ACL reconstruction. Although the findings of recent research suggest bracing after ACL reconstruction is unnecessary, it remains commonplace for patients and surgeons to utilize braces following surgery. Nyland et al.37 noted that during rehabilitation, “safe training without brace use is essential to stimulate joint loads needed for tissue healing, collagen health, restoration of biomechanical tissue integrity, and to develop a more responsive neuromuscular control system.” It remains the job of the rehabilitation team to appropriately prescribe exercises and activities that result in the intended healing, without reliance on external bracing. Weaning patients from brace use requires careful consideration of the patients’ function, kinesiophobia level, and patient confidence. This decision should always be made with the collaboration of the patient and the surgeon. Once the patient has successfully completed a comprehensive rehabilitation program and is ready to return to sport, functional bracing may once again be utilized. A review by Lang et al.47 found that brace use for the first 6 to 12 months following return to sport can increase the athlete’s confidence. The systematic review by Lowe et al.46 arrived at a similar conclusion, suggesting brace use for 6 to 12 months following return to sport to decrease kinesiophobia and improve patient confidence, allowing for return to previous level of competition. Preventing reinjury to the ACL once an athlete returns to play is another primary goal of rehabilitation. The review by Lowe et al.46 found limited evidence to suggest bracing decreases the rate of re-injury. However, individuals who participate in high-risk activities would benefit from brace use to reduce reinjury rates.1 Adolescent patients may also benefit from bracing to prevent rerupture, as they have higher rates of reinjury compared with other populations, however, there is not conclusive evidence to suggest bracing can or cannot prevent reinjury.47

Recommendations Postoperative bracing can reduce tibial rotation, but not restore it, regardless of graft type in patients following isolated ACL repair.30,35,38 Bracing is not effective in matching physiological ACL function of limiting anterior tibial translation, as a mature repair will provide this function.31,32,39 No brace effectively mimics native ACL function. Therefore bracing is not generally supported to address the common impairments seen following ACL repair.37,40,41 The American Academy of Orthopedic Surgeons (AAOS) finds there is moderate evidence for lack of evidence for FKO use following ACL reconstruction.48 Patients with kinesiophobia after surgery, those who participate in high-risk sports, or adolescent athletes may benefit the most by using bracing after surgical repair.1,45-47 Given the increasingly high rates of surgical success and continued surgical innovation, there is generally no conclusive scientific evidence to support the routine use of an FKO following ACL repair, especially when patients complete a comprehensive rehabilitation program.1,36

Orthoses for Osteoarthritis In healthy tibiofemoral and patellofemoral joints, the articular surfaces are covered in articular cartilage. The role of the articular cartilage is to provide for smooth movement of the knee by reducing friction and providing even force distribution across joint surfaces. Articular cartilage by nature is both avascular and aneural in adult humans. This cartilage is composed of a complex matrix of water, chondrocytes, and proteoglycans.28 OA is characterized by a disruption or alteration of the cartilage matrix, usually resulting in surface fibrillation, fissures, and eventual removal of cartilage from the underlying bone.28 OA is a common source of knee pain and discomfort and is associated with high rates of disability. The development and progression of OA is multifactorial, and there are multiple models that outline the development and progression of the disease that are beyond the context of this chapter. OA that develops in either the tibiofemoral or patellofemoral joint causes considerable pain and disability and imposes a major economic burden on those affected and society as a whole.49 The inability of the cartilage to sustain loads and distribute forces in the tibiofemoral joint often results in degradation of the cartilage and a reduction of joint space, known as collapse, in one or more compartments of the knee. This breakdown can cause pain and swelling, with unicompartmental collapse causing a change in the alignment of the joint.50 OA that affects the medial compartment of the tibiofemoral joint may cause an increase in genu varus alignment, whereas lateral collapse may cause an increase in genu valgus alignment. Patients with knee OA report joint pain and demonstrate ROM loss. These symptoms are typically exacerbated in weight-bearing activities, such as the stance phase of gait, negotiating stairs, or getting up from sitting. Conservative interventions, such as exercise, bracing, injections, or medications are commonly used in managing knee OA, with total or unicompartmental joint arthroplasty utilized when symptoms cannot be managed with conservative interventions. Braces have been designed to help alleviate these symptoms, as well to address inappropriate joint loading as a

11 • Orthoses for Knee Dysfunction

Fig. 11.12 Ossur unloader one brace. This is an example of a medial unloading brace used in the treatment of moderate to severe osteoarthritis of the knee. The location of the hinge, sidebars, and straps provide leverage to unload a single compartment in the knee. € (© Ossur.)

result of unicompartmental collapse. Unloading braces are designed for this specific purpose, and consist of external stays, hinges, and straps (Fig. 11.12). As with PKOs and FKOs, they can be used off-the-shelf or custom made for a specific individual. They aim to decrease the compressive load, or “unload” the surface, and restore joint alignment.51 They can be used to address varus or valgus alignments. Valgus unloading braces used to reduce the load on the medial compartment are more common, as medial compartment OA with varus alignment is the most common type of unicompartmental knee OA.52 The use of these braces has become more popular as clinicians and patients attempt to reduce pain and avoid or prolong the need for joint arthroplasty. In contrast to unloading bracing, some clinicians opt for soft brace use, especially for those patients with mild to moderate OA.49 A systematic review with meta-analysis showed promising benefit, with moderate improvements in pain and small to moderate improvements in function.49 Based on the current research, the OA Research Society International guidelines for managing knee OA gives unloader bracing a recommendation score of 76% for reducing pain.53 The AAOS found inconclusive evidence regarding brace use and were not able to recommend for or against brace use in the treatment of OA.54 Some of the inconsistency with regards to brace prescription may be explained by the highly individualized nature of the presentation and progression of OA, as well as the lack of long-term controlled research.

BIOMECHANICAL IMPLICATIONS The ability for valgus bracing to provide this desired unloading effect has long been unclear, and the focus of much research and clinical debate.52,55-57 In a systematic review

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and meta-analysis, Moyer et al.52 found that valgus bracing can decrease knee joint loads, with moderate- to high-effect sizes. Specifically, these changes in biomechanics were found during walking and through multiple mechanisms. The authors of this study offered the following mechanisms of action: direct medial compartment load, indirect load distribution, muscle co-contraction, and increase in medial knee joint space. However, this research was not able to identify individuals who would respond well to bracing or what prescriptive criteria should include. In the patellofemoral joint, bracing has been shown to alter the patellar position in a static weight-bearing position.58 Patellofemoral joint OA is further discussed later in this chapter. Instability of the tibiofemoral joint in patients with OA can result in altered muscle activation patterns as the muscles attempt to dynamically stabilize the joint. However, this change in muscle activation patterns may also increase the joint load, ultimately becoming counterproductive. Fantini et al.59 examined the effects an unloader brace would have on muscle activation patterns during gait among individuals with medial knee OA. The researchers found significant decreases in muscle activity during walking with an unloading brace, suggesting the external brace provided additional mechanical stabilization. Petersen et al.55 found similar results, finding that brace use and the resulting decrease in muscle co-contraction may contribute to decreased pain. When studied in a healthy population, a similar study found no change in muscle activation patterns in braced and unbraced conditions.60 In a sample of individuals with end-stage OA, utilizing a newly designed pneumatic unloader knee brace over the course of 3 months resulted in a significant increase in quadriceps and hamstring strength compared to the unbraced group.61 These findings suggest that an unloading brace may provide for mechanical stability in those with knee OA but does not have a similar effect in those with healthy joints. New or novel designs of unloading braces need further examination to determine their effects on muscle activation and strength. The varus alignment that develops as a result of medial compartment collapse changes the force distribution within the tibiofemoral joint. Due to this malalignment, the GRFs experienced during ambulation is shifted medially; this shift is known as the knee adduction moment (KAM) and results in increased load in the medial tibiofemoral compartment.55 Reduction of the KAM is one of the proposed mechanisms of action described by Moyer et al.52 A significant reduction in KAM through the use of an unloading brace has been described in various biomechanical studies among individuals with OA.55,57,62-66 In a systematic review by Petersen et al.55 the authors found consensus among the research that a valgus unloader brace significantly reduced the KAM forces in the arthritic knee. The reduction in KAM force from unloading brace use has been shown to be up to 26%, and up to 10% with soft brace use.63,66 Fu et al.64 found an even larger reduction in KAM when knee bracing was used in conjunction with lateral wedging insoles with arch support. When compared with FKO bracing, unloading braces seem to be more effective in reducing the KAM.65 New brace technology that combines valgus effect with tibial external rotation and distraction to further decrease medial joint compression has shown promising

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effects on KAM, but further research will be needed to establish the effectiveness of this design.57

EVIDENCE OF EFFECTIVENESS In many cases the biomechanical changes that come from unloader brace use as described by Moyer et al.52 translate into pain reduction for patients with knee OA. With decreased pain, conservative intervention approaches can then focus on addressing other impairments and improving overall function. Soft braces may provide for pain reduction and improved function in those individuals with mild OA; however an unloading brace is likely to be required in individuals with joint deformity49,67 (Fig. 11.13). Meta-analysis of randomized trials supports the ability of an unloading brace to reduce pain and improve overall function.68 A recent systematic review by Gohal et al.69 found that valgus unloader braces are an effective treatment for reducing pain in this population. More specifically, unloader braces have been shown to improve gait. Improving walking as a treatment outcome has been rated as very important in up to 89% of this population.70 The systematic review by Petersen et al.55 found that the reduction in pain experienced by brace users resulted in increased walking speed, increased step length, and in some cases, increased gait symmetry. Similar findings are discussed in a literature review conducted by Maleki et al.71 who identified increased gait speed and increased step length in individuals using unloading braces. Due to the reduction in the KAM, patients have been shown to increase gait speed and overall knee ROM during the stance phase of gait.63 In a survey of unloading brace users, Briggs et al.70 found significant improvements in quality of life,

pain, stiffness, and overall function. In patients with mild OA, using a soft brace was found to result in decreased 10 m Walk and Get-up and Go times, indicating increased speed.67 This study also found an increase in patient confidence in level and perturbed walking.67 Braces that provide for a decrease in pain and improvement in patient function allows for patients to maintain a healthy activity level and to increase overall physical health.70 Other orthoses that may be used in conservative management include lateral wedged insoles. When compared to valgus bracing, lateral wedged insoles have been found to produce a similar reduction on KAM forces, pain reduction, and gait parameters.72,73 When used in conjunction, valgus unloading braces and lateral wedged insoles produce greater reductions in KAM than either used independently.64 The addition of stochastic resonance electrical stimulation to a knee sleeve has been shown to not offer significant improvements over the sleeve use itself.74 The use of a transcutaneous joint stimulator was shown to be ineffective in reducing pain in isolation but offers some improvements when used with an unloader brace.75 These results suggest that electrical stimulation in isolation is not likely to produce the desired treatment effect, but could be augmented by the addition of an unloading brace. Aside from the beneficial treatment effect of these braces, like all treatments, they do not come without potential side effects. Negative side effects of brace use are not commonly researched and are occasionally reported when present. Potential side effects include small reductions in available active range of motion and skin irritation from poorly fitting braces. As a general rule with knee orthoses, brace fit can be improved with the use of a custom brace versus an off-theshelf model. Another possible limitation to effectiveness is

Fig. 11.13 (A) Hinged knee brace with straps produced by Donjoy. This brace provides moderate compression with increased support from dual hinged sidebars. This brace would be appropriate for patients with mild to moderate OA. (B) OA Fullforce Knee Brace by DonJoy. Notice the longer lateral support on the femoral component of the brace. When combined with straps and hinges, this brace unloads the medial aspect of the knee. (A, Courtesy of DonJoy; B, Courtesy DJO Global. Retrieved from https://www.djoglobal.com/sites/default/files/styles/product_large/public/11-1578_OAFullforce_hires. jpg?itok¼ubXIPAFS.)

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patient adherence to brace usage and brace cost.76 Unloading braces in particular tend to be larger and bulkier than smaller sleeves, which may limit a patient’s ability to effectively don and doff the brace. Long-term (>1 year) brace usage has shown to be low, at 28% in this population.76 There is no clear prescriptive criteria for the use of bracing in OA either, which may present a limitation in providing braces to appropriate patients.

RECOMMENDATIONS Recent research suggests that unloading braces can alter tibiofemoral and patellofemoral joint positions, both statically and dynamically.52,58 Unloading braces are also effective in decreasing muscle co-contraction, providing an increase in joint stability without sacrificing muscle strength.55,59,61 Additionally, both unloader and soft braces reduce the KAM force experienced during gait, which distributes forces more uniformly in the joint, thereby reducing pain.55,57,62-66 These biomechanical changes result in decreased pain and improved function, specifically gait parameters. These improvements result in increased quality of life and confidence in patients with knee OA.70 Further research is needed to examine the effects that new brace designs to the market have on biomechanics, pain, and function among this patient population.57,61 The majority of these recent studies focus on relatively short-term effects of brace use. Due to the chronic and progressive nature of OA, it would be beneficial to examine both the long-term effects of brace use and the possibility for slowing the progression of the disease.77 Conservative intervention continues to be the first line of treatment for patients with knee OA. Physical therapy, exercise, weight reduction, bracing, and antiinflammatory medications are among the most common conservative interventions.78,79 Physical therapy carries an Osteoarthritis Research International recommendation grade of 89%, regular exercise carries a grade of 96%, and bracing was graded at 76%.53 Despite the inconclusive opinion from the American Academy of Orthopaedic Surgeons, the addition of a brace to these interventions may prove to be useful, but more long-term randomized studies are necessary. Identifying which patients will benefit from the addition of bracing to a conservative program can be difficult for many practitioners and may present as a barrier to brace use. Establishment of an industry-wide validated model of brace implementation would prove to be greatly beneficial. However, clinicians may be able to match patient impairments with the known biomechanical effects of certain braces to produce a desired treatment effect. As a general rule, those with a passively correctable varus or valgus deformity as a result of unicompartmental OA are ideal patients for unloader brace use.78 In those patients with mild OA, a soft brace may be an effective treatment.51

Orthoses for Patellofemoral Disorders It is important to consider the contributions of the patellofemoral joint to both normal tibiofemoral joint motion and painful conditions of the knee. The patella is a sesamoid

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bone positioned in the tendon of the quadriceps femoris. On its posterior, it has two large facets medially and laterally, and a small odd facet on the medial aspect.28 These facets articulate with the medial and lateral femoral condyles during flexion and extension movements of the knee, respectively. When the knee is extended and the quadriceps relaxed, there is relatively little contact between the patella and the femur. Normal alignment finds the patella positioned just laterally to the femoral trochlear notch at rest.28 Under normal conditions the patella functions to increase the moment arm of the quadriceps tendon, therefore the patella is critical to normal function of the quadriceps muscle and tibiofemoral joint.28 During tibiofemoral flexion, the patella glides distally on the femur. At the same time the patellofemoral joint surface experiences an increase in compressive force.28 During knee extension, the patella glides superiorly on the femur. In addition to superior and inferior translation, there is movement of the patella medially and laterally, as well as tilting and rotation during tibiofemoral flexion and extension.28 The term “patellar tracking” is often used to describe this complex set of motions that occur at the patellofemoral joint. Compressive force at the patellofemoral joint is also affected by other factors besides tibiofemoral joint angle, such as weight-bearing or external loading. Abnormal knee function and pain have been hypothesized to be caused by problems with static or dynamic patellofemoral alignment, tracking, and force distribution across the joint surface or a combination thereof. Models that explain normal and abnormal patellofemoral joint motion and force distribution are far more complex, however, and are beyond the scope of this chapter. Having knowledge regarding normal function is important to understanding the purpose of patellofemoral orthoses. Patellofemoral orthoses, like other knee braces, are a form of conservative treatment that are frequently used in conjunction with other nonoperative measures. They function to reduce the pain experienced in the anterior knee and retropatellar area in individuals with patellofemoral pain syndrome (PFPS) or patellofemoral OA by modifying patellar position.80 Designs of orthoses for this purpose are highly variable and range from simple straps to knee sleeves to full patellar support braces (see Figs. 11.2 and 11.14). Patellofemoral braces are generally less bulky than tibiofemoral counterparts and can be worn under trousers.81 There are significant differences in prescriptive criteria and little consensus among health care professionals regarding the use of these orthoses.82

PATELLOFEMORAL OSTEOARTHRITIS OA that affects the patellofemoral joint can be a significant cause for anterior and retropatellar pain. Due to the compressive nature of the patellofemoral joint, patellofemoral OA tends to be a particularly painful condition. Bracing in this population is thought to decrease contact stress across the patellofemoral joint by encouraging proper alignment or tracking, thereby reducing painful compression.58,81 Restoring normal forces across a larger surface area on the facets of the posterior patella may reduce focal stress through any one area that has degenerative changes. Bracing is also thought to increase proprioceptive input and facilitate a feeling of stability, which may encourage

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Participants were randomized to braced or nonbraced conditions for a treatment duration of 6 weeks. At the end of the study, there was a significant improvement in pain with activity as scored on the Knee Osteoarthritis Outcome Score (KOOS) in the group that used bracing. Additionally, a significant decrease in bone marrow lesion size was observed in the brace group. The short-term results of this study represent a very significant finding, as OA is a chronic condition, suggesting that components can be addressed in as little as 6 weeks.

Fig. 11.14 Patella strap by DonJoy. Example of a compressive strap worn directly over the patellar tendon. (Courtesy DJO Global. Retrieved from: https://www.djoglobal.com/sites/default/files/styles/product_large/ public/images/products/patella-front.jpg?itok¼ukUDqXKI.)

participation in physical activity.50 Unlike bulky FKOs or other tibiofemoral braces, knee sleeves used in this population are typically soft and can be worn underneath long pants.

Biomechanical Implications Weakness of the quadriceps is a common impairment that is observed in individuals with OA of the knee. In a recent secondary analysis of a randomized controlled trial, Callaghan et al.83 studied the effect of wearing a knee brace on quadriceps strength in individuals who have patellofemoral OA. This study utilized an off-the-shelf knee sleeve, which allowed full ROM of the knee. This type of brace is commonly used in the treatment of patellofemoral pain syndrome (PFPS) and for general knee joint support. After 6 and 12 weeks, there was found to be no difference in maximum voluntary contraction or arthrogenous muscle inhibition, meaning the use of the brace did not reduce the strength or activation of the quadriceps. Correcting improper patellar tracking or position may also be a goal in the treatment of patellofemoral OA. In a small scale (n ¼ 26), patella position and patellofemoral joint space were measured using MRI.58 The results of this study indicate that bracing increases the contact area between the posterior patella and femoral trochlea, thereby distributing forces in a more even manner when compared to a nonbraced condition.58 Although promising, this research was conducted in a static position, which reduces the clinician’s ability to apply the results to more dynamic functional activities that are often impaired, such as ambulation. In another randomized study by Callaghan et al.81 pain and bone marrow lesion size was measured in the patellofemoral compartment in patients with patellofemoral OA.

Conservative Management The positive results on the KOOS of the previous study by Callaghan et al.81 are in contrast to those reported by Yu et al.,84 who found that the addition of a patellofemoral brace to a multidisciplinary program did not provide additional benefits. Participants in this study were assessed at multiple intervals up to 1 year. The authors report that the addition of bracing as an intervention did not result in superior outcomes in terms of pain or function as compared with a nonbraced rehabilitation program at any follow-up point. A randomized clinical trial by Crossley et al.85 demonstrated improvements in KOOS scores, indicating improved pain and function after 3 months of conservative treatment. Although the conservative management in this study did not include brace use, it does support the efficacy of conservative interventions in the treatment of patellofemoral OA. Recommendations OA affecting the patellofemoral joint frequently results in pain and decreased function in affected individuals. Conservative management of a multidisciplinary nature has been shown to improve these outcomes in both short- and longterm follow-up studies.84,85 The effects of the addition of a brace to conservative management is not well understood. Current literature suggests that brace use will not weaken or inhibit quadriceps function, can change the static position of the patella, and possibly have a positive effect on bone marrow lesion size.58,81,83 No large-scale negative effects of brace use have been reported in the recent literature. Bracing for patients with patellofemoral OA may be used to complement a conservative multidisciplinary approach to improve pain and function.

PATELLOFEMORAL PAIN SYNDROME PFPS is a global term used to describe pain that occurs in the anterior patellar or retropatellar areas. Symptoms in the area are generally worsened during prolonged sitting, descending stairs, walking down slopes, athletic activities, squatting, or kneeling.23,80,82,86,87 The repetitive nature of these activities contributes to the onset of symptoms. PFPS is a common disorder of the knee, affecting 10% to 20% of the general population, with females, especially athletic women being more commonly affected.88,89 Due to the complex nature of normal patellar function, it is likely that there is a wide variety of biomechanical reasons that patellar tracking becomes abnormal.90 Despite etiology of PFPS remaining unclear, the basic premise of PFPS is that abnormal movement of the patella in the femoral trochlear results in altered force distribution and pain in the

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joint.80,91 When possible, identifying the underlying cause of altered tracking would be beneficial for directing conservative treatment, including orthoses use, for those with PFPS. For example, if a patient demonstrates excessive lateral tracking of the patella, a brace designed to apply a medially directed force may be used to keep the patella situated in the femoral trochlea. Additional conservative treatment might include quadriceps strengthening, stretching of lateral thigh and knee structures, and avoidance of painful activities. A review of conservative management alone and in combination with orthoses use is provided later in this chapter.

Biomechanical Implications Patellar strapping is commonly used to control pain in individuals with PFPS related to patellar tendinopathy.92 These straps have been researched with regards to proprioception, pain, muscle activity, and dynamic alignment.86,92-94 Unfortunately, the vast amount of literature pertaining to these orthoses is under powered. In those individuals who have patellar tendinopathy and low proprioceptive acuity, a patellar strap has been shown to demonstrate similar improvements in proprioception.92 However, those with normal proprioceptive acuity and PFPS did not demonstrate any improvement by utilizing a patellar strap.92 A randomized controlled trial conducted by de Vries et al.93 demonstrated that patellar straps were found to decrease pain during athletic activities but were not superior to placebo taping. Patellar straps have also been shown to decrease vastus lateralis muscle activation prior to single limb landing, possibly resulting in decreased tensile stress on the patellar tendon.94 In a later study, Rosen et al.86 found that patellar straps reduced pain in single limb landing and resulted in improved patellar alignment. Sinclair et al.87 examined the use of a knee sleeve on controlling patellar tracking and pain during common sport movements, such as running and cutting, in athletes. The results of their study suggest significant reduction of patellofemoral force, resulting in decreased pain and improved overall function. When used for longer periods of time, a knee sleeve has been shown to improve knee pain and improve gait parameters in individuals with PFPS, and significant increase in gait speed, step length, and knee flexion angles have been reported.95 Conservative Management Effective exercise interventions should target the underlying impairments found to contribute to patellofemoral pain. Commonly, targeted strengthening of the quadriceps, hip extensors, and hip abductors are utilized.23,90 Limiting patellofemoral loading during exercise interventions is advocated. Other frequently used interventions include muscle stretching of the hamstrings, hip flexors, quadriceps, triceps surae, and ITB.23 Patient education of the nature of PFPS, avoidance of aggravating activities, and indications for brace use should also be included.90 Petersen et al.91 conducted a randomized clinical trial of over 150 participants to examine the effects physical therapy alone and in combination with knee bracing had on pain and function in individuals with PFPS. Both groups in the study demonstrated improvements in pain and functional outcome measures in the short and long term.

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However, the group that received bracing and physical therapy in combination demonstrated greater improvements in pain and function in the short term. At a 1-year follow-up, both groups demonstrated similar improvements. The findings of this larger scale, higher powered study are significant for brace prescription. They suggest that early intervention with a combination of bracing and physical therapy is important and leads to greater short-term improvements. Barton et al.90 arrived at a similar conclusion, that bracing can be an effective intervention for short-term pain relief, but is likely not as effective in the long term. In a Cochrane review by Smith et al.80 the authors conclude that there is very low-quality evidence that using a knee orthosis in combination with physical therapy may not reduce pain.

Recommendations The overall low quality of available evidence and dissonance among the evidence that does exist shows the need for improved and continued research methodology to help guide clinicians’ utilization of orthoses for PFPS. Additionally, it makes the task of prescribing such an orthosis challenging. Solinsky et al.82 explored the factors influencing brace prescription for PFPS across sports medicine professionals (physicians, physical therapists, and athletic trainers). The findings suggest that there is little consensus among the professions and significant differences in prescription criteria, as well as bracing frequency. This implies that depending on which professional a patient encounters, they are likely to be assessed and prescribed orthoses in a different manner. PFPS should initially be managed with conservative intervention, which is individually tailored to the impairments of the patient and may include the use of a patellofemoral orthosis. When used, orthoses should be used in conjunction with selected exercise and behavior modification interventions.

Summary This chapter reviews the normal structure and function of the tibiofemoral and patellofemoral joints and the common pathologic conditions that affect these joints. The different categories of orthoses for the knee complex are prophylactic orthoses, functional orthoses, and rehabilitation orthoses. Emphasis was placed on unloading knee orthoses and patellofemoral orthoses as a subcategory of rehabilitation orthoses. A review of the literature was presented. Although there continues to be debate among the research and clinicians regarding the use of these orthoses, improvements in the quality and strength of recommended orthoses has improved compared with previous orthoses. Identifying appropriate patients who would benefit from brace use is key to brace prescription. Interprofessional communication among the patients and the health care team, with input from the patient, is essential. This chapter discusses the application of the current research to allow the clinician to make the best possible decision for their patient’s care. It is important for clinicians to continue to view knee orthosis use in a complementary sense to other conservative interventions, such as a comprehensive evidence-based rehabilitation program.

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The intent of this chapter is to provide clinicians with the ability to evaluate the design and the intended treatment effects of a given knee orthosis and for appropriate application in the clinical setting. This chapter also highlights evidence in

current research, including gaps in present knowledge. These gaps include the long-term effects of knee orthosis use and effects of new or novel brace design with the hopes of encouraging participation in ongoing research on the topic.

Case Example 11.1 M.G. is an 18-year-old college freshman who is referred to you with the diagnosis of an acute left anterior cruciate ligament (ACL) tear for management of knee pain and swelling. She reports feeling a large pop in her knee followed by immediate swelling after an awkward landing playing intramural volleyball. Complete ACL tear was confirmed with MRI. The incident happened 1 week ago, and she has been on bilateral crutches since. She would like to return to playing intramural volleyball and softball and is scheduled for surgical repair in 4 weeks. On examination, she demonstrates significant weakness of the left quadriceps and hamstrings, significant knee joint effusion, knee flexion of 100 degrees, knee extension lacking 8 degrees, and difficulty with weight bearing, ambulation, balance, and stairs. She reports a feeling of instability, like her knee is going to buckle, when she tries to ambulate without assistance.

appropriate healing at this point. She was provided with a functional knee brace postoperatively. She has been compliant with brace use and her home exercise program. She reports a feeling of increased knee stiffness and demonstrates active flexion of 80 degrees and active extension lacking 3 degrees. She has a follow up with the orthopedic surgeon tomorrow.

QUESTIONS TO CONSIDER 1. Given M.G.’s history and current presentation, what additional tests and measures would aide in your evaluation process? What other functional tests could be performed? 2. What are your short-term goals with this patient, knowing that she will undergo surgical repair in 4 weeks? 3. Based on M.G.’s goals and your understanding of current literature, what would your recommendations for brace use be at this time? M.G. comes back to your clinic to begin postoperative rehabilitation 14 days after her surgery. Surgery was successful and uncomplicated, using a hamstring autograft. She demonstrates

RECOMMENDATIONS The use of an FKO in the postoperative rehabilitation phase is not supported by current evidence to reduce impairments associated with surgery.37,40,41,48 After successfully treating M.G. postoperatively, she has returned to pain-free daily function and light running with no pain or reactive effusion. Among other interventions, you have incorporated neuromuscular training to facilitate proprioception and dynamic strengthening to prepare her for return to sport. Based on her selected sports, sex, and age, you identify that she may be at higher risk for reinjury of the ACL and recommend that she obtain an FKO to wear while she plays sports.1,46,47

QUESTIONS TO CONSIDER 1. Based on current research, is the use of an FKO warranted at this point in her rehabilitation? If not, how would you address that with the patient and her physician? 2. M.G. is curious regarding the use of a brace once she returns to playing recreational sports. What advice can you give her? How might you include bracing in your plan of care at that point?

Case Example 11.2 F.L. is 72-year-old retired construction worker referred to your clinic for the management of right knee pain. Radiographs obtained from his physician reveal medial compartment tibiofemoral OA with considerable joint space narrowing. His knee pain has been getting progressively worse over the past 2 years. He walks 9 holes of golf twice per week and reports considerable pain on the medial aspect of the knee with prolonged standing and walking. At this point, F.L. cannot stand for more than 20 minutes without pain. He also has pain and stiffness with going up and down stairs and getting up from sitting. He reports that he has had two joint injections to the knee over the past 6 months, which provided short-term relief. Previously, he had used a neoprene knee sleeve which provided on-and-off results. You treat F.L. with a physical therapy regimen centered on strengthening and joint mobility to improve his overall function. After 4 weeks of treatment, F.L. demonstrates minimal improvements in pain and function. F.L.’s physician recommends that F.L. undergo a total knee arthroplasty. However, F.L. does not want to have the procedure because of the associated risks and lengthy postoperative rehabilitation. He asks for your recommendation about other conservative interventions.

QUESTIONS TO CONSIDER 1. What are your short- and long-term physical therapy goals with this patient? 2. Given your knowledge of the disease process of osteoarthritis, what is his prognosis? 3. Based on the patient’s goals and expectations and utilizing your understanding of current research, what is your recommendation regarding brace use with F.L.? What evidence supports your decision? 4. Besides brace use, what are other conservative interventions that may be appropriate for this patient? RECOMMENDATIONS Utilizing the most current evidence available, you decide that wearing a valgus unloading brace may help diminish F.L.’s pain and increase his functional ability and his quality of life. You work closely with an orthotist to determine the most appropriate brace for this individual case. During the process, you educate F. L. that the evidence suggests that he can expect short-term benefits from brace use, but the long-term outcomes are not well understood. You emphasize that he should continue with his current regimen of strengthening, mobility exercises, and aerobic exercise in addition to using the valgus unloading brace.

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Section II • Orthoses in Rehabilitation on knee joint effusion. A prospective, randomized study. The Knee. 2015;22(6):559–564. https://doi.org/10.1016/j.knee.2015.04.015. Dai B, Butler RJ, Garrett WE, Queen RM. Anterior Cruciate Ligament Reconstruction in Adolescent Patients: Limb Asymmetry and Functional Knee Bracing. Am J Sports Med. 2012;40(12):2756–2763. https://doi.org/10.1177/0363546512460837. Sugimoto D, LeBlanc JC, Wooley SE, Micheli LJ, Kramer DE. The Effectiveness of a Functional Knee Brace on Joint-Position Sense in Anterior Cruciate Ligament-Reconstructed Individuals. J Sport Rehabil. 2016;25 (2):190–194. https://doi.org/10.1123/jsr.2014-0226. Harput G, Ulusoy B, Ozer H, Baltaci G, Richards J. External supports improve knee performance in anterior cruciate ligament reconstructed individuals with higher kinesiophobia levels. The Knee. 2016;23 (5):807–812. https://doi.org/10.1016/j.knee.2016.05.008. Lowe WR, Warth RJ, Davis EP, Bailey L. Functional Bracing After Anterior Cruciate Ligament Reconstruction: A Systematic Review. J Am Acad Orthop Surg. 2017;25(3):239–249. https://doi.org/ 10.5435/JAAOS-D-15-00710. Lang PJ, Sugimoto D, Micheli LJ. Prevention, treatment, and rehabilitation of anterior cruciate ligament injuries in children. Open Access J Sports Med. 2017;8:133–141. https://doi.org/10.2147/OAJSM.S133940. American Academy of Orthopaedic Surgeons. Management of Anterior Cruciate Ligament Injuries. OrthoGuidelines. http://www. orthoguidelines.org/guideline-detail?id¼1259. Accessed 22 February 2018. Cudejko T, van der Esch M, van der Leeden M, et al. Effect of Soft Braces on Pain and Physical Function in Patients With Knee Osteoarthritis: Systematic Review With Meta-Analyses. Arch Phys Med Rehabil. July 2017. https://doi.org/10.1016/j.apmr.2017.04.029. Duivenvoorden T, Brouwer RW, van Raaij TM, Verhagen AP, Verhaar JA, Bierma-Zeinstra SM. Braces and orthoses for treating osteoarthritis of the knee. In: Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd; 2015. https://doi.org/10.1002/14651858. CD004020.pub3. Coudeyre E, Nguyen C, Chabaud A, et al. A decision-making tool to prescribe knee orthoses in daily practice for patients with osteoarthritis. Ann Phys Rehabil Med. February 2018;https://doi.org/10.1016/j. rehab.2018.01.001. Moyer RF, Birmingham TB, Bryant DM, Giffin JR, Marriott KA, Leitch KM. Biomechanical effects of valgus knee bracing: a systematic review and meta-analysis. Osteoarthritis Cartilage. 2015;23(2): 178–188. https://doi.org/10.1016/j.joca.2014.11.018. Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008;16(2):137–162. https://doi.org/10.1016/j.joca.2007.12.013. Jevsevar D. Treatment of osteoarthritis of the knee: evidence-based guideline, 2nd ed. J Am Acad Orthop Surg. 2013;21(9). Petersen W, Ellermann A, Zantop T, et al. Biomechanical effect of unloader braces for medial osteoarthritis of the knee: a systematic review (CRD 42015026136). Arch Orthop Trauma Surg. 2016;136(5): 649–656. https://doi.org/10.1007/s00402-015-2388-2. Steadman JR, Briggs KK, Pomeroy SM, Wijdicks CA. Current state of unloading braces for knee osteoarthritis. Knee Surg Sports Traumatol Arthrosc Off J ESSKA. 2016;24(1):42–50. https://doi.org/10.1007/ s00167-014-3305-x. Laroche D, Morisset C, Fortunet C, Gremeaux V, Maillefert J-F, Ornetti P. Biomechanical effectiveness of a distraction–rotation knee brace in medial knee osteoarthritis: Preliminary results. The Knee. 2014;21(3):710–716. https://doi.org/10.1016/j.knee.2014. 02.015. Callaghan MJ, Guney H, Reeves ND, et al. A knee brace alters patella position in patellofemoral osteoarthritis: a study using weight bearing magnetic resonance imaging. Osteoarthritis Cartilage. 2016;24(12): 2055–2060. https://doi.org/10.1016/j.joca.2016.07.003. Fantini Pagani CH, Willwacher S, Kleis B, Br€ uggemann G-P. Influence of a valgus knee brace on muscle activation and cocontraction in patients with medial knee osteoarthritis. J Electromyogr Kinesiol. 2013;23(2):490–500. https://doi.org/10.1016/j.jelekin. 2012.10.007. Ebert JR, Hambly K, Joss B, Ackland TR, Donnelly CJ. Does an Unloader Brace Reduce Knee Loading in Normally Aligned Knees? Clin Orthop. 2014;472(3):915–922. https://doi.org/10.1007/s11999013-3297-8. Cherian JJ, Bhave A, Kapadia BH, Starr R, McElroy MJ, Mont MA. Strength and Functional Improvement Using Pneumatic Brace with

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76. 77.

78. 79.

Extension Assist for End-Stage Knee Osteoarthritis: A Prospective, Randomized trial. J Arthroplasty. 2015;30(5):747–753. https://doi.org/ 10.1016/j.arth.2014.11.036. Larsen BL, Jacofsky MC, Brown JA, Jacofsky DJ. Valgus bracing affords short-term treatment solution across walking and sit-to-stand activities. J Arthroplasty. 2013;28(5):792–797. https://doi.org/10.1016/j. arth.2012.09.022. Lamberg EM, Streb R, Werner M, Kremenic I, Penna J. The 2- and 8week effects of decompressive brace use in people with medial compartment knee osteoarthritis. Prosthet Orthot Int. 2016;40(4):447–453. https://doi.org/10.1177/0309364615589537. Fu HCH, Lie CWH, Ng TP, Chen KW, Tse CY, Wong WH. Prospective study on the effects of orthotic treatment for medial knee osteoarthritis in Chinese patients: clinical outcome and gait analysis. Hong Kong Med J Xianggang Yi Xue Za Zhi. 2015;21(2):98–106. https://doi.org/ 10.12809/hkmj144311. Dessery Y, Belzile EL, Turmel S, Corbeil P. Comparison of three knee braces in the treatment of medial knee osteoarthritis. The Knee. 2014;21(6): 1107–1114. https://doi.org/10.1016/j.knee.2014.07.024. Schween R, Gehring D, Gollhofer A. Immediate effects of an elastic knee sleeve on frontal plane gait biomechanics in knee osteoarthritis. PloS One. 2015;10(1): e0115782. https://doi.org/10.1371/journal. pone.0115782. Cudejko T, van der Esch M, van der Leeden M, et al. The immediate effect of a soft knee brace on pain, activity limitations, self-reported knee instability, and self-reported knee confidence in patients with knee osteoarthritis. Arthritis Res Ther. 2017;19(1). https://doi.org/ 10.1186/s13075-017-1456-0. Moyer RF, Birmingham TB, Bryant DM, Giffin JR, Marriott KA, Leitch KM. Valgus bracing for knee osteoarthritis: a meta-analysis of randomized trials. Arthritis Care Res. 2015;67(4):493–501. https:// doi.org/10.1002/acr.22472. Gohal C, Shanmugaraj A, Tate P, et al. Effectiveness of Valgus Offloading Knee Braces in the Treatment of Medial Compartment Knee Osteoarthritis: A Systematic Review. Sports Health. March 2018. https:// doi.org/10.1177/1941738118763913 1941738118763913. Briggs KK, Matheny LM, Steadman JR. Improvement in quality of life with use of an unloader knee brace in active patients with OA: a prospective cohort study. J Knee Surg. 2012;25(5):417–421. https://doi. org/10.1055/s-0032-1313748. Maleki M, Arazpour M, Joghtaei M, Hutchins SW, Aboutorabi A, Pouyan A. The effect of knee orthoses on gait parameters in medial knee compartment osteoarthritis: A literature review. Prosthet Orthot Int. 2016;40(2):193–201. https://doi.org/10.1177/ 0309364614547411. Jones RK, Nester CJ, Richards JD, et al. A comparison of the biomechanical effects of valgus knee braces and lateral wedged insoles in patients with knee osteoarthritis. Gait Posture. 2013;37(3):368–372. https://doi.org/10.1016/j.gaitpost.2012.08.002. Arazpour M, Bani MA, Maleki M, Ghomshe FT, Kashani RV, Hutchins SW. Comparison of the efficacy of laterally wedged insoles and bespoke unloader knee orthoses in treating medial compartment knee osteoarthritis. Prosthet Orthot Int. 2013;37(1):50–57. https:// doi.org/10.1177/0309364612447094. Collins A, Blackburn T, Olcott C, Jordan JM, Yu B, Weinhold P. A kinetic and kinematic analysis of the effect of stochastic resonance electrical stimulation and knee sleeve during gait in osteoarthritis of the knee. J Appl Biomech. 2014;30(1):104–112. https://doi.org/ 10.1123/jab.2012-0257. Hungerford DS, Maclaughlin EJ, Mines CM, et al. Synergistic effect of using a transcutaneous electrical joint stimulator and an unloading brace in treating osteoarthritis of the knee. Am J Orthop Belle Mead NJ. 2013;42(10):456–463. Squyer E, Stamper DL, Hamilton DT, Sabin JA, Leopold SS. Unloader knee braces for osteoarthritis: do patients actually wear them? Clin Orthop. 2013;471(6):1982–1991. https://doi.org/10.1007/s11999-013-2814-0. Cherian JJ, Jauregui JJ, Leichliter AK, Elmallah RK, Bhave A, Mont MA. The effects of various physical non-operative modalities on the pain in osteoarthritis of the knee. Bone Jt J. 2016;98-B(1 Suppl A):89–94. https://doi.org/10.1302/0301-620X.98B1.36353. Hussain S, Neilly D, Baliga S, Patil S, Meek R. Knee osteoarthritis: a review of management options. Scott Med J. 2016;61(1):7–16. https://doi.org/10.1177/0036933015619588. Poddar SK, Widstrom L. Nonoperative Options for Management of Articular Cartilage Disease. Clin Sports Med. 2017;36(3):447–456. https://doi.org/10.1016/j.csm.2017.02.003.

11 • Orthoses for Knee Dysfunction 80. Smith TO, Drew BT, Meek TH, Clark AB. Knee orthoses for treating patellofemoral pain syndrome. In: Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd; 2015. https://doi.org/10.1002/ 14651858.CD010513.pub2. 81. Callaghan MJ, Parkes MJ, Hutchinson CE, et al. A randomised trial of a brace for patellofemoral osteoarthritis targeting knee pain and bone marrow lesions. Ann Rheum Dis. 2015;74(6):1164–1170. https:// doi.org/10.1136/annrheumdis-2014-206376. 82. Solinsky R, Beaupre GS, Fredericson M. Variable Criteria for Patellofemoral Bracing Among Sports Medicine Professionals. PM&R. 2014; 6(6):498–505. https://doi.org/10.1016/j.pmrj.2014.01.008. 83. Callaghan MJ, Parkes MJ, Felson DT. The Effect of Knee Braces on Quadriceps Strength and Inhibition in Subjects With Patellofemoral Osteoarthritis. J Orthop Sports Phys Ther. 2015;46(1):19–25. https:// doi.org/10.2519/jospt.2016.5093. 84. Yu SP, Williams M, Eyles JP, Chen JS, Makovey J, Hunter DJ. Effectiveness of knee bracing in osteoarthritis: pragmatic trial in a multidisciplinary clinic. Int J Rheum Dis. 2016;19(3):279–286. https://doi. org/10.1111/1756-185X.12796. 85. Crossley KM, Vicenzino B, Lentzos J, et al. Exercise, education, manualtherapy and taping compared to education for patellofemoral osteoarthritis: a blinded, randomised clinical trial. Osteoarthritis Cartilage. 2015;23(9):1457–1464. https://doi.org/10.1016/j.joca.2015.04.024. 86. Rosen AB, Ko JN, Brown C. Single-limb landing biomechanics are altered and patellar tendinopathy related pain is reduced with acute infrapatellar strap application. The Knee. 2017;24(4):761–767. https://doi.org/10.1016/j.knee.2017.03.003. 87. Sinclair JK, Selfe J, Taylor PJ, Shore HF, Richards JD. Influence of a knee brace intervention on perceived pain and patellofemoral loading in recreational athletes. Clin Biomech. 2016;37(Supplement C):7–12. https://doi.org/10.1016/j.clinbiomech.2016.05.002.

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88. Laprade J, Culham E. Radiographic Measures in Subjects Who Are Asymptomatic and Subjects With Patellofemoral Pain Syndrome. Clin Orthop Relat Res. 2003;414:172. https://doi.org/10.1097/01.blo. 0000079269.91782.f5. 89. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med. 2002;36(2):95–101. 90. Barton CJ, Lack S, Hemmings S, Tufail S, Morrissey D. The ‘Best Practice Guide to Conservative Management of Patellofemoral Pain’: incorporating level 1 evidence with expert clinical reasoning. Br J Sports Med. 2015;49 (14):923–934. https://doi.org/10.1136/bjsports-2014-093637. 91. Petersen W, Ellermann A, Rembitzki IV, et al. The Patella Pro study — effect of a knee brace on patellofemoral pain syndrome: design of a randomized clinical trial (DRKS-ID:DRKS00003291). BMC Musculoskelet Disord. 2014;15:200. https://doi.org/10.1186/1471-2474-15-200. 92. de Vries AJ, van den Akker-Scheek I, Haak SL, Diercks RL, van der Worp H, Zwerver J. Effect of a patellar strap on the joint position sense of the symptomatic knee in athletes with patellar tendinopathy. J Sci Med Sport. April 2017. https://doi.org/10.1016/j.jsams.2017.04.020. 93. de Vries A, Zwerver J, Diercks R, et al. Effect of patellar strap and sports tape on pain in patellar tendinopathy: A randomized controlled trial. Scand J Med Sci Sports. 2016;26(10):1217–1224. https://doi.org/ 10.1111/sms.12556. 94. Rosen AB, Ko J, Simpson KJ, Brown CN. Patellar tendon straps decrease pre-landing quadriceps activation in males with patellar tendinopathy. Phys Ther Sport. 2017;24(Supplement C):13–19. https://doi.org/ 10.1016/j.ptsp.2016.09.007. 95. Arazpour M, Notarki TT, Salimi A, Bani MA, Nabavi H, Hutchins SW. The effect of patellofemoral bracing on walking in individuals with patellofemoral pain syndrome. Prosthet Orthot Int. 2013;37 (6):465–470. https://doi.org/10.1177/0309364613476535.

12

Orthoses in Orthopedic Care and Trauma☆ MELISSA THACKER, BRADLEY CONNER, and MICHELLE M. LUSARDI

LEARNING OBJECTIVES

On completion of this chapter, the reader will be able to do the following: 1. Review the characteristics of normal bone structure and function across the life span. 2. Describe the most common musculoskeletal injuries that occur at various points in the life span. 3. Identify orthotic interventions for congenital and growth-related musculoskeletal impairments. 4. Classify fracture of bone by type and severity and describe the interventions most often used by orthopedists and orthopedic surgeons on the basis of fracture type. 5. Discuss the different orthotic options for fracture management: joint immobilization, fracture bracing, and external stabilization in common orthopedic injuries to the extremities. 6. Delineate the roles of health care team members in the rehabilitation and orthotic management of individuals with congenital and acquired musculoskeletal impairment.

Orthoses play a significant role in orthopedic and rehabilitative care of individuals with many different types of musculoskeletal pathologic conditions and impairments. Dysfunction of the musculoskeletal system can be the result of congenital or developmental disorders or can be acquired as a result of overuse injury, systemic disease, infection, neoplasm, or trauma at any point in the life span. This chapter focuses on the use of orthoses to manage congenital and developmental musculoskeletal problems in children and fractures of long bones of the lower extremity. The understanding of how orthoses are helpful in the care of those with musculoskeletal impairments is founded on knowledge of the development and physiology of musculoskeletal tissues (bone, cartilage, ligaments, menisci, muscles, and their tendons or aponeuroses); the kinesiological relationships among these tissues; and an understanding of how these tissues remodel in response to physical stressors (forces).1,2 This chapter begins with an overview of the anatomy of bone, its growth and remodeling, and the principles behind the rehabilitation (examination and intervention) of persons with disorders of bone. Then the authors look specifically at disorders of the hip joint and orthotic/orthopedic strategies for limb fractures.

Bone Structure and Function In anatomy classes and texts, students learn that the mature adult human skeleton is composed of 206 bones (Fig. 12.1), ranging from the long bones of the extremities, the blocklike vertebrae of the spine, the encasing protective ribs and skull, ☆

The authors extend appreciation to William J. Barringer, Melvin L. Stills, Joshua L. Carter, and Mark Charlson, whose work in prior editions provided the foundation for this chapter.

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and the multiarticulating carpals and tarsals of the wrist and ankles that enable positioning of the hands and feet for functional activities.3,4 Bony prominences formed during development from the force of muscle contraction at tendinous origins and insertions are identified.1 Students scrutinize articular surfaces to understand how joints move, consider the hyaline cartilage that protects the joint from repeated loading and shear during activity, and learn to examine the ligaments that maintain alignment for normal joint function. From a skeletal model or examination of bone specimens in anatomy laboratory, it is not intuitively apparent that living bone is a dynamic and metabolically active tissue serving multiple purposes and physiological roles.5 These include storage and homeostasis of calcium, phosphate, magnesium, sodium, and carbonate (via ongoing osteoblastic and osteoclastic activity in conjunction with kidney function); production of erythrocytes, granular leukocytes, and platelets in the marrow; physical growth and development (by responsiveness to the pituitary hormones at the epiphyseal plate); provision of a protective and functional frame for the organs of the thorax and abdomen (how would people breathe without ribs?); and body weight support when the body is either at rest or in motion during functional activities.6 Bone is a dense, regular, connective tissue derived from embryonic mesoderm. It contains a combination of specialized cells (osteoblasts, osteocytes, osteoclasts) embedded in a matrix of minerals (70%), protein (22%), and water (8%). The many bones of the human body can be described as long or short tubular bone (e.g., the femur, tibia, metatarsals, phalanges), flat bone (e.g., the pelvis or skull), irregular bone (e.g., the tarsals and carpals), sesamoid bone embedded within tendons (e.g., patella), or accessory bones (e.g., ossicles of the middle ear). Alternatively, they can be classified as primarily cortical (dense) or cancellous (trabecular) bone

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metaphyses serve as an area of transition from cortical to cancellous bone and are supplied by separate metaphysical arterioles. The epiphyses are metabolically active areas of cancellous bone with supportive trabeculae, with an extensive capillary network derived from epiphyseal arteries. The epiphysis is actively remodeled over the life span in response

on the basis of the density and arrangement of their components. Long bones are subdivided into regions, each of which has its own blood supply (Fig. 12.2). The diaphysis (shaft) is supplied by one or more nutrient arteries that penetrate the layers of the bony cortex, dividing into central longitudinal arteries within the marrow cavity. The flared

Frontal bone Nasal bone

Orbit

Zygomatic bone

Maxilla Mandible Clavicle Manubrium Scapula

Sternum

Costal cartilage Ribs Xiphoid process Humerus

Vertebral column

Radius Coxal (hip) bone Ulna Ilium Carpals Sacrum Metacarpals Coccyx Pubis Phalanges Ischium

Greater trochanter

Femur

Patella

Tibia Fibula

Tarsals

Metatarsals

A

Phalanges

Fig. 12.1 The bones of the human skeleton. (A) Anterior view. Continued

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Parietal bone Occipital bone Clavicle

Cervical vertebrae (7)

Acromion process Scapula

Thoracic vertebrae (12)

Ribs

Humerus

Ulna Lumbar vertebrae (5)

Radius

Coxal (hip) bone

Carpals Metacarpals Coccyx

Phalanges

Ischium

Sacrum

Femur

Axial skeleton Appendicular skeleton

Tibia Fibula

Tarsals Phalanges Metatarsals

B

Calcaneus

Fig. 12.1, cont’d (B) Posterior view. (From Thibodeau GA, Patton KT. Anatomy and Physiology. 5th ed. St. Louis: Mosby; 2003.)

to weight bearing and muscle contraction during activity.7 In childhood and adolescence, before skeletal maturation, the bony metaphyses and epiphyses are connected by cartilaginous epiphyseal (growth) plate, which calcifies and fuses throughout various periods of development. The periosteum is a layer of less dense, vascularized connective tissue that

overlies and protects the external surface of all bone and houses osteoblastic cells necessary for bone deposition and growth. The periosteum is replaced by articular (hyaline) cartilage within the joint capsule. The endosteum, a thin connective tissue lining of the marrow cavity of long bones and the internal spaces of cancellous bone of the marrow

12 • Orthoses in Orthopedic Care and Trauma

Epiphyseal vessel

Epiphysis

Epiphyseal plate Metaphysis Metaphyseal vessel

Periosteum Diaphysis

Periosteal vessel

Nutrient artery Fig. 12.2 Diagram of the regions (epiphysis, epiphyseal plate, metaphysis, and diaphysis) of a long bone and their arterial vascular supply. (Modified from Lundon K. Orthopedic Rehabilitation Science, Principles for Clinical Management of Bone. Boston: Butterworth Heinemann; 2000.)

space, also houses osteoblasts. Both linings are active as part of osteogenesis during growth and fracture healing. Cortical bone is the most highly mineralized type of bone found in the shafts (diaphyses) of the long bones of the body and serves as the outer protective layer of the metaphysis and epiphysis of tubular bone, as well as the external layers of flat, irregular, and sesamoid bones. Most of the bones in the human skeleton (80%–85%) are primarily cortical with cancellous/trabecular bone in the metaphyseal and epiphyseal region. Cross section of a long tubular bone reveals three layers of cortical bone: the inner or endosteal region next to the marrow cavity, the metabolic intracortical or haversian region with its haversian canals surrounded by concentric layered rings (osteons) and Volkmann canals containing a perpendicularly arranged anastomosing capillary network, and the dense outer periosteal region (Fig. 12.3).

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Cancellous (trabecular) bone with its honeycomb or spongy appearance is much more metabolically active and much less mineralized than cortical bone. Cancellous bone is composed of branching bony spicules (trabeculae) arranged in interconnecting lamellae to form a framework for weight bearing (Fig. 12.4A). In the vertebral bodies, for example, trabeculae are arranged in an interconnecting horizontal and vertical network oriented perpendicular to the lines of weight-bearing stress into a boxlike shape (see Fig. 12.4B). In contrast, trabeculae in the proximal femur form an archlike structure to support weight-bearing forces between the hip joint and femoral shaft in living bone, cavities between trabeculae are filled with bone marrow. When bone becomes osteoporotic, the cavities enlarge due to loss of bone mass. Three types of cells are embedded within the various compartments of bone. Osteoblasts, bone building cells, synthesize and secrete the organic matrix of bone (osteoid) that mineralizes as bone matures. They are located under periosteum and endosteum and are active in times of bone growth and repair. Osteocytes are matured and inactive osteoblasts that have become embedded within bone matrix. Osteocytes remain connected to active osteoblasts via long dendritic processes running through the canaliculi (small channels) within the bone matrix. Both osteoblasts and osteocytes are responsive to circulating growth hormones, growth factors, and cytokines, as well as mechanical stressors and fluid flow within the bone itself.8,9 Osteocytes are thought to be involved in mineral exchange, detection of strain and fatigue, and control of mechanically induced remodeling.10 Osteoclasts, derived from precursor cells in bone marrow, are macrophage-like cells that can move throughout bone to resorb bone by releasing minerals from the matrix and removing damaged organic components of bone.11,12 The epiphyses of long bones, the vertebrae, and large flat bones house nociceptors and mechanoreceptors and a network of afferent sensory neurons that contribute to exteroceptive (primarily pain) pathways.13 The periosteum has a particularly rich neural network with branches that continue along with penetrating nutrient arteries into the haversian canals into the diaphysis.

Blood vessels Outer circumferential lamellae

Inner circumferential lamellae Endosteum

Periosteum Haversian canal Osteon

A

Interstitial lamellae Volkmann canal

N. Kupiec 1999

B

Fig. 12.3 (A) A cross section through the diaphysis of a long bone, with the external periosteal layer, the middle haversian/intracortical layer, the inner endosteal layer, and the marrow cavity. (B) Diagram of a cross section through the diaphysis of a long bone. (From Lundon K. Orthopedic Rehabilitation Science: Principles for Clinical Management of Bone. Boston: Butterworth-Heinemann; 2000.)

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A B

C Fig. 12.4 (A) Scanning electron microscope view of cancellous/trabecular bone. (B) The trabecular pattern in a healthy lumbar vertebra demonstrates bone tissue’s response to vertical and horizontal forces during upright activity. (C) The relationship of form and function is demonstrated by the arched bridgelike trabecular pattern in this cross section of the proximal femur. C, Cortical bone; CA, cancellous bone. (From Lundon K. Orthopedic Rehabilitation Science: Principles for Clinical Management of Bone. Boston: Butterworth Heinemann; 2000.)

Bone Growth and Remodeling Over the Life Span During childhood and adolescence, growth occurs through the process of modeling, in which bones increase in length and diameter and are reshaped until the epiphyseal plates calcify and skeletal maturity is achieved (typically in midadolescence for females and early adulthood for males).14 In adulthood, bone health is maintained by the ongoing process of remodeling, in which there is a balance and coupling between osteoblastic deposition of new bone substance and osteoclastic resorption of existing bone.15 This ongoing process of turnover means that the internal architecture of living bone is actively restructured and replaced at a rate of approximately 5% per year in cortical bone and up to 20% per year in cancellous bone.5 The rate of bone formation, resorption, and turnover is influenced by both systemic hormones and other substances (e.g., parathyroid hormone, calcitonin, vitamin D from the kidney, growth hormone, adrenocorticosteroids, estrogen, progesterone, androgens); local cell-derived growth factors; and availability of essential

nutrients (calcium, fluoride, vitamin A, vitamin D, and vitamin E).16–18 These substances, along with blood or urinary levels of certain enzymes active during turnover and metabolites of bone resorption, are monitored as biomarkers to track progression of bone diseases associated with high rates of bone resorption (e.g., Paget disease, osteoporosis, hyperparathyroidism) and to determine efficacy of medicalpharmaceutical interventions for these diseases.19–21 In the prenatal period and in infancy, the flat bones of the skull develop as the fetal mesenchyme that forms the periosteum begins to ossify (intramembranous ossification). Most long bones, as well as the vertebrae and pelvis, develop from a cartilaginous framework or template. In this process of endochondral bone formation, cartilage cells mature and eventually ossify.7 During childhood and adolescence, bones grow in both length and diameter and are dynamically modeled toward their mature configurations.22 During puberty, accumulation of bone mass accelerates; by the end of puberty, as much as 90% of mature bone mass is established.23 For young children with abnormal skeletal development, orthoses attempt to capitalize on the dynamic modeling process, applying external forces to influence bone

12 • Orthoses in Orthopedic Care and Trauma

shape and length.24 For approximately 15 years following puberty, after closure of the epiphyseal plates of the long bones, bone mass continues to increase—a process described as consolidation.22 Gender differences in peak bone mass have been well documented: Average peak bone mass in women is approximately 20% less than that of men. Early in the midlife period, both men and women enter a period of gradual endochondral bone loss that appears to be genetically determined; the rate of bone loss is also influenced by hormonal status, nutrition, smoking and alcohol use, and activity level.25–28 It is estimated that males will lose between 15% and 40% of cancellous bone mass and 5% to 15% of cortical bone mass over their lifetime. In women, menopause accelerates the rate of bone loss; there may be up to a 50% decrease from peak cancellous bone mass and 30% decrease in cortical bone mass over their lifetimes.29 Significant loss of bone mass is associated with increasing vulnerability to fracture, especially among postmenopausal women.

Orthoses in the Management of Hip Dysfunction Hip orthoses are important in the management of hip disorders in infants and children, as well as in the postsurgical care of children and adults. An understanding of the designs of and indications for various hip orthoses is essential for physicians and rehabilitation professionals working with individuals who have orthopedic problems of the pelvis, hip joint, or proximal femur. For children with developmental dysplasia of the hip (DDH) or Legg-Calv
e-Perthes disease (LCPD), hip orthoses are the primary intervention for prevention of future deformity and disability. Hip orthoses are essential elements of postoperative care and rehabilitation programs for children with musculoskeletal and neuromuscular conditions who have had surgical intervention for bony deformity or soft tissue contracture. Hip orthoses can also be major postoperative interventions for adults who have had repair of a traumatic injury or a complex total hip arthroplasty. In cases of recurrent hip dislocations, hip orthoses may be indicated to provide external support to prevent future occurrence of dislocation. The efficacy of orthotic intervention is influenced by patient and caregiver adherence: The key to successful use of these orthoses is clear, and open communication exists among the physician, therapist, orthotist, and family concerning the primary goals of the orthosis, its proper application and wearing schedule, and the possible difficulties that may be encountered. Positive health care outcomes and happy patients and families are contingent on the ability of the health care team to communicate.

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2. Avascular necrosis of the femoral head associated with inadequate blood supply during childhood 3. Loss of cartilage and abnormal bone deposition associated with osteoarthritis 4. Loss of bone strength and density in osteoporosis Orthotic intervention is an important component in the orthopedic management of many of these conditions. Most often, hip orthoses are used to protect or position the hip joint by limiting motion within a desirable range of flexion/extension and abduction/adduction. It is important to note that hip orthoses alone are not effective in controlling internal/external rotation of the hip joint. If precise rotational control is desired, a hip-knee-ankle-foot orthosis (HKAFO) must be used.

HIP STRUCTURE AND FUNCTION The hip (coxofemoral) joint is a synovial joint formed by the concave socketlike acetabulum of the pelvis and the rounded ball-like head of the femur (Fig. 12.5). Because of the unique bony structure of the hip joint, movement is possible in all three planes of motion: flexion/extension in the sagittal plane, abduction/adduction in the frontal plane, and internal/external rotation in the transverse plane. Most functional activities blend movement of the femur on the pelvis (or of the pelvis on the femur) across all three planes of motion. The hip joint has two important functions. First, it must support the weight of the head, arms, and trunk during functional activities (e.g., erect sitting and standing, walking, running, stair climbing, and transitional movements

Tubercle of ilium

Ilium

Acetabulum Line of fusion of bones

Ischium

WHEN ARE HIP ORTHOSIS INDICATED?

Pubis

Most nontraumatic hip joint dysfunction or pathology occurs either in childhood or in late adult life and is frequently related to one or more of the four following factors:

Obturator foramen

1. Inadequate or ineffective development of the acetabulum and head of the femur in infancy

Fig. 12.5 Anatomy of the hip. (From Berry DJ, Lieberman JR. Surgery of the Hip. Volume 2, Sections VII–XII. Philadelphia: Elsevier; 2013.)

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ge ⫹ sex

Axis of femoral head

8–15º normal

Da

Axis of femoral condyles at knee

2S

Me fem d tor o si

Latera l rsion femoral teve torsio An n

Angle of inclination Angle of inclination

A

Abnormal

Retroversion Fig. 12.7 Normal relationship between the axis of the femoral neck and the axis of the femoral condyles (viewed as if looking down the center of the femoral shaft) is between 8 and 15 degrees. Excessive anteversion leads to medial (internal) femoral torsion. Insufficient angulation, retroversion, is associated with lateral (external) femoral torsion. (From Staheli LT. Medical femoral torsion. Orthop Clin North Am. 1980;11:40.)

to the shaft and condyles in the transverse plane, called the angle of anteversion, is also a key determinant of hip joint function (Fig. 12.7). Anteversion may be as much as 40 degrees at birth, decreasing during normal development to approximately 15 degrees in adulthood.31 These two angulations determine how well the femoral head is seated within the acetabulum and, in effect, the biomechanical stability of the hip joint. The functional stability of the hip joint is supported by a strong fibrous joint capsule and by the iliofemoral, ischiofemoral, and pubofemoral ligaments. Fibers of the capsule and ligaments are somewhat obliquely oriented, becoming most taut when the hip is in an extended position.

INFANTS AND CHILDREN WITH DEVELOPMENTAL DYSPLASIA OF THE HIP

Axis of head and neck

Axis of femoral shaft

Axis of femoral shaft

Normal

l ia ral on

in activities of daily living). Second, it must effectively transmit forces from the pelvis to the lower extremities during quiet standing, gait, and other closed chain activities.30 The acetabulum is formed at the convergence of the pubis, ischium, and ilium. Its primary orientation is in the vertical, facing laterally, but it also has a slight inferior inclination and an anteverted, or anterior-facing, tilt. Developmentally, the depth of the acetabulum is dynamically shaped by motion of the head of the femur during leg movement and weight bearing. The acetabulum is not fully ossified until late adolescence or early young adulthood. The articular surface of the acetabulum is a horseshoe-shaped, hyaline cartilage–covered area around its anterior, superior, and posterior edges. A space along the inferior edge, called the acetabular notch, is nonarticular, has no cartilage covering, and is spanned by the transverse acetabular ligament. The acetabular labrum is a fibrocartilaginous ring that encircles the exterior perimeter of the acetabulum, increasing joint depth and concavity. The center of the acetabulum, the acetabular fossa, contains fibroelastic fat and the ligamentum teres, and is covered by synovial membrane. The femoral components of the hip joint include the femoral head, the femoral neck, and the greater and lesser trochanters. The spherical articular surface of the femoral head is covered with hyaline cartilage. Because the femoral head is larger and somewhat differently shaped than the acetabulum, some portion of its articular surface is exposed in any position of the hip joint. The femur and acetabulum are most congruent when positioned in a combination of flexion, abduction, and external rotation. The proximal femur, composed primarily of trabecular bone, is designed to withstand significant loading while also permitting movement through large excursions of range of motion. The orientation of the femoral head and neck in the frontal plane, with respect to the shaft of the femur, is described as its angle of inclination (Fig. 12.6). In infancy the angle of inclination may be as much as 150 degrees but decreases during normal development to approximately 125 degrees in mid-adulthood and to 120 degrees in later life.31 The orientation of the proximal femur

B

Fig. 12.6 (A) Normal angle of inclination between the neck and shaft of the femur is 125 degrees in adults. A pathological increase in the angle of inclination is called coxa valga, and a pathological decrease in the angle of inclination (B) is called coxa vara. (From The hip complex. In: Norkin CC, Levangie PK, eds. Joint Structure and Function: A Comprehensive Analysis. 2nd ed. Philadelphia: FA Davis; 1992:305.)

DDH is the current terminology for a condition previously called congenital dislocation of the hip. This new term includes a variety of congenital hip pathologies including dysplasia, subluxation, and dislocation. This terminology is preferred because it includes those infants with normal physical examination at birth who are later found to have a subluxed or dislocated hip, in addition to those who are immediately identified as having hip pathologies.32–34

INCIDENCE AND ETIOLOGY OF DEVELOPMENTAL DYSPLASIA OF THE HIP Instability of the hip due to DDH occurs in 11.7 of every 1000 live births, with most of these classified as hip subluxation (9.2/1000), followed by true dislocation (1.3/1000) and dislocatable hips (1.2/1000).33,35 Commonly, female, family history, and breech presentation are reported as risk factors for DDH.36–38A higher incidence of DDH is also found among newborns with other musculoskeletal abnormalities

12 • Orthoses in Orthopedic Care and Trauma

including torticollis, metatarsus varus, clubfoot, or other unusual syndromes.36,37,39Other factors have been identified in late presenting DDH. Late presenting DDH is defined as a diagnosis after 3 months of age. In late presenting DDH, a history of swaddling and cephalic presentation were found to have increased risk of DDH. Cephalic presentation incidence was attributed to a decrease in monitoring due to normal birth presentation. With late presenting DDH, the likelihood of irreducible hip dislocations is high.40 At birth the acetabulum is quite shallow, covering less than half of the femoral head. In addition, the joint capsule is loose and elastic. These two factors make the neonate hip relatively unstable and susceptible to subluxation and dislocation. Normal development of the hip joint in the first year of life is a function of the stresses and strains placed on the femoral head and acetabulum during movement. In the presence of subluxation or dislocation, modeling of the acetabulum and femoral head is compromised. The most common clinical signs of DDH include asymmetry of the gluteal folds, unequal length of the femur bone (Galeazzi sign), dislocation of the hip with adduction (Barlow maneuver), and repositioning of the femur into the acetabulum with abduction associated with an audible “click” or “clunk” (Ortolani sign; Fig. 12.8).41 On clinical examination, a “clunk” (Ortolani sign) felt when upward pressure is applied at the level of the greater trochanter on the newborn or infant’s flexed and abducted hip (see Fig. 12.8) indicates that a dislocated hip has been manually reduced.42 The goal of orthotic management in DDH is to achieve optimal seating of the femoral head within the acetabulum while permitting the kicking movements that assist shaping of the acetabulum and femoral head for stability of the hip joint.43,44 This is best achieved if the child is routinely positioned in flexion and

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abduction at the hip. If DDH is recognized early and appropriate intervention is initiated, the hip joint is likely to develop normally. If unrecognized and untreated, DDH often leads to significant deformity of the hip as the child grows, resulting in compromised mobility and other functional limitations.

EARLY ORTHOTIC MANAGEMENT OF DEVELOPMENTAL DYSPLASIA OF THE HIP: BIRTH TO 6 MONTHS In 1958 Professor Arnold Pavlik of Czechoslovakia described an orthosis for the treatment of dysplasia, subluxation, and dislocation of the hip.45,46 The orthosis he developed, the Pavlik harness, relies on hip flexion and abduction to stabilize the hip at risk. Although a multitude of braces and orthoses have been used historically in the treatment of hip instability, including hip spica casts, the Frejka pillow, the Craig splint, the Ilfeld splint, and the von Rosen splint, the Pavlik harness has become widely accepted as a mainstay for the initial treatment for the unstable hip in neonates from birth to 6 months of age. At first glance, the Pavlik harness seems a confusing collection of webbing, hook-and-loop material, padding, and straps. In reality, this dynamic orthosis (Fig. 12.9) has three major components: 1. A shoulder and chest harness that provides a proximal anchor for the device 2. A pair of booties and stirrups used as the distal attachment 3. Anterior and posterior leg straps between chest harness and booties used to position the hip joint optimally

Fig. 12.8 Clinical diagnosis of developmental dysplasia of the hip. (From Campion JC, Benson M. Developmental dysplasia of the hip. Surgery. 2007;25 [4]:176–180, Copyright 2007 Elsevier Ltd.)

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a well-fit orthosis, extension and adduction are limited, whereas flexion and abduction are freely permitted: The infant is able to kick actively within this restricted range while wearing the orthosis. This position and movement encourage elongation of adductor contractures, which in turn assists in the reduction of the hip and enhances acetabular development. Three common problems indicate that the fit of the harness requires adjustment43,49: 1. If the leg straps are adjusted too tightly, the infant cannot kick actively. 2. If the anterior straps are positioned too far medially on the chest strap, the limb is positioned in excessive adduction rather than the desired abduction. 3. If the calf strap is positioned too far distally on the lower leg, it does not position the limb in the desired amount of hip flexion.

Fig. 12.9 A Pavlik harness positions the infant’s lower extremities in hip flexion and abduction in an effort to position the femoral head optimally within the acetabulum, assisting normal bony development of the hip joint. The anterior leg straps allow hip flexion but limit hip extension; the posterior flaps allow abduction but limit adduction. (Courtesy of Wheaton Brace Company.)

The anterior strap allows flexion but limits extension, whereas the posterior strap allows abduction but limits adduction. The child is free to move into flexion and abduction, the motions that are most likely to assist functional shaping of the acetabulum in the months after birth.45–47 To be effective, however, the fit of the harness must be accurately adjusted for the growing infant and the orthosis must be properly applied. The family/caregiver must be involved in an intensive education program when the newborn is being fit with the Pavlik harness. Nurses, physical and occupational therapists, pediatricians, and orthopedic residents who work with newborns also need to understand the function and fit of this important orthosis. The guidelines for properly fitting a Pavlik harness include the following key points43,48: 1. The shoulder straps cross in the back to prevent the orthosis from sliding off the infant’s shoulders. 2. The chest strap is fit around the thorax at the infant’s nipple line. 3. The proximal calf strap on the bootie is fit just distal to the knee joint. 4. The anterior leg straps are attached to the chest strap at the anterior axillary line. 5. The posterior leg straps are attached to the chest strap just over the infant’s scapulae. In a correctly fit orthosis, the lower extremity is positioned in 100 to 120 degrees of hip flexion, as indicated by the physician’s evaluation and recommendation. The limbs are also positioned in 30 to 40 degrees of hip abduction. The distance between the infant’s thighs (when the hips are moved passively into adduction) should be no more than 8 to 10 cm. In

Optimal outcomes in infants with DDH are associated with early aggressive intervention of the unstable hip using the Pavlik harness.50,51 Families and health care professionals must seek proper orthopedic care to avoid misdiagnosis and mistreatment. One of the most common misdiagnoses is mistaking dislocation for subluxation and implementing a triple- or double-diapering strategy for intervention. Although this strategy does position the infant’s hip in some degree of flexion and abduction, bulky diapers alone are insufficient for reducing dislocation. Initially, most infants wear the Pavlik harness 24 hours a day. The parents can be permitted to remove the harness for bathing, at the discretion of the orthopedist. Importantly, especially early in treatment, the fit and function of the orthosis must be reevaluated frequently to ensure proper position in the orthosis. The many straps of the Pavlik harness can be confusing to even the most caring of families. The proper donning and doffing sequence should be thoroughly explained and demonstrated to the family. Additional strategies to enhance optimal reduction of the hip such as prone sleeping should be encouraged. Families must be instructed in proper skin care and in bathing the newborn or infant wearing the orthosis. Initially, they may be advised to use diapers, but not any type of shirt, under the orthosis. The importance of keeping regularly scheduled recheck appointments for effective monitoring of hip position and refitting of the orthosis as the infant grows cannot be overstressed to the parents or caregivers.51–53 Missed appointments often result in less than optimal positioning of the femoral head with respect to the acetabulum, a less than satisfactory outcome of early intervention, and the necessity of more invasive treatment procedures as the child grows. As a general rule, the length of treatment in the harness is equal to the child’s age when a stable hip reduction is achieved plus an additional 3 months. Thus if a stable reduction is achieved at 4 months of age, the total treatment time would be 7 months. Over time, when hip development is progressing as desired, the wearing schedule can be decreased to night and naptime wear. This often welcomed change in wearing time can begin as early as 3 months of age if x-ray, ultrasound, and physical examination demonstrate the desired bone development. When the orthopedist determines that the hip is normal according to radiographs and ultrasound and is satisfied with the clinical

12 • Orthoses in Orthopedic Care and Trauma

examination, the orthosis can be discontinued. If development of the hip is slow or the infant undergoes rapid growth, it may be advisable to continue the treatment with another type of hip abduction orthosis designed for older and larger babies, to maintain the position of flexion and abduction for a longer period of time.

MANAGEMENT OF DEVELOPMENTAL DYSPLASIA OF THE HIP: AGE 6 MONTHS AND OLDER For older infants and toddlers (4–18 months) whose DDH was unrecognized or inadequately managed early in infancy, intervention is often much more aggressive and may include an abduction brace, traction, open or closed reduction, and hip spica casting.33,54–56 For infants who are growing quickly or whose bone development has been slow, an alternative to the Pavlik harness is necessary. After the age of 6 months, especially as the infant begins to pull into standing in preparation for walking, the Pavlik harness can no longer provide the desired positioning for reduction. Often, the infant is simply too large to fit into the harness. By this time, families who have been compliant with harness application and wearing have grown to dislike it and are ready for other forms of intervention. A custom-fit prefabricated thermoplastic hip abduction orthosis is often the next step in orthotic management of DDH. This orthosis consists of a plastic frame with waist section and thigh cuffs, waterproof foam liner, and hookand-loop material closures. The static version is fixed at 90 degrees of hip flexion and 120 degrees of hip abduction (Fig. 12.10). An adjustable joint can be incorporated into the abduction bar; however, hip flexion is maintained at 90 degrees. This orthosis appears to be static, but the child is able to move within the thigh sections while the safe zone for continued management of hip position is maintained. Many families view the hip abduction orthosis as an improvement over the Pavlik harness: The caregivers and the infant are free from cumbersome straps, the orthosis is easily removed and reapplied for diaper changing and

Fig. 12.10 A posterior view of a static hip abduction orthosis that positions the infant in 90 degrees of hip flexion and 120 degrees of hip abduction.

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hygiene, and the orthosis itself is waterproof and easier to keep clean. Parents and caregivers can hold the infant without struggling with straps, and the baby is able to sit comfortably for feeding and play. Because most hip abduction orthoses are prefabricated, the knowledge and skills of an orthotist are necessary to ensure a proper custom fit for each child. To determine what the necessary modifications are, the orthotist evaluates three areas: 1. The length of the thigh cuffs. Thigh cuffs are trimmed proximal to the popliteal fossae. Cuffs that are too long can lead to neurovascular compromise if the child prefers to sleep in a supine position, as the risk of compression of the legs against the distal edge of the cuffs is present. 2. The width of the anterior opening of the waist component. Although the plastic is flexible, the opening may need to be enlarged for heavy or large-framed infants. 3. The foam padding of the thigh and waist components. All edges must be smooth to avoid skin irritation or breakdown, and the circumference of the padding should fit without undue tightness. Modifications may require reheating or trimming of the plastic or foam padding. Usually this fitting takes place in the orthotist’s office or the clinic setting, where the necessary tools are readily available. Once the fit is evaluated and modified as appropriate for the individual child, the parents or caregivers are instructed in proper donning/doffing and orthotic care. The static hip abduction orthosis is used in either of two ways. First, the orthosis may be a continuation of the course of treatment established by the Pavlik harness, as determined by the orthopedist’s evaluation of the child’s hip. As a continuation of treatment, the orthosis can be worn day and night; most often, however, it is reserved for nighttime use while the child is sleeping.41,43,54 The use of the orthosis at night is believed to assist development of acetabular growth cartilage. If the orthosis is worn consistently for several months and evidence of effective reduction and reshaping of the joint is present, it is less likely that more aggressive forms of treatment will be necessary as the child grows. The second application for the hip abduction orthosis is for follow-up management for children with DDH who require an orthopedic intervention such as traction, surgical reduction, or casting. In this case the orthosis provides external stability to the hip during the postoperative weeks and months, while the baby regains range of motion and continues to grow and progress through the stages of motor development. This extra stability reduces parental and physician concern about dislocation and other undesired outcomes of the orthopedic procedure. The static hip abduction orthosis has obvious advantages over plaster or synthetic hip spica casts, including greater ease in diaper hygiene and bathing, and is often welcomed by families as a positive next step in treatment. Fitting requires the knowledge and skills of an orthotist familiar with proper fitting techniques and who can manage potentially irritable babies just freed from a confining hip spica cast.

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GOALS OF ORTHOTIC INTERVENTION FOR CHILDREN WITH DEVELOPMENTAL DYSPLASIA OF THE HIP To be effective, orthotic intervention for DDH must have a set of clearly described treatment objectives against which success can be measured. The components necessary for effective orthotic interventions for children with DDH include the following: 1. Clearly presented verbal, psychomotor, and written instructions for the child’s family or caregivers, with an additional goal of minimizing stress in an already stressful situation. 2. Effective communication among members of the health care team about the appropriate use and potential pitfalls of the orthosis. This often includes education about the orthosis provided by the orthotist and careful monitoring of family compliance and coping by all members of the team (orthotists, orthopedists, pediatricians, therapists, nurses, and other health professionals who may be involved in the case). 3. Safe and effective hip reduction to minimize the necessity of more aggressive casting or surgery. This requires proper orthotic fit and adjustment, as well as consistency in wearing schedules. The ultimate goal is to facilitate normal development of the hip joint, providing the child with a pain-free, stable, functional hip that will last throughout his or her lifetime.

COMPLICATIONS OF ORTHOTIC MANAGEMENT OF DEVELOPMENTAL DYSPLASIA OF THE HIP In most cases the Pavlik harness, perhaps followed by abduction splint use as the child grows, is a successful intervention for DDH. A small percentage of infants with DDH managed by the Pavlik harness (35 degrees) and less total coverage of the femoral head within the acetabulum (90 degrees ▪ Neutral to slight abduction Neutral to slight external rotation

▪

Discourages flexor or

Common Symptoms

Examination Procedures

Skin/soft tissue: ▪ Breakdown of the skin over the sacrum Pain: ▪ Back and neck Posture: ▪ Compensatory kyphosis ▪ Hips and knees extended, adducted and internally rotated Skin/soft tissue: ▪ Breakdown of the skin over the lower ischial tuberosity Pain: ▪ Hip, back, neck Posture: ▪ Scoliosis ▪ Asymmetrical height of pelvic crests Skin/soft tissue: ▪ Ischial or trochanteric breakdown Pain: ▪ Low back Posture: ▪ Pelvis drifts to one side of w/c ▪ Functional or actual leg length discrepancy

Posture: ▪ Compare pelvic position sitting in wheelchair to sitting on a firm mat Flexibility: ▪ Assess active and passive range of motion of pelvis and hip joints ▪ Measure thigh length on both sides Wheelchair: ▪ Assess condition and appropriateness of wheelchair components

Skin/soft tissue: ▪ Sacral breakdown Pain: ▪ Hips, back and/or neck Posture: ▪ Compensatory kyphosis ▪ Posterior pelvic tilt ▪ Knee extension, ankle plantarflexion

▪ ROM assessment of both hips

▪ Isolated motor

▪

control ▪ Tonal assessment ▪ Reflex assessment ▪ Tonic labyrinthine supine ▪ Tonic labyrinthine prone Symmetrical tonic neck reflex

16 • Prescription Wheelchairs: Seating and Mobility Systems

409

Table 16.1 Postural Evaluation by Body Segment: Possible Causes and Examination Procedures (Continued) Body Segment

Desired Posture

▪

extensor synergies Wide base of support increases stability

Common Deviations

Possible Causes

Common Symptoms

Examination Procedures

▪ Asymmetrical

tonic neck reflex

Excessive flexion, abduction, external rotation

Physical: ▪ Anterior pelvic tilt ▪ Proximal hypotonia or weakness ▪ Windswept deformity (low side of pelvis) Equipment: ▪ Abductor pommel too wide or too far proximal

Skin/soft tissue:

▪ ROM assessment

distal, lateral thigh(s) as they press against the w/c sides Pain: ▪ Low back Posture: ▪ “Frog leg” position

▪ Isolated motor

▪ Pressure on

of both hips control

▪ Tonal assessment ▪ Reflex assessment

▪ Tonic ▪ ▪ ▪

Knees

Flexion near 90 degrees

Excessive knee flexion

Physical: ▪ Short hamstrings ▪ Hypertonic hamstrings Equipment: ▪ Footrests too far back on w/c

▪ Discourages ▪

Feet

extensor tone Minimizes stress on 2-joint muscles

▪ Neutral

dorsiflexion/ plantarflexion Plantigrade foot, supported on footplate

▪ Avoids ▪

stimulation of reflex activity Helps to maintain functional ankle ROM

Excessive knee extension

Physical: ▪ Dominant extensor tone Equipment: ▪ Footrests too far forward on w/c ▪ Seat depth too long

Excessive dorsiflexion with eversion

Physical: ▪ Component of LE flexor synergy ▪ Stimulation of plantar-grasp reflex Excessive knee flexion ▪ Limited ankle plantarflexion Equipment: ▪ Excessive pressure on metatarsal heads from poorly placed footplates

Excessive plantarflexion with inversion

Physical: ▪ Component of LE extensor synergy ▪ Stimulation of positive supporting reaction or other primitive reflex pattern ▪ Limited ankle dorsiflexion Equipment: ▪ Footrests too low ▪ Feet not fully supported on footplates

labyrinthine supine Tonic labyrinthine prone Symmetrical tonic neck reflex Asymmetrical tonic neck reflex

Skin/soft tissue:

▪ ROM assessment

popliteal fossa Pain: ▪ Paresthesias legs and feet Posture: ▪ Feet slip off footrest posteriorly Skin/soft tissue: ▪ Sacral pressure Pain: ▪ (See posterior pelvic tilt) Posture: ▪ Feet are too far forward on footplates ▪ (See posterior pelvic tilt)

▪ Isolated motor

Skin/soft tissue:

▪ ROM assessment

Pain: ▪ Fatigue and discomfort in the ankles Posture: ▪ Heel(s) the only part of the foot in contact with footplates Skin/soft tissue: ▪ Plantarflexion contractures ▪ Supinated foot Postural: ▪ “Drop foot”

▪

▪ Pressure on

▪ DF contractures ▪ Pronated foot

both knees control

▪ Muscle tone, reflexes

▪ Equipment—

footrest hangers and footplates

▪ ▪

both feet and ankles Isolated motor control Muscle tone, reflexes Equipment— footrest hangers and footplate adjustability

Continued on following page

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Table 16.1 Postural Evaluation by Body Segment: Possible Causes and Examination Procedures (Continued) Body Segment Spine

Desired Posture

Common Deviations

Possible Causes

Common Symptoms

Examination Procedures

“Plumb line” posture with slight lumbar and cervical lordosis, slight thoracic kyphosis

Scoliosis

Physical: ▪ Compensatory righting for a pelvic obliquity ▪ (See pelvic obliquity) Equipment: ▪ (See pelvic obliquity)

Skin/soft tissue: ▪ Breakdown in skin fold created by concavity ▪ Unilateral ischial breakdown

▪ Assess symmetry

Excessive kyphosis thoracic and lumbar spine and excessive lordosis of the cervical spine

Physical: ▪ Compensatory righting for a posterior pelvic tilt ▪ (See posterior pelvic tilt) Equipment: ▪ (See posterior pelvic tilt)

Pain: ▪ Hip, back, neck Posture: ▪ Pelvic obliquity ▪ Windswept hips ▪ “Habitual” leaning to one side Skin/soft tissue: ▪ Breakdown thoracic spinous processes Pain: ▪ Neck and back Posture: ▪ Posterior pelvic tilt ▪ Hip extension, adduction, internal rotation

Scapular protraction

Physical: ▪ Increased flexor tone in upper extremities ▪ Hypotonia Equipment: ▪ Sling back support ▪ Concave back support

▪ Minimize stress ▪

Shoulder Girdle

on trunk musculature Provides mechanically stable alignment, minimizing available lateral flexion and rotation of spine

Neutral with regard to scapulae protraction or retraction

Scapular retraction

Head

Midline vertical, eyes horizontal

Laterally flexed

Increased cervical lordosis

Physical: ▪ Increased extensor tone in upper extremities ▪ Hypotonia with proximal “fixing” Equipment: ▪ Inadequate block against strong extensor pattern

Physical: ▪ Scoliosis with compensatory righting ▪ Less than fair head control ▪ Asymmetrical muscle tone Equipment: ▪ Inadequate proximal support (pelvis, trunk, or head)

Physical: ▪ Increased flexion of trunk with compensatory righting to bring the eyes to midline, horizontal

▪ ▪ ▪ ▪ ▪

of shoulders, pelvic crests Assess alignment of spinous processes Assess flexibility of spine Assess equipment Seat, back, belt Footrest hangers and footplates

Skin/soft tissue: ▪ Breakdown inferior border of scapulae Pain: ▪ Rhomboids area Posture: ▪ “Winging” of scapulae Skin/soft tissue: ▪ Breakdown, spine of scapulae Pain: ▪ Upper back Posture: ▪ Shoulders externally rotated, adducted and retracted

▪ Assess alignment,

Skin/soft tissue: ▪ Irritation from backrest or headrest causing skin breakdown or hair loss Pain: ▪ Neck Posture: ▪ Uneven shoulder height (scoliosis) ▪ Even shoulder height (lack of head control) Skin/soft tissue: ▪ Irritation of skin near the occipital protuberance

▪ ROM of the neck ▪ Head control ▪ Functional

▪ ▪ ▪

symmetry and position of scapulae relative to spinous processes Assess active scapulae muscle control Assess passive scapulae motion Assess equipment—back support

assessment

▪ Muscle tone ▪ Equipment ▪ Proximal support structures

▪ Back support ▪ Head support

16 • Prescription Wheelchairs: Seating and Mobility Systems

411

Table 16.1 Postural Evaluation by Body Segment: Possible Causes and Examination Procedures (Continued) Body Segment

Upper Extremities

Desired Posture

Relaxed, free for propulsion or other functional activities

Common Deviations

Required for postural support on tray or arm rests

Possible Causes

Common Symptoms

Equipment: ▪ Inadequate proximal support

▪ Neck

Physical: ▪ Paralysis of upper extremities Equipment: ▪ Inadequate proximal support

Examination Procedures

Pain:

Posture: ▪ Kyphotic spine Or ▪ Increase lumbar lordosis Skins/soft tissue:

▪ Breakdown near

elbows Pain: ▪ Shoulders Posture: ▪ Leaning on one or both UEs

▪ Observation ▪ Functional assessment

▪ Isolated motor control

▪ Tonal assessment ▪ Reflex assessment ▪ Tonic labyrinthine supine

▪ Tonic labyrinthine prone

▪ Symmetrical tonic neck reflex

▪ Asymmetrical

tonic neck reflex

Always begin postural evaluation with assessment of the pelvis and move in a proximal to distal direction from the base of support. These are general guidelines only—optimal position varies according to medical and functional needs.

also important to distribute the forces associated with corrective components of the seating system over the greatest possible surface area to ensure comfort and soft tissue protection.8 This is especially true for clients who have both motor and sensory impairments, because they are at increased risk for pressure-related damage to the skin and underlying soft tissues.11,12 Pressure ulcers occur when unprotected weight-bearing results in ischemia of the skin and soft tissues, especially those surrounding bony prominences. The propensity for developing pressure ulcers is exacerbated by many factors, including cumulative pressure and shear forces caused by sitting for extended periods of time, the experience of high pressures for short periods of time, impaired sensory and motor function, and poor sitting posture.13 Other mediating factors include the presence of heat and moisture buildup between the skin and the seating system, illness, and inadequate nutrition and hydration.14-16 Chronic problems with pressure ulcers can have a devastating effect on quality and extent of life,17,18 so prevention is of paramount importance in developing seating interventions. Proper size and set up of the wheelchair are essential to pressure management.19 Equally important are the strategic use of external postural supports that offer pressure-relieving properties, client education/training in weight shifting and monitoring strategies, and, if needed, the addition of active seating options such as tilt or recline.12 As already mentioned, all seating interventions begin by addressing seating concerns at the pelvis and lower extremities, as these regions of the body form the base of support in sitting. Key to success is identifying appropriate seat and back supports to assist with positioning the pelvis,

distribution of weight-bearing forces over the largest possible pressure-tolerant areas, and/or offloading any areas that have a history of soft-tissue breakdown.20 Both passive and active pressure-relieving technologies are available. Passive technologies are the most commonly prescribed and consist of wheelchair cushions and related seating components that increase the surface area for weight-bearing through the processes of envelopment and/or redistribution of weight-bearing forces. Areas at high risk for breakdown include the ischial tuberosities, the sacrum, and greater trochanters, while more pressure tolerant areas include the distal femurs and fleshy areas of the buttocks. Many pressure-relieving cushions, such as the one shown in Fig. 16.3, accomplish both goals by

Fig. 16.3 Hybrid cushion includes a contoured base for redistribution of pressures and air-filled bladder to achieve envelopment. (Courtesy Permobil Inc.)

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Section II • Orthoses in Rehabilitation

Fig. 16.4 Power wheelchair with power tilt. (Courtesy Permobil Inc.)

Fig. 16.6 Power wheelchair with power standing feature. (Courtesy Permobil Inc.)

Fig. 16.5 Power wheelchair with power reclining back and elevating leg rests. (Courtesy Permobil Inc.)

combining a shape that redistributes weight-bearing forces with air- or fluid-filled inserts to achieve envelopment. Active technologies include dynamic seat cushions and/ or the use of wheelchair frames that permit tilt, recline, or standing. Dynamic seat cushions typically consist of a series of alternating chambers. A motor pumps air or fluid through chambers to change the configuration of the support surface gently and continuously, much like an alternating-pressure mattress used in hospital beds for clients who are unable to change position. Power or manual tilt (Fig. 16.4), recline (Fig. 16.5), or standing systems (Fig. 16.6) alternate weight-bearing surfaces by changing the client’s position in space to periodically off-weight areas of concern. Comfort and functional outcomes are as important as postural alignment and soft-tissue protection.21 Clients need to feel secure in their seating systems to function optimally. Individuals who experience discomfort or feelings of insecurity when seated report dissatisfaction with their equipment, which may lead to equipment abandonment.22 The process of identifying priorities for seating systems can be quite challenging. It may be necessary to make

compromises to achieve the overall best outcome for the client. For example, consider a client who has been using an air-filled cushion with excellent pressure management, but this cushion does not provide the necessary corrective forces to achieve optimal postural alignment. The team may recommend an alternative intervention that meets all identified needs, but the client may resist that option. The obligation of the team is to educate the client about the risks and benefits of recommended and preferred equipment so he or she can make an informed choice. Health professionals should remember that the client is the only one who can decide what is best for his or her circumstances. Forcing choices on an individual is likely to have negative consequences. The best solution is one that meets all the needs identified to the greatest extent possible but yields to optimal client satisfaction. Clinicians need to be familiar with the types of commercially available seating options so they can educate their clients and make appropriate recommendations. Familiarity with specific manufactured products is less important than understanding the properties offered by the different options. The rehabilitation technology supplier member of the team is available for consultation to match desired outcomes to specific makes and models. What is of utmost importance is for clinicians to be able to identify seating problems and whether they are flexible or fixed. Flexible deformities can be corrected within the seating system, whereas fixed deformities cannot be corrected so will need accommodation. Table 16.2 provides an overview of common fixed and flexible problems that occur at each segment of the body, beginning with the pelvis. Generic solutions are proposed, and these can be matched to commercially available products with the help of the rehabilitation technology supplier. Categories of available seating components and their properties are discussed here.

16 • Prescription Wheelchairs: Seating and Mobility Systems

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Table 16.2 Common Problems and Possible Solutions for Wheelchair Seating Body Segment

Common Problems

Possible Solution(s)

Pelvis

Flexible posterior tilt

▪ Supportive seat and back with belt placed between 60 and 90 degrees to seat rails (distal to ASIS) ▪ “Squeeze” frame (inclinable seat) to increase hip flexion and capture the pelvis in good alignment ▪ Accommodate the pelvis by opening up the seat to back angle >90 degrees

Fixed (structural) posterior pelvic tilt Flexible obliquity Fixed obliquity Hips

Hip adduction Hip extension—flexible Hip extension—fixed

Thigh

Thigh length discrepancy

Knees

Flexion contracture Extension contracture

Feet

Fixed deformities

Spine

Poor trunk control, no asymmetries Fair trunk control, no asymmetries Flexible scoliosis Fixed scoliosis Flexible kyphosis Fixed kyphosis

Shoulder Girdle

Excessive protraction Excessive retraction

Head and Neck

Poor head control

Fair head control Cervical hyperextension

▪ Supportive seat and back with belt placed between 60 and 90 degrees to seat rails (distal to ASIS) ▪ Accommodate by building up under the high side of the obliquity ▪ Proper pelvic position ▪ Removable abductor pommel placed at most distal point on seat at midline ▪ Proper pelvic position ▪ Increase flexion past 90 degrees with inclinable seat ▪ Accommodate by opening up to seat to back angle ▪ Proper pelvic position ▪ Asymmetrical seat or cushion depth ▪ Accommodate with shorter seat depth and footplates that extend posteriorly ▪ Accommodate with elevating leg rests (preferably fixed vs. adjustable to prevent asymmetries) and unnecessary addition of weight

▪ Support with foot cradle, adjustable angle footplate, heel loops, toe straps, as needed ▪ Proper pelvic alignment ▪ Lateral supports mounted on high back ▪ Tilt in space wheelchair ▪ Lateral supports mounted to a high back ▪ Proper pelvic position ▪ Three- (to four-) point pressure system ▪ Proper pelvic position, three-point pressure system for support ▪ Total contact system may be needed to ensure skin protection ▪ Proper pelvic position ▪ Lumbar support on tilt in space system ▪ Clavicular pads if needed ▪ Accommodate with concave backrest and soft, supportive materials ▪ Firm back ▪ Clavicular pads ▪ Lap tray ▪ Concave back support, lap tray, humeral wings on tray ▪ Proper pelvic alignment ▪ Tilt in space wheelchair frame ▪ Posterior headrest ▪ Increase support with lateral and anterior support as needed and tolerated ▪ Removable head rest, used especially for travel ▪ Proper alignment of pelvis and spine

Always begin at the pelvis when attempting to solve postural problems.

SEATING COMPONENTS Seating components vary according to shape, size, and component materials. Garber23 divides wheelchair seating into two basic categories based on purpose: (1) seating for positioning and (2) seating for pressure management. This classification helps clarify the functional division in seating products, but it is too simplistic for most seating systems. It fails to recognize that many clients require management of both positioning and pressure. These two needs should be considered in combination, especially for clients who have both motor and sensory loss. The two main components of the seating system are the seat and back supports. These work together to support the pelvis in a neutral position in all three planes of available movement: anterior/posterior tilt in the sagittal plane, rotation in the horizontal plane, or obliquity in the frontal plane.

Most clients, even those who use wheelchairs on a temporary basis, will benefit from some form of support beyond the upholstery offered on standard wheelchairs.24 The seat and back material that is standard on most wheelchairs offers little resistance to forces that impact pelvic positioning, which may include gravity, tonic reflex activity, and hypertonicity. The three most common postural deviations of the pelvis include the posterior pelvic tilt, pelvic obliquity, and pelvic rotation.25 Each of these deviations impact posture in other regions of the body. The most common is the posterior pelvic tilt, which occurs in response to the gravitational pull on the pelvis in unsupported sitting. A posterior pelvic tilt is accompanied by flexion of the lumbar and thoracic regions and hyperextension of the cervical spine, because automatic righting reactions work to center the upper body over the

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Fig. 16.7 Posterior pelvic tilt and associated postural deformities, including flexion of lumbar and thoracic spines and hyperextension of the cervical spine. (Courtesy Annmarie Sherrick.)

base of support and right the eyes to a forward facing, horizontal orientation.26 The posterior pelvic tilt and associated postural deformities are illustrated in Fig. 16.7. This posture is associated with muscle fatigue and abnormally high disk pressures, both of which contribute to discomfort and pain after prolonged sitting.27 Another common postural deviation stems from the pelvic obliquity, which is shown in Fig. 16.8. This posture is often associated with clients who have asymmetrical muscle tone. For example, clients who have increased muscle tone on the right side of the body may present with a right pelvic obliquity—that is, the pelvic crest on the right side of the body sits higher compared to the left side. This position of the pelvis results in asymmetrical positioning of the hips and thighs, as well as a scoliosis of the spine, with the convexity of the curve occurring on the opposite side. Correction of the pelvic obliquity with well-prescribed seat and back supports may resolve the other asymmetries without additional seating interventions, depending on the degree to which the asymmetries are flexible. Pelvic obliquity caused by abnormal muscle tone may be accompanied by pelvic rotation, depending on the distribution of hypertonicity that is acting on the pelvis and lower extremities. Table 16.1 outlines possible causes of the posterior pelvic tilt, pelvic obliquity, and pelvic rotation. It is important to look beyond the presenting symptoms to identify the cause of pelvic deviations, because the information obtained will help determine whether the seating system will need to provide correction or accommodation. Further, the extent to which external postural support is needed in other areas of the seating system will depend on the amount of correction that can be achieved at the pelvis. When postural deviations are flexible, correction can generally be accomplished through the action of three counteractive forces: an inferior force from the seat cushion to capture the ischial tuberosities, a posterior force from a back support to capture the posterior superior iliac spines of the

Fig. 16.8 Left pelvic obliquity with compensatory right C-curve scoliosis. (Courtesy Annmarie Sherrick.)

pelvis, and an anterior corrective force that can be established either with an anterior positioning strap or the introduction of hip flexion into the seating system (so the knees sit higher than the hip joints). These three counteracting forces will work together to achieve neutral pelvic alignment if adequate flexibility is present. Accommodation of pelvic deviations is needed when deformities are fixed, because application of external forces to an immovable pelvis will likely result in excessive pressure buildup, pain, and ultimately soft tissue injury such as a pressure ulcer. Care must be taken to provide a supportive seat and back, but the goal shifts from achieving correction to achieving comfort and support. These goals are achieved with the use of soft, accommodative materials that are capable of enveloping bony prominences, distributing weight-bearing pressures to the largest possible pressuretolerant surface area, and creating an upright, balanced posture that maximizes the functional capacity of the client. Commercially available seating components vary in their ability to provide the correction or accommodation needed, and clients will respond differently to available options, depending on body shape and composition, perceptions of comfort, aesthetic preferences, and other factors. Successive trials with different options may be needed to identify the best solutions for individual clients. The lowest cost seating components are solid, padded seats and backs. They are the easiest to manufacture and may provide some benefits over standard fabric upholstery. However, their planar (noncontoured) shape is not effective in accommodating contoured body surfaces, which creates the potential for high pressure buildup in the areas of bony prominences. Fortunately, many manufacturers offer

16 • Prescription Wheelchairs: Seating and Mobility Systems

contoured seating components, which distribute weightbearing forces more effectively.28 Two types of contoured surfaces exist: (1) precontoured (generically contoured) and (2) custom contoured. The design of precontoured seats and backs is based on average anthropometric measurements,29 and they come in a variety of sizes to fit most wheelchairs and clients. See Fig. 16.9 for an example of precontoured seat and back cushions. These seat/back options are designed to support neutral alignment of the pelvis and the natural curves of the spine. Some back supports also provide lateral supports to assist with side-to-side balance, as shown in Fig. 16.10. The effectiveness of these surfaces for either postural support or pressure management depends not only on the properties of their component materials but also on the precision of fit, so careful measurement and matching the client to available options is key to successful outcomes. Custom-contoured surfaces are constructed directly from the shape of the client. Many technologies are available to assist with the development of custom-contoured cushions, including hand-shaping foam, computer-assisted design/ computer-assisted manufacturing systems, and “foam-inplace” technologies, among others.30 These systems are designed to record the shape of the client’s body as precisely as possible to manufacture support surfaces that match the contours of that individual. Custom-contoured systems are generally reserved for use with clients who have severe, fixed musculoskeletal deformities and little ability to move actively. They offer the best option for distribution of weight-bearing forces but are quite costly, restrictive, heavy, and offer no ability to be modified if the client’s needs change. It is important to gain knowledge about the properties associated with the materials used to manufacture the component parts of seating systems. The most commonly used materials include foams, air, gel, or a combination of these.

Fig. 16.9 Precontoured seat and back. (Courtesy Permobil Inc.)

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Fig. 16.10 Back rest with lateral supports. (Courtesy Sunrise Medical, Fresno, California.)

The properties and characteristics (including advantages and disadvantages) of each material must be carefully considered according to its ability to provide the necessary support while minimizing the risk factors associated with the development of pressure and soft tissue injuries. These include the materials’ ability to distribute weight-bearing forces, reduce shear and friction, and control temperature and moisture.16,20,31 Foams are the most common component material used in making support surfaces. Two types of foam are available: elastic (available as either a closed-cell or open-cell material) and viscoelastic. Both types have advantages that make them well suited for use in postural supports as well as disadvantages that must be considered. Elastic foams deform in proportion to the applied load, which helps them reduce peak pressure over bony prominences.31 They do not, however, provide good envelopment, and they tend to insulate heat and keep it near the body. Viscoelastic foams are temperature sensitive, meaning they become softer and more compliant at higher temperatures.31 This characteristic helps them provide even better pressure distribution than elastic foams, but clinicians must carefully assess individual clients’ reactions to the warming effect in areas of concern. Fluid-filled cushions are often composed of materials such as air, gel, or viscous fluids that are enclosed in one or more compartments.31 Most of these products provide greater immersion into the cushion, thus distributing pressure over larger areas of the body and reducing pressures at bony prominences (see Fig. 16.3). The type of material used in the cushion influences both skin temperature and the moisture buildup where the support surface contacts the body.32 Understanding the different kinds of materials helps the clinician select an appropriate seat cushion for pressure management and positioning. Covers used for seating components are also important to consider, because they can alter the performance

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characteristics of the underlying supportive materials.32 An inflexible cover will prevent a cushion from providing optimal envelopment, and those that have high friction coefficients will override the benefits of cushion materials that were selected for their low friction coefficients. Cover materials also needs to be resilient, easy to clean, in some cases moisture resistant, and aesthetically pleasing to the client. Once the team has identified the best seat and back supports to achieve optimal proximal alignment, consideration can be given to more distal body segments, beginning with the lower extremities. Table 16.1 provides evaluation guidelines for all remaining regions of the body. Table 16.2 presents common problems and possible solutions, and Table 16.3 describes different seating components and accessories with their relative advantages and disadvantages. It is generally desirable to minimize stress or stretch on the hamstring muscles when positioning the lower

extremities, so the knees should be flexed to 90 degrees or more with the footrests positioned as close to the wheelchair frame as possible without interfering with the caster wheels. This also accomplishes a related goal of achieving the smallest possible overall turning radius of the wheelchair. Footrest options will generally depend on the selection of the frame of the wheelchair. Some are integral components of the frame (Fig. 16.11), whereas others are designed to be removable for ease of transfers and other functional activities as shown in Fig. 16.12. It is important to account for the thickness of the seat cushion when determining the length of the footrest to be ordered. Manufacturers consider “minimal footrest extension” to be the distance between the standard upholstery and the top of the footplate, but this does not account for the thickness of an added seat cushion. For example, if the client’s measurement between the popliteal fossa and

Table 16.3 Advantages and Disadvantages of Various Wheelchair Components Wheelchair Component Leg and foot supports

Options

Advantages

Disadvantages

▪ Swing-away foot

▪ Lightweight support for lower extremities ▪ Removable for transfers

▪ Add to weight of wheelchair

▪ Lightweight ▪ Few moving parts ▪ Very stable ▪ Often allows increased knee flexion angle; more comfortable

▪ Very little adjustability ▪ Both lower extremities supported at

rests

▪ Flip-up foot platform

and compact for user

▪ Manual elevating leg rests

Arm supports

▪

Flip-back arm rests

▪ Tubular swingaway arm rest

▪ Detachable,

adjustableheight arm rest

management also requires recline or tilt to elevate the legs above the heart level) May increase lower extremity comfort

▪ ▪ Stable arm support ▪ Typically lightweight ▪ Easy to manage

user

same angle

▪ Unable to accommodate moderate or severe ankle contractures

▪ Not removable; may interfere with transfers for some users

▪ Heavier than standard leg supports ▪ Many moving and adjustable parts; higher maintenance needs

▪ More strength and dexterity needed to manage

▪ Multiple moving parts ▪ Require maintenance to work properly

▪ May not be adjustable enough for all individuals

▪ Extremely lightweight ▪ Easy for wheelchair user to manage ▪ Requires very little hand dexterity and strength

▪ May not feel stable to user ▪ May not tolerate extreme or repeated

▪ Support upper extremities in multiple positions ▪ Removable for transfers

▪ Heavier ▪ More moving parts; higher

stresses

▪ Attachment hardware requires maintenance

maintenance requirement

▪ May be difficult for users to manager,

▪ Desk-length arm

▪ Allow wheelchair user to approach tables, sinks, desks for

▪

▪ Full-length arm

▪ ▪ ▪

▪ ▪ ▪

rest rest

Wheel locks

▪ Allows multiple leg positions ▪ May prevent some dependent edema (true edema

(vs. platform)

▪ Require maintenance ▪ Require management by wheelchair

▪ Pull-to lock ▪ Push-to lock ▪ Under-seat or scissor locks

improved function Lighter in weight than full-length arm supports Provide full arm support Provide improved support during transfers

▪ Allow closer access for transfers to surfaces ▪ Move away from wheels so hands do not hit with propulsion ▪ Lock easily and securely ▪ Complete clearance for hands during propulsion ▪ No interference in transfers

especially to replace parts on the wheelchair May not provide adequate support during transfers Do not provide full arm support Heavier than desk-length arm Do not allow close approach to tables, sinks, or desks

▪ May be more difficult to lock ▪ May interfere with propulsion ▪ May interfere with transfers ▪ Significantly better balance and ▪

coordination required for locking and unlocking More difficult to adjust

16 • Prescription Wheelchairs: Seating and Mobility Systems

Fig. 16.11 Rigid frame ultralight wheelchair with integrated foot support. (Courtesy Permobil Inc.)

Fig. 16.12 Manual wheelchair with cross-brace folding mechanism. (Courtesy Sunrise Medical, Fresno, California.)

the foot is 1700 and he or she will be sitting on a 300 cushion, the minimum footrest extension needed on the chair as delivered will be 1400 . Trunk positioning can be considered once the base of support is optimized (pelvis and lower extremities). The seat and back supports chosen to achieve optimal pelvic positioning

417

will likely have a positive impact on resultant posture of the trunk, but it may be necessary to provide additional postural support if motor control of the upper body is limited. For example, lateral trunk supports may be needed to support the client in midline. These may be provided as integral components to the back rest or attached to the frame to enable some adjustability (see Fig. 16.10). Back height is an important consideration. The minimum recommended height of a back support is one that captures the posterior superior iliac spines of the pelvis to provide pelvic stability. Clients who have functional use of the upper extremities for manual propulsion or other activities will need a back support that is no higher than the inferior angle of the scapulae to permit freedom of movement of the shoulder girdles. Back supports that reach the top of the shoulders are generally reserved for clients who have poor trunk control and no functional movement of the upper extremities. The specific height chosen will depend on how much trunk support is needed and whether other accessories, such as lateral trunk supports or a head rest, will be used because they will need a point of attachment. “Back height” specified by wheelchair manufacturers is the distance between the top of the standard seat upholstery and the top of the standard back upholstery. The measurement needed for the wheelchair prescription must account for the seat cushion thickness, just as it had to be considered for the footrest measurement. Here, the prescribed height of the back support will be the patient’s measurement from the bottom of the buttocks in sitting to the height of the desired back support on the client, plus the thickness of the cushion. For example, if the patient needs a back support that reaches a height that is just below the inferior angle of the scapulae and their body measurement from buttocks to inferior angle is 1400 , the total prescribed back height will be 1700 . Head or neck supports are needed for clients who have poor head control or if the wheelchair will be equipped with the ability to tilt or recline. Head and neck rest pads come in a variety of shapes and styles. There are also many hardware attachment options. The type that is prescribed will depend on related functional needs of the client. Upper extremity support will vary from none to those that provide full support of the forearms and hands of clients who have no active motor control of the upper extremities. Some considerations include the need to have removable armrests to facilitate independent and obstacle-free transfers, adjustable height to assist with different functional activities, and those that can move with the backrest as the wheelchair is reclining. Options, advantages, and disadvantages are presented in Table 16.3.

The Frame The wheelchair frame is closely integrated with both the seating and mobility systems of the wheelchair. It provides a solid base for the attachment of seating components and facilitates the client’s access to the mobility structures. Table 16.4 provides an overview of wheelchair configurations for clients needing long-term, permanent solutions for seating and mobility. Manual wheelchair frames can be folding or rigid in structure. Folding frame wheelchairs have two side

Table 16.4 Wheelchair Configurations for Clients Needing Long-Term, Permanent Solutions Wheeled Mobility Device

Advantages

Disadvantages

Possible Application

Semiadjustable manual wheelchair (lightweight)

▪ Simple to use ▪ Folds for transportation ▪ Lighter weight than

▪ Not custom fit ▪ Lack of axle adjustability may

▪ Intermittent or temporary use ▪ Possible use for in-home applications if

▪ ▪ ▪ ▪ Fully adjustable manual wheelchair with a folding frame (ultra-lightweight)

▪

▪ ▪

▪

▪ User wants to transport in trunk of vehicle ▪ Environment includes travel over uneven

especially of rear axle position Custom fit to user Accommodates custom seating Accommodates to uneven ground by flexing Folds side to side for easy transportation

▪ Very light frame ▪ Maximal adjustability,

▪

especially of rear axle position Custom fit to user Fewer removable or adjustable parts than folding frame Accommodates custom seating

▪ Light frame ▪ Maneuvers such as ▪

manual wheelchair Minimizes stress on shoulders

▪ Allows rotation in space ▪

Reclining frame wheelchair

users

▪ Full-time wheelchair user with permanent

▪ ▪

Tilt-in-space frame wheelchair

environment tolerates

▪ Many adjustable or removable

▪

Power assist manual wheelchair

limit manual propulsion by user

▪ Still may be too heavy for many

▪ Very light frame ▪ Maximal adjustability,

▪

Fully adjustable manual wheelchair with a rigid frame (ultra-lightweight)

standard wheelchair Partial adjustability Easier to propel Durable Will accommodate custom seating

for pressure management or other benefits Available for both manual and powered wheelchairs

▪ Allows for change in seat▪

to-back angle, often to full supine position Available for both manual and powered wheelchairs

parts More complex design, requires more maintenance Some propulsion energy lost in flex of frame

▪ Does not accommodate to ▪

uneven terrain as easily as folding frame May be more difficult to transport in trunk of car (less compact when folded)

▪ Heavier than nonpower assist ▪ More difficult to disassemble for transport

▪ Frame often heavier and bulkier ▪ Usually does not fold for ▪

transportation If on manual wheelchair, typically has small rear wheels, requiring an attendant to propel

▪ Frame often heavier and bulkier ▪ Rear wheels set further back to ▪

provide larger base of support when in recline position Difficult to propel if used with manual wheelchair

disability surfaces

▪ Full-time wheelchair user with permanent disability

▪ User wants most efficient system for propulsion

▪ Used mainly indoors or on even terrains

▪ Lightweight manual wheelchair user with limited endurance or shoulder limitations

▪ Manual wheelchair user with long-distance ambulation needs or difficulty managing outdoor terrain independently

▪ Wheelchair user requires rotation in space for pressure management or other medical reason, such as respiratory disease

▪ Used when a need for change in seat to back angle is required

▪ Used for pressure management ▪ May be used for self-care in wheelchair ▪ May be used when supine bed transfers are required

▪ Often used when building sitting tolerance during initial rehabilitation

Powered scooter

▪ ▪ ▪ ▪

Powered wheelchair

Allows simple-to-learn powered mobility Good outdoor access Swivel seat for ease of transfers Baskets and other accessories for function, such as shopping

▪ Full access to powered ▪ ▪ ▪

mobility for both indoor and outdoor use Multiple access methods possible Accommodates custom seating supports Accommodates power seating options, such as tilt or recline

▪ ▪ ▪

Only one access method Large turning radius; difficult to use in many homes Does not accommodate custom seating; few seating support options

▪ Used with individuals who have limited endurance

▪ Often used for primarily outdoor mobility purposes

▪ Heavy ▪ Requires van for transportation ▪ Less maneuverable than manual

▪ Individuals who cannot propel manual

▪ Requires more initial training for

▪ May be used in work or school applications

wheelchair

optimal safety and function

wheelchair effectively

▪ Used for indoor and outdoor mobility for long distances

for part-time manual wheelchair users

16 • Prescription Wheelchairs: Seating and Mobility Systems

frames attached by a center cross brace to permit folding the chair from side to side. Rigid frame chairs consist of side frames that are welded together to act as a single unit. Rigid frame chairs can be reduced in size for transportation purposes by folding the back onto the seat and removing the rear wheels if the chair is equipped with quick-release axles. Rigid frame wheelchairs are more efficient to propel because they are lighter in weight and none of the propulsion force applied by the user is absorbed by moving parts. Standard weight manual wheelchairs (such as those used in hospitals) typically have steel frames. They are very durable but also heavy to propel and lift. Lightweight wheelchairs are usually made of aluminum, and ultralight wheelchairs are typically composed of aluminum, titanium, or carbon fiber. Aluminum is widely available, easy to weld, and typically less costly, but it can rust and corrode when exposed to the elements. Aluminum provides a stiffer ride, and this can offer some advantage on smooth terrain. Titanium has a very high strength-to-weight ratio, and therefore less material is needed to build a frame. The result is an overall lighter frame that does not corrode and has inherent vibration dampening. Titanium costs more than aluminum, so justification of the medical need to third-party payers can be challenging. Carbon fiber offers many functional advantages to other options because it is extremely light and durable, but it remains cost-prohibitive in most cases. Some manual wheelchair frames offer options, such as adjustable rear axle plates and front caster housings, to move the seating system forward, back, up, or down on the wheel base to increase propulsion efficiency, enhance maneuverability, and reduce the risk of overuse injuries.33 Some clients will be unable to achieve functional independence with manual wheelchairs regardless of how lightweight or optimally configured, so power wheelchairs must then be considered. A power wheelchair is composed of a power base over which the seating system is placed. The power base houses the motors, batteries, and software options. Both manual and power wheelchairs can be equipped with special function frames, such as tilt, recline, standing, or elevation. These features require additional medical justification and assist with pressure redistribution, positioning, pain management, physiological functions, comfort, and functional independence.34,35 Recliner frames, such as the one shown in Fig. 16.5, permit an increase in the seat-to-back angle. They are typically paired with elevating leg rests to allow the client to assume a full supine position. This can be advantageous for pressure redistribution, self-catheterization, change in hip angle for pain management, and to allow for gravity to assist with positioning. Caution should be used when prescribing recliner frames for clients who have spasticity, as the change in the hip angle can trigger spasms and disrupt overall positioning. Movement to and from sitting can also increase shear forces, which contribute to the development of pressure ulcers. A tilt frame allows the client to remain in one position because the seat-to-back angle is fixed. Pressure redistribution is accomplished by tilting the upper portion of the frame over the lower portion, as shown in Fig. 16.4. Tilt is often a

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better option for clients with hypertonicity for the reasons mentioned previously. Seat elevators are only available on power chairs. They allow the client to raise or lower the seat height relative to the ground, which can increase functional independence in activities such as transfers. Standing frames, such as the one shown in Fig. 16.6, are available on both manual and power wheelchairs. They are integrated into the base and allow the client to achieve a standing position while being supported by the seat and back of the wheelchair. Standing is associated with many physiological benefits, including tone management, an increase in bone density, facilitation of bowel and bladder regulation, and pressure redistribution. It also provides advantages for environmental access and social participation.

The Mobility System The mobility structure provides the means of propelling the wheelchair. It is composed of the drive wheels, caster wheels, tires, and client interface component, such as the hand rims on a manual wheelchair or joystick on many power wheelchairs. Goals of the mobility system focus on the facilitation of movement within the client’s environment and commonly include the following: 1. Provide independent mobility in all environments of interest to the client. 2. Provide speed and agility that equals or exceeds gross motor abilities of “typically functioning” age-related peers. 3. Maximize participation in all MR-ADLs. 4. Minimize energy expenditure and prevent injury through ergonomically sound design. Selection of the client’s most reliable source of motor control is key to prescribing the most appropriate mobility system.4 The access method can be entirely manual, entirely power, or manual with power assistance. Table 16.5 summarizes the indications, advantages, and disadvantages of the various wheeled technologies.

MANUAL WHEELCHAIRS Manual wheelchairs typically have two sets of wheels. The two large wheels range in size from 2000 to 2600 and are located in the rear. Two smaller caster wheels can range from 300 to 800 . They are connected to the front of the wheelchair frame by caster housings. Casters swivel to permit steering and maneuverability of the chair. Rear wheels are composed of tires mounted on rims that are connected to their hubs by metal spokes (called spoked wheels) or synthetic spokes (called mag wheels). Push rims (sometimes called hand rims) are attached to the outside of the wheels. They are slightly smaller in diameter than the wheels and are the access point for propulsion and maneuverability. Factors to consider when selecting the most appropriate wheels include weight and the environment in which they will most often be used. Spoked wheels are lighter but require more maintenance and are not well-suited for moist environments. Mag wheels require little maintenance but

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Table 16.5 Mobility Options: Considerations, Common Problems, and Possible Solutions Propulsion Type

Indications

Considerations

Common Problems

Possible Solution(s)

Manual wheelchair: bilateral upper extremity

Clients who have adequate UE strength to achieve functional mobility (speed, distance, endurance)

▪ ▪

Physical: ▪ Shoulder and wrist pain ▪ Excessive shoulder abduction ▪ Short propulsion stroke Equipment: ▪ Inadequate seating system ▪ Seat too wide ▪ Seat too high ▪ Rear axle position too far back ▪ Wheelchair tipping backward on inclines

▪ Lightweight frame and

▪

Weight of chair Adjustability to optimize positioning and UE alignment for propulsion Availability of accessories needed, including appropriate wheel/caster sizes, tires, footrests, etc. to fit environmental and lifestyle needs

▪ ▪ ▪

▪ ▪ ▪ ▪

Manual wheelchair: unilateral upper and lower extremity

Manual wheelchair: unilateral upper extremity (UE) (one arm drive) Power assist wheels

Hemiplegia

▪ Rear wheel alignment for UE ▪

propulsion Low seat to allow LE propulsion

Physical:

▪ Posterior pelvic tilt ▪ Short propulsion

strokes on rear wheel

▪ Inadequate heel! toe

progression during propulsion Equipment: ▪ Casters interfering with feet ▪ Nonfunctional thigh not fully supported due to height of footrest to allow for ground clearance ▪ Footrest supporting non-functional LE bottoms out on ramps

Impaired motor control in all but one UE

▪ Requires larger hand to grasp ▪ ▪

Manual wheelchair user with shoulder pain Impaired shoulder or hand function

and propel two rims on stronger side Added weight to frame and additional step for folding High risk for overuse syndrome

▪ Increased weight of each wheel ▪ ▪ ▪

Physical:

▪ Shoulder and wrist

accessories to decrease strain Narrower wheelchair to optimize UE to push rim alignment Upright postural alignment with appropriate seating system Align seating system to achieve elbow flexion of 100–120 degrees when hands are at the top of the push rims Rear axle in line with or anterior to center of shoulder joint Education for proper propulsion technique to decreased coefficient of drag on push rim Consider use of antitippers during training phase

▪ Pelvic belt and/or shorter ▪

▪ ▪

▪

seat depth to prevent posterior pelvic tilt during foot propulsion Top of cushion to floor measurement less than or equal to patient measurement of popliteal fossa to bottom of foot Optimize seat width and axle position for UE propulsion Split seat to allow for hip flexion, increased thigh support, and more clearance for footrest on side of impairment 600 or smaller caster to increase clearance for foot propulsion

▪ Consider power options

pain

▪ Difficulty

maneuvering chair on all surfaces and tight spaces

Physical: increases difficulty when folding Increased shoulder pain experienced when or propelling in fully manual loading wheelchair mode Allows for mobility over a into vehicle variety of terrain with less strain to shoulder/wrist joints Requires additional maintenance Increased overall width of chair to accommodate power components in axles

▪ Consider wheelchair van ▪ Second set of lightweight rear wheels to use as a backup

16 • Prescription Wheelchairs: Seating and Mobility Systems

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Table 16.5 Mobility Options: Considerations, Common Problems, and Possible Solutions (Continued) Propulsion Type

Indications

Considerations

Common Problems

Possible Solution(s)

Power wheelchair: joystick controller

Unable to propel manual wheelchair but has consistent and reliable volitional control capable of activating a joystick

▪ Environmental access—requires

Equipment:

▪ Consider swing away

▪

▪ Joystick in the way of

▪ ▪ ▪

Power wheelchair: sip and puff

No reliable motor control of upper or lower extremities

ramps and elevators Increased maintenance requirements over manual Permits independence for clients who cannot propel manual wheelchairs Limited options for community transportation Proportional control of the wheelchair is possible

▪ Requires increased training/ ▪ ▪ ▪ ▪

maintenance Oral motor control is needed Nonproportional control so minimal option to vary speed “on the fly” Difficulty conversing when driving the chair Additional steps in activation needed to access power seat functions

transfers and pulling up to tables Physical: ▪ Difficulty with control when ataxia is present

Equipment: Difficulty tracking on uneven ground Physical: ▪ Disruption of seated position can cause client to lose access to controller ▪ Client fatigue

▪ ▪

▪ Consider specialized path correction system

▪ Provide secondary ▪ ▪

▪ ▪ ▪ Power wheelchair: head array system

Availability of reliable head/ neck control

▪ Requires increased training, set ▪ ▪

up and maintenance Nonproportional control so cannot vary speed “on the fly” Additional steps in activation needed to access power seat functions

add weight to the wheelchair, and performance may be affected by extreme temperatures. Standard wheelchairs offer few options in the selection of wheel size or configuration. Most are equipped with 2400 rear wheels and 800 front casters. Higher cost models, including lightweight and ultralightweight wheelchairs, can be equipped with different-sized wheels and casters, as well as adjustable rear axle and caster housings. These features permit the adjustment of the client’s orientation in space to improve alignment for positioning or propulsion efficiency. The degree to which these features can be adjusted depends on the wheelchair frame. Figs. 16.12 and 16.13 illustrate the differences between the standard and ultralight options for adjustability. Adjustable rear axle and caster housings are important for clients who use wheelchairs on a full-time basis, because they are at a higher risk of developing overuse injuries with associated pain and loss of function from repetitive movements.21,36,37 The two main areas of focus are the shoulders (e.g., rotator cuff tears) and wrists (e.g., carpal tunnel syndrome).38

hardware for obstacle free transfers Adjust wheelchair programming to decrease responsiveness to involuntary movements Consider manual wheelchair as a backup

emergency shutoff system (“kill switch”) to avoid accidents Modify drive parameters to fine tune driving Train client and caregivers in the use of positional markers to increase reliable access to controller Chest strap and pelvic belt to ensure proper alignment Attendant control as a backup Manual wheelchair as backup

Equipment:

▪ Consider specialized path

uneven ground ▪ Equipment malfunction with greater number of more intricate parts Physical: ▪ Hairstyle and head wear can impact proximity switches ▪ Neck pain and fatigue

▪ Modify drive parameters

▪ Difficulty tracking on

correction system

to fine tune driving

▪ Chest strap and pelvic belt ▪ ▪ ▪

to maintain proximity to switches Optional attendant control Shorter hairstyle/low ponytail/no hats Manual wheelchair as a backup

Ease of bilateral upper extremity manual wheelchair propulsion is maximized when the wheelchair is as light and as small as possible and the client’s weight is distributed rearward (with the seat moved back in relation to the rear wheels) to decrease rolling resistance.39 Research has determined that the optimal upper extremity to push rim position allows for 100 to 120 degrees of elbow flexion when the client’s hand is resting on the top of the push rim (Fig. 16.14). This position tends to maximize efficiency in propulsion and minimize overuse impact on the shoulders.39,40 Wheelchair propulsion biomechanics, wheelchair configuration, and training are all important considerations in the prevention of injuries. Clients will need training to effectively manage wheelchairs that are configured to maximize propulsion efficiency. The client’s center of gravity will be shifted to a position that is lower than what it would be in a standard wheelchair, and this may make transfers more challenging. The center of gravity is also shifted further back, which will make it easier for the chair to tip backward (into a “wheelie”). This feature makes it easier to navigate curbs and other common environmental barriers, but it

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Fig. 16.13 Ultralight wheelchair with rigid frame. (Courtesy Sunrise Medical, Fresno, California.) Fig. 16.15 Anti-tip tubes with wheels. (Courtesy Permobil Inc.)

Fig. 16.14 Optimal upper extremity to push rim position for manual wheelchair propulsion. (Courtesy Permobil Inc.)

may be necessary to utilize anti-tip tubes (Fig. 16.15) during the initial training period to prevent the client from tipping over backward when propelling the wheelchair up ramps and other inclines. Clients who propel manual wheelchairs will also require training to consistently use proper propulsion techniques.41 Long, smooth strokes limit excessive forces on upper

extremity joints and decrease the rate of loading on the push rims. In contrast, short, choppy pushes are associated with higher energy expenditure and the development of repetitive use syndromes. Allowing the hands to drop below the rims during the “recovery” (nonpropulsion) phase of the stroke aids in smooth motion and protects the shoulders from injury.39 Clients who do not have functional use of both upper extremities can use other propulsion techniques.42 Those with hemiplegia typically use one upper and lower extremity to achieve functional manual wheelchair propulsion. The stronger upper extremity manages the push rim on the rear wheel for propulsion in tandem with the lower extremity, which also manages directional control and variations in speed and acceleration. Clients who lack reliable motor control in both upper extremities may propel their wheelchairs with their feet, bypassing the use of the push rims altogether. Lower extremity propulsion mandates careful prescription of the seat height to achieve optimal heel-toe progression, and this typically requires smaller rear wheels and casters, as well as adjustable axle plates and caster housings. Clients who have functional use of only one upper extremity may be able to propel manual wheelchairs with one arm drive or lever drive systems.43 These options connect the axles of both drive wheels (either with a dual push rim or a lever system) so that the client can control both wheels and have effective directional control from one side of the chair. This method is very taxing, however, and can only be used for short distances. A power wheelchair option is typically a better solution. Power assist wheels may be an alternative for some clients who are at high risk for overuse injuries but are not

16 • Prescription Wheelchairs: Seating and Mobility Systems

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quite ready to consider the accessibility challenges associated with power wheelchairs.44 Power assist wheels are interchangeable with the rear wheels on manual wheelchairs, and this is easily accomplished on chairs equipped with quick-release axles. The difference between a manual rear wheel and a power assist rear wheel is the presence of batteries and motors within the hubs of the wheels. The client propels power assist wheels with the push rims in the same way, but the physical effort is boosted by the power assist motors, making it possible to travel longer distances and/or travel over more challenging terrains with less risk of repetitive strain injuries. Power assist wheels are heavier than standard wheels, so it is more difficult to remove them if folding the wheelchair for car transport. It is also challenging to propel or have a caregiver push the wheelchair if the power assist wheels are broken. However, clients may easily interchange them with nonmotorized wheels when power assist wheels need maintenance or repair.

POWER WHEELCHAIRS

Fig. 16.16 Mid-wheel drive power wheelchair. (Courtesy Permobil Inc.)

One of the most important decisions for any client is that of manual versus power mobility. Both mobility systems have advantages and disadvantages, and overall function is greatly affected by this decision. Conditions and impairments that often indicate need for power mobility include the following: 1. Severe upper extremity or upper trunk weakness leading to an inability to propel any type of manual wheelchair 2. Ataxic or uncoordinated movement of the upper extremities 3. Endurance limitations, whether from neuromuscular or cardiopulmonary impairment 4. Progressive conditions that will likely lead to loss of upper extremity strength or poor endurance (e.g., amyotrophic lateral sclerosis or multiple sclerosis) 5. Orthopedic problems in the upper extremity joints (e.g., arthritis or preexisting rotator cuff or carpal tunnel impairments) 6. Environments that require long-distance travel on a regular basis or travel over rough terrain Once a determination has been made that power mobility is necessary, one of the next decisions is the access method for control of the device.45 Scooters are the least complicated versions of power mobility devices. Propulsion is activated by the client through a tiller that is directly connected to the front wheel of the device. Scooters are typically only appropriate for clients who require minimal assistance with positioning and travel on very limited terrains, including indoor surfaces and smoother outdoor surfaces. Power wheelchairs can be equipped with mid-wheel drive (Fig. 16.16), front wheel drive (Fig. 16.17), or rear wheel drive (Fig. 16.18). The drive wheels are connected to the motors that control the speed and acceleration of the wheelchair in response to a joystick or other client access method, including switch arrays, sip and puff, and head-controlled devices, among others. These options make it likely that even clients with significant impairments and functional limitations can achieve independent

Fig. 16.17 Front wheel drive power wheelchair. (Courtesy Permobil Inc.)

mobility. For example, clients who have Duchene muscular dystrophy tend to lose gross motor control while retaining fine motor control of the fingers. A joystick can be programmed to respond to the smallest joystick excursions to achieve full speed of the wheelchair. Other motor impairments can be accommodated, such as the need to ignore extraneous movements caused by tremors or muscle spasms.46,47 Assessment for the appropriate method of access depends first on achieving the best seating solutions to optimize any available source of reliable motor control. Some input methods, such as sip and puff and head control systems, require longer training periods. A thorough evaluation with multiple episodes of training may be required before the best access method is selected.

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by the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) to recognize expertise in wheelchair prescription.51 Some third-party payers will not consider requests for payment of certain types of wheelchairs unless an ATP/SMS is involved in the recommendation and delivery of the wheelchair.52 The team engages in assessment, prescription, and training. All aspects of the process must be carefully documented to ensure funding, tracking of client needs over time, and accuracy of the medical record.

SUBJECTIVE/HISTORY

Fig. 16.18 Rear wheel drive power wheelchair. (Courtesy Sunrise Medical, Fresno, California.)

Special care is needed for the prescription of power wheelchairs. Clinicians must be able to provide adjustments in many of the drive parameters, including but not limited to speed, acceleration, starting and stopping, turning and changing directions, locking, unlocking, and free-wheeling. Regardless of the type of wheelchair that is being recommended, a detailed client assessment is needed to identify which options are appropriate for each client. Clients with significant impairments and functional limitations will benefit from the experience of specially trained clinicians who work with complex rehabilitation technology on a regular basis. Errors in prescription or ordering will come at great costs to the client, not only in dollars but in overall functional potential. Less experienced clinicians are encouraged to refer clients to wheelchair clinics for recommendations and prescriptions.

The Seating and Mobility Assessment Process The seating and mobility assessment is a highly complex process involving multiple component evaluations, tests, and measures.21 The client’s needs should be considered in the broadest possible context. This will ensure appropriate recommendations, provide meaningful outcome measures, and justify requests for third-party payment.48-50 Specially trained clinicians, organized in a team structure, are usually responsible for performing seating and mobility assessments. The team may include a physical therapist, occupational therapist, speech-language pathologist, a physician, a rehabilitation technology supplier, and other professionals identified as important by the client. It is particularly helpful if one or more of the rehabilitation professionals and the rehabilitation technology supplier are Assistive Technology Professionals/Seating and Mobility Specialists (ATP/SMSs). These two credentials are provided

A detailed history is an essential component of a seating and mobility assessment. Information collected typically includes all medical diagnoses and related health information, experience with assistive technology in the past, a description of the client’s usual daily activities, the home and other environments in which the equipment will be used, transportation needs of the client, and details about potential funding sources. The information collected will help the team establish goals and interventions and often translates into the best justification for any recommendations.

DIAGNOSES AND RELATED HEALTH INFORMATION All diagnoses and related impairments and limitations are relevant to the assessment process. First, determine if the client relies solely on a wheelchair for mobility or if some ambulation potential exists (with or without assistive devices). Third-party payment may be in jeopardy if the team fails to establish a clear justification of need for the seating and mobility systems. It is important to know the dates of onset of the client’s diagnoses and whether impairments are static or progressive in nature. Information about associated health concerns is also important. Note the presence of difficulties with breathing, cardiovascular or circulatory problems, seizure disorders, bowel and bladder incontinence, nutrition and digestion, medications and side effects, previous or planned surgeries, orthopedic concerns such as subluxation or dislocation of the hip or shoulder, osteoporosis, other orthotic interventions (including leg, foot, or trunk orthoses), history of pressure ulcers or other skin conditions, sensation, pain, visual deficits, hearing deficits, and cognitive and behavioral problems.53 Diagnostic information and related health concerns have a direct impact on the selection of seating and mobility components, as well as approval of insurance coverage of prescribed equipment.

PRIOR EXPERIENCE WITH ASSISTIVE TECHNOLOGY It is helpful to fully understand the client’s experiences with assistive technology. Some clients will be referred for assessment of need for a first wheelchair, but others will have important experiences that need specific exploration. The age, make, and model of any devices currently in use should be recorded, along with the sizes of all items and their present condition. It is important to note the client’s posture and function while using this equipment and to determine and document why the person has been referred for assessment. Helpful considerations might include the following:

16 • Prescription Wheelchairs: Seating and Mobility Systems

1. Did the client outgrow the equipment? 2. Did the equipment meet or exceed its expected life span? 3. Has there been a change in medical condition or functional status? 4. What does the client like/dislike about the current equipment? 5. How is the current equipment used, and is that use appropriate and effective? 6. What, if any, experience has the client had with other equipment? 7. What are the client’s goals for any modifications or new seating or mobility devices? 8. Does the client use any other assistive technology that will need to interface with the seating and mobility systems, such as an augmentative communication device or respiratory equipment?

MOBILITY-RELATED ACTIVITIES OF DAILY LIVING The client’s home environment or other environments in which the equipment will be used must be understood, including those accessed for school, work, or recreation.21 Ask the client to describe typical activities of daily living that will involve the use of the wheelchair, including methods of transfer, optimal height of the wheelchair seat for transfers to other surfaces, and techniques used to accomplish selfcare, vocational, and avocational activities. Information about the mode of community transportation (e.g., car, adapted van, public transportation, schoolprovided transportation) is important to ensure that the new seating and mobility systems will be compatible with what is still in use. Even small differences in the size and configuration of new devices can create problems. Consider van tie-down systems and the clearance available if the client enters a van using an automatic lift. It is better to anticipate these needs than to discover them once a new wheelchair is delivered.

FUNDING SOURCES Most clients will seek third-party payment for seating and mobility systems. Prescribers will need to be familiar with the rules and regulations of potential payers from the start of the prescription process to ensure that any necessary documentation is targeted to the requirements of the funding agency. The most common payers are Medicare (federal insurance), Medicaid (state insurance), and private health insurance companies. Some clients may be eligible for benefits from the Veteran’s Administration if the need for a wheelchair is related to illnesses or injuries that resulted from service in the armed forces. Medicare and Medicaid are government agencies that are regulated by the Centers for Medicare and Medicaid (CMS). Federal regulations that affect Medicare change periodically in response to policy changes, and states have some flexibility to alter Medicaid rules beyond those established by CMS. Clinicians can rely on their rehabilitation technology suppliers to keep them up-to-date about coverage trends.

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PHYSICAL EXAMINATION AND ASSOCIATED CONSIDERATIONS The physical examination begins with observation of the client as he or she enters the clinic. Make note of any postural deviations, difficulties with wheelchair propulsion, overall movement quality, and evidence of discomfort. Information gleaned from the subjective assessment helps the team to hone in on potential areas of concern, even those that go beyond the scope of the seating and mobility assessment team. For example, the history of pressure ulcers will need to be addressed with the prescription of an appropriate seating system and a means to achieve intermittent pressure relief, but it also may be appropriate to refer the client to other health professionals for counseling on nutrition, bowel and bladder management, or other medical issues. A gross assessment can be made by conducting a review of major systems, including a quick screen of the functions associated with cardiovascular, pulmonary, integumentary, musculoskeletal, neuromuscular systems, as well as the communication and cognitive abilities of the individual.54 Components of the cardiovascular and pulmonary assessments include determination of blood pressure, heart rate, pulse oximetry, respiratory rate, and edema. Skin condition must be assessed, particularly those areas of the body that are prone to pressure buildup within the seating system. Direct observation of any affected areas is essential. Gross assessment of musculoskeletal and neuromuscular status includes a quick screen of available range of motion in all major joints and recording of the client’s height and weight. The client’s ability to propel and other aspects of wheelchair management provides general information about the neuromuscular system. Cognitive function and the client’s ability to communicate can be observed while collecting information throughout the assessment process.

TESTS AND MEASURES USED IN SEATING AND MOBILITY ASSESSMENTS The gross review of systems helps determine anything that requires more comprehensive assessment with specific tests and measures. The examination should take place with the client in different positions, including assessment of postural alignment in the current wheelchair, sitting and supine on a mat, and simulation of any proposed interventions. Many tests and measures are used during the seating and wheeled mobility examination process. Some are necessary for all clients, and others are used only in particular instances and are determined based on the client’s presenting symptoms. See Table 16.1 for common symptoms encountered during seating assessments. The Table is arranged according to body segments (beginning with the pelvis) and presents possible physical and equipment causes for presenting symptoms, as well as examination procedures that can be used to identify underlying causes. Many of the tests and measures used are incorporated into the mat evaluation, with observation of the client in seated and supine positions. The team assesses the following

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Section II • Orthoses in Rehabilitation

with the client seated on the edge of the mat: postural asymmetries, sitting balance, available range of motion in the spine and pelvis, functional abilities (e.g., transfers and reaching), and the influence of abnormal muscle tone and reflex activity on posture and function. Results obtained in sitting are compared with those discovered in the supine mat evaluation. This position is often used for measuring specific joint range of motion, strength, coordination, and the influence of abnormal muscle tone and reflexes (and how this differs in supine compared with sitting). Attention must be paid to isolated hip joint mobility; orthopedic deformities such as pelvic asymmetries, hip joint subluxations or dislocations; and flexibility of the spine and pelvic regions.21 Examination in both supine and sitting positions offers an important means to assess the flexibility of postural deformities. Gravitational pull on the body influences postural reactions differently in each position. Postural deformities that are present during the sitting assessment but disappear in the supine mat evaluation can be considered flexible and may be correctible in the seating system. In contrast, postural asymmetries that are present in sitting and remain unchanged in supine should be considered fixed. Attempts to correct them in the seating system will result in pain and/or soft tissue injury. Simulation techniques are helpful.53 Hand simulation is often performed with the client seated on the mat. The therapist uses his or her hands to mimic forces that can be applied by components of the seating system. This technique helps the therapist determine if external supports will provide the desired effect on the client’s posture, how much force is required, and the optimal location and direction of the force that needs to be applied.21 A seating simulator offers a means to verify the results of the hand simulation. This device is a highly adjustable wheelchair frame with many interchangeable components.55 It is first preset to provide the desired supports; then the client sits in it so the therapist can determine if the settings produce the desired postural and functional outcomes. The third simulation method involves the use of commercially available seating and mobility products that offer a close approximation of those that are being considered by the team. This approach provides the advantage of testing the actual components that may be prescribed to determine their effectiveness in meeting the established goals and helpful evidence to support funding requests made to third-party payers. A variety of more specialized tests and measures may be indicated for some clients. These include pressure mapping (Fig. 16.19),56 custom contour seat simulation, pulse oximetry and other circulatory assessments during simulation, and functional wheelchair propulsion testing.57 These specific measures are generally not appropriate for all seating and mobility assessments but can be mixed and matched according to the needs of the client. All these tests and measures provide the therapist with the necessary information required for the evaluation and determination of final equipment selections. Examination findings should be organized according to body segment for easy translation into necessary

Fig. 16.19 Image of CONFORMat. (CONFORMat™ image courtesy of Tekscan, Inc., South Boston, MA)

interventions. Table 16.1 details the desired seated posture for each body segment, common deviations and associated symptoms, possible physical and equipment causes, and the examination procedures that should be used to determine the underlying cause of deviations. Specific information about neuromuscular, musculoskeletal, cardiopulmonary, and integumentary status is collected using standardized tests and measures as the client progresses through the examination process. It is helpful to decide which tests and measures can be performed in each position (sitting in the existing equipment, sitting on the edge of the mat, and laying supine) to minimize the need to have the client change positions.

Neuromuscular Evaluators should make note of any weakness, incoordination, influence of abnormal muscle tone causing asymmetries, and/or hyperflexed or hyperextended posturing causing variations from the optimal postural alignment in sitting. It is important to compare seated postures in current equipment to seated postures on the mat, because inappropriate equipment may be a contributing cause to presenting problems. The results of the neuromuscular assessment are an important factor in identifying an appropriate intervention. For example, asymmetrical muscle tone in the trunk can cause lateral trunk flexion and ultimately scoliosis if left unchecked. The use of carefully placed lateral trunk supports in combination with a tilt-in space frame may inhibit the reflex activity responsible and help to keep the client aligned after intermittent spasms. It is important to note whether neuromuscular conditions are static or progressive, because seating and mobility systems designed for individuals with progressive disorders will need to be easily modified to meet the client’s needs over the expected life of the wheelchair, which is typically 3 to 5 years.

16 • Prescription Wheelchairs: Seating and Mobility Systems

Musculoskeletal The musculoskeletal assessment will reveal the need to correct or accommodate postural deformities. Every attempt should be made to correct flexible postural problems to prevent them from becoming fixed problems. For example, the common postural deviations caused by a flexible posterior pelvic tilt can often be corrected by providing three carefully placed external forces to maintain the pelvis in neutral alignment. Clients who present with fixed postural deformities will need accommodation to envelope and protect any rigid bony prominences and distribute weight-bearing forces to prevent discomfort and soft tissue injury. Cardiopulmonary Some clients will present with impairments and limitations in the cardiovascular system, which may translate into the need to provide extra soft-tissue protection if the client has vascular problems that limit the ability to heal. More commonly, cardiopulmonary impairments limit endurance and may indicate the need for a power wheelchair for functional mobility, even when upper extremity function may be adequate to propel a manual wheelchair. Integumentary Any existing problems with the integumentary system should be addressed by making accommodations to protect areas of existing skin or soft tissue injury to minimize the risk of future damage. This is accomplished by prescription of a cushion that is capable of offloading any areas of the body that have a history of skin breakdown and distributing all seating pressures across the largest possible surface area of more pressure-tolerant body parts.20,21 Comorbidities Many clients who rely on the permanent use of a wheelchair for seating and mobility will present with impairments and limitations of more than one system. Interventions then may require a careful risk/benefit analysis about how much correction, accommodation, and compensation is needed. For example, a client with significant musculoskeletal deformities, paralysis, and abnormal muscle tone will present with many challenges that must be addressed. It will be important to balance multiple needs to optimize outcomes of function, comfort, skin protection, and other factors identified as important by the client. The data collected during the examination process is matched to commercially available seating and mobility components to develop a seating system that corrects or accommodates postural problems identified, a wheelchair frame that can provide the desired body-in-space positioning, and a mobility system capable of providing the client

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with a safe and efficient means of locomotion in all environments of interest.

Ordering the Wheelchair Inadequate support or improper fit of the wheelchair can lead to a variety of problems for both seating and mobility, so even those clients who require a wheelchair on a temporary or part-time basis should be prescribed a wheelchair that fits properly and provides a minimally supportive seat and back to avoid injury or secondary impairments. Manufacturers of standard wheelchairs provide guidelines for measuring clients and their environments of intended use to ensure the best fit possible. See Table 16.6 for standard wheelchair dimensions and Table 16.3 for accessories that can be used to personalize the wheelchair to help meet the client’s individual and environmental needs. Clients who require full-time, permanent use of a wheelchair will require more than basic fit and support to address impairments and limitations and should be referred to a team of specialists at a wheelchair clinic as previously discussed.50 All members of the team help to generate the plan of care, specific interventions, and a comprehensive wheelchair prescription that will meet all needs identified through the evaluation process. Each team member plays a vital role in helping ensure the best outcome through service coordination, ongoing communication with all parties involved, and clear documentation of the process. The physical or occupational therapist typically assumes the role of lead coordinator of the process. He or she helps to ensure that the prescription moves through all required steps so the client can receive the equipment in a timely manner. The therapist works closely with the rehabilitation technology supplier to identify specific manufacturers’ products to meet the client’s goals and needs identified in the assessment process. The therapist incorporates those details into a letter of medical necessity. This document is the key to obtaining approval of third-party payment. The letter of medical necessity must be clear, concise, and comprehensive, as well as consistent with the guidelines for coverage specified by the funding source. The purpose of this letter is to provide a clear picture of the client and the equipment being recommended. This letter must contain several elements. The introductory paragraph should describe the client in detail, including the diagnoses and associated limitations and impairments, onset dates, prognosis, a summary of the history and the systems review, as well as the reason for any unusual requests. For example, most wheelchairs are expected to last a minimum of 3 to 5 years. Requests

Table 16.6 Standard Wheelchair Configurations for Clients Needing Short-Term, Temporary Solutions Frame Adult Sizes

Hemi Height

Seat to Floor

Seat Size 00

16–22 wide (in 2 increments) by 16 or 1800 deep 18 16 or 1616

00

00

19 ¾

00

17 ½

Back Height 00

16 ½

00

16 ½

Seat and Back Sling style upholstery

Armrests Styles

Footrest

▪ Fixed full or desk

▪ Fixed with flip up footplates ▪ Swing away/removable footrests ▪ Swing away/removable elevating leg

▪

length Removable full or desk length

rests with calf pads

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to pay for new equipment within that timeframe must be accompanied by a convincing argument as to why the replacement is needed. Next, detailed information is provided about the specific tests and measures used during the examination and outcomes of the evaluation. These include, but are not limited to, the individual’s functional status, strength, range of motion, musculoskeletal deformities, neuromuscular status, abnormal muscle tone or reflex findings, and the results of the simulation processes. This information can be organized and reported on a standardized form or in a narrative style. The seating and mobility assessment will have revealed problems associated with the musculoskeletal, neuromuscular, integumentary, and cardiopulmonary systems. It is important for the therapist to document the relationship between the impairments and limitations identified and the seating and mobility interventions that are being recommended to justify the medical need for each component of the seating and mobility system. Each part of the system must be specified and accompanied by medical and/or functional justification to support the selection. Third-party payers may also require an explanation about why lower cost options were not effective for the client. Finally, a summary of the client information and contact information for the primary therapist and the prescribing physician should be provided so that the funding source may contact these individuals if any questions arise during the review process. Meticulous preparation of the letter of medical necessity may mean the difference between efficient funding of the seating and mobility system and a long, drawn-out review process that could delay the delivery of equipment by several months. The rehabilitation technology supplier assumes primary responsibility for all aspects of the intervention once the letter of medical necessity has been provided. He or she is responsible for submitting the medical documentation to the third-party payer, along with a detailed cost invoice of all parts of the wheelchair being requested. The rehabilitation technology supplier also acts as the conduit for any questions that arise during the review process. Once funding is approved, the rehabilitation technology supplier orders the prescribed equipment (often from several different manufacturers), assembles the equipment according to the specifications prescribed, and notifies the therapist that the seating and mobility system is ready for delivery. The client then returns to the seating clinic for fitting, adjustment, and training. Delivery is a critical element in the intervention process and directly affects the outcomes related to the use of the equipment.

demonstration, and in writing) and must include review of the owner’s manuals provided by the equipment manufacturers. The client should have the opportunity to function in and use the equipment during the delivery process to ensure that the goals established during the examination process have been effectively attained. Regardless of the type of wheelchair selected or the access method chosen, intensive training of the person using the wheelchair is necessary.50 Training takes place across settings and over time. Wheelchair skills are typically introduced during inpatient rehabilitation, but training usually continues after discharge until the new client gains independence with advanced skills. Initial training may begin with loaner or temporary equipment used to assess options and designs that will allow optimal mobility before a wheelchair prescription is finalized. Additional training is typically necessary once the permanent wheelchair and associated equipment have been delivered. Clients who use manual wheelchairs need training in the safe use of equipment, which includes effective management of obstacles in all environments typically accessed (home, community, work, and leisure settings). They need to learn how to perform or direct basic maintenance of the equipment (including cleaning procedures and maintaining moving parts) and know when and whom to contact if something out of the ordinary occurs with the wheelchair. Clients who use power wheelchairs often require more extensive periods of training to achieve optimal safety, mobility, and function.45 This training must include management of indoor terrain and obstacles, such as turning in tight spaces, managing door frames and transitions between flooring surfaces, and negotiating other indoor obstacles, such as elevators. Training should also include outdoor terrain, such as ramps, curbs, side slopes, grassy surfaces, gravel surfaces, and safe operation on crowded sidewalks or when crossing streets. If a power seating system is prescribed (e.g., tilt or recline), the client must be educated regarding the proper and safe use of this system, including how often to use it and under what conditions it should (and should not) be used. Although the assessment and prescription for a wheelchair usually takes place in a specialty clinic, functional training after delivery of the equipment is typically provided by outpatient or home care therapy services. Therapists who are unfamiliar with any aspects of the new equipment or training protocol can obtain assistance from the prescribing clinicians and/or rehabilitation technology supplier.

Delivering the Wheelchair

Follow-Up

Delivery of equipment may occur several months after the examination and prescription process for all but very basic wheelchair prescriptions. It is important for the therapist to ensure that the status and needs of the client have not changed since the initial seating and mobility assessment. The delivery process includes making necessary adjustments as well as training the client and any caregivers in the use, maintenance, and care of the equipment.50 Instructions should be provided in multiple formats (i.e., verbal,

The final component of an adaptive seating evaluation is reexamination, also known as follow-up.50 Periodic reexamination of equipment and client needs is essential to maintain optimal function. Most seating and mobility equipment has a usable life span of 3 to 5 years, but shorter life spans can be expected if the client is particularly active or if the equipment is used in harsh or demanding environments. It is important to establish appointments for reexamination to evaluate whether the client’s needs continue

16 • Prescription Wheelchairs: Seating and Mobility Systems

to be met by the equipment. It is also important for the client to be prepared to independently assess the need for follow-up with clinicians or the rehabilitation technology supplier. The client is the most knowledgeable person regarding the adequacy of the equipment over time, so it is important to provide the information needed to recognize the need for adjustments, modifications, repairs, and eventual replacement.

State of the Art The science and art associated with wheelchair prescription is still in its infancy. There is a great deal of interest among clinicians to increase the availability of evidence to support clinical decision-making in the practice of wheelchair seating and mobility.58,59 Some work has been done to develop and validate outcome measures to facilitate evidence-based practice in this field,57,60,61 but few randomized, controlled clinical trials have been conducted.62,63 More effort has been focused on the development of national seating and wheelchair standards. RESNA has been actively working toward the development of wheelchair position papers, as cited throughout this chapter. These guides are intended to provide objective information to consumers and clinicians about the safety and performance of wheelchairs. The standards established have provided a platform for research into characteristics of wheelchairs that are most beneficial to consumers and assist with justification for third-party payment of higher-quality products based on ultimate cost effectiveness.64

Summary Wheelchairs are essential aids for daily living for people with mobility impairments. They have the capacity to impact virtually every aspect of life in a positive or negative way, including health, happiness, vocational potential, avocational pursuit, and environmental access. Recommendations must be considered carefully and be as unique as the individual for whom the wheelchair is being prescribed. Even clients who require the most basic wheelchairs deserve careful assessment to ensure proper fit and function over the expected life of the wheelchair. Insurance companies typically cover the cost of a wheelchair every 3 to 5 years, so it is of critical importance to make sound recommendations to ensure client safety, comfort, and function.

References 1. National Institute of Child Health and Human Development. National Institutes of Health (NIH) Research Plan on Rehabilitation. In: Eunice Kennedy Shriver; 2016. https://www.nichd.nih.gov/publications/pubs/ Documents/NIH_ResearchPlan_Rehabilitation.pdf. 2. Smith EM, Sakakibara BM, Miller WC. A review of factors influencing participation in social and community activities for wheelchair users. Disabil Rehabil Assist Technol. 2016;11(5):361–374. 3. Giesbrecht EM, Mortenson WB, Miller WC. Prevalence and facility level correlates of need for wheelchair seating assessment among long-term care residents. Gerontology. 2012;58(4):378–384. 4. Cook AM, Hussey SM. Seating systems as extrinsic enablers for assistive technologies. In: Cook AM, Hussey SM, eds. Assistive Technologies: Principles and Practice. vol 1. 2nd ed. St. Louis: Mosby; 2002:165–211.

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5. Engstrom B. Seating and Mobility for the Physically Challenged. In: Risks and Possibilities When Using Wheelchairs. vol 1. 2nd ed. Sweden: Posturalis Books; 2002. 6. Clark J, Morrow M, Michael S. Wheelchair postural support for young people with progressive neuromuscular disorders. Int J Ther Rehabil. 2004;11(8):365–373. 7. Babinec M, Cole E, Crane B, et al. RESNA position on the application of wheelchairs, seating systems, and secondary supports for positioning versus restraint. Assist Technol. 2015;27(4):263–271. 8. Hastings JD, Rogers Fanucchi E, Burns SP. Wheelchair configuration and postural alignment in persons with spinal cord injury. Arch Phys Med Rehabil. 2003;84(1):528–534. 9. Waugh K, Crane B. A Clinical Application Guide to Standardized Wheelchair Seating Measures of the Body and Support Surfaces. Denver, CO: Assistive Technology Partners, University of Colorado School of Medicine; 2013. https://www.assistivetechnologypartners.org. 10. Chen CL, Teng YL, Lou SZ, et al. User satisfaction with orthotic devices and service in Taiwan. PLoS One. 2014;9(10). https://doi.org/ 10.1371/journal.pone.0110661. e110661. 11. Stinson M, Ferguson R, Porter-Armstrong A. Exploring repositioning movement in sitting with ‘at risk’ groups using accelerometry and interface pressure mapping technologies. J Tissue Viability. 2018;27 (1):10–15. 12. Bergman-Evans B, Cuddigan J, Bergstrom N. Clinical practice guidelines: prediction and prevention of pressure ulcers. J Gerontol Nurs. 1994;20(9):19–26. 13. Stephens M, Bartley CA. Understanding the association between pressure ulcers and sitting in adults. J Tissue Viability. 2018;27(1):59–73. 14. Bergstrom N, Braden BJ, Laguzza A, et al. The Braden Scale for predicting pressure sore risk. Nurs Res. 1987;36(4):205–210. 15. Houghton PE, Campbell KE, Panel CPG. Canadian Best Practice Guidelines for the Prevention and Management of Pressure Ulcers in People with Spinal Cord Injury. A resource handbook for clinicians. 2013. http://www.onf.org. 16. International review. Pressure ulcer prevention: pressure, shear, friction and microclimate in context. In: A consensus document. London: Wounds International; 2010. http://www.wounds international.com/consensus-documents/view/international-reviewpressure-ulcer-prevention-pressure-shear-friction-and-microclimatein-context-1. 17. Allman RM. Pressure ulcer prevalence, incidence, risk factors, and impact. Clin Geriatr Med. 1997;13(3):421–436. 18. Cuddigan J, Berlowitz DR, Ayello AE. Pressure ulcers in America: prevalence, incidence, and implications for the future. Adv Skin Wound Care. 2001;14(4):208–215. 19. Ham R, Aldersea P, Porter D. Wheelchair Users and Postural Seating: A Clinical Approach. vol 1. New York: Churchill Livingstone; 1998. 20. Call E, Hetzel T, McLean C, et al. Off loading wheelchair cushion provides best case reduction in tissue deformation as indicated by MRI. J Tissue Viability. 2017;26(3):172–179. 21. Minkel JL. Seating and mobility considerations for people with spinal cord injury. Phys Ther. 2000;80(7):701–709. 22. Weiss-Lambrou R. Satisfaction and comfort. In: Scherer MJ, ed. Assistive Technology: Matching Device and Consumer for Successful Rehabilitation. Washington, DC: American Psychological Association; 2002:77–94. 23. Garber SL. Wheelchair cushions: a historical review. Am J Occup Ther. 1985;39(7):453–459. 24. Rader J. Individualized wheelchair seating: Reducing restraints and improving comfort and function. Top Geriatr Rehabil. 1999;15 (2):34–47. 25. Lacoste M, Therrien M, Prince F. Stability of children with cerebral palsy in their wheelchair seating: perceptions of parents and therapists. Disabil Rehabil Assist Technol. 2009;4(3):143–150. 26. Shumway-Cook A, Woollacott MH. Development of Postural Control – Chapter 8. In: Motor control: translating research into clinical practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012. 27. Zacharkow D. Posture: Sitting, Standing, Chair Design and Exercise. Charles C. Thomas: Springfield, IL; 1988. 28. Hobson DA. Seating and mobility for the severely disabled: Technology overview and classification. In: Leslie J, ed. Rehabilitation Engineering. Boca Raton, FL: CRC Press; 1988:201–218. 29. Paquet V, Feathers D. An anthropometric study of manual and powered wheelchair users. Int J Ind Ergon. 2004;33(3):191–204.

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30. St. Georges M, Valiquette C, Drouin G. Computer-aided design in wheelchair seating. J Rehabil Res Dev. 1989;26(4):23–30. 31. Brienza DM, Geyer MJ. Understanding support surface technologies. Adv Skin Wound Care. 2000;13(5):237–244. 32. Stewart SFC, Palmieri V, Cochran GVB. Wheelchair cushion effect on skin temperature, heat flux, and relative humidity. Arch Phys Med Rehabil. 1980;61(5):229–233. 33. DiGiovine C, Rosen L, Berner T, et al. RESNA position on the application of ultralight manual wheelchairs. Arlington, VA: Rehabilitation Engineering and Assistive Technology Society of North America; 2012. https://www.resna.org/sites/default/files/legacy/resources/positionpapers/UltraLightweightManualWheelchairs.pdf. 34. Dicianno BE, Arva J, Lieberman JM, et al. RESNA position on the application of tilt, recline, and elevating legrests for wheelchairs. Assist Technol. 2009;21(1):13–22. 35. Dicianno BE, Morgan A, Lieberman J, et al. Rehabilitation Engineering & Assistive Technology Society (RESNA) position on the application of wheelchair standing devices: Current state of the literature. Assistive Technology. 2016;28(1):57–62. 36. McLaurin CA, Brubaker CE. Biomechanics and the wheelchair. Prosthet Orthot Int. 1991;15(1):24–37. 37. Curtis KA, Drysdale GA, Lama D, et al. Shoulder pain in wheelchair users with tetraplegia and paraplegia. Arch Phys Med Rehabil. 1999;80(4):453–457. 38. Boninger ML, Cooper RA, Roberson RN, et al. Wrist biomechanics during two speeds of wheelchair propulsion: an analysis using a local coordinate system. Arch Phys Med Rehabil. 1997;78(4):364–372. 39. Koontz AM, Boninger ML. Proper propulsion. Rehab Manag. 2003;16 (6):18–22. 40. van der Woude LH, Veeger DJ, Rosendal RH, et al. Seat height in hand rim wheelchair propulsion. J Rehabil Res Dev. 1989;26(4):31–50. 41. van der Woude LH, Veeger HE, Rozendal RH. Propulsion technique in hand rim wheelchair ambulation. J Med Eng Technol. 1989;13(1– 2):136–141. 42. van der Woude LH, Dallmeijer AJ, Janssen TWJ, et al. Alternative modes of manual wheelchair ambulation: an overview. Am J Phys Med Rehabil. 2001;80(10):765–777. 43. Mandy A, Redhead L, McCudden C, et al. A comparison of vertical reaction forces during propulsion of three different one-arm drive wheelchairs by hemiplegic users. Disabil Rehabil Assist Technol. 2014;9 (3):242–247. 44. Kloosterman M, Snoek GJ, Lucas HV, et al. A systematic review on the pros and cons of using a pushrim-activated power-assisted wheelchair. Clin Rehabil. 2012;27(4):299–313. 45. Leaman J, Hung M. A comprehensive review of smart wheelchairs: past, present, and future. IEEE T Hum-Mach Syst. 2017;47 (4):486–499. 46. Rosen L, Arva J, Furumasu J, et al. RESNA position on the application of power wheelchairs for pediatric users. Assist Technol. 2009;21 (1):218–226. 47. Rosen L, Plummer T, Sabet A. RESNA position on the application of power mobility devices for pediatric users: Update 2017. Arlington, VA: Rehabilitation Engineering and Assistive Technology Society of North America; 2017. https://www.resna.org/sites/default/files/legacy/

48. 49. 50.

51. 52.

53. 54. 55. 56. 57. 58. 59. 60.

61. 62. 63. 64.

Position-Papers/RESNA%20Ped%20Power%20Paper%2010_25_ 17%20-BOD%20approval%20Nov2_2017.pdf. Mortenson WB, Miller WC, Miller-Pogar J. Measuring wheelchair intervention outcomes: Development of the Wheelchair Outcome Measure. Disabil Rehabil Assist Technol. 2009;2(5):275–285. Kenny S, Gowran RJ. Outcome measures for wheelchair and seating provision: a critical appraisal. Br J Occup Ther. 2014;77(2):67–77. Arledge S, Armstrong W, Babinec M, et al. RESNA wheelchair service provision guide. Arlington, VA: Rehabilitation Engineering and Assistive Technology Society of North America; 2011. https://www. resna.org/sites/default/files/legacy/resources/position-papers/ RESNAWheelchairServiceProvisionGuide.pdf. Rehabilitation Engineering and Assistive Technology Society of North America. Assistive technology professional certification. https://www. resna.org/certification; 2018. Centers for Medicare and Medicaid. Documentation checklist for prior authorization request. https://www.cms.gov/Research-Statistics-Dataand-Systems/Monitoring-Programs/Medicare-FFS-CompliancePrograms/DMEPOS/Downloads/DMEPOS_PA_Documentation_ Checklist_2017-03-24.pdf. Zollars JA, Knezevich J. Special seating: an illustrated guide. Minneapolis, MN: Otto Bock Orthopedic Industry; 1996. American Physical Therapy Association. Guide to Physical Therapist Practice. Phys Ther. 2001;81(1):21–138. Trefler E, Taylor SJ. Prescription and positioning: evaluating the physically disabled individual for wheelchair seating. Prosthet Orthot Int. 1991;15:217–224. Ferguson-Pell M, Cardi MD. Prototype development and comparative evaluation of wheelchair pressure mapping system. Assist Technol. 1993;5(2):78–91. Kirby RL, Swuste J, Dupuis DJ, et al. The Wheelchair Skills Test: a pilot study of a new outcome measure. Arch Phys Med Rehabil. 2002;83 (1):10–18. Rader JD, Jones D, Miller L. The importance of individualized wheelchair seating for frail older adults. J Gerontol Nurs. 2000;26 (11):24–32. 46–47. Scherer MJ. Outcomes of assistive technology use on quality of life. Disabil Rehabil. 1996;18(9):439–448. Aissaoui R, Boucher C, Bourbonnais D, et al. Effect of seat cushion on dynamic stability in sitting during a reaching task in wheelchair users with paraplegia. Arch Phys Med Rehabil. 2001;82 (2):274–281. May LA, Butt C, Minor L, et al. Measurement reliability of functional tasks for persons who self-propel a manual wheelchair. Arch Phys Med Rehabil. 2003;84(4):578–583. Conine TA, Hershler C, Daechsel D, et al. Pressure ulcer prophylaxis in elderly patients using polyurethane foam or Jay wheelchair cushions. Int J Rehabil Res. 1994;17(2):123–137. Geyer MJ, Brienza DM, Karg P, et al. A randomized control trial to evaluate pressure-reducing seat cushions for elderly wheelchair users. Adv Skin Wound Care. 2001;14(3):120–129. Axelson P, Minkel J, Chesney DA. Guide to Wheelchair Selection: How to Use the ANSI/RESNA Standards to Buy a Wheelchair. Washington, DC: Paralyzed Veterans of America; 1994.

17

Etiology of Amputation☆ MILAGROS JORGE

LEARNING OBJECTIVES

On completion of this chapter, the reader will be able to do the following: 1. Describe the epidemiology of nontraumatic, traumatic, and congenital amputation. 2. Identify the major causes of limb loss in the United States. 3. Discuss major risk factors for dysvascular/neuropathic-related amputation. 4. Explain the differences in risk factors of amputation among various racial and ethnic groups. 5. Describe health promotion efforts for the prevention of dysvascular disease. 6. Identify key issues considered by the rehabilitation team when they are caring for persons with limb loss.

Throughout the history of medicine, amputation has been a relatively frequently performed medical procedure and has often been the only available alternative for complex fractures or infections of the extremities. The earliest amputations were generally undertaken to save lives; however, their outcomes were often unsuccessful—many resulted in death from shock caused by blood loss or the onset of infection and septicemia in those who survived the operation. In these early amputations, removal of the compromised limb segment as quickly as possible was essential. With the advent of antisepsis, asepsis, and anesthesia in the mid-19th century, physicians focused increasingly on the surgical procedure and conservation of tissue.1 Today, when amputation is necessary, surgery is undertaken with consideration for the functional aspects of the residual limb. This chapter reports on the etiology of amputation or limb loss in the United States and other Western nations. The epidemiology of amputation and factors contributing to changes in the incidence and prevalence of limb loss are presented. An overview of key concerns regarding the rehabilitative process and expected outcomes for persons with limb pathology resulting in limb loss are discussed.

Epidemiology of Amputation Surveillance data on persons living with limb loss are limited because there is no national database in the United States for compiling data specific to persons with amputation. Information on persons with amputation is derived from a variety of sources including information on hospital discharge diagnoses. The National Health Interview Survey (NHIS) is the principal source of information on the health of Americans and is one of the major data collection programs of the National Center for Health Statistics (NCHS), which is part of the Centers for Disease Control and Prevention (CDC).2 The 1996 NHIS is the most current database; it ☆ The author extends appreciation to Caroline C. Nielsen, whose work in prior editions provided the foundation for this chapter.

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has the most comprehensive information on amputation and persons living with limb loss.3 The NHIS revised instrument is currently under construction and is slated for dissemination in 2019.4 Based on the 1996 NHIS, the number of Americans living with limb loss is estimated at 1.6 million.5 According to the Amputee Coalition, each year in the United States an estimated 185,000 persons lose a limb.6 Limb loss occurs for a variety of reasons including dysvascular diseases, trauma, cancer, and congenital anomalies (Figs. 17.1 and 17.2). In 2008, Ziegler-Graham and colleagues7 conducted an epidemiologic study that estimated the prevalence of limb loss in the United States for the period 2005 to 2050. According to statistical analysis based on the figure that 1.6 million Americans were living with limb loss in 2005, it was estimated that the number of persons living with limb loss would increase to 3.6 million by the year 2050. It is anticipated that the number of persons living with amputation will more than double in the next 45 years. Increases in life span and health-related age factors will figure significantly in the greater number of persons living with limb loss (Fig. 17.3). (See Case Examples 17.1 to 17.3.) The leading cause of amputation is dysvascular disease. Predisposing factors for amputation include diabetes, hypertension, and dyslipidemia. Health conditions that affect the blood vessels—such as peripheral vascular disease (PVD), peripheral artery disease (PAD), and diabetes—are the leading causes of amputation. Dysvascular disease accounts for approximately 82% of all limb-loss hospital discharges.8 Most of these were lower extremity amputations, which are performed 11 times more frequently than upper extremity amputations.9 More amputations occur among men than among women, and amputation rates increase steeply with age.10 The health condition most frequently related to amputation is dysvascular disease, including PVD and PAD complicated by neuropathy. Although PVD and neuropathy are frequently associated with type 2 diabetes, vascular disease also occurs independently of diabetes. However, diabetes is the leading cause of nontraumatic

17 • Etiology of Amputation

Cancer 0.9%

Trauma 16.4%

Congenital anomalies 0.8%

Neuropathy & vascular conditions 81.9% Fig. 17.1 Causes of amputation in percent. The majority of amputations result from a disease process. (Data from Dillingham TR, Pezzin LE, Mackenzie EJ. Limb amputation and limb deficiency: epidemiology and recent trends in the United States. South Med J. 2002;95[8]:875–883)

LIMB LOSS IN THE U.S.A.

433

lower extremity amputation.11 The number of persons with diabetes and prediabetes in the U.S. population continues to rise. According to the National Diabetes Statistics for 2017, an estimated 30.3 million people of all ages, or nearly 10% of the U.S. population, had diabetes in 2015.The percentage of adults with diabetes increased with age, reaching a high of 25.2% among those aged 65 years.12 The increasing frequency of amputation for PVD likely reflects the growth in the older population (see Fig. 17.4).13 This increase is likely to continue with current population projections. The population in the age group 45 to 64 years is projected to increase by 23.8% between 2002 and 2020, and the population at greatest risk for amputation, those 65 to 85 years of age and older, is expected to increase by 71%.13 The population of individuals older than 85 years of age is projected to increase at the highest rate. Diabetes and smoking are the strongest risk factors for developing PAD. Other well-known risk factors are advanced

2.1 Million

185K

507

People living with limb loss.

People have an amputation each year.

People lose a limb each day.

1,558 military personnel lost a limb as a result of the wars in Iraq and Afganistan.

Gender of Amputation Patients, 2013

Female (31%)

Male (69%)

Age at Amputation, 2013

Causes of Amputation

Vascular Disease (54%) Trauma (45%) Cancer (2%)

Types of Amputations

3.6 million people will be living with limb loss by 2050.

LIMB LOSS AWARENESS MONTH

36% of people living with limb loss experience depression.

The Amputee Coalition has designated April as Limb Loss Awareness Month to raise awareness about limb loss and limb loss prevention. To learn more, go to amputee-coalition.org.

85% of lower-limb amputations are preceded by a foot ulcer.

(6%)

Upper limb (35%) Lower limb (65%)

Fig. 17.2 Amputee Coalition of America statistics for year 2013 per 100,000 amputations. (From Limb Loss in the USA facts graph from the Amputee Coalition of America 2013.)

3000 2500 2000 1500

1000 750 2000

2010

2020

2030

2040

2050

25% Increase 10% Increase No change 10% Decrease 25% Decrease Fig. 17.3 Projected number of Americans living with limb amputation secondary to dysvascular disease (log scale) from years 2000 to 2050. (From Ziegler-Graham K, MacKenzie EJ, Ephraim PL, et al. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil. 2008;89:426.)

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Section III • Prostheses in Rehabilitation

age, hypertension, and hyperlipidemia.14 The number of Americans with diabetes with limb loss will continue to rise because of the persistent reports that diabetes is a national health problem. Diabetes is the leading cause of new cases of nontraumatic lower extremity amputations among adults.15 The number of hospital discharges for nontraumatic lower extremity amputation with diabetes as a listed diagnosis increased from 45,000 in 1991 to 86,000 in 1996. From 1988 to 2006, the number of hospital discharges for persons with diabetes who had experienced amputation increased by 20%.10,11 The relationship between diabetes and PVD with diabetes is well established. PVD has variable clinical presentations ranging from asymptomatic to severe ischemia and claudication (Fig. 17.4). Because of the known complications of dysvascular disease in persons with diabetes and PAD, education efforts have been enhanced regarding the care of persons with diabetes in an effort to prevent diabetic foot ulcers.16 More recent data provided by the CDC indicate a decline in lower limb amputations for persons with diabetes.17 The CDC report is based on the findings of researchers who investigated the number of hospitalizations for nontraumatic lower extremity amputation in persons aged 40 and older with a diagnosis of diabetes in the years from 1988 to 2008.18 However, the authors reported that throughout the entire study period (1988–2008), diabetes-related nontraumatic lower extremity amputations were higher among persons 75 years of age or older, men more than women, and blacks more than whites. Despite the reports of decline in recent years, the reality is that with the projected increase in the number of persons with diabetes and with the rise in the life span for octogenarians, there is a need for intensive prevention and treatment that will avoid loss of limbs for persons with dysvascular disease. The second leading cause of amputation is trauma. Traumatic amputation is most common in the young adult age group (20–29 years of age). The leading causes of traumarelated amputation are injuries involving machinery

Fig. 17.4 Clinical presentation of peripheral artery disease (PAD). The clinical presentation of PAD can be variable and may not produce symptoms of limb pain. It can produce typical claudication pain, atypical leg pain, or critical limb ischemia. (Slide from presentation by Dr. James S. Stills Duke Medical Center https://www.slideshare.net/ DukeHeartCenter/diagnosis-and-management-of-peripheral-arterialdisease.)

(40.1%), power tools and appliances (27.8%), firearms (8.5%), and motor vehicle crashes (8%).4 The incidence of trauma-related major amputation continues to decrease over time. This reduction is attributable to the implementation of new safety regulations, the development of safer farm and industrial machinery, improved safety in work conditions, and medical advancement in techniques for salvaging traumatized limbs. Whenever there is a period of significant armed conflict, the number of veterans with traumatic amputation increases. U.S. engagement in military operations in Afghanistan, Iraq and Syria, including Operation Freedom’s Sentinel (OFS–Afghanistan), Operation Inherent Resolve (OIR–Iraq and Syria), Operation New Dawn (OND– Iraq), Operation Iraqi Freedom (OIF–Iraq), and Operation Enduring Freedom (OEF–Afghanistan), has caused 1645 service men and women to sustain traumatic amputations or limb loss.12 As reported in the 2015 U.S. Congressional Research Report, “A Guide to U.S. Military Casualty Statistics,” U.S. military engagements that have persisted continuously for the past 15 years have resulted in numerous traumatic amputations.19 Table 17.2 and Fig. 17.1 provide data on “Individuals With Battle-Injury Major Limb Amputations” for OEF, OFS, OIF, OND, and OIR from October 7, 2001 to June 1, 2015. The third cause of limb loss is cancer related—primary cancer or secondary cancer due to metastatic disease. There are a number of cancers that can affect the limbs and may present the need for amputation.20–22 Primary bone cancers are very rare; they account for less than 0.2% of all carcinomas. The three most common forms of bone cancer are (1) osteosarcoma, (2) chrondosarcoma, and (3) Ewing sarcoma. In 2017, the estimated number of new bone and joint cancer cases was reported as 3260 total new cases; 1820 males and 1440 females. The estimated number of deaths from bone and joint cancers was reported as 1550 total cases: 890 males and 660 females.23 Primary bone cancers are extremely rare—less than 0.2% of all cancers.23 The tumor most commonly associated with amputation is osteosarcoma, which primarily affects children and adolescents in the 11- to 20-year-old age group.24 Currently amputation is no longer the primary intervention for osteosarcoma, and the current rate of amputation for this disease is less than 1%. With the development of new surgical techniques for limb salvage, including bone graft and joint replacement, and advancements in chemotherapy and radiation, the incidence of amputation as a consequence of osteosarcoma has decreased significantly. Amputation is reserved for when the tumor is located in an anatomic region that is not amenable to limb salvage. Congenital limb deficiencies as well as the amputations used to adjust or correct them are relatively rare, and little has changed over time in the birth prevalence of such deficiencies. Rates ranging from 3.8 to 5.3 per 10,000 births have been reported.25 This percentage has remained relatively stable and represents less than 1% of all amputations.

Levels of Amputation Amputation can be performed as a disarticulation of a joint or as a transection through a long bone. The level of amputation is usually named by the joint or major bone through which the amputation has been made (Table 17.1).25 An

17 • Etiology of Amputation

Table 17.1 Terminology Used to Describe the Site of Lower Extremity Amputation Site

Terminology

Toe

Phalangeal

Forefoot

Ray resection (one or more complete metatarsal) Transmetatarsal (across the metatarsal shaft)

Midfoot

Partial foot (e.g., Chopart, Boyd, Pirogoff)

At the ankle

Syme

Below the knee

Transtibial (long, standard, short)

At the knee

Knee disarticulation

Above the knee

Transfemoral (long, standard, short)

At the hip

Hip disarticulation

At the pelvis

Hemipelvectomy

435

Because dysvascular disease typically affects both lower extremities, a significant number of individuals eventually undergo amputation of both lower extremities. Approximately 50% of persons undergoing diabetes-related amputation will have a contralateral amputation within 3 to 5 years.27 Between 25% and 45% of persons with amputations have had amputations of both lower extremities, most often at the transtibial level in both limbs or a combination of transtibial amputation of one limb and transfemoral amputation of the other.13 Today the majority of transtibial and transfemoral amputations are performed with an understanding of wound healing and the functional needs and constraints of prosthetic fitting so that rehabilitation outcomes are usually positive. Other levels of amputation, although less commonly performed, continue to pose challenges for the surgeon, prosthetist, physical therapist, and patient during prosthetic fitting and rehabilitation.

Table 17.2 Classification of Longitudinal Congenital Limb Deficiencies

Causes of Amputation

Limb Segment

Upper Extremity Bone Segmenta

Lower Extremity Bone Segmenta

Proximal

Humeral

Femoral

Distal

Radial Central Carpal Metacarpal Phalangeal

Tibial Central Tarsal Metatarsal Phalangeal

Currently the most likely reasons for amputation are poor wound healing associated with diabetes4,28 and dysvascular disease,26 trauma,4,16 or cancer.23 Children with congenital limb deficiencies are a special population and may require surgical revision during or after periods of significant growth or after conversion to a more functional level for prosthetic fitting.

Combined (indicated by the bone segments that remain)

Partial or complete Specific carpal, ray, or phalanx remaining

Partial or complete Specific carpal, ray, or phalanx remaining

a

May be partial or complete. Modified from May BJ. Amputations and Prosthetics: A Case Study Approach. Philadelphia: Davis; 1996:221.

amputation that involves the lower extremity can affect an individual’s ability to stand and walk, requiring the use of prosthetics and, often, an assistive device for mobility. Amputation involving the upper extremity can affect other activities of daily living, such as feeding, grooming, dressing, and a host of activities that require manipulative skills. Because of the complex nature of skilled hand function, prosthetic substitution for upper limb amputation does not typically restore function to the same degree that lower extremity prosthetics do. The amputation surgeries that are most commonly performed today involve the lower extremity below the knee (including transtibial, foot, and toe amputations), accounting for 97% of all hospital discharges following dysvascular limb loss (Table 17.2). This high percentage reflects the prevalence of PVD of the lower extremities. Transfemoral amputations account for approximately 26% of all dysvascular amputations.25,26 In general the proportion of lower limb amputations in relation to upper limb amputations is increasing. This most likely reflects an increase in the number of older persons with lower extremity amputations rather than an actual decrease in the number of upper extremity amputations.

DIABETES AND PERIPHERAL ARTERY DISEASE Diabetic foot ulceration is a common complication of diabetes that often results in lower extremity amputation.29 Elevated blood sugars associated with diabetes damage blood vessels and nerve fibers and impair circulation. Nerve damage causes peripheral neuropathy, a condition of loss of sensation to the feet. The loss of protective sensation in the feet would not alert an individual to foreign substances in their shoes, such as pebbles or gravel. This lack of awareness can lead to blisters or other minor injuries. Once the skin is broken, sores on the feet may not heal because of poor circulation. The CDC confirms that neuropathy is a major contributor to diabetic amputations.29 The prevalence of PAD in persons with diabetes is four times greater than that in persons without diabetes.29 Dysvascular disease is the most common contributing factor to lower extremity amputations. Dysvascularity accounts for 87% of all amputations in the United States.26 In epidemiologic studies, two symptoms are classic indicators of vascular insufficiency: intermittent claudication and loss of one or more lower extremity pulses. Intermittent claudication is a significant cramping pain, usually in the calf, that is induced by walking or other prolonged muscle contraction and relieved by a short period of rest. In arteriosclerosis obliterans, at least one major arterial pulse (the dorsalis pedis artery at the ankle, popliteal artery at the knee, or femoral artery in the groin) is often absent or markedly impaired (see Fig. 17.4).30 The major risk factors for the development of PAD are the same as those for cardiovascular and cerebrovascular disease, most notably poorly managed hypertension, high serum cholesterol and triglyceride levels, and a history of tobacco use. Peripheral neuropathy and PAD

%

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Section III • Prostheses in Rehabilitation

30 25 20 15 10 5 0

Men Women

40-49

50-59

60-69

70-79

≥80

Fig. 17.5 Clinical impact. Age-related prevalence of peripheral artery disease. The prevalence of peripheral artery disease increases with age, and it affects men more than women. (From Allison MA, Ho E, Denenberg JO, et al. Ethnic-specific prevalence of peripheral arterial disease in the United States. Am J Prev Med. 2007;32:328–333.)

are the major predisposing factors for lower extremity amputation in individuals with diabetes.31 The prevalence and incidence of PAD are both sharply age related, rising more than 10% among patients in their 60s and 70s. With aging of the global population, it seems likely that PAD will be increasingly common in the future (Fig. 17.5). The prevalence of more severe or symptomatic disease seems to be higher among men than among women.31 The “2016 American Heart Association/American College of Cardiology (AHA/ACC) Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease” states that diabetes is an important risk factor for the development of PAD. The presence of diabetes increases the risk of adverse outcomes among patients with PAD, including progression to chronic limb ischemia and amputation.33 The age-adjusted rate of lower extremity amputation among persons with diabetes in the United States is approximately 28 times that of the nondiabetic population. More than 50% of the lower limb amputations in the United States are diabetes related.29 Although major improvements have been made in noninvasive diagnosis, surgical revascularization procedures, and wound-healing techniques, between 2% and 5% of individuals with PAD and without diabetes and between 6% and 25% of those with diabetes eventually undergo an amputation.24,25 The incidence of lower extremity amputation among persons with diabetes is almost 50% higher for men than for women.4,31 Clinical factors that contribute to lower limb amputation in persons with diabetes include lower extremity infection due to nonhealing neuropathic foot ulcers, severe ischemic pain, absent or decreased pulses, local necrosis, osteomyelitis, systemic toxicity, acute embolic disease, and severe venous thrombosis. In individuals with diabetes, the prevalence and severity of dysvascularity increases significantly with age and the duration of diabetes, particularly in men. Initial amputation may involve a toe or foot; subsequent revision to transtibial or transfemoral levels is likely to occur with progression of the underlying disease. In individuals with diabetes, dysvascular disease increases the risk of a nonhealing neuropathic ulcer, infection, or gangrene, all of which increase the likelihood of amputation. Some 20% to 50% of patients will have amputation of the contralateral leg in 1 to 3 years.32 Patients with diabetes who are 65 years of age or older account for most diabetes-related lower extremity amputations. African Americans are at greater risk for both diabetes and PAD. Consequently African Americans are at increased risk for lower extremity amputation.33

Peripheral neuropathy is the most common risk factor for foot ulcers in people with diabetes.34 Neuropathy is as important and powerful as dysvascular disease as a predisposing factor for lower extremity amputation. More than 80% of all nontraumatic amputations in diabetic patients are the result of foot ulcers.35 Peripheral neuropathy is suspected when one or more of the following clinical signs are present: (1) deficits of sensation (loss of Achilles and patellar reflexes, decreased vibratory sensation, and loss of protective sensation), (2) motor impairments (weakness and atrophy of the intrinsic muscles of the foot), and/or (3) autonomic dysfunction (inadequate or abnormal hemodynamic mechanism, tropic changes of the skin, and distal loss of hair).20 The resulting loss of thermal, pain, and protective sensation increases the vulnerability of the foot to acute high-pressure and repetitive low-pressure trauma. Patients may also experience significant numbness or painful paresthesia of the foot and lower leg. Individuals with peripheral neuropathy may not be aware of minor trauma, pressure from poorly fitting shoes along the sides and tops of their feet, or pressure from thickening plantar callus, all of which contribute to the risk of ulceration, infection, and gangrene. Motor neuropathy and associated weakness and atrophy contribute to the development of bony deformity of the foot. The bony prominences and malalignments associated with foot deformity change weight-bearing pressure dynamics during walking, further increasing the risk of ulceration. Peripheral neuropathy is one of the most crucial precursors of foot ulceration, especially in the presence of dysvascular disease. Nonhealing or infected neuropathic ulcers precede approximately 80% of nontraumatic lower extremity amputations in individuals with diabetes.35 The American Diabetes Association (ADA) defines diabetic peripheral neuropathy as “the presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes after the exclusion of other causes.”36 There is no gold standard for diagnosing diabetic peripheral neuropathy.36 Its symptoms are similar to those of peripheral neuropathy of other sources: numbness or reduced ability to feel pain, muscle weakness, difficulty walking, and serious foot problems. Lower extremity amputation continues to be a major health problem for persons with dysvascular disease, diabetes mellitus, and peripheral neuropathy. When limb loss occurs in these individuals, it is associated with significant morbidity, functional limitation and disability, mortality, and high health care costs. Approximately 185,000 persons undergo amputation each year in the United States.7 The average cost per hospitalization for an amputation is approximately $30,000. The cost of health care for persons with chronic diseases such as diabetes and PAD is estimated by the ADA at $330 billion per year.37 A major cost associated with diabetic medical care is that of lower limb amputation. In the United States, public health concerns are under the auspices of the CDC,38 which includes the NCHS39 and the Department of Health and Human Services. Healthy People 2020 is a public health initiative with four overarching goals: (1) to attain high-quality, longer lives free of preventable disease, disability, injury, and premature death; (2) to achieve health equity, eliminate disparities, and improve the health of all groups; (3) to create social and physical

17 • Etiology of Amputation

environments that promote good health for all; and (4) to promote quality of life, healthy development, and healthy behaviors across all life stages.38 Reducing the incidence of lower extremity amputations in persons with diabetes is a key health care objective in terms of quality of life and the containment of health care costs. It is estimated that the current prevalence of 1.6 million persons living with limb loss will more than double to 3.6 million by the year 2050.7 However, planned health promotion initiatives at national, state, and local levels that address health concerns—such as the rise in obesity and diabetes and the clinical impact of diabetes as well as other factors that influence dysvascular disease, such as smoking—aim to improve patient outcomes and reduce the occurrence of amputation. The development of evidence-based clinical guidelines for the management of dysvascular disease,40 diabetes mellitus,41 peripheral neuropathy,28 and clinical research–supported recommendations for the management of diabetic foot ulcers addresses critical factors such as disease prevention,42 access to health care,26 interventions,43 and patient education.42 These are intended to reduce the incidence of nontraumatic limb loss.

Case Example 17.1 A Patient With Dysvascular Disease–Related Amputation T.S. is a 67-year-old African American man with a 10-year history of type 2 diabetes mellitus. Until 2 years ago, he smoked one pack of cigarettes daily, but he quit after coronary artery bypass grafting following an acute myocardial infarction. He became insulin-dependent at the time of his myocardial infarction and cardiac surgery. His comorbid medical problems include hypertension, managed pharmaceutically with a beta blocker, and moderate vision loss secondary to diabetic retinopathy. T.S. underwent complete transmetatarsal amputation of the left foot 6 months earlier because of a nonhealing plantar ulcer under the second and third metatarsal heads that had progressed to osteomyelitis. Three weeks earlier, intermittent claudication of the right calf became severe enough to warrant medical attention. On evaluation, T.S. was noted to have a neuropathic ulcer under his first metatarsal head, probing to bone. Doppler studies were monophasic, suggesting that the vascular supply required for healing was inadequate. Arteriography indicated a markedly diminished distal arterial flow to the foot but an adequate arterial supply to the mid-tibial level. T.S. had failed a revascularization attempt with stent placement. After an interdisciplinary meeting involving his internist (who helps him manage his diabetes), cardiologist (who helps him manage his hypertension and heart disease), vascular surgeon (who oversaw this evaluation), physical therapist and prosthetist (who explained the process of rehabilitation), social worker (who explained services and support available to those with amputation), and family, T.S. concurred with the recommendation for an “elective” transtibial amputation. Two weeks after his surgery, he was impatiently waiting for his wound to heal to the point where he could begin prosthetic training.

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QUESTIONS TO CONSIDER

▪ What possible medical and physiologic factors contributed to this patient’s loss of limb?

▪ What impact will his current health status and comorbid

conditions have on his prognosis for rehabilitation, both in terms of eventual outcome and in the duration of this episode of care? ▪ What plan of care for the preprosthetic phase of his rehabilitation would you propose? ▪ How would the International Classification of Functioning disablement framework apply to T.S.?

Amputation Rates and Racial and Ethnic Populations Evidence indicates that certain racial and ethnic groups are at increased risk for lower extremity amputation. This increased risk appears to be linked to a higher prevalence of diabetes complicated by PAD. The ADA reports that “African Americans and Hispanics are over 50% more likely to have diabetes as non-Hispanic whites.”37 African Americans are two to four times more likely to lose a limb as a result of diabetes complications.25 Hispanic Americans are diagnosed with diabetes at twice the rate of whites.39 Based on the 2012 data available, hospital admissions for lower extremity amputations in Hispanic persons 18 years of age and older with diabetes were 50% higher than those for non-Hispanic whites.44 Research into the epidemiology of race and ethnicity is advancing to further elucidate the essential contributing factors. The Hispanic Community Health Study/Study of Latinos—sponsored by the National Heart, Lung, and Blood Institute and six other centers as well as the National Institutes of Health indicates that the prevalence of diabetes in the Hispanic community has variability based on country of origin, length of stay in the Unites States, as well as access to health care.44 American Indians and Alaska Natives have a two to five times higher prevalence of diabetes than the overall population in the United States.45 The National Limb Loss Information fact sheet reports that “Amputation rates among American Indians are 3 to 4 times higher than those for the general population.”46 Why these populations have a significantly higher rate of lower extremity amputation is unclear. Potential contributors include a genetic or familial predisposition to diabetes, a higher prevalence of hypertension and smoking, or both. Health promotion and education efforts that target this high-risk population (including programs aimed at the effective management of diabetes, minimization of other risk factors, and special foot care programs for early detection of neuropathic and traumatic lesions) are effective strategies to reduce the likelihood of amputation. Further research is necessary to better understand the causes of racial differences in amputation rates and to identify and promote health initiatives that will alleviate this excess risk among minority populations. Outcomes of Dysvascular Conditions and Amputation The morbidity and mortality risks associated with systemic diseases, such as diabetes and vascular disease, continue after amputation. As a result, death in the years immediately

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after amputation is not uncommon. One third of elderly persons receiving lower limb amputation die within a year of surgery.47,48 Because neuropathy and PVD occur in a symmetric distribution, the risk of subsequent reamputation of the ipsilateral site or amputation of the contralateral lower extremity is high. Dillingham and colleagues report that 26% of patients required another amputation procedure within a 12-month period.48 The most common causes of death in persons with amputation include complications of diabetes, cardiovascular disease, and renal disease. Evidence is growing that the incidence of lower extremity amputation in persons with diabetes can be significantly reduced through particular kinds of preventive care. Large clinical centers have demonstrated the effect of early intervention for the diabetic population by using an interdisciplinary team approach to preventive care. Interventions to prevent neuropathy and PVD target smoking cessation programs as well as dietary, exercise, and pharmaceutical interventions to obtain better control of hypertension, hyperlipidemia, and hyperglycemia. These efforts are likely to further reduce the incidence of amputation, heart disease, and stroke among people with diabetes. For those with existing diabetic neuropathy or PVD, intensive foot care programs should focus on the prevention of ulceration and early intervention to prevent the expansion of small lesions as well as their infection and the development of gangrene.40 Foot care programs are most effective if they develop in a team setting and focus on patient education. Surgical revascularization procedures are performed to avoid amputation in persons with chronic foot ulceration. The revascularization procedures include vascular bypass, angioplasty, stent placement, and end-stage limb-salvage procedures.24 The decision to undergo amputation often follows a long struggle to care for an increasingly frail foot by the patient, family, and health care providers. In this circumstance, elective amputation is often perceived by both patient and family as a positive step toward a more active and less stressful life. The interdisciplinary team approach best addresses the complex needs of the individual with diabetes, including clinical evaluation, determination of risk status, patient education, footwear selection, decision making about amputation, and rehabilitation after surgery.

TRAUMATIC AMPUTATION Traumatic amputation is defined as an injury to an extremity that results in immediate separation of the limb or will result in loss of the limb as a result of accident or injury.49 Traumatic loss of a limb, the second most common cause of amputation, occurs most frequently as a result of motor vehicle accidents, farming accidents, the use of power tools or firearms, or after severe burns and electrocution. Trauma-related amputation occurs most commonly among young adult men but can happen at any age to individuals of either sex. Because the mechanism of injury in traumatic amputation is variable, this type of amputation is usually classified or categorized according to the severity of tissue damage. The extent of injury to the musculoskeletal system depends on three interacting factors: (1) movement of the object that caused the injury; (2) the direction, magnitude, and speed of the energy vector; and (3) the particular body tissue involved.

Table 17.3 Indications and Contraindications for Replantation of Amputations INDICATIONS FOR REPLANTATION

▪ ▪ ▪ ▪ ▪

Amputations in children Multiple finger and hand amputations Thumb Single-finger injuries Ring avulsion injuries

CONTRAINDICATIONS TO REPLANTATION ▪ Severe crush injury ▪ Prolonged warm ischemia, especially of muscle ▪ Severe contamination ▪ Medical comorbidities that can affect anesthesia, healing, therapy, or ability to cooperate with care ▪ Life-threatening injuries ▪ Refusal to accept blood transfusions or blood products in cases of major amputations The indications and contraindications are not absolute, and the decision for replantation is best made by the patient and physician after a discussion of the potential outcome, benefits, risks, possible complications, and available alternatives to the replantation. This discussion is very dependent on the surgeon’s judgment of the potential outcome in a given patient. From https://www.microsurgeon.org/replantation.php. Accessed April 23, 2018.

In partial traumatic amputations, at least half the diameter of the injured extremity is severed or damaged significantly. This kind of injury can incur extensive bleeding because all of the blood vessels involved may not be vasoconstrictive. A second type of traumatic amputation occurs when the limb becomes completely detached from the body. As much as 1 L of blood may be lost before the arteries spasm and become vasoconstrictive. For optimal outcome, surgical intervention for revascularization or treatment of the amputated site is usually necessary within the first 6 hours after the accident.50 One of the primary efforts of the surgical team for a person with lower extremity amputation is to preserve limb length to the extent that healing is possible.50 Replantation is the surgical procedure to reattach the part of the body that has been amputated.51 When replantation is considered, the window of opportunity is much narrower. The decision to replant is a difficult one and is influenced by the patient’s age and overall health status, the level of the extremity injury, and the condition of the amputated part (Table 17.3). Replantation has been most successful in the distal upper extremity. The goal of upper extremity replantation is to provide a mechanism for functional grasp rather than solely for cosmetic restoration of the limb. The period of recovery and rehabilitation after replantation is often significantly longer than that after amputation. Persons with trauma-related amputation undergo extreme physiologic changes as well as psychologic trauma. With the sudden loss of a body part, the patient may experience an extended period of grieving. Addressing the patient’s psychologic as well as physical needs is important for optimal outcome. An interdisciplinary team approach to rehabilitation is the most effective means of addressing the comprehensive needs of a patient who has unexpectedly lost a limb to trauma.51

17 • Etiology of Amputation

Case Example 17.2 A Patient With Traumatic Amputation C.J., a 20-year-old female, was on active duty with the National Guard in Afghanistan when a rocket-propelled grenade hit her convoy and she sustained significant shrapnel injuries to both lower extremities. After emergency care on the ground, C.J.’s condition was considered critical enough to warrant immediate transport to a military hospital in Germany. Trauma surgeons at the center determined that her wounds were severe enough to require mid-length transtibial amputation on the right and a long transfemoral amputation on the left. Because of wound contamination from shrapnel and debris and a resulting high risk of infection, C.J.’s surgical wounds were initially left open (unsutured) while local and intravenous antimicrobials were administered. After several days of care, C.J. was returned to the operating room for revision and closure of her wounds. She now has significant edema and serosanguineous drainage on the right limb with a small area of wound dehiscence in the middle of the suture line. Although the left residual limb is not as edematous, the suture line there is inflamed and ecchymotic, with more than a dozen healing puncture wounds from shrapnel fragments over the anterior and lateral thigh. Once she is medically stable, C.J. will be moved to a military rehabilitation hospital in the United States for preprosthetic care and rehabilitation.

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tibia, or proximal humerus—during times of rapid growth. Most patients have a history of worsening, increasingly deep-seated pain, sometimes accompanied by localized swelling. Children with osteosarcoma are vulnerable to pathologic fracture, an event that often prompts diagnosis. Since the early 1990s, the need for amputation in osteosarcoma has been greatly reduced by advances in early detection, imaging techniques, chemotherapy regimens, and limb resectioning and salvage procedures. Tumor resection followed by limb reconstruction frequently provides a functional extremity. Weight bearing is limited, and the limb is protected by an orthosis early in rehabilitation. Once satisfactory healing has occurred, full weight bearing and nearnormal activity can be resumed. The American Cancer Society reports a 5-year survival rate of 60% to 80% for patients with localized nonmetastatic osteosarcoma that is resectable.38,52 When the cancer has metastasized, the 5-year survival rate is about 15% to 30%.52 Rhabdomyosarcoma is a rare malignant tumor occurring in the extremities that predominantly affects children. Chemotherapy and radiation are often the primary forms of medical management. On occasion amputation is performed along with chemotherapy and radiation.53

QUESTIONS TO CONSIDER

▪ Given the circumstances of these traumatic amputations,

how does this patient’s prognosis differ from that of the previous patient (Case Example 17.1) with a dysvascular/neuropathic amputation? ▪ How might the rehabilitation of this patient be similar to or different from that of the patient in Case Example 17.1 in terms of eventual outcome and duration of care? ▪ What plan of care would you implement to promote wound healing?

CANCER Cancer of the bone and joint is a rare form of cancer. Surveillance, Epidemiology and End Results data from the U.S. National Cancer Institute from 1988 to 2001 reported 4062 cases of bone and joint cancer. Of these, 27% occurred in children 9 years of age or younger. There are three typical histologic types of bone cancer: (1) osteosarcoma, (2) chondrosarcoma, and (3) Ewing sarcoma. These cancers arise from the growing end of long bones (osteosarcoma), cartilage (chondrosarcoma), and the axial skeleton (Ewing sarcoma).23 The limb-presenting cancers are osteosarcoma and chondrosarcoma. Sixty-three percent of these cancers were diagnosed as osteosarcoma and 54% as chondrosarcoma. Amputation because of a primary cancer generally results from osteogenic sarcoma (osteosarcoma) (Fig. 17.6). This type of cancer occurs predominantly in late childhood, adolescence, or the early young adult years. The incidence is slightly higher among young males than among females. Osteosarcoma typically occurs at or near the epiphyses of long bones—especially the distal femur, proximal

Case Example 17.3 Osteosarcoma

A Patient With

R.K. is a 16-year-old male high school student who sustained an unexpected fracture of the distal femur in a collision during playoffs for the state soccer title. He had experienced increasing lateral knee pain during the previous 4 weeks but had not complained to his coaches or parents for fear he would have to “sit out.” Examination in the emergency department revealed a swollen and tender distal femur and knee. A radiograph showed a fracture just proximal to a radiodense lesion of the medial femoral condyle, including the articular surfaces of the knee. Magnetic resonance imaging indicated that the tumor extended posteriorly, close to the neurovascular bundle in the popliteal fossa. Biopsy confirmed osteosarcoma. The orthopedic surgeon and oncologist reviewed the options for limb salvage and amputation with R.K. and his parents, recommending amputation because the location of the tumor precluded the wide clear margins at the knee required for endoprosthetic knee replacement or cadaver allograft salvage strategies. R.K.’s fractured limb was stabilized in a knee orthosis while a preoperative course of chemotherapy was undertaken and the possibility of metastasis to the lungs was evaluated by further testing. Resection of the tumor to a midlength transfemoral level of amputation was planned once the initial course of chemotherapy had been completed, to be followed by a second course of chemotherapy. R.K. and his family were encouraged by visits from a survivor of osteosarcoma who had had a transfemoral amputation 7 years earlier and was now a competitive runner at the national and paralympic level. Continued on following page

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Case Example 17.3 A Patient With Osteosarcoma (Continued) QUESTIONS TO CONSIDER

▪ How does the diagnosis of a serious cancer affect the

rehabilitation of young people with medically necessary amputations? ▪ What psychologic factors must be considered? ▪ What physiologic factors must be considered? ▪ What are the similarities and differences in the prognosis and plan of care for this patient with cancer-related amputation as compared with the previous patients with dysvascular/neuropathic and trauma-related etiologies in terms of eventual outcome and duration of this episode of care?

CONGENITAL LIMB DEFICIENCIES Congenital amputation is the absence of a limb or part of a limb at birth. An infant with congenital amputation may be missing an entire limb or just a portion of one. Commonly, if the entire limb is absent, it has been termed “amelia”; when a part of the limb is missing, such as a missing fibula, it has been termed “longitudinal deficiency”; and when a midportion of the limb is missing, it has been termed “phocomelia.”54 Using an international system of classification based on skeletal elements, the preferred terminology for congenital limb deficiencies is either transverse or longitudinal deficiencies (see Table 17.2).55 Transverse deficiencies are described by the level at which the limb terminates. In transverse deficiency the limb develops to a point and then ceases to develop; it resembles an amputation residual limb in which the limb has developed normally to a particular level beyond which no skeletal elements are present (Fig. 17.7).

Fig. 17.6 Magnetic resonance image of the distal femur of a patient with osteosarcoma of the bone and marrow canal. The bright signal beyond the bone indicates invasion of surrounding soft tissue. (From http://www.radiologyassistant.nl/en/p4bc9b622f0885/bone-tumor-h-0.html.)

€ Fig. 17.7 Running with a transtibial prosthesis using a Cheetah carbon-fiber prosthetic foot. (© Ossur.)

17 • Etiology of Amputation

In longitudinal deficiencies, a reduction or absence occurs within the long axis of the limb, but normal skeletal components are present distal to the affected bones.55 The incidence of congenital limb deficiency has remained relatively stable over time, accounting for only approximately 0.8% of all limb loss–related hospital discharges. The overall prevalence is 7.9 per 10,000 live births.56 Most are due to primary intrauterine growth inhibition or disruptions secondary to intrauterine destruction of normal embryonic tissues. The upper extremities are more commonly affected.56 Upper limb deficiencies in children vary from minor abnormalities of the fingers to major limb absences. Embryologic differentiation of the upper limbs occurs most rapidly at 5 to 8 weeks’ gestation, often before pregnancy has been recognized or confirmed. During this period the upper limbs are particularly vulnerable to malformation. The etiology of limb malformation is unclear. Potential contributing factors cited in the research literature include (1) exposure to chemical agents or drugs, (2) fetal position or constriction, (3) endocrine disorders, (4) exposure to radiation, (5) immune reactions, (6) occult infections and other diseases, (7) single-gene disorders, (8) chromosomal disorders, and (9) other syndromes of unknown cause.41 In many children an upper limb deficiency is the only anomaly. However, as many as 12% of these children have other malformations that do not involve the limbs. The use of prosthetics is a common intervention for children with congenital limb deficiencies. Sometimes surgery is necessary to prepare the existing limb for the most effective use of a prosthesis, especially after periods of rapid growth. The goals of prosthetic training for the child should be to enhance the function of the limb and provide a cosmetic replacement for a missing limb. Rehabilitation efforts are designed with the child’s cognitive, motor, and psychologic development in mind.

Rehabilitation Issues for the Person With an Amputation Several factors influence the success of rehabilitation after amputation. These include age, health status, cognitive status, sequence of onset of disability, concurrent disease and comorbidity, and the level of amputation.57 With anticipated growth in the aging segments of the population and the presence of chronic dysvascular conditions, amputation in the U.S. geriatric population will probably double from 28,000 to 58,000 per year by 2030.3 The number of persons living with limb loss will more than double from 1.6 million in 2005 to 3.6 million in 2050. Prosthetic, physical therapy, and health care needs will increase to ensure continued independence, quality of life, and participation in activities of daily living among these individuals. Persons with limb loss will require considerable rehabilitation resources.58,59 The physical rehabilitation60 process for persons with amputation occurs in different stages, beginning with a postoperative acute phase, where positioning, skin protection, sensory and proprioceptive training, joint range of

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motion, and muscle strengthening occur in conjunction with general conditioning activities. This leads to functional training for independence in mobility including transfer skills, balance exercises, wheelchair mobility, and ambulation with assistive devices that extends to the subacute phase of rehabilitation. The preprosthetic phase includes management of the residual limb including wound care, edema control, shaping, desensitization, and increasing joint and muscle flexibility. Strengthening of the trunk as well as the extremities is essential for prosthetic use. Traditionally, physical therapists have focused on the ability to perform functional activities such as walking, turning, and managing ramps and other uneven or unpredictable surfaces safely, independently, and efficiently with and without a prosthesis. Physical therapists assist physicians and prosthetists in determining an individual’s readiness for prosthetic fitting and are often involved in decisions about prosthetic components. After initial fitting, physical therapists coordinate prosthetic training, consulting with prosthetists if problems with prosthetic alignment arise. Once these basic mobility activities are mastered, the therapist can serve as a consultant to assist the person with amputation in returning to preamputation employment and leisure activities. The rehabilitation process for persons with lower limb amputation is aimed at maximizing functional mobility outcomes. In order to achieve functional ambulation, prosthetists and physical therapists must address issues of residual limb or phantom pain management,61 muscle strengthening,62 balance, and ambulation training.63,64 Quality-of-life indicators and outcome measures ultimately evaluate the success of the rehabilitation process.65–67 As many as 70% of persons with a lower extremity amputation report using their prosthesis on a full-time basis: putting it on in the early morning, wearing it all day, and taking it off in the evening.65 Two major reasons for limited use or nonuse are generally cited: physical discomfort when walking with the prosthesis and psychologic discomfort. The wide variation reported in the success of functional ambulation with a prosthesis after below-knee amputation appears to be related to age and concurrent disease.68 Healing time, indicated by time between surgery and fitting for the first prosthesis, correlates with age but not with the cause of amputation. Age is also more important than the etiology of amputation in predicting the total length of time in rehabilitation and achievement of functional ambulation: older adults with amputation are likely to require a longer rehabilitation period to accomplish an ambulatory status equal to that of the younger group.69 Although most people recovering from amputation achieve some level of upright mobility, a smaller percentage of older persons with concurrent chronic disease become functional ambulators as compared with younger persons who had amputations because of trauma or osteomyelitis. Today, U.S. veterans with traumatic amputations have greater options for returning to active duty than were available in the recent past due to the prosthetic and rehabilitation training provided in Veterans Administration medical centers. U.S. military service members injured in Afghanistan and Iraq who sustained limb loss—including transfemoral and transradial levels of amputation—have remained on active duty and continue to serve successfully.70

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The typical age at the time of initial lower limb dysvascular amputation is between 51 and 69 years; therefore consideration must be given to the special rehabilitation needs of the older patient. The complexity of issues during rehabilitation of the older adult who is undergoing an amputation is often compounded by comorbidity, fragile social supports, and limited resources.68 In patients with dysvascular conditions, concomitant cerebrovascular disease can have a more complicated rehabilitation process. A preamputation history of stroke or occurrence of stroke during the course of rehabilitation is not uncommon. Similarly, cardiovascular disease can limit endurance and exercise tolerance; endurance training becomes a critical component of the postamputation preprosthetic rehabilitation program. Optimal rehabilitation care begins with consultation and patient and family education efforts before surgery. A specialized interdisciplinary team most effectively provides this presurgical and perisurgical care (Table 17.4). Team members often include a surgeon, physical therapist, certified prosthetist, occupational therapist, nurse or nurse practitioner, recreational therapist, psychologist, and social worker.70 The patient and family members are active and essential members of the team as well. Effective communication provides the team with the necessary information to develop a tentative treatment plan from the time of amputation to discharge home.

With a specialized treatment team and the use of new lightweight, dynamic prosthetic designs, the potential for rehabilitation of the older patient has increased significantly in the past decade. At the time of surgery, special consideration is given to the optimal level of amputation. This is a particularly important concern for the older patient. The selection of the surgical level of amputation is probably one of the most important decisions to be made for the patient undergoing an amputation. A lower limb prosthesis ideally becomes a full-body weight-bearing device. However, bony prominences, adhesions of the suture line scar, fragile skin and open areas, shearing forces at the skin/ socket interface, and perspiration can complicate this function. The energy cost of ambulation71 must be considered, especially for older patients with significant deconditioning or comorbid conditions. The higher the level of amputation and loss of joints, long bone length, and muscle insertion, the greater the impairment of normal locomotor mechanisms. This leads to increased energy costs in prosthetic control and functional ambulation and a greater likelihood of functional limitation and disability. Preservation of the knee joint seems to be a key determinant in determining the potential for functional ambulation and successful rehabilitation outcome. Persons with transtibial amputation who have an intact anatomic knee joint demonstrate a more energy-efficient prosthetic gait pattern and postural responses; they are more likely to ambulate without additional assistive devices

Table 17.4 Members and Roles of the Multidisciplinary Team for Rehabilitation After Amputation Team Member

Role

Physician

Often serves as coordinator of the team Assesses need for amputation, performs surgery, monitors healing of suture line Monitors and manages patient’s overall medical care and health status Monitors condition of remaining extremity for patients with peripheral vascular disease (PVD), neuropathy, or diabetes

Physical therapist

Provides preoperative education about the rehabilitation process and instruction in single-limb mobility Designs and manages a preprosthetic rehabilitation program that focuses on mobility and preparation for prosthetic training Evaluates patient’s readiness for prosthetic fitting; can make recommendations for prosthetic fitting Designs and manages a prosthetic training program that focuses on functional ambulation and prosthetic management Monitors condition of the remaining extremity for patients with PVD, neuropathy, or diabetes

Prosthetist

Designs, fabricates, and fits the prosthesis Adapts the prosthesis to individuals, adjusts alignment, repairs/replaces components when necessary Monitors fit, function, and comfort of the prosthesis Monitors condition of the remaining extremity for patients with PVD, neuropathy, or diabetes

Occupational therapist

Assesses and treats patients with upper extremity amputation, monitors readiness for prosthetic fitting, recommends components Assists with problem solving in activities of daily living for patients with upper or lower limb amputations Makes recommendations for environmental modification and assistive/adaptive equipment to facilitate functional independence

Social worker

Provides financial counseling and coordination of support services Acts as liaison with third-party payers and community agencies Assists with patient’s and family’s social, psychologic, and financial issues

Dietitian

Evaluates nutritional status and provides nutritional counseling, especially for patients with diabetes or heart disease or those who are on chemotherapy or are recovering from trauma

Nurse/nurse practitioner

Monitors patient’s health and functional status during rehabilitation Provides ongoing patient education on comorbid and chronic health issues Monitors condition of remaining extremity for patients with PVD, neuropathy, or diabetes

Vocational counselor

Assesses patient’s employment status and potential Assists with education, training, and placement

Modified from May B. Assessment and treatment of individuals following lower extremity amputation. In: O’Sullivan SB, Schmitz TJ, eds. Physical Rehabilitation: Assessment and Treatment. Philadelphia: Davis; 1994:379.

17 • Etiology of Amputation

(walkers, crutches, or canes). They are also more likely to be full-time prosthetic wearers than are persons with transfemoral amputation. The benefits of preserving the knee, particularly among older adults, are so crucial that a transtibial amputation may be attempted even with the risk of inadequate healing; this may necessitate later revision to a higher level.72 The patient with a bilateral transfemoral amputation faces additional rehabilitation challenges. The significant increase in energy consumption that is required can prevent long distance ambulation. Many older patients, as well as younger persons with bilateral transfemoral amputation, may choose wheelchair mobility as a more energy-efficient and effective means of locomotion. Ambulation potential depends on cardiac function, strength, balance, and endurance.72 Options for prosthetic components for the older person with an amputation have increased dramatically in the past 20 years. Selecting the most appropriate components for the individual requires input from the entire rehabilitation team in close communication with the patient and family members.

Rehabilitation Environment Traditionally, preprosthetic and early prosthetic programs have occurred in rehabilitation departments of acute care hospitals. However, in today’s health care arena, where length of stay in acute or tertiary care facilities is very limited, early prosthetic rehabilitation is more than likely to begin in the home through home care physical therapy services, in the community through ambulatory preprosthetic rehabilitation, or in a skilled nursing facility. Patients who qualify for a subacute rehabilitation or skilled nursing home stay would also receive the preprosthetic rehabilitation programs necessary to prepare for prosthetic use after limb loss. In this environment, the care is specialized for the older person with an amputation. A quality subacute rehabilitation or skilled nursing facility should have the complement of professional services and essential postamputation rehabilitation treatment team necessary to address the complex needs of this group of patients., Today’s health care environment does not offer older persons with an amputation an acute inpatient rehabilitation stay until they are ready for prosthetic fitting or after they have received the prosthesis and are ready for intensive rehabilitation with the device. For patients with multiple medical complications, rehabilitation may be continued in a subacute setting or skilled nursing facility. For patients without complications and with a strong social support network, an outpatient rehabilitation program may be preferable. This plan allows them to reintegrate into the home and community while maintaining support of the treatment team. The most effective care and rehabilitation for individuals undergoing an amputation require the skills and ongoing support of an integrated treatment team.63,73

Summary Amputation and limb loss can occur as a result of trauma or health conditions (nontraumatic). Amputation can affect

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persons of all ages. Most nontraumatic amputation surgeries are performed in older citizens who have dysvascular disease with or with diabetes mellitus. Traumatic amputation occurs in U.S. military service men and women engaged in military operations in Afghanistan, Iraq, and Syria, where explosive devices often cause limb loss to soldiers. Traumatic amputations are also the result of motor vehicle accidents, the use of power tool and firearms, and recreational activities. Congenital amputations occur rarely, and amputation due to cancer persists as a medical concern but is diminishing with the new surgical approaches and limb salvage techniques. Medical advances in the treatment of persons with dysvascular disease and diabetes mellitus offer encouragement that the rise in amputations in the elderly population will decrease in the coming years. The improved education initiatives directed at preventing diabetic foot ulcers or early management of persons with diabetic foot ulcers also provide encouragement that the rate of amputation in persons with diabetes mellitus and dysvascular disease will decrease. Advances in the field of prosthetics enable young, athletic persons with limb loss to return to active lifestyles including return to active military service for injured service men and women. The rehabilitation process after amputation is essential for making sure that patients have the opportunity to maximize their functional abilities and quality of life. Although the rehabilitation phases after amputation may present many challenges for patients, their families, and the professionals involved in their care, they also provide many opportunities for success and reward. An optimal outcome after amputation is best achieved through interaction with a patient-centered, interdisciplinary health care team. With effective physical rehabilitation and prosthetic care, most individuals with amputations can return to a level of activity and lifestyle similar to that of their preamputation status.

References 1. Wilson Jr BB. The modern history of amputation surgery and artificial limbs. Orthop Clin North Am. 1972;3:267–285. 2. https://catalog.data.gov/dataset/national-health-interview-survey. Accessed February 8, 2018. 3. Adams P, Hendershot G, Marano M. Centers for Disease Control and Prevention/National Center for Health Statistics. Current estimates from the National Health Interview Survey, 1996. Vital Health Stat 10. 1999;200:1–203. 4. https://www.cdc.gov/nchs/nhis/2019_quest_redesign.htm. Accessed January 31, 2018. 5. Adams P, Hendershot G, Marano M. Centers for Disease Control and Prevention/National Center for Health Statistics. Current estimates from the National Health Interview Survey, 1996. Vital Health Stat 10. 1999;200:1–203. 6. https://www.amputee-coalition.org/limb-loss-resource-center/resourcesfiltered/resources-by-topic/limb-loss-statistics/limb-loss-statistics/. Accessed January 31, 2018. 7. Ziegler-Graham K, MacKenzie EJ, Ephraim PL, et al. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil. 2008;89:422–429. 8. Dillingham Timothy R, et al. Limb amputation and limb deficiency: epidemiology and recent trends in the United States. Southern Medical Journal. Aug. 2002;875+. Academic OneFile. 9. Shurr DG, Michael JW. Introduction to prosthetics and orthotics. In: Prosthetics and Orthotics. 2nd ed. Norwalk, CT: Appleton & Lange; 2000:1–19. 10. Dillingham TR, Pezzin LE, Mackenzie EJ. Limb amputation and limb deficiency: epidemiology and recent trends in the United States. South Med J. 2002;95(8):875–883. 11. Li Y, Burros NR, Gregg EW, Albright A, Geiss LS. Declining Rates of Hospitalization for Nontraumatic Lower-Extremity Amputation in

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Section III • Prostheses in Rehabilitation the Diabetic Population Aged 40 Years or Older: U.S. 1988-2008. Diabetes Care. 2012 Feb;35(2):273–277. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetesstatistics-report.pdf. Accessed February 8, 2018. Miller AP, Huff CM, Roubin GS. Vascular disease in the older adult. Journal of Geriatric Cardiology : JGC.2016;13(9):727–732. https://doi. org/10.11909/j.issn.1671-5411.2016.09.011. Criqui MH. Peripheral arterial disease: epidemiological aspects. Vasc Med. 2001;6(suppl 1):3–7. Li Y, Burros NR, Gregg EW, Albright A, Geiss LS. Declining Rates of Hospitalization for Nontraumatic Lower-Extremity Amputation in the Diabetic Population Aged 40 Years or Older: U.S. 1988-2008. Diabetes Care. 2012 Feb;35(2):273–277. Monteiro-Soares M, Martins-Mendes D, Vaz-Carneiro A, DinisRibeiro M. Lower-limb amputation following foot ulcers in patients with diabetes: classification systems, external validation and comparative analysis. Diabetes Metab Res Rev. Jul 2015;31(5):515–529. http://www.cdc.gov/media. Accessed February 8, 2018. Li Y, Burros NR, Gregg EW, Albright A, Geiss LS. Declining Rates of Hospitalization for Nontraumatic Lower-Extremity Amputation in the Diabetic Population Aged 40 Years or Older: U.S. 1988-2008. Diabetes Care. 2012 Feb;35(2):273–277. U.S Congressional Report. A Guide to U.S. Military Casualty Statistics: Operation Freedom’s Sentinel, Operation Inherent Resolve, Operation New Dawn, Operation Iraqi Freedom, and Operation Enduring Freedom. Hannah Fischer Information Research Specialist. August 7, 2015; https://fas.org/sgp/crs/natsec/RS22452.pdf. Mastboom MJL, Verspoor FGM, Gelderblom H, van de Sande MAJ. Limb Amputation after Multiple Treatments of Tenosynovial Giant Cell Tumour: Series of 4 Dutch Cases. Hindawi Case Reports in Orthopedics. 2017; Volume 2017, Article ID 7402570, 6 pages https://doi.org/10. 1155/2017/7402570. Tsuzuki S, Park HE, Eber MR, Peters CM, Shiozawa Y. Skeletal complications in cancer patients with bone metastases. International Journal of Urology. 2016;23:825–832. https://doi.org/10.1111/iju.13170. Gunaratne DA, Howle JR, Veness MJ. Merkel cell carcinoma: A case of palliative upper limb amputation in a patient with refractory in-transit metastases. Australasian Journal of Dermatology. 2016;57:e53–e56. https://doi.org/10.1111/ajd.12424. American Cancer Society Cancer Facts & Figures 2017. https:// www.cancer.org/content/dam/cancer-org/research/cancer-factsand-statistics/annual-cancer-facts-and-figures/2017/cancer-facts-andfigures-2017.pdf. Accessed February 17, 2018. Jiang F, Shi Y, Li GJ, Zhou FA. Meta-analysis of limb salvage versus amputation in the treatment of patients with Enneking II pathologic fracture osteosarcoma. Indian Journal of Cancer. January 2014;51. 21-14. Dillingham Timothy R, et al. Limb amputation and limb deficiency: epidemiology and recent trends in the United States. Southern Medical Journal. Aug. 2002;875+. Academic OneFile. Cumming J, Barr S, Howe TE. Prosthetic rehabilitation for older dysvascular people following a unilateral transfemoral amputation. In: The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.; 2015. Humphry LL, Palumbo PJ, Butters MA, et al. The contribution of non-insulin dependent diabetes to lower-extremity amputation in the community. Arch Intern Med. 1994;154(8):885–892. Borkosky SL, Roukis TS. Incidence of re-amputation following partial first ray amputation associated with diabetes mellitus and peripheral sensory neuropathy: a systematic review. Diabetic Foot & Ankle. 2012;3:12169. https://doi.org/10.3402/dfa.v3i0.12169. Age-Adjusted Hospital Discharge Rates for Neuropathy as FirstListed Diagnosis per 1,000 Diabetic Population, by Sex, United States, 1988–2007. https://www.cdc.gov/diabetes/statistics/hosplea/ diabetes_complications/fig4_neuro.htm. Arteriosclerosis obliterans (ASO). http://www.derm-hokudai.jp/ shimizu-dermatology/pdf/11-05.pdf. Accessed February 18, 2018. Criqui MH, Aboyans V. Epidemiology of peripheral artery disease. Cir Res. 2015 Apr 24;116(9):1509–1526. https://doi.org/10.1161/ CIRCRESAHA.116.303849. Meltzer DD, Pels S, Payne WG, et al. Decreasing amputation rates in patients with diabetes mellitus. An outcome study. J Am Podiatr Med Assoc. 2002;92(8):425–428. African Americans Diabetes and Amputations. https://vascular.org/ news-advocacy/african-americans-diabetes-and-amputation-trends. Accessed February 18, 2018.

34. Duby JJ, Campbell RK, Setter SM, White JR, Rasmussen KA. Diabetic neuropathy: an intensive review. American Journal of Health-System Pharmacy. 2004;61(2):160–173. 35. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005;293(2):217–228. 36. Carrington AL, Abbott CA, Griffiths J, Jackson N, et al. Foot Care Program for Diabetic Unilateral Lower-Limb Amputees. Diabetes Care. 2001;24(2):26–221. 37. American Diabetes Association. Standards of medical care in diabetes2014. Diabetes Care. 2014;37(Suppl 1). S14–80. 38. Centers for Disease Control and Prevention. https://www.cdc.gov/. Accessed February 18, 2018. 39. National Center for Health Statistics. https://www.cdc.gov/nchs/ index.htm. Accessed February 18, 2018. 40. Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: a report of the American College of Cardiology/ American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135:e726–e779. https://doi.org/10.1161/ CIR.0000000000000471. 41. Gnesin F, Thuesen AC, K€ahler LK, Gluud C, Madsbad S, Hemmingsen B. Metformin monotherapy for adults with type 2 diabetes mellitus (Protocol). In: Cochrane Database of Systematic Reviews. Published by John Wiley & Sons, Ltd.; 2018. Issue 1. Art. No.: CD012906. https://doi.org/10.1002/14651858.CD012906 (web archive link) 2018 The Cochrane Collaboration. 42. Dorresteijn JAN, Kriegsman DMW, Assendelft WJJ, Valk GD. Patient education for preventing diabetic foot ulceration (Review). Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 43. Wang HT, Yuan JQ, Zhang B, Dong ML, Mao C, Hu D. Phototherapy for treating foot ulcers in people with diabetes (Review). Cochrane Database of Systematic Reviews 2017, Issue 6. Art. No.: CD011979 https://doi.org/ 10.1002/14651858.CD011979.pub2 (web archive link) 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 44. Schneiderman N, Llabre M, Cowie CC, Barnhart J, Carnethon M, et al. Prevalence of Diabetes Among Hispanics/Latinos From Diverse Backgrounds: The Hispanic Community Health Study/Study of Latinos (HCHS/SOL). Diabetes Care. 2014;37:2233–2239. https://doi.org/ 10.2337/dc13-293Hispanic. 45. Diabetes Among American Indians and Alaska Natives. https:// www.cdc.gov/media/matte/2011/11_diabetes_Native_American. pdf. Accessed February 19, 2018. 46. National Limb Loss Information Center Fact Sheet. http://www. amputee-coalition.org/fact_sheets/multicultural/all_groups.html. Accessed February 19, 2018. 47. Schofield CJ, Libby G, Brennan GM, MacAlpine RR, et al. Mortality and Hospitalization in Patients After Amputation. Diabetes Care. 2006;29: 2252–2256. 48. Bertoni AG, Krop JS, Anderson GF, Brancati FL. Diabetes-Related Morbidity and Mortality in a National Sample of U.S. Elders. Diabetes Care. 2002 Mar;25(3):471–475. https://doi.org/10.2337/diacare. 25.3.471. 49. Healey AJ, Tai N. Traumatic amputation—a contemporary approach. Trauma. 2009;11:177–187. 50. Ramirez C, Menaker J. Traumatic Amputations. 2017 @ www. ahcmedia.com/articles/140552-traumatic-amputations. Accessed February 19, 2018. 51. Sorenson K, Allison KT. An overview of limb replantation. Trauma. 2009;11:209–220. 52. Survival rates for localized osteosarcoma. https://www.cancer.org/ cancer/osteosarcoma/detection-diagnosis-staging/survival-rates.html. Accessed February 18, 2018. 53. Sabapathy SR, Venkatramani H, Shankar SU. Rhabdom¬yosarcoma of the thumb: a case report with a review of the literature. Indian J Plast Surg. 2007;40(2):189–193. 54. Congenital Amputation. http://www.healthofchildren.com/C/ Congenital-Amputation.html. Accessed February 19, 2018. 55. Day HJB. “The ISO/ISPO Classification of Congenital Limb Deficiency”. In Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles. Chapter 33 O and P Virtual Library @ http://www. oandplibrary.org/alp/ Accessed February 19, 2018. 56. Boyd SAB. Common Congenital Limb Defects. http://www.merckmanuals. com/professional/pediatrics/congenital-craniofacial-and-musculoskeletalabnormalities/common-congenital-limb-defects. Accessed February 19, 2018.

17 • Etiology of Amputation 57. Esquenazi A, DiGiacomo R. Rehabilitation after amputation. J Am Podiatr Med Assoc. 2001 Jan;91(1):13–22. 58. Dillingham TR, Pezzin LE, Shore AD. Reamputation, mortality, and health care costs among persons with dysvascular lower-limb amputations. Archives of Physical Medicine. 2005;86(3):480–486. https:// doi.org/10.1016/j.apmr.2004.06.072. 59. MacKenzie EJ, Castillo RC, Jones AS, Bosse MJ, Kellam JF, et al. HealthCare Costs Associated with Amputation or Reconstruction of a LimbThreatening Injury. J Bone and Joint Surgery. 2007;89(8):1685–1692. https://doi.org/10.2106/JBJS.F.01350. 60. Fiedler G, Akins J, Cooper R, Munoz S, Cooper RA, et al. Rehabilitation of People with Lower-Limb Amputations. Curr Phys Med Rehabil Rep. 2014;2:263–272. https://doi.org/10.1007/s40141-014-0068-8. 61. Johnson MI, Mulvey MR, Bagnall AM. Transcutaneous electrical nerve stimulation (TENS) for phantom pain and stump pain following amputation in adults. In Cochrane Database of Systematic Reviews. Published by John Wiley & Sons, Ltd; 2015 Issue 8. Art. No.: CD007264 Copyright © 2015 The Cochrane Collaboration. 62. Lane R, Harwood A, Watson L, Leng GC. Exercise for intermittent claudication. Cochrane Database of Systematic Reviews. Published by John Wiley & Sons, Ltd; 2017. Issue 12. Art. No.: CD000990. DOI: 10.1002/14651858.CD000990.pub4. Copyright © 2017 The Cochrane Collaboration. 63. Fletcher DD, Andrews KL, Hallett JW, Butters MA, Rowland CM, Jacobsen SJ. Trends in rehabilitation after amputation for geriatric patients with vascular disease: implications for future health resource allocation. Arch Phys Rehab. 2002 Oct;83(10):1389–1393. 64. Paxton RJ, Murray AM, Stevens JE, Sherk KA, Christensen CL. Physical activity, ambulation, and comorbidities in people with diabetes and lower-limb amputation. JRRD. 2016;53(6):1069–1078. 65. Dillingham TR, Pezzin LE, Mackenzie EJ, et al. Use and satisfaction with prosthetic devices among persons with trauma-related amputations: a

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long-term outcome study. Am J Phys Med Rehabil. 2001;80(8): 563–571. Green GV, Short K, Easley M, Pauley T, Devlin M, Heslin K. Transtibial amputation. Prosthetic use and functional outcome. Foot Ankle Clin. 2001;6(2):315–327. Falls sustained during inpatient rehabilitation after lower limb amputation: prevalence and predictors. Am J Phys Med Rehabil. 2006;85(6):521–545. MacKenzie HM, Rice DB, Sealy CM, Cox PD, Deathe B, Payne MWCP. Physical Barriers to outcome measure administration and completion at discharge from inpatient rehabilitation of people with amputation. JRRD. 2016;53(6):1061–1068. Green GV, Short K, Easley M. Transtibial amputation. Prosthetic use and functional outcome. Foot Ankle Clin. 2001;6(2):315–327. Hershkovitz A, Dudkiewicz I, Brill S. Rehabilitation outcome of postacute lower limb geriatric amputees. Disabil Rehabil. 2013;35(3): 221–227. The process of returning to duty or not after limb loss. http://www. amputee-coalition.org/military-instep/returning-to-duty.html. Accessed February 20, 2018. Houdi KH, Pollmann E, Groenewold M, Wiggerts H, Polomski W. The energy cost for step-to-step transition in amputee walking. Gait and Posture. 2009;30(1):35–40. Waters RL. 2002 “The Energy Expenditure of Amputee Gait”. In Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles. http://www.oandplibrary.org/alp/chap15-01.asp Accessed February 20, 2018. Stineman MG, Kwong PL, Kurichi JE, et al. The effectiveness of inpatient rehabilitation in the acute postoperative phase of care after transtibial or transfemoral amputation: study of an integrated health care delivery system. Arch Phys Med Rehabil. 2008;89(10): 1863–1872.

18

High-Risk Foot and Wound Healing☆ MILAGROS JORGE and EDDIE J. TRAYLOR

LEARNING OBJECTIVES

On completion of this chapter, the reader will be able to do the following: 1. Explain the relationship between diabetes and the risk to developing foot disorders and delayed wound healing. 2. Identify the interactive factors that contribute to pressure ulceration in persons with vulnerable feet. 3. Describe the components of a thorough foot examination for persons with vulnerable feet at risk for pressure ulceration. 4. Explain the importance of each component of a thorough wound examination. 5. Compare and contrast the efficacy and drawbacks of the most commonly used options for reducing pressure to promote ulcer healing and prevention in the vulnerable foot. 6. Determine which wounds would benefit from the addition of therapeutic modalities. 7. Develop a comprehensive treatment plan to manage vulnerable feet, including those with delayed healing of open wounds. 8. Describe the revised National Pressure Ulcer Advisory Panel pressure injury staging system.

The thought of losing a limb has to be one of the most frightening things a person will ever face. For the majority of the population, the idea likely conjures up some sort of catastrophic event that can be pushed to the back of the mind as something that is unlikely to occur. Unfortunately, individuals with vulnerable feet, or feet with a high risk for injury, face the very real possibility of losing a limb in the foreseeable future. A high-risk foot is one that has an underlying disease process that puts the tissues at a greater risk of tissue breakdown. In many cases the foot wound is the result of an underlying disease such as diabetes, a condition that will negatively affect wound healing. Diabetes is the leading cause of nontraumatic lower extremity amputation.1 The number of persons with diabetes and prediabetes in the U.S. population continues to rise. According to the National Diabetes Statistics 2017, an estimated 30.3 million people of all ages, or nearly 10% of the U.S. population, has diabetes.2 Eighty-six million U.S. adults have prediabetes, and 90% of them do not know they have the condition.2 Persons with diabetes often develop peripheral neuropathy and lose sensation to the feet, which can predispose them to injury due to insensate feet. Insensate feet fail to respond to prolonged pressure or mechanical stress, which

☆ The authors extend appreciation to Edward Mahoney and Carolyn B. Kelly, whose work in prior editions provided the foundation for this chapter.

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can lead to skin irritation and pressure sores such as heel ulceration or plantar surface ulceration. Often there is delayed wound healing due to neuropathic changes, impaired circulation, and edema. Delayed wound healing can result in wound site infection, tissue necrosis, and amputation. Early intervention in the instruction of proper foot care for persons with diabetes and in the management of skin abrasions, pressure sores, and open wounds is a preventive measure for avoiding foot ulceration and lower extremity amputation.3 This chapter addresses the clinical management of persons with vulnerable feet at high risk for skin breakdown due to pressure injuries that result in foot ulceration and place the individual at risk for foot amputation or limb loss. The importance of conducting a comprehensive physical examination that includes assessment of the vascular, sensory, motor, and autonomic systems, as well as a mobility assessment and footwear inspection, will be introduced. Current interventions and evidence-based treatment strategies aimed at preventing wounds to vulnerable feet or seek to minimize delayed wound healing will be discussed. Wound management through proper wound assessment; the use of electrotherapeutic and other modalities for infection control and healthy tissue proliferation; the importance of offloading pressure techniques such as using total contact casts (TCCs) and other pressure relieving strategies; and the use of clinical approaches that seek to prevent recurrence of injury to vulnerable feet will be highlighted in the chapter.

18 • High-Risk Foot and Wound Healing

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Normal Wound Healing

Assessment of the High-Risk Foot

To fully appreciate the impact of different disease states on wound healing, it is necessary to begin with an understanding of normal wound healing. Wound healing involves a coordinated interaction of three phases: inflammation, proliferation, and remodeling.4 Although these stages do overlap to some degree, they are discussed individually for purposes of clarity. The body’s first response to injury during the inflammatory phase is to stop the bleeding at the site of injury through a process known as hemostasis. In response to an injury, platelets, which are formed in bone marrow and are free floating in the vascular system, are attracted to the injury site. The platelets also undergo activation, which causes them to change from a round shape into a sticky form that enables them to adhere to the injured area.5 The platelet plug may be enough to stop the bleeding in minor injuries, or it may be augmented by the coagulation cascade to form a larger clot. An in-depth discussion on the coagulation cascade is beyond the scope of this chapter. In terms of wound healing, coagulation is only one part of the role of the platelet. The second role, which is critical to wound healing, is the secretion of numerous growth factors and cytokines that set the stage for later phases of wound healing. The first cells to arrive at the wound site in response to the coagulation cascade are granulocytes, which are a form of white blood cells. Neutrophils are the most abundant of the granulocytes and are found in the wound within 24 hours after injury. These cells are nonspecific and phagocytic, which is crucial for disposing of damaged cells in the area. Other granulocytes include phagocytic eosinophils and basophils, which release histamine. The next leukocytic cells to respond are monocytes, which become macrophages in the wounded area. Macrophages are phagocytic but can also be thought of as growth factor factories because they play such a critical role in producing the growth factors that guide the remainder of the healing process. Toward the latter stages of the inflammatory response, the wound is well into the proliferative phase of healing. The goal of this phase is to resurface the wound with a layer of viable epithelium. For this to occur, a well-vascularized dermal matrix is laid down in the wound bed. To accomplish this, new blood vessels are formed (neovascularization), and collagen is created by fibroblasts (fibroplasia). At the same time, new skin is being produced through the process of reepithelialization, and wound contraction is occurring, which helps to approximate the wound margins and make the resultant scar smaller. The duration of this phase is greatly influenced by the size of the wound but is generally considered to last up to several weeks. Despite wound closure, the healing process is not yet complete as tissues continue to remodel. In fact, the remodeling phase is by far the longest and can last for more than a year from wound closure until the tissues have reached their maximum strength. Even after the wound has completely remodeled, it will not regain the same strength that uninjured tissue has and will continue to require close monitoring and protection to prevent reulceration.

According to the most recent data from the Centers for Disease Control and Prevention, diabetes is the leading cause of nontraumatic lower extremity amputation.6 With that in mind, it is of particular importance to assess the patient’s diabetes status (Fig. 18.1). Following a thorough review of systems, a quick but thorough objective examination of the foot should occur. This examination should include assessments of the vascular, sensory, motor, and autonomic systems, as well as a mobility assessment and footwear inspection.

VASCULAR ASSESSMENT It could be argued that a thorough vascular assessment is the most crucial aspect of the evaluation of vulnerable feet. Not only can impaired blood flow be a causative agent for the development of ulceration, it will impact healing of ulcers regardless of the etiology. A clinical vascular examination can be performed quickly and help the clinician decide if circulation is adequate or if further, more advanced testing is required. The examination should begin with an assessment of the pedal pulses (dorsalis pedis and posterior tibial). Pulses can be recorded as present or absent or can be graded on a more qualitative basis (Fig. 18.2): 0 ¼ Unable to palpate 1+ ¼ Barely perceptible 2+ ¼ Weak 3+ ¼ Normal 4+ ¼ Bounding pulse; possible Charcot joint or aneurysm The assessment of pulses should not be used alone to determine the extent of arterial compromise but should be correlated with other findings from the clinical examination. The lack of a palpable pulse (grade 0) is not sensitive for the detection of peripheral artery disease (PAD). In a study by Collins and colleagues, more than two thirds of limbs with diagnosed PAD still had palpable pulses.7 Pulse palpation may be most useful for the comparison between the left and right limb to detect abnormalities. The ankle-brachial index (ABI) is a simple, noninvasive clinical test that should be applied to diagnose PAD. ABI assessment is the “gold standard” for screening and diagnosing PAD.8 In an effort to standardize the measurement technique when obtaining an ABI value, the American Heart Association (AHA), in 2012, developed a scientific position statement entitled “Measurement and Interpretation of the ABI.”9 The ABI is the ratio of the systolic blood pressure at the ankle (pedal arteries) to the blood pressure in the upper arm (brachial artery). The ABI should be performed by a clinician who has received specific education and training in the measurement technique using proper equipment. The AHA recommends using Doppler. The Wound Osteotomy and Continence Nursing society reports the ABI obtained using a pocket Doppler is interchangeable with vascular laboratory tests to detect PAD.10 The systolic pressure is recorded in both arms, unless contraindicated (lymphedema, dialysis port), and the higher of the two values should be used. In the foot the dorsalis pedis and posterior

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Section III • Prostheses in Rehabilitation

No Do you have diabetes?

Move on to next line of questioning

Yes When were you diagnosed? How well is your diabetes controlled? Do you know your hemoglobin A1C level?

Not well controlled; A1C is greater than 7%

Do you have difficulty avoiding large fluctuations in blood sugar levels?

Well controlled; A1C is normal or improving

No

Yes

Have you had a recent change to your diabetes medications?

No

Have you had a recent change to your diabetes medications?

Consider referral to physician Yes Ensure patient has follow-up visit with physician to assess effect of new medications Record medications and move to next line of questioning

Consider referral to physician

No

Fig. 18.1 Flow sheet for diabetes assessment.

tibial artery are both assessed and the highest value is used (Fig. 18.3). Normal: 1 to 1.29. • Borderline: 0.91 to 0.99 • Mild PAD: 0.71 to 0.90 • Medium severe PAD: 0.41 to 0.7 • Severe PAD: < 0.4 ABI ¼

highest ankle systolic pressure highest brachial systolic pressure

A normal ABI is 1.0, which indicates normal arterial blood flow to the foot. An ABI value of less than 0.9 should be referred to the referring physician, who may in turn make a referral to a vascular specialist for further testing. In the case of individuals with long-standing diabetes, an ABI greater than 1.2 may be obtained because of calcified vessels

in the lower extremity. If this is the case, the ABI value is of no significance as it pertains to arterial flow and further testing is required. One test that can be performed is the toe pressure test. By using a specially designed cuff that fits over the digit and a Doppler flowmeter, the pressure in the digital arteries, which are less affected by calcification, can be assessed (Fig. 18.4). A systolic toe pressure greater than 50 mm Hg is generally considered normal; an increased risk of amputation and failure to heal is associated with pressures less than 30 mm Hg.10 Another noninvasive vascular assessment technique is transcutaneous oxygen pressure (TcPO2). Low TcPO2 measurement, a measurement of skin perfusion, is a predictor of ulceration4 and healing.11 In 1999 the American Diabetes Association’s Consensus Development Conference on Diabetic Foot Wound Care recommended use of abnormal toe systolic pressures and TcPO2 measurements12,13 to predict

18 • High-Risk Foot and Wound Healing

Normal

Abnormal

1.0 = Ankle = 120 Arm 120

0.7 = Ankle = 83 Arm 120

120

120

A

165

161

Stenosis

153

115

138

99

120

83

B

Fig. 18.3 Ankle-brachial index ratio of pedal systolic pressure and brachial systolic pressure.

C Fig. 18.2 Palpation of pedal pulses. (A) Dorsalis pedis pulse. (B) Posterior tibial pulse. (C) Popliteal pulse.

poor outcomes.14 In general, no single noninvasive test provides enough information to make decisions about vascular intervention. Analysis is usually done by a vascular specialist who interprets the results of a combination of tests. If signs of arterial insufficiency are present and the patient has a foot wound, or if the patient has none of the typical symptoms of ischemia but has a nonhealing wound despite adequate control of infection and external pressure, referral for further vascular evaluation is warranted. Many patients have significant arterial disease but few clinical signs, such

Fig. 18.4 Toe cuff for the assessment of digital blood flow.

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as pain or open wounds, that warrant the risks involved with an invasive vascular procedure. They should still be educated in foot care and proper shoe fit. Because better circulation may be necessary to heal an open wound than to keep unbroken skin intact, the goal for patients with arterial insufficiency is to prevent foot wounds from occurring.

SENSORY ASSESSMENT Patients in all settings, with many different diagnoses, may have impaired sensation. Diabetes is the most common reason for impaired sensation, but it is also associated with chronic alcoholism, syphilis, Hansen disease (formerly leprosy), spinal cord injury, and peripheral nerve injuries. Regardless of the cause, when the ability to perceive an external stimulus is diminished, it increases the risk for ulceration. In patients with diabetes, a loss of protective sensation is the leading cause of foot ulceration.15,16 Simply put, if a patient cannot feel discomfort, there is no stimulus to change anything. In the case of a foot rubbing on a shoe or brace, an individual with intact sensation will stop to adjust the problem because of discomfort, whereas the person with impaired sensation may be unaware of the problem until the shoes are removed and blood is seen on the sock. Protective sensation can be assessed in several different ways in the clinic, with very little special equipment needed. The two simplest methods are Semmes-Weinstein monofilaments and tuning forks. A 5.07 monofilament, which takes 10 g of perpendicular force to bend, is the most widely used clinical tool for the assessment of protective sensation (Fig. 18.5). The patient is instructed to close his or her eyes, and the monofilament is applied perpendicular to the skin surface with enough pressure to cause it to bend. Inability to sense the monofilament is considered to be a positive test for the loss of protective sensation. Care must be taken to avoid areas with thick callus, because the test results will not be valid. Alternatively, a tuning fork can be used for vibratory testing. A study by Oyer and associates found a vibrating 128-Hz tuning fork placed on the toe was more sensitive to the onset of neuropathic changes than monofilament testing.17,18 In this testing procedure a clanging tuning fork is placed on the area to be tested and remains there until the subject can no longer feel the vibration. The tuning fork is then quickly moved to an area of known intact sensation on either the subject or examiner. If the vibration can still be felt in that site, the test is positive for a loss of vibratory sensation. Other authors19 have found similar results using similar methods with tuning forks of different frequencies, for example, 512 Hz, which may be more convenient because the 512-Hz tuning fork is smaller (Fig. 18.6).19

MOTOR ASSESSMENT A thorough musculoskeletal evaluation is necessary to determine a given patient’s likelihood for ulceration. Deformities and abnormal biomechanics often change pressure distribution in the foot and can lead to discomfort, callus, and, ultimately, ulceration. The clinician can begin to assess for motor impairments while the patient is seated. The wear pattern on shoes, as well as the presence of calluses on the foot, can identify potential pathologies that ultimately may

Fig. 18.5 Semmes-Weinstein monofilament.

lead to ulcer formation. Following a visual inspection of the feet and footwear, a musculoskeletal examination that includes reflexes, strength, and range of motion should be performed. Particular attention should be paid to toe extension and dorsiflexion range of motion because limitations in either one greatly increases weight-bearing forces through the forefoot in the latter stance phases of gait. This becomes increasingly important to assess if the patient has diabetes, because a loss of dorsiflexion has been widely documented in that population.20 If a patient is ambulatory, a gait assessment should be a standard part of the high-risk foot assessment.21 Major deviations from the normal gait pattern can be assessed with a quick visual inspection. For example, patients with peroneal nerve injuries have difficulty with foot clearance and have a shorter loading response, which increases pressure at the forefoot. Alternatively, a patient could have increased forefoot pressure in terminal stance as a result of limited dorsiflexion range of motion. A mild limitation in motion may present as an early heel rise, whereas a more severe restriction can lead to excessive knee flexion for clearance during the swing phase of gait. With a static foot assessment, it may be apparent that both individuals have increased forefoot pressure, but the cause would not be known, with the result that the optimal intervention could not be selected. With careful gait analysis, the clinician can determine the cause of the pressure and choose appropriate interventions, such as a rocker bottom shoe to substitute for the midfoot rocker in the first case or an orthosis to aid in

18 • High-Risk Foot and Wound Healing

451

because these areas are easily injured from rubbing on shoes. Persons with diabetes who have motor neuropathy may develop a high-risk foot, commonly referred to as an “intrinsic minus” foot because of the impairment in function of the small muscles of the foot. The intrinsic minus foot presents as a pes cavus (high arch) deformity with prominent MTHs. Compounding matters is the distal migration of the metatarsal fat pad into the toe sulcus as a result of muscle imbalance. Now the metatarsal region has increased pressure because of the foot shape, as well as the loss of fat pad over the MTH that would normally increase the total surface area being loaded.23 Partial foot amputation is another deformity that alters plantar pressure distribution. Because the surface area to carry the force of body weight is smaller, pressure on the remaining structures increases. Studies that have looked at great toe amputation in patients with diabetes have found an increase in plantar pressure and the development of new deformities and ulcerations after amputation.24,25 As loss of parts of the foot occurs, the mechanics of the foot change, transferring stresses to new areas with the potential for ulceration. Plantar ulceration has been associated with lower extremity peripheral neuropathy and excessive plantar pressures.26 Pressure on the soft tissues of the foot is related to three variables: the magnitude of the force applied to the foot, the amount of surface over which the force is applied, and the length of time over which the force is sustained. Because much of the focus in treating and preventing foot ulcers is on reducing pressure, one must understand the relationship of pressure to these three variables. The following formula should be considered: Pressure ¼ Force=Area

Fig. 18.6 Tuning fork for the assessment of neuropathy.

dorsiflexion in the second case. Chapter 5 provides an indepth review of the gait assessment. Many of the deformities that occur as a result of motor neuropathy are more subtle than the previous examples. As neuropathy advances, the intrinsic muscles atrophy and become weaker, leading to muscle imbalances and changes in joint alignment.19,22 When tissues over these joints are then loaded, they are unable to withstand the same amount of pressure and begin to break down. As extensor muscles on the dorsum of the foot overpower flexor muscles of the plantar aspect, the net result is extension at the metatarsophalangeal joint, which increases pressure at the plantar aspect of the metatarsal head (MTH). This occurs with both claw and hammer toe deformities, the difference being that claw toes are characterized by flexion of both interphalangeal (IP) joints, whereas hammer toes have flexion at the proximal IP and extension at the distal IP joint. Care must also be taken to protect the distal tips of the toes, as well as the dorsum of the IP joints,

As indicated, anything that increases the magnitude of the force applied to the foot or decreases the area over which the force is applied increases pressure and makes tissue damage more likely. Immediate injury can occur from extremely high force applied over a small area, as when a patient steps on a tack or piece of glass. Injury occurs because tremendously high pressure exceeds the tensile strength of the skin. Pressure on the foot can also become excessive when a moderate amount of force is repeatedly applied over a small surface area—when bony deformities cause small localized areas of weight bearing or when partial foot amputations decrease the patient’s weight-bearing surface. The force applied to the foot (body weight) remains essentially the same, but the actual pressure on the tissues is greater because of reduction of the surface area. In patients with diabetes, factors such as limited joint mobility, structural abnormalities, and previous amputation27 can lead to increased force or decreased surface area. All of these are associated with increased plantar pressures and ulceration. Further complicating this picture is the time factor. In looking at tissue ischemia and resultant ulceration, Kosiak found an inverse relationship between the amount of pressure applied to tissues and length of time that the pressure was sustained.28 Low pressures sustained over long periods of time caused tissue necrosis. This is the mechanism of tissue injury when decubitus ulceration occurs in bedridden, poorly mobile patients. Tissue necrosis also occurs along

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the medial or lateral borders of the feet or tops of hammer toes when patients wear shoes that are too tight. Kosiak found that as the magnitude of pressure increased, fewer hours were necessary to induce injury. The most common cause of skin breakdown in the neuropathic foot is repeated bouts of moderate pressure during everyday walking.29 For health professionals who care for patients with diabetic foot problems, two facts from this research hold particular significance. First, when the inflammatory changes (heat and swelling) began to persist from 1 day to the next, breakdown of the tissue was prevented by discontinuing the repeated stress. Second, breakdown was prevented by either decreasing the amount of pressure per repetition or by reducing the number of repetitions.

AUTONOMIC ASSESSMENT Autonomic changes represent the third category of changes associated with polyneuropathy.30,31 With roles including the regulation of moisture and blood flow, as well as controlling hair and nail growth and overall skin integrity, the autonomic system is crucial to healthy feet. Cracks and fissures in the foot, as well as nail pathologies, can predispose people to ulceration or infection. Because these are all end products of autonomic dysfunction, patients need to be educated on how to prevent them from occurring. Patients with autonomic dysfunction, most commonly from diabetes, should be educated to moisturize their feet often so as to avoid drying and cracking of the skin. Creams or non–alcohol-based lotions should be applied liberally to the feet and legs, but the areas between the toes should be avoided because the excess moisture can lead to fungal infections. Not only is moisturized skin more comfortable, it is also stronger and less likely to develop cracks and fissures, which are easy entries for infections. If nails are too thick to be trimmed safely at home with regular nail clippers, the patient should be encouraged to seek professional help for nail care. One of the most damaging outcomes related to dysfunction of the autonomic system is diabetic neuropathic osteoarthropathy, also known as Charcot foot. This destructive process can significantly alter the bony architecture of the foot and can lead to excessive plantar pressures32 and subsequent ulceration if left unchecked (Fig. 18.7). This process was first recognized in patients with syphilis during the 19th century by Jean-Martin Charcot. Although several neuropathic diseases, including syphilis and Hansen disease, can cause a Charcot arthropathy, it is most commonly seen in persons with diabetes.32 Charcot foot is a progressive disorder that leads to joint dislocation, fractures, and deformity of the foot.33 Charcot surmised that when the proper functioning of the autonomic system was impaired by disease, it led to an increase in blood flow to the bones, which then led to bone resorption. Over time, this became known as the neurovascular theory.34 A second theory states that development of a Charcot foot is related to trauma in an insensate foot. Because of the lack of sensation, there is no perception of the trauma, and thus no adjustments to compensate for it. If the joint continues to be loaded, it will stay inflamed and eventually break down. This became the neurotraumatic theory.35 Charcot foot is thought to be an inflammatory

Fig. 18.7 Charcot foot with ulceration of the plantar midfoot.

process.36 The underlying cause is persistent hyperglycemia and microvascular disease, leading to nerve injury via osmotic changes and ischemia.36 There is sensory neuropathy, loss of pain sensation, and the incidence of trauma including recurrent microtrauma. Upon clinical examination, the foot is erythematous and edematous, has an elevated skin temperature, and has reduced sensation to nociceptive pain and pressure.37 Charcot foot can become debilitating if not recognized early enough to arrest the development of the rocker bottom deformity that is characteristic of the disease. It is often misdiagnosed because no single diagnostic test can confirm its presence. Medical history, clinical manifestations, and radiographic findings all must be considered. Unfortunately, the clinical presentation of a red, hot, swollen foot often leads to the diagnosis of cellulitis, which is treated with antibiotics. During the time the patient is being treated with antibiotics for an infection that does not exist, they are continuing to damage the foot by walking on it. Radiographs taken in the acute phase are not sensitive to the development of neuropathic fractures, and bone scans do not differentiate Charcot foot from osteomyelitis.38 Magnetic resonance imaging, although a costly imaging techniques, is extremely useful for evaluating the foot and ankle in suspected Charcot neuropathy and is capable of identifying bone injury prior to complete fracture.38

18 • High-Risk Foot and Wound Healing

Charcot foot should be suspected if a patient with neuropathy presents with sudden onset of localized swelling, warmth, and erythema in the absence of an open wound. Appropriate treatment for Charcot foot should be initiated until this condition is ruled out on further testing. During acute Charcot arthropathy, joint destruction can be minimized by immobilization in a TCC and avoidance of weight bearing until signs of healing become apparent (decreased temperature, decreased swelling, and improved radiographic findings). Both lack of compliance with non–weight bearing and use of orthotic devices in place of cast immobilization have shown prolonged healing times.39 When cast immobilization is discontinued, the use of an orthotic device for continued protection of the joints during the initial return to weight bearing should be considered.40 The architectural changes that occur in the foot secondary to neuropathic osteoarthropathy result in high-pressure areas. Because of this, following the period of immobilization and limited weight bearing, patients with a history of Charcot foot must be provided with appropriate footwear to stabilize the foot and reduce plantar pressure. Surgical intervention may be indicated for unstable or severely malaligned fractures or dislocations, which create problems with recurrent ulceration, fitting of shoes, ability to ambulate, and recalcitrant ulcers.41 Some of these procedures require months of immobilization and avoidance of weight bearing, which can be difficult for many patients with diabetes and neuropathy. Such surgery is usually advocated only if nonsurgical management fails.

FOOTWEAR ASSESSMENT The analysis of the high-risk foot truly begins before the patient sits on the examination table. The type and appearance of the footwear they are wearing can give insight as to the cause of their pathology. Shoes that either do not fit properly or are excessively worn can cause problems, including blisters, calluses, and wounds. On the other hand, shoes that someone refuses to wear are not useful as they will just sit in the closet. Characteristics of the proper shoe for the high-risk foot include: • Snug fit at the heel to prevent pistoning (moving up and down) of the heel • Wide toe box to accommodate for deformities such as bunions and hallux valgus • Deep toe box to accommodate claw/hammer toes and molded inserts • Fashionable enough that the patient will wear the shoes It is recommended that people shop for new shoes in the mid to late afternoon to ensure the best fit. Because foot size changes throughout the day, a shoe purchased to fit the foot early in the morning may be too small by late evening, and conversely a shoe bought at night may be too large for the foot in the morning.

GAIT AND BALANCE Motor neuropathy causes weakness of foot and ankle musculature that may result in gait deviations that change plantar pressure patterns or contribute to instability. Gait and balance are also affected by damage to sensory nerves,

453

which leads to an inability to sense where the foot is in space. The use of ankle-foot orthoses or shoe modifications may help restore a more normal gait, stabilize joints, or improve balance.40 Studies have found that patients with peripheral neuropathy secondary to diabetes have problems with gait and postural stability.42,43 In examining a patient with a high-risk foot, physical therapists must include not only the patients’ foot problems but also their overall functional status. To reduce the morbidity associated with falls, recommendations that address safety and function should be included in the treatment plan.44

Wound Assessment Although it is clear that the most effective way to prevent amputations is to avoid getting wounds in the first place, that is not always possible. When a wound does develop, regardless of the etiology, a thorough wound assessment becomes a necessity. The comprehensive wound assessment begins with a thorough patient history, which helps the clinician not only gain a better understanding of the cause of the wound, but also forecast healing rates of the wound more accurately. It is often helpful to take the entire patient history prior to undressing the wound, because there is a tendency to focus solely on the wound once it is visible and forget about other factors that may be important. Once the patient history is reviewed, the wound can be carefully undressed. In addition to the components already discussed for the evaluation of the high-risk foot, the assessment also includes an examination of the immediate wound and periwound area. The wound should be assessed for location, color, odor, size/depth, and drainage type and amount, and the periwound tissues should be assessed for any abnormalities (Fig. 18.8).

LOCATION After a thorough medical history has been taken, the examiner may have a good hypothesis as to the cause of a wound before even seeing it. The objective examination can either confirm or refute this hypothesis. One of the first objective findings that should be documented is wound location. Although traumatic wounds can occur in any anatomic location, many of the common wound etiologies tend to occur most frequently in certain areas. Diabetic foot (neuropathic) ulcers are most common on the plantar aspect of the digits and MTHs, more specifically, the great toe and first MTH, but they can occur in any area of high stress.26 Ulceration secondary to neuropathy is also common on the dorsum of the toes, as well as bony prominences, such as the lateral aspect of the first and fifth MTHs and the base of the fifth metatarsal, and anywhere a shoe or brace may be rubbing. Wounds secondary to vascular insufficiency can occur in any location that has impaired blood flow but are most frequently found on the toes, dorsum, and lateral aspects of the foot, as well as the lateral leg. In contrast, wounds of venous origin tend to be in what is often referred to as the “gaiter” area, just proximal to the medial malleolus. It should be noted that these are general guidelines, and an accurate diagnosis cannot be made based solely on location. When describing wound location, the clinician should be as precise as possible, often using bony landmarks as

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descriptors. This becomes increasingly important when multiple wounds are present.

WOUND COLOR A simple designation for wound color is to use the redyellow-black staging system, which was first published in the United States in 1988 and had been used in Europe prior to that.45 Red wounds are generally healthy, well vascularized, and progressing through the normal stages of healing. The red appearance is attributed to the deposition of highly

vascularized collagen, known as granulation tissue. This tissue is fragile and may bleed with excessive force or friction. Granulation tissue that bleeds with minimal pressure or has a dusky appearance is called friable and should be investigated further as it is typically a sign of increased bacteria present in the wound. Yellow wounds indicate fibrinous slough or infection is present. Slough has a stringy, adherent characteristic and can be removed by a variety of methods, which are discussed later in this chapter (Preparing the Wound Bed by Eliminating the Source of Inflammation or Infection). Wounds also may have a black appearance,

Subjective exam: Pain:

Last dressing change:

Comments: Objective exam: Mode of arrival:

Edema:

Assistive device:

Sensation:

Wearing prescribed dressings/footwear?

Pulses:

Wound location:

(R)

DP

If other, enter location:

PT

Wound stage:

Popliteal

Wound color:

ABI

Color

(L)

Predébridement

Postdébridement

%

%

%

%

%

%

Range of motion: Special Tests:

Results:

Odor:

Size: L:

2

cm W:

D:

Drainage amount: Drainage type: Periwound: Nails: Fig. 18.8 Wound assessment flow sheet. Continued

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455

Comments:

Treatment: Wound cleansed with Débridement performed today?

Débridement type:

Modalities: Dressings:

Offloading:

Comments:

Assessment: Tolerance to treatment: Comments:

Plan: Comments: Follow up: Nails: Edema: Sensation: Pulses:

(L)

(R)

DP PT Popliteal ABI

Range of motion: Special Tests:

Results: Fig. 18.8—cont’d

which signifies the presence of eschar. Eschar is often hard to the touch but can be soft or boggy if there is a lot of fluid present. In most cases, it is beneficial to remove the eschar because the necrotic tissue promotes the proliferation of bacteria. Several instances when this is not advised are intact eschar on heels and vascular wounds that would not be able to heal following d
ebridement. In addition to the red-yellow-black system that is focused on the dermis, the clinician must also be aware of deeper structures that may be apparent in the wound bed. The first tissue encountered beneath the dermis is known as

subcutaneous tissue, fat, or adipose. This should have a pale yellow, moist appearance when healthy but dries out and darkens when it is nonviable. Healthy muscle has a bright red color, and the striations are often visible in the tissue. Damaged muscle takes on a dusky gray appearance with a much-less-pliable texture. The remaining structures that will be encountered in a deep wound bed—ligaments, tendons, bone—all should be white if well vascularized. If these tissues are compromised, they will take on a dusky yellow appearance and continue to darken as damage proceeds.

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For documentation purposes, the use of percentages is helpful in describing the wound color. For example, a wound could be 80% red, with 20% firmly adhered yellow fibrin. It is also suggested that the percentage should be documented before and after treatment if there is any significant change in the wound appearance. The use of clinical pathways and other intervention strategies such as dedicated foot clinics in the diagnosis and treatment of patients with diabetes at risk for foot ulceration can improve patient outcomes by reducing the need for lower extremity amputation.46

ODOR One of the most troubling aspects of a wound from a patient’s perspective is odor. Most significant wounds will have some odor when dressings are removed. As a clinician, it is important to know whether or not the odor is caused by infection or simply from the dressing having been in place for an extended period. Before making this determination, dressings should be removed and the wound should be rinsed with sterile water or saline. Odors that are eradicated are likely caused by drainage on the dressings. This is especially true of occlusive dressings, such as hydrocolloids. If cleansing the wound does not eliminate the odor, it is more likely caused by necrotic or infected tissue. Wounds with a strong odor often contain anaerobic and aerobic bacteria and are referred to as polymicrobial; anaerobic bacteria create odor by releasing compounds including putrescine and cadaverine. These odors can be extremely strong and are often described as acrid smelling. Aerobic bacteria also are capable of producing foul odors. Because the strength of an odor is subjective, it is recommended that descriptions such as sweet, fishy, necrotic, putrid, and the like also be included in the assessment of the odor. Infection should be considered when previously odor-free wounds develop an odor, but it should also be pointed out that some infections do not produce any odor at all.

SIZE Wound size should be documented on a routine basis because it is an easy way to monitor progress in wound healing. For most wounds, unless they are perfectly symmetric, a diameter or even length and width may not give an accurate representation as to the true size of the wound. When length and width are used, the largest length is recorded, and the width is recorded perpendicular to the length. Although improvements can be seen as these numbers decrease, it is difficult to accurately calculate a total surface area for the wound or a percent area reduction because wounds are irregularly shaped. Alternative methods include photography with a transparent film over the wound, wound tracings with transparent film, and digital cameras that can calculate the surface area of the wound. Newer technologies using smartphone applications for wound imaging and measurement are being developed. All of these options enable the clinician to calculate surface area and percent reduction in size. Regardless of the method used to calculate wound size, the orientation of the wound should be standardized to

ensure that subsequent measurements are assessing the same dimension. Bony landmarks can be used for this purpose, but it is most common to describe length in a cephalocaudal (head-to-toe) fashion and width perpendicular to that. Unfortunately, the largest dimensions of most wounds will not line up perfectly with axes along the cephalocaudal and perpendicular plane. For this reason, many clinicians describe wound orientation using a clock face, with 12 o’clock being at the head and 6 o’clock at the feet. Using this system, a wound could be described as 6 cm in length from 10 o’clock to 4 o’clock and 3 cm in width from 1 o’clock to 7 o’clock. Undermining, tunneling, or any other abnormality in the wound can also be described using the clock face, which will help with consistency in measurement, especially if another clinician is measuring the wound.

DEPTH A thorough understanding of anatomy is necessary for an accurate staging of wounds. In turn, an accurate staging of wounds relies on being able to assess wound depth properly. Before depth can be measured, the wound must be free of nonviable tissue so the wound base can be visualized or probed. The wound can then be probed with a sterile probe held perpendicular to the skin surface. Because wounds do not all have a uniform depth throughout, the deepest point should be measured and the location where the measurement was taken should be documented. After the depth measurement is obtained, wounds can be classified in several ways, depending on the etiology. Table 18.1 reviews different wound classification systems that rely on wound depth as a part of the staging criteria.47–50 The revised pressure injury classification system by the National Pressure Ulcer Advisory Panel includes illustrations that clarify proper staging of pressure injuries.

DRAINAGE The ideal wound will have enough moisture to prevent desiccation of the wound bed, but not so much that it causes breakdown of periwound tissues. The characteristics of wound drainage will vary depending on multiple factors, including wound location, vascular status, and presence of infection. Drainage should be classified by amount and type to accurately describe what is occurring in the wound. Assessing the amount of drainage is somewhat subjective in that it is not practical, or even possible in many cases, to weigh the amount of exudate from the wound. Instead, the clinician describes the amount of exudate along a continuum, such as the following one: None ! Scant ! Minimal ! Moderate ! Heavy ! Copious This can be difficult to quantify, especially for the inexperienced clinician, because different dressings will absorb vastly different amounts of fluid and thus could make a heavily draining wound appear drier, or vice versa. Wounds with underlying arterial insufficiency tend to be drier because less circulation is getting to the wound bed, whereas patients with wounds that are venous in nature often experience heavy drainage because of the edema present. When the amount of exudate increases and a reason is

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Table 18.1 Wound Classification Systems Classification System 47

Intended Wound Etiologies

Grades

Comments

Wagner

Diabetic foot

0¼ 1¼ 2¼ 3¼ 4¼ 5¼

Intact skin Superficial ulcer Deep ulcer (through dermis) Infection Partial foot gangrene Full foot gangrene

University of Texas48

Diabetic foot

A0 ¼ Preulcerative or postulcerative lesion AI ¼ Superficial wound AII ¼ Involves tendon or capsule AIII ¼ Involves bone or joint

Partial/full

All wounds

Partial ¼ Involves epidermis and up to part of the dermis Full ¼ Involves structures deep to the dermis

Burns49

Burns

Superficial ¼ Epidermis only Superficial partial ¼ Superficial dermis involved Deep partial ¼ Deep dermis involved Full thickness ¼ Subcutaneous tissue involved Subdermal ¼ Muscle, tendon, bone involved

Some experts do not make a distinction between fullthickness and subdermal burns, because both require surgery to heal130

National Pressure Ulcer Advisory Panel50

Pressure injury stages

1. ¼ Blanchable erythema or Nonblanchable erythema; skin is intact 2. ¼ Partial-thickness skin loss with exposed dermis 3. ¼ Full-thickness skin loss 4 ¼ Full-thickness skin and tissue loss to subfascial tissues (muscle, tendon, ligament, capsule, bone) Unstageable full-thickness pressure injury: Obscured full-thickness skin and tissue loss and slough.

When teaching about the unstageable pressure injury, explain it is termed “unstageable” because the wound base cannot be visualized, not because the clinician cannot determine the stage of injury.

not clearly stated that relates to the change, such as changes in treatment approach (i.e., surgical intervention to increase blood flow, discontinuation of compression therapy, or resting in dependent positions), then infection should be considered as a likely cause. The presence of infection causes the wound to remain in the inflammatory phase of wound healing, which results in increased drainage. Infected wounds often exhibit purulent drainage, which can be yellow, green, tan, or even creamy or cloudy. These wounds often require a combination of local and systemic agents to treat the infection. In addition to purulent drainage, drainage can also be serous (watery), sanguineous (bloody), or serosanguineous (pink or reddish, watery).

PERIWOUND SKIN The area immediately surrounding a wound, known as the periwound skin, should be assessed carefully because it can give clues as to the state of the wound. Evidence of excessive pressure, excess moisture, decreased vascularity, and the presence of infection can all be found in the periwound skin with a quick visual inspection and palpation. Table 18.2 lists periwound findings and their significance. In addition to the factors listed in Table 18.2, the amount of soft tissue over prominent areas also can be assessed. Decreased amounts of soft-tissue bulk have been identified in persons with diabetic neuropathy in comparison with

Letter stage changes as follows: B ¼ Infection C ¼ Ischemia D ¼ Infection and ischemia

persons without diabetes used as controls.51 With less soft tissue present, peak pressures at the prominent areas are increased, which increases the likelihood of ulceration.

Wound Management The larger concept of wound bed preparation and wound healing involves understanding the source of the wound and addressing the patient in a wholistic manner.52,53 The acronym “TIME”54 is used to highlight key factors that must be addressed: T ¼ Tissue management I ¼ Inflammation and infection control M ¼ Moisture Balance E ¼ Epithelial (edge) advancement Successful wound healing interventions can be categorized into a few essential steps, which are discussed in detail. These overlapping steps include: 1. Preparing the wound bed by eliminating the source of inflammation or infection; 2. Providing an optimal wound healing environment; 3. Reducing further trauma to the wound; and, finally, 4. Keeping the wound healed once it has closed and preventing new ulcers from forming.

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Table 18.2 Periwound Skin Assessment Appearance

Description

Significance

Callus

Area of hyperkeratosis, typically in response to high pressures54,110,111

Frequently associated with neuropathy and/or bony deformity. Indicates area susceptible to breakdown110

Blister

Fluid-filled area causing separation of epidermis from dermis

Shearing forces from rubbing on shoes, brace, bed, etc.; may also be caused by adhesive dressings on skin

Erythema

Redness

Indicates inflammation caused by local stress or infection; redness in immediate periwound area is normal in acute wounds, but excessive redness or redness that persists for 30 to 60 min after the stress is removed requires intervention; erythema associated with infection is often well demarcated; if red streaks are noted (lymphangitis), consult physician because it is a sign of spreading infection

Maceration

Changes in tissue caused by excessive moisture

Can lead to skin breakdown; may be a result of excessive sweating, heavy wound drainage, incontinence, or inappropriate dressings

Induration

Hardening of the tissue because of edema

Chronic edema impairs wound healing; induration is often associated with infection or venous disease

Hemosiderin

Brownish discoloration of the skin around a wound. Associated with deposition of hemoglobin in extravascular tissues

Often associated with venous disease

Excoriation

Wearing away of the skin

Indicates an area of trauma; often preceded by maceration and/or blistering

Presence of scars

A scar is the final result of a previous injury

May give clues to the chronicity of the problem as well as the extent of damage in the area

Temperature

Can be palpated or assessed with infrared thermometer; is typically compared with adjacent areas or to contralateral side

Nonspecific indicator of inflammation; helpful to monitor “hot spots” that may be at risk of breakdown, or for resolution of a Charcot fracture

Edema

Swelling in the tissues

Bilateral edema suggests a systemic problem; unilateral edema indicates a localized problem; can occur with infection, inflammation, venous dysfunction, and lymphedema; consider Charcot foot if insensate

Other changes

Taut, shiny, hairless, cracked skin

Taut, shiny skin with a loss of hair indicates impaired blood flow; cracked skin is associated with aging, diabetes, or vascular disease. Important to moisturize skin frequently

PREPARING THE WOUND BED BY ELIMINATING THE SOURCE OF INFLAMMATION OR INFECTION The current model of infections that is most widely used involves the interaction between the host response and the amount of bacteria present in the wound. As outlined by this model, a patient with a healthy immune response is able to tolerate a higher bacterial load without developing signs of infection than a patient with an impaired immune response. The amount of bacteria in a wound is usually described on a continuum from sterile to a systemic infection. Sterile wounds have no bacteria, whereas systemic infections have overwhelmed the wound with bacteria and cause systemic immune responses. Intermediate stages include contaminated wounds, characterized by bacteria that is present but not invading the tissue; colonized wounds which are still capable of healing despite invading bacteria; and critical colonization in which the bacteria are overwhelming the immune system and are creating a localized response.54–56 It is in the colonized and critically colonized wounds, and in infected wounds in conjunction with systemic medications, that selective d
ebridement, modalities, and topical dressings are most helpful in optimizing the wound environment.

A very effective means of reducing inflammation and the risk of infection is removal of the tissue that may harbor bacteria, through a process known as d
ebridement. There are many ways that d
ebridement can be performed, and all of them are within the scope of practice of the physical therapist except for surgical d
ebridement. Because surgical d
ebridement may involve the excision of viable and nonviable tissue to ensure that all of the necrotic or infected tissue is removed from the area, it is called nonselective d
ebridement. Slightly less aggressive is sharp d
ebridement. Sharp and surgical d
ebridement both use sterile sharp instruments to remove tissue, but the tissue that is being d
ebrided is limited to nonviable tissue in sharp d
ebridement. For this reason, sharp d
ebridement is referred to as selective d
ebridement. Despite being widely accepted, or perhaps because it is so widely accepted as a standard of care, there is limited evidence on the effectiveness of sharp or surgical d
ebridement. D
ebridement with sharp instruments is the quickest way to remove undesirable tissue, but is also the riskiest method and is best used by the experienced clinician. Risks can be minimized by using the appropriate equipment and assessing the patient thoroughly to ensure that they do not have any of the contraindications/precautions listed in Box 18.1.

18 • High-Risk Foot and Wound Healing

Box 18.1 Contraindications and Precautions to
bridement Sharp and Surgical De Medically unstable patient (surgical only)112 Dry gangrene or lack of vascular supply to heal wound112 Intact, dry eschar on heel113 Impaired clotting mechanism or on anticoagulants53 Pyoderma gangrenosum113 Clinician without a thorough knowledge of anatomy of the area to be d
ebrided

In addition to sharp and surgical d
ebridement, mechanical, acoustic, enzymatic, larval, and autolytic forms of d
ebridement are also viable options. Of these, all are classified as selective with the exception of mechanical d
ebridement. Mechanical d
ebridement can be performed using a variety of methods, including abrasion, wet-to-dry dressings, and whirlpool. All of these methods may remove nonviable tissue but can be detrimental to healthy tissue and, if used at all, should be limited to cases in which the majority of the wound is nonviable. Historically, whirlpools were frequently included in the treatment plan for an individual with a wound. Proposed benefits were increasing blood flow to the area because of the warm water, as well as the ability to remove dressings and necrotic tissue. The whirlpool also has many shortcomings as a wound care modality, including the risk of crosscontamination, unregulated pressures on the wound, exacerbation of dependent edema, and excessive maceration. As a result, pulsatile lavage with suction (PLWS) has largely replaced the whirlpool as the hydrotherapy of choice for wound management. There are no absolute contraindications to the use of PLWS, but care must be taken around exposed vessels, vital organs, and fistulas. Precautions must also be taken to reduce the risk of cross-contamination, including using personal protective equipment, treating in a private room, using a shield to prevent backsplash, and disposing of single-use components properly. PLWS delivers a stream of irrigating solution (irrigant) such as saline or saline with antibiotic. The irrigant solution that can be directed at the area of interest to d
ebride slough and reduce bacterial counts on the wound.57 It appears that the effectiveness of lavage improves as the amount of irrigant used to flush out bacteria is increased.58 With PLWS, the water pressure can be controlled and can be delivered within the safe range of 4 to 15 psi, which is effective at removing nonviable tissue and bacteria without traumatizing healthy tissue.58 For the purposes of reducing bacterial levels, the higher end of that range is recommended, because nearly 85% of bacteria can be removed from a wound with 15 psi. Acoustic, or ultrasonic, energy is the newest form of d
ebridement to enter the wound care arena.59 Currently, there are several ultrasonic d
ebridement devices on the market that are capable of performing selective d
ebridement. These devices are classified as low frequency (kilohertz range, as opposed to megahertz with conventional ultrasound) and highintensity ultrasound devices. Studies have demonstrated effectiveness of these devices at increasing fibrinolysis, improving blood flow to the wound, and reducing bacterial

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counts, and anecdotally it seems to be faster than sharp d
ebridement in many cases.60–62 Although capable of producing extremely rapid d
ebridement and a reduction in bacteria, the use of ultrasonic d
ebridement will likely be cost-prohibitive for clinics that do not specialize in wound healing. For that reason an in-depth discussion of ultrasonic d
ebridement is not included in this chapter. The remaining forms of d
ebridement tend to be slower but are less harmful to healthy tissue. Larval therapy63 involves the use of sterile maggots, which secrete enzymes to liquefy necrotic tissue but have no negative effect on granulation tissue. Similarly, enzymatic d
ebridement involves the application of topical agent to the wound surface. The enzyme works to denature the protein in the necrotic tissue on the wound bed.64 Autolytic d
ebridement uses the body’s own self-produced enzymes to rid a wound slowly of necrotic tissue.64 In a moist wound, phagocytic cells and proteolytic enzymes can soften and liquefy the necrotic tissue, which is then digested by macrophages. These d
ebridement strategies should not necessarily be thought of as independent of each other. For example, sharp d
ebridement is often done in conjunction with enzymatic or autolytic d
ebridement. All of the forms of d
ebridement serve to reduce the risk of infection by removing the energy source for the bacteria. There also are interventions that specifically target the bacteria rather than the necrotic tissue. Over the past decade or so, the number of dressings that have been developed to reduce bacteria in the wound has increased dramatically. These include a variety of dressings that contain silver, methylene blue, gentian violet, polyhexamethylene biguanide, iodine, or honey. These dressings have been shown to be superior to nonantimicrobial dressings in the reduction of bacteria, but there is insufficient evidence to state one antimicrobial dressing is superior to another in terms of promoting wound healing.65,66 These dressings are available in so many varieties, ranging in absorptive capacity, adhesive versus nonadhesive, amorphous versus sheet form, and the like, that there is likely a good option for nearly any wound type. What is most important to remember is that none of these dressings should be used as a replacement for systemic antibiotics. It is common to use topical antimicrobial dressings along with systemic medications, especially in the case of arterial insufficiency. For example, a patient with a diabetic foot ulcer may have an infected toe with poor vascularity. In this case the amount of the systemic antibiotic getting to the infected area may be limited and could benefit from a topical agent to reduce the degree of surface bacteria. There are several problems with the continued use of antimicrobial dressings, namely cost and the concern over developing resistance. Because they are impregnated with antimicrobial agents, these dressings are more expensive than a comparable nonantimicrobial dressing and are not intended to be used for the duration of wound healing. Likewise, there is some concern in the wound care community that overuse of silver dressings may lead to the development of resistant strains of bacteria, similar to what happened with the widespread use of antibiotics. In addition to antimicrobial dressings and the interventions already discussed, two therapeutic modalities that

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have strong evidence supporting their use in the management of infections are electrical stimulation67 and ultraviolet light, also referred to as phototherapy.68 Phototherapy includes the use of ultraviolet light, as well as laser light. Electrical stimulation units and ultraviolet light equipment are likely to be found in most physical therapy clinics because these modalities have been standard equipment in physical therapy clinics. Electrical stimulation for wound healing can be delivered either as a direct or pulsed current: Direct current allows the current to flow constantly in one direction. Pulsed current is separated by a period of no current flow. There are two types of pulsed current— monophasic and biphasic. In both types of pulsed current the electric current is delivered in short bursts; however, in monophasic the current flows in one direction, whereas in biphasic the current is bidirectional. The most common waveforms for electrical stimulation in wound healing are high-voltage pulsed current and low-intensity direct current (or microcurrent). Both of these currents are monophasic, (current will flow only in one direction). As a result of this, charged particles will be drawn toward the oppositely charged electrode and repelled from the like-charge electrode, just as a positive pole and negative pole on a magnet will stick together and two positives will push each other apart. This concept is known as galvanotaxis and is the basis for the use of electrical stimulation in tissue healing. When the goal is to treat an infection, the negative pole (cathode) should be used at the wound site and the positive pole (anode) can be placed approximately 15 to 30 cm away. By applying cathodal stimulation to the wound, activated neutrophils are recruited which can attack the bacteria that is present.67,69 The treatment electrode may be placed on the immediate periwound skin or directly in the wound. If stimulation is applied directly to the wound, the wound must be filled with hydrogel or saline-moistened gauze. Treatment is usually continued until signs of infection are no longer present or until progress halts, at which time polarity is reversed to jump start healing. Ultraviolet C light is another modality used for the treatment of pressure ulcer wounds. Ultraviolet therapy is effective in reducing microorganisms in colonized wounds and promoting granular tissue formation, reepithelialization, and sloughing off necrotic tissue. Studies show the use ultraviolet phototherapy has a shorter mean time to complete wound healing when compared with a control group.70,71 Low laser light therapy is also used for the treatment of wounds.72,73 However, the results of the use of low laser light therapy to promote wound healing have been variable with low or no efficacy.73

PROVIDING AN OPTIMAL WOUND-HEALING ENVIRONMENT As mentioned previously, it is somewhat of an artificial delineation to break wound healing down into different steps because there is so much overlap. Early in the wound-healing process the primary goal may be removal of nonviable tissue, as mentioned in the previous section, but selective d
ebridement would be of no use if concurrent steps were not taken to optimize the wound-healing environment. Once bacteria in the wound are controlled and an adequate arterial supply is ensured, the focus of ther-

apy can shift to moist wound healing. Moist wound healing includes the use of dressings and, in some cases, compression therapy to create a wound bed that is neither too wet (macerated) or too dry (desiccated) to be suitable to wound healing. An analogy to a beach is commonly used to help explain this concept, in which the optimal wound environment is the wet sand and suboptimal environments are underwater or on dry land. To create a moist wound bed, the clinician must have a good understanding of the wound etiology and a familiarity with the available wound care dressings. Certain wounds, such as those associated with infection, venous insufficiency, and lymphedema, tend to drain heavily and require absorbent dressings, whereas wounds without an adequate blood supply tend to be dry and often require the addition of moisture. With the appropriate use of cleansing agents, protection of the periwound skin, and selection of suitable dressings, wound healing can be positively influenced. Educating a patient about appropriate cleansing agents is particularly important if a patient will be cleansing the wound at home. The patient should be educated not to scrub the wound and to avoid the use of harsh chemicals such as bleach, iodine, hydrogen peroxide, alcohol, or surgical scrub brushes for daily cleansing, unless specifically prescribed for the management of a heavily colonized wound. Although some of these chemicals can be extremely effective at controlling bacteria, they are all cytotoxic and can impede wound healing. The general rule of thumb “if you wouldn’t put it in your eye, don’t put it on your wound” works well. For healthy granulating wounds, normal saline or sterile water are effective for mild cleansing and the removal of small particles of adhered dressing that may be present. Some wounds have bacteria that are adhered to the surface forming a matrix known as a biofilm. In these cases a noncytotoxic wound surfactant is a better option. Once the wound is clean, consideration can shift to the periwound area. This skin is vulnerable to injury from adhesive dressings or excess wound drainage, but damage can be limited or prevented with the use of a skin protectant. There are literally hundreds of dressings on the market, making it impractical, if not impossible, to keep up with all of them. By having a general understanding of each class of dressings, the clinician should be able to choose a dressing that is not only safe but effective in the management of the wound at hand. Table 18.3 outlines the characteristics of some of the most commonly used classifications of dressings. No single dressing is intended to treat a wound through all phases of wound healing, nor is each patient with the same diagnosis going to respond the same. It is important to reassess the characteristics of the wound at each patient visit to ensure that the dressing being used remains the best option. Factors such as ease of use, whether or not the patient can change the dressing independently, how often it will need changing, the degree of discomfort associated with dressing changes, and cost need to be considered. For example, a hydrocolloid is easy to apply but would not be cost-effective for a wound that needs to be changed twice per day, and a transparent film may be inexpensive and easy to use but inappropriate for an individual with poor periwound skin integrity. Acute wounds in an otherwise healthy individual may heal without difficulty if appropriate dressings are used.

18 • High-Risk Foot and Wound Healing

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Table 18.3 Common Wound Care Dressings Indication

Dressing Type

Contraindications

Comments

Absorption

Alginate

Excessively dry wounds Full-thickness burns

Secondary dressing required

Hydrofiber

None

Secondary dressing required

Foam

Excessively dry wounds

Adhesive and nonadhesive varieties Absorptive capacity varies between brands

Alginate

Excessively dry wounds Full-thickness burns

Secondary dressing required

Silver nitrate

Skin hypersensitivity

Effective on hypergranulation

Add moisture

Hydrogels

Moderate to heavy exudate

Gel or sheet forms

Maintain moisture

Hydrocolloids

Local or systemic infection Caution with fragile periwound skin

May increase wound odor at dressing removal

Transparent films

Cavity wounds Tracts, tunnels, undermining Infection Excessive exudates

May decrease need for unnecessary dressing changes because wound can be visualized

Fragile skin

Silicone

None

Reduces scarring May be used to prevent an absorbent secondary dressing from adhering

Antimicrobial

Silver

Avoid use with enzymatic d
ebriders

Most dressing classifications have a silver version

Honey

None

Requires secondary dressing

Polyhexamethylene biguanide

Avoid gauze-based dressing over exposed nerves, vessels, and tendons

Important to keep gauze moist to avoid adhering to wound bed

Methylene blue/ gentian violet

Full-thickness burns

Requires premoistening with sterile water or saline Requires secondary dressing

Cadexomer iodine

Iodine sensitivity Hashimoto thyroiditis Nontoxic nodular goiter Graves disease Pregnant or lactating women

Sheet and gel forms available Requires secondary dressing

Hydrocolloid

Local or systemic infection Caution with fragile periwound skin

May increase wound odor at dressing removal

Transparent film

Cavity wounds Tracts, tunnels, undermining Infection Excessive exudates

No absorptive capacity

Collagenase

Hypersensitivity to collagenase Do not use with silvers

Requires daily application Requires secondary dressing

Gauze

Directly on healthy granulation tissue Exposed nerves, vessels, tendons

Wet-to-dry dressing is not recommended; if used, it should be restricted to necrotic wounds Effective as a secondary dressing

Active bleeding

D
ebridement

In chronic wounds or patients with impaired wound healing potential, the use of certain modalities can be used to stimulate wound healing. Electrical stimulation, pneumatic compression, negative-pressure wound therapy, ultrasound, and laser have all been shown to be effective in the management of wounds. It is beyond the scope of this chapter to go into an in-depth discussion of each of these modalities.

REDUCING FURTHER TRAUMA TO THE WOUND Regardless of the advanced wound care dressing used, wounds will not heal unless the wound can be protected

from further trauma. In most cases, trauma comes in the form of weight-bearing forces. In a bed-bound individual, dynamic air mattresses and air-fluidized beds are used to disperse forces, which in turn, reduce the amount of pressure at the wound site and allow it to heal. For persons who are more active, offloading can be even more of a challenge because there is a balance that needs to be met between maintaining function and providing pressure relief to the wound. Take the case of an individual with drop foot whose ankle-foot orthosis is causing a wound on the plantar aspect of the fifth MTH. The patient needs to continue to wear the orthosis in order to walk, but if the patient does so, the wound will continue to deteriorate. The challenge for

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the clinician is to offload the foot so that the wound can heal as quickly as possible, enabling the patient to return to the patient’s normal activities. Many of the advances in pressure reduction strategies for the foot have come about because of diabetes. As a result of the neuropathic and arterial changes discussed previously, many of these individuals will develop foot ulcers that will require offloading. Many of these wounds would respond well to several weeks of complete bed rest because all weight-bearing forces would be eliminated from the bottom of the foot. This is not practical for most patients and even if it were a possibility, it is not without risk (i.e., blood clots, deconditioning, and pressure ulcers). Maintaining non– weight bearing at home is also a major challenge for most patients. When a patient sustains an orthopedic fracture to the foot, pain serves as negative feedback and prevents the person from weight bearing. In the presence of neuropathy, the sensation of pain is diminished so the deterrent from putting the foot on the floor is absent. Although non–weight bearing or partial weight bearing is encouraged through the use of an assistive device, it is prudent to assume the device will not be used all the time and to protect the foot as if you intend weight bearing to occur.

Total Contact Casting The gold standard for offloading the neuropathic foot has traditionally been the TCC (Fig. 18.9). Initially used in the management of Hansen disease (formerly leprosy), the

Fig. 18.9 Total contact cast.

TCC was first brought to the United States by Dr. Paul Brand.74 Using the simple equation, pressure ¼ force/area, it is evident that pressure can be reduced by reducing the amount of weight (force) going through the wound and by increasing the total area that the patient’s weight is spread over. The TCC has intimate contact with the entire plantar aspect of the foot, with the exception of the wound location. This serves to increase the weight-bearing surface area and reduce the force through the wound. In addition, immobilization of the ankle in neutral prevents dorsiflexion and weight transfer toward the front of the foot during the late stance phases of gait. The TCC reduces vertical and shear forces acting on the foot. Numerous studies report favorable results in healing diabetic foot ulcers with the use of the TCC.74–78 Three randomized control studies found that TCC for patients with neuropathic foot ulcers had 90% healing and healed in a shorter time span compared with patients who did not have total contact casting but had other offloading strategies such as non–weight-bearing status, use of walker aid, and/or use of removable air cast.79–81 The traditional TCC was made of plaster material, which required the patient to be non–weight bearing for at least 24 hours. Many clinics currently do a combination of plaster and fiberglass or all fiberglass casts to allow patients to return to weight bearing more quickly. The initial TCC also had contact with the entire foot, including the wound. Since that time, a modified approach in which the wound site is isolated has been shown to reduce pressure significantly more than the true “total contact” method.82 Although it has demonstrated superiority in offloading, the TCC is not appropriate for all cases. It should not be used in cases of excessive drainage, vascular insufficiency, infection, or fluctuating edema and for wounds that are deeper than they are wide. Because the condition of the foot cannot be monitored while it is enclosed in a cast, the patient must be able to recognize the warning signs indicating the need to have the cast changed. These signs include excessive swelling of the leg that causes the cast to become too tight, loosening of the cast that allows the foot and leg to move within the cast, a sudden increase in body temperature or of blood glucose level that might indicate infection, staining and drainage through the cast, excessive odor from the cast, new complaints of pain, and damage to the cast.

Removable Cast Walkers Despite being the gold standard for offloading the neuropathic foot, the TCC is not widely used because of concerns over iatrogenic complications, as well as a lack of experience among clinicians. In its place, removable cast walkers have become the most widely used method to offload the foot. The removable cast walker is an orthotic device with double uprights fixed at a 90-degree angle to a rocker-soled walking platform. As with the TCC and walking splint, the fixed position of the ankle prevents propulsion at the forefoot, where the greatest pressures tend to occur. Removable cast walkers are available from various manufacturers. Because they are not custom made for each patient, care must be taken when fitting the device to ensure that it accommodates the contours of the patient’s foot and ankle, particularly in the area of the uprights. A custom-molded insert can be added to most manufactured walkers.

18 • High-Risk Foot and Wound Healing

Instant Total Contact Cast A major advantage of the TCC over the removable walker is the forced compliance because of the inability of the patient to remove the cast. Because the cast cannot be removed, it is ensured that the wound is being offloaded 24 hours per day. Several studies show the removable cast walkers to be comparable with the TCC for pressure reduction.83,84 However, other investigators report faster healing times with the TCC as opposed to removable cast walkers.79–81 Under the assumption that the seemingly conflicting data was a function of the cam walker being removed, researchers designed studies that compared TCCs and removable cast walkers to cast walkers that were made nonremovable by wrapping them with a layer of fiberglass (Fig. 18.10). These nonremovable cast walkers were named instant total contact casts (iTCCs). Results of one study found the iTCC to be equivalent to the TCC in the proportion of wounds that healed in 12 weeks,85 whereas the second study found healing rates with the iTCC to be comparable with healing rates of the conventional TCC in previous studies and superior to the removable cast walker.86 Based on the available evidence, the iTCC is a viable option for a neuropathic wound, especially for the clinician that has not been trained in the application of, or does not have the time to apply, a TCC. Wound-Healing Shoes The cast, splint, and cam walker should all be considered as therapies of choice to offload neuropathic ulcerations. It is tempting to use less-restrictive devices because the devices

Fig. 18.10 Instant total contact cast fabricated by applying fiberglass to a removable cast walker.

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that cover the leg seem like such an inconvenience to the patient. For most patients, putting them in devices that will be less than optimally effective is doing them a disservice. In some cases where a cast is contraindicated or the leg will not fit in a cam walker, devices that go only as high as the ankle may be useful. One of these devices is the wedge shoe, which has an elevated toe portion in relation to the heel so as to offload the forefoot (Fig. 18.11). The wedge shoe causes the body weight to shift back toward the heel, decreasing forces at the forefoot, albeit not to the same extent as the devices that transfer weight up the leg.87 For pressure to be reduced, the area to be offloaded must be distal to the fulcrum of the shoe. To maximize pressure reduction, patients should be instructed to take short steps with the contralateral leg. This ensures that they do not propel over the wedge, causing contact between the distal end of the shoe and the ground. In clinical experience, this is often difficult for patients to do, and the telltale “clicking” of a patient in a wedge shoe can usually be heard as soon as the patient walks into the clinic. When a patient takes a large enough step to allow the front of the shoe to hit the ground, pressure at the forefoot is increased but may still be less than if the patient were ambulating in a regular shoe because of the rigidity of the wedge shoe’s sole. This rigidity serves to reduce the transfer of weight toward the forefoot that typically happens in terminal stance, but it does not isolate the at-risk area in relation to the rest of the forefoot. The addition of a custom-molded insert with a relief area has been shown to be effective at addressing this problem.76 The issue of compliance with the wedge shoe, and all shoe offloading devices, remains a question. On one side, it could be argued that wedge shoes are less cumbersome, so are more likely to be worn; and on the other side that they are easier to remove, making it more likely that the foot will be left unprotected. Another issue is that wedge shoes are difficult for patients with limited dorsiflexion and could actually increase forefoot pressure if a patient has a limited range of motion. Walking in a wedge shoe feels very unnatural because of the functional leg-length discrepancy created. This can be difficult to manage for patients with balance issues and can also lead to back discomfort. Finally, one last drawback to the wedge shoe is that it cannot be used to offload bilaterally because it shifts the patient’s weight too far posteriorly.

Fig. 18.11 OrthoWedge shoe. (Courtesy Darco International, Huntington, WV).

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Section III • Prostheses in Rehabilitation

An alternative shoe-type device to the wedge shoe is a shoe with modifiable insoles.88 An example of this device, the DH shoe by Royce Medical Co. (Ossur North America, Aliso Vejo, CA), has an insole with pegs that can quickly be removed to relieve pressure to the at-risk area (Fig. 18.12). Advantages of this shoe type versus the wedge shoe include the ability to offload any part of the foot, not just the forefoot, a flat sole that is safer for those with balance issues, and the ability to offload bilateral feet simultaneously. A disadvantage to this type of shoe is that the flexible sole allows for a toe break during the gait cycle, which allows weight to transfer anteriorly.

Other Pressure-Relieving Options There are several temporary offloading options89,90 that can be applied directly to the foot in cases in which the previous described options either are unavailable or undesirable. The first option is adhesive felted foam (Fig. 18.13).89 A custom-

Fig. 18.12 DH Wound Healing shoe, which has pegs that can be € removed. (© Ossur.)

fit piece of ¼-inch felt-backed foam is adhered to the plantar surface of the foot. A U-shaped aperture is cut in the foam to reduce pressure around the ulcer. The margins of the aperture are positioned close to but not overlapping the wound edge, extending distally beyond the wound. The entire plantar surface of the foot must be examined to identify all vulnerable spots that need accommodation before the pad is applied. For forefoot ulcers, the pad extends proximally along the midfoot to increase the weight carriage in this area. All edges of the foam pad should be beveled to minimize chances of skin breakdown from edge pressure. When a bony deformity is particularly prominent, an additional layer of foam can be used to relieve pressure adequately from the ulcer site. A thin dressing is placed flatly over the ulcer. A healing sandal is used for ambulation. If the area is preulcerative or postulcerative, an extra-depth shoe can be worn. The felted foam should be thought of as temporary because the pressure relief provided by the foam pad decreases significantly by the fourth day.91 Consequently, changing the pad every 3 or 4 days might be beneficial. Felted foam is generally well accepted by the patient. Because this method allows for easier mobility than a TCC or walking splint, patients tend to walk more. This may not be desirable considering the possible effect of cumulative pressure. Despite walking more, patients using felted foam as an offloading method seem to respond well to the therapy as measured by the percentage of wounds that heal and the amount of time they take to heal.92–94 The major benefit of the felted foam appears to constant wear time, without the excess bulk and seems to be a good option for patients that tend to walk barefoot, even though they are instructed not to. Another temporary form of offloading is the football dressing. The football dressing was first proposed by Rader and Barry as a simple alternative to total contact casting for neuropathic ulcers.95 The football dressing involves three layers of cast padding: the first is fan-folded over the toes, the second is wrapped circumferentially around the foot, and the third covers up to the lower one third of the leg. A layer of gauze is then applied and covered with an elastic wrap. Although there are limited data that support the use of the football dressing, a retrospective analysis of its use found it to have comparable effectiveness compared with the published data for the TCC and iTCC for the management of wounds across the spectrum on the University of Texas Diabetic Foot Classification System.95 Some clinicians have had success using the football dressing in conjunction with a removable cam walker to ensure that the foot has some degree of protection even if the cam walker is removed.96

PREVENTION OF ULCERATION OR REULCERATION

Fig. 18.13 Felted foam pressure relief. Edges of the foam have been beveled.

The simplest and most cost-effective way to treat a wound is to avoid getting one in the first place. This is best accomplished through risk identification, patient education, fitting with appropriate footwear, and follow up for routine care. Being able to classify patients based on their risk for developing ulceration is critical for the proper management of each individual. One of the most widely used risk classifications was developed by the International Working Group on the Diabetic Foot (IWGDF). This classification system has been shown to predict foot complications (Table 18.4).97–99

18 • High-Risk Foot and Wound Healing

Table 18.4 International Working Group on the Diabetic Foot Risk Classification Risk Category

Definition

0

No neuropathy

1

With neuropathy, no deformity or peripheral vascular disease

2

With neuropathy and deformity or peripheral vascular disease

3

History of ulceration or amputation

In 2008 Lavery and associates published a revision of the IWGDF classification system.100 In their new model, risk category 2 was divided into two groups, labeled 2A and 2B. Group 2A included patients with sensory neuropathy and deformity, and group 2B consisted of patients with peripheral arterial occlusive disease. Group 3 was divided into those with a history of an ulcer (3A) and those with a history of amputation (3B). When they applied this new classification system to 1666 patients with diabetes, they found that there were significantly more foot complications in the “B” groups than in the “A” groups. In addition, they found that there was little clinical difference between groups 1 and 2A and thought those two groups could be combined. These changes led to the development of the Texas Foot Risk Classification (Table 18.5). Once a patient’s risk factors have been identified, patient education can be tailored to the individual patient’s needs. It is often helpful to have a small pamphlet or flier available for patients to take home that outlines what is safe and unsafe for them to do. A comprehensive educational pamphlet should include skin care, skin inspection, and footwear guidelines as shown in Box 18.2. Recommendations should be adjusted based on the patient’s individual needs; for example, performing nail care at home would not be advisable for a patient with vascular compromise or who has difficulty reaching or seeing his or her feet. Risk stratification is also important in determining the most appropriate footwear for a patient. Patients in the risk category 0 do not typically require special footwear but should be educated on proper shoe fit. The proper shoe should match the contours of the foot and should be comfortable at the time of purchase (no break-in period). High-risk patients should have the width and length of their feet measured

Table 18.5 Texas Foot Risk Classification Risk Group

Characteristics

0

No neuropathy or arterial disease

1

Neuropathy present

2

Arterial disease present

3

History of ulceration

4

History of amputation

From Lavery LA, Peters EJ, Williams JR, et al. Reevaluating the way we classify the diabetic foot: Restructuring the diabetic foot risk classification system of the International Working Group on the Diabetic Foot. Diabetes Care. 2008;31(1):154–156.

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every time they buy a new pair of shoes. It is also a wise investment for each clinic that deals with high-risk feet to obtain a shoe-measuring device (Fig. 18.14), because many problems can be avoided with proper fitting shoes. Width is measured across the widest part of the forefoot, typically across the MTHs, with the patient standing. Two measurements need to be taken for shoe length; one is the heel-totoe length and the other is the heel-to-arch length. This extra measurement helps to ensure that the toe break in the shoe is in line with the MTHs. If the heel-to-toe and heel-to-arch lengths are the same, then that is the correct shoe size. If they are different, the patient should be fit with the larger of the two sizes. Patients should be instructed to try on new shoes in the mid to late afternoon, after they have been on their feet for most of the day. If they shop in the morning, they risk having shoes that are too tight by evening, and if they wait until evening to shop, shoes may be too large in the morning. A well-fitting shoe should have approximately one thumb’s width between the longest toe and the end of the shoe, and the material on the dorsum of the shoe should be pinchable if the shoe is not too narrow or shallow. Patients who have a loss of sensation and no other risk factors (category 1 of original IWGDF) also do not require protective footwear but may benefit from a soft nonmolded insert in the shoe. It is important that they are educated on what to look for in a shoe. High heels increase forefoot pressure, shoes with narrow toes squeeze the foot, thongs can irritate between the toes, and slip on shoes do not stay in place very well. A supportive shoe allows the foot to stay in proper biomechanical alignment while remaining relaxed. Athletic shoes and shoes made with more flexible materials are excellent options for this low-risk group because they reduce pressure in comparison with leather shoes.101,102 For higher-risk groups, specialty footwear, including custom insoles and extra-depth or molded shoes, is indicated. Custom inserts are molded to the foot and reduce pressure at the heel and forefoot compared with flat insoles by spreading weight-bearing forces over a larger area.103 The ideal insert strikes the perfect balance between durability and cushioning. No single material has been identified that accomplishes both tasks effectively, so most orthotics are fabricated with several different materials.104 Although these multidensity insoles seem to strike a balance between support and pressure relief, they are thicker than a flat insole and require the use of an extra-depth shoe. Custom-molded insoles in combination with extra-depth shoes are effective at preventing recurrent ulceration in diabetics (Fig. 18.15).103,105 One of the most difficult times in the wound healing process is the transition from “treatment” footwear to everyday footwear. These patients comprise group 3 in the Texas Foot Risk Classification. Because most people with a diabetic foot ulcer see the return to normal footwear as a goal, it is often tempting for both the patient and clinician to rush this process once the wound has completely epithelialized. At this point in the healing process, the wound may not be mature enough to handle the pressure increase from the treatment shoe to a regular shoe. As an intermediary, some of the shoe-type offloading devices mentioned earlier in this chapter can serve as a bridge between treatment devices that immobilize the ankle and permanent footwear. Depending on the degree of deformity, individuals in these risk groups

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Section III • Prostheses in Rehabilitation

Box 18.2 Guidelines for Preventative Foot Care Skin care DO:

Wash feet daily. Dry them well, especially between the toes. Apply a thin coat of moisturizer to feet daily, avoiding between the toes. Trim toenails after washing and drying feet. Cut toenails straight across; smooth any sharp edges with an emery board. Have a podiatrist handle any thickened or ingrown toenails. Thin thick corns or calluses by gently using a pumice stone or by professional care. Check water temperature with a thermometer or elbow before bathing. Wear socks at night if feet are cold. Use sunscreen on the tops of feet during the summer. Ask health care provider to check feet at each visit. DO NOT: Soak feet. This can dry them out and cause cracking. Use moisturizer between toes. Moisture between the toes allows germs to grow. Cut corns and calluses. Use chemical agents, corn plasters, strong antiseptics, or adhesive tape on feet, because they can damage skin. Use hot water bottles or heating pads, because they can burn feet. Foot Self-Inspection DO:

DO NOT: Footwear DO:

DO NOT:

Inspect all surfaces of the feet daily (including between the toes) for signs of injury: reddened areas, blisters, cuts, cracks, or sores. Report any injuries to a health care provider immediately. Feel for areas of increased temperature. Check for tender areas on the bottom of feet. Use a mirror if necessary to see the bottom of feet. Have a family member, friend, or health care professional check feet if necessary. Wait to report problems to a health care provider. Early attention can often prevent small problems from becoming big ones. Wear shoes that fit the size and shape of feet and leave room for any necessary insoles. Ask a health care provider to recommend the correct type of shoe. Break in new shoes slowly, checking feet frequently for signs of irritation. Report signs of irritation to a health care provider. Keep shoes and insoles in good repair. Always wear socks or stockings with shoes, wearing a clean pair daily. Before putting on shoes, check for rough areas, torn linings, or loose objects that can injure a foot. Walk barefoot (use slippers at night, special shoes or sandals for the beach). Wear socks that are too baggy or have holes or prominent seams. Wear socks or stockings that are constricting at the top. Wear sandals with thongs between the toes.

Fig. 18.14 Brannock foot measuring device. (Courtesy The Brannock Device Co., Liverpool, NY).

will need to be fit with custom insoles and either extra-depth or custom-molded shoes.106 For added pressure relief, areas surrounding the postulcerative site can be built up with firmer materials to transfer weight away from the maturing

Fig. 18.15 Extra-depth shoe with removable insoles.

18 • High-Risk Foot and Wound Healing

467

in the shoe. When a full-length shoe is combined with a rigid rocker bottom and a custom-molded insert, pressures at the forefoot of both the involved and contralateral foot were reduced compared with a regular shoe with a toe filler.109 Persons wearing this combination also had faster walking speeds and physical performance test scores compared with patients in regular footwear with a toe filler. Based on these findings, the best option for those in risk category 4 is a fulllength, rigid rocker bottom shoe, with a custom-molded insole.

Summary Fig. 18.16 Rocker bottom shoe.

tissue. To reduce the risk of blisters caused by shear forces, any adjustments should be made to the underside of the insole so the foot remains in contact with a smooth surface. More aggressive shoe modifications can be used for those who require pressure reduction beyond what in-shoe modifications can achieve. The most effective of these modifications is adding a rocker bottom to the outer sole of the shoe (Fig. 18.16). Diabetic shoes with molded inserts and rocker bottom soles decrease pressure at the heel and forefoot and simultaneously increase midfoot pressures, which is typically a less vulnerable area.116 A review by Cavanagh reported mixed results pertaining to the effectiveness of rocker bottom soles but notes several major flaws in the studies that found them to be ineffective.107 The reduced pressure associated with the rocker sole has been shown to be clinically significant because it reduced the recurrence rate compared with patients wearing their own shoes.108 Many of the strategies used for patients transitioning back to permanent footwear following an ulceration can be applied to the Texas Foot Risk Classification group 4, or more simply, those whose status is postamputation. Pressure relief remains critical, and rocker bottom shoes are effective in limiting the transfer of weight anteriorly, but there are some unique complications associated with transmetatarsal amputations. Depending on the amputation site, the long extensors of the foot may be damaged or be put at a mechanical disadvantage relative to the intact plantar flexors which attach to the posterior heel. The result of this imbalance is an equinus deformity which increases pressure at the distal end of the foot. A second problem is proper shoe fit. A short shoe that is fit to the amputation can reduce pressure on the distal foot but also increases pressure on the contralateral foot; however, short shoes were not well received by patients because of cosmesis. Appearance may seem trivial in relation to preventing the recurrence of an ulcer, but it is naïve to overlook appearance. If shoes are disliked so much that they are not worn, they serve no purpose at all. Along the same line of reasoning, patients need to be educated about the importance of not only wearing their shoes while outside but also in the house, where shoes are frequently removed. If this is not feasible, some other form of offloading, such as a customized sandal, may be helpful to increase compliance with offloading. Conversely, a full-length shoe is more cosmetically pleasing but may increase shear forces as a result of the foot sliding forward

The largest group of people with vulnerable feet at risk for vascular, sensory, motor, and autonomic changes that can result in wounds that fail to heal and are the source of loss of toes, foot, or limb is the population of individuals with diabetes. With an ever-increasing number of individuals diagnosed with diabetes, it is important that the clinician be able to identify risk factors so as to reduce future complications. This chapter reviewed the assessment of the vulnerable foot, as well as a comprehensive wound evaluation. Applicable interventions were provided and organized according to the treatment goal to assist with the development of a successful treatment plan. Finally, footwear recommendations based on risk stratification were discussed to ensure that clients are given the best chance to return to their activities without ulcer formation or recurrence.

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19

Amputation Surgeries for the Lower Limb☆ PATRICK D. GRIMM and BENJAMIN K. POTTER

LEARNING OBJECTIVES

On completion of this chapter, the reader will be able to do the following: 1. Understand the most common indications for lower extremity amputation and compare and contrast the key methods of assessment used to decide when amputation is necessary. 2. Determine the most appropriate level of amputation based on resultant biomechanics and the need for adequate soft tissue coverage, as well as appreciate the surgical techniques used to manage bone, soft tissue, nerves, and blood vessels during lower extremity amputations. 3. Anticipate postoperative care requirements, common complications, and expected outcomes following lower extremity amputation. 4. Provide an overview of the most commonly used surgical approaches, as well as special considerations, for each level of amputation. 5. Describe current areas of active research in the field of lower extremity amputation in regard to prosthesis anchorage, methods of active prosthesis control, and strategies for treatment and prevention of amputation-related neuromas.

Introduction Approximately 180,000 lower extremity amputations are performed in the United States each year.1 The most common reasons to perform an amputation include vascular insufficiency, trauma, and neoplasm. Overall, more than 90% of lower extremity amputations are performed as a result of vascular disease, with a significant portion of those patients carrying a diagnosis of diabetes mellitus (DM).2 The amputation of a limb is a truly life-altering event, affecting the physical, functional, and psychological dimensions of a person’s world3; however, when done for the right reasons and with appropriate technique, an amputation can be an important step towards recovery. Therefore amputation surgery should be approached as a reconstructive procedure, not merely an ablation or afterthought of treatment failure. The primary aim in performing an amputation is removal of the diseased, ischemic, mangled, or otherwise nonfunctional portion of the extremity. Once accomplished, the surgeon can then focus on reconstruction with the goal of creating the best possible conditions for the rapid return of maximal function and improved quality of life. Although surgical technique is a key determinant in the success of an amputation,4 other important factors include adequate preoperative counseling,5 close postoperative follow-up with appropriate management of comorbidities and complications during the perioperative period,6,7 and a properly implemented rehabilitation plan. This chapter provides an overview of the indications for lower extremity amputations, surgical principles and ☆

The authors extend appreciation to Michelle M. Lusardi and Judith L. Pepe, whose work in the prior edition provided the foundation for this chapter.

techniques, postoperative care, commonly encountered complications, and future directions in the field of lower extremity amputations. Rehabilitation professionals play a vital role in the care of lower extremity amputees. Indeed, the surgical procedure and immediate perioperative care represent but a small fraction of the long path towards recovery. The goal of this chapter is to help rehabilitation professionals to care for amputees by cultivating a better understanding of the rationale behind the surgical procedures performed and the expected postoperative course.

Indications for Lower Extremity Amputation DYSVASCULAR AND NEUROPATHIC DISEASE Prevalence and Risk Factors Peripheral artery disease (PAD) is a term that includes a variety of disease processes that affect noncardiac, nonintracranial arteries, the most common of which is atherosclerosis.8 A basic understanding of this disease is important given that up to 90% of lower extremity amputations in the United States are due to dysvascular disease.2 One of the strongest risk factors for developing PAD is DM, reflected by the fact that 70% of patients who have amputations for dysvascular limb also have DM.9 The overall prevalence of PAD in the United States, across all ethnicities, is estimated to range from approximately 2% in persons 40 to 49 years of age to 20% or higher in persons older than age 80 years.10 Risk factors for PAD include history of smoking, DM, untreated or poorly managed hypercholesteremia, untreated or poorly managed hypertension, kidney dysfunction, and chronic 471

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inflammation.11 Significant morbidity and mortality are associated with PAD. It is estimated that one in four individuals with PAD undergoes some form of amputation, one in three will likely die within 5 years of diagnosis, and only one in four will survive more than 10 years after diagnosis.12-14 Comorbid conditions that amplify risk of death in the year following PAD-related amputation include congestive heart failure, renal failure, and liver disease, as well as postoperative systemic sepsis.15

Patient Assessment The assessment of an individual with compromised peripheral circulation begins with a careful and detailed health history and review of risk factors, continues with physical examination and routine blood work, and is followed by additional imaging or invasive tests as needed.8,16 A common symptom of chronic arterial vascular insufficiency is claudication. This vascular-related pain has been described as a deep aching, cramping, muscle fatigue, or tightness that develops during physical activity and dissipates with rest. Although most common in the superficial posterior compartment (gastrocnemius and soleus) of the lower leg, claudication can occur in any muscle with compromised blood supply, including the muscles of the thigh and hip. Claudication is the result of accumulation of lactic acid as a by-product of anaerobic metabolism during muscle contraction. When an individual has persistent pain while at rest (a.k.a. “rest pain”), nocturnal recumbent pain, or ischemic skin lesions, the individual is classified as having critical limb ischemia and is at high risk of amputation if revascularization fails or cannot be undertaken.17 Acute or sudden occlusion of an arterial vessel is marked by constant and unrelenting pain and may be accompanied by feelings of tingling, numbness, or coldness as peripheral nerves of the lower limb are affected by ischemia.18,19 The signs of acute limb ischemia can be remembered as the five P’s: pain, paresthesia, pallor, poikilothermia (cold skin), and pulselessness. Although a limb with chronic arterial insufficiency demonstrates dependent rubor, the skin of an acutely compromised limb may be quite pale or blanched distal to the site of occlusion. Acute occlusion is often an emergent situation, requiring pharmacologic or surgical intervention to restore blood flow to the limb. The physical examination is an essential component of any patient assessment and provides key information for decision-making. The examination begins with visual inspection of the lower extremity and feet, concentrating on skin condition, presence or absence of hair, and nail condition.8 Open wounds, callus, ecchymosis, dry necrosis, erythema, mottling, and altered pigmentation are documented. Wounds that lie under or are surrounded by callus on the plantar or weight-bearing surfaces of the foot are most likely neuropathic ulcers. Dry, blackened, or moist gangrenous wounds in the nail beds and between toes are likely signs of vascular insufficiency. Although “healthy” traumatic wounds often display clear serosanguineous drainage, any thickened, yellowish, or foul-smelling discharge from a wound suggests soft tissue or bone infection. When evaluating diabetic foot ulcers, the depth of ulceration and vascular supply to the region significantly guide treatment decisions (Table 19.1). Motor neuropathy may cause atrophy of the intrinsic muscles of the foot, allowing stronger flexor

Table 19.1 Wagner Classification of Diabetic Ulcers and Common Treatment Recommendations Grade

Description

Treatment

0

Skin intact but foot at risk

Accommodative footwear or total contact casting

1

Localized superficial ulcer

Total contact casting,  irrigation and d
ebridement

2

Ulcer deep to tendon, bone, ligament, or joint

Surgical d
ebridement, irrigation, antibiotics, total contact casting, correction of deforming forces

3

Deep abscess or osteomyelitis

Surgical d
ebridement, irrigation, antibiotics, total contact casting, correction of deforming forces, may require partial foot amputation or ray resection

4

Gangrene of toes or forefoot

Local amputation—partial foot or ray resection

5

Gangrene of entire foot

Amputation

Adapted from Anakwenze OA, Milby AH, Gans I, et al. Foot and ankle infections: diagnosis and management. J Am Acad Orthop Surg. 2012;20:684–693.

muscles to pull the toes into a claw deformity.20 These newly created pressure points are at risk for ulceration. Protective sensation (as measured by perception of SemmesWeinstein 5.07 filament), as well as touch, pressure, vibration, and position sense, are likely to be impaired or inconsistent.21 In addition, impairment of the autonomic system often causes dry, tight, shining, easily cracked skin, as well as altered blood flow to the bones of the foot, increasing risk of Charcot arthopathy in addition to ulceration.22,23

Vascular Examination The least invasive and simplest strategy used to assess adequacy of vascular supply to the distal limb is palpation of distal lower extremity pulses at the dorsalis pedis and posterior tibial arteries, popliteal pulse at the knee, and femoral pulse at the groin. If all pulses are palpable, it is highly likely that there is adequate circulation to heal a neuropathic ulcer. However, absent distal pedal pulses do not confirm vascular insufficiency; pedal pulses are nonpalpable in up to 10% of the general population.24 Further examination should proceed in a stepwise, systematic fashion, beginning first with measurement of the ankle-brachial index (ABI).8,25 This noninvasive method measures the systolic blood pressure at the level of the ankle and compares it with the systolic blood pressure of the brachial artery above the elbow. Values less than 0.9 indicate PAD, whereas values greater than 1.4 are suggestive of poorly compressible arteries due to calcification. A word of caution—it has been estimated that 30% of patients with critical limb ischemia have a normal or near normal ABI due to this phenomenon; thus physical examination remains critical and additional, more sensitive testing may be indicated.26 Further noninvasive tests (Table 19.2) include measurement of the toe-brachial index (normal
0.7) and transcutaneous oximetry (>30 mm Hg suggests adequate perfusion for wound healing).27 Segmental leg pressures,

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Table 19.2 These noninvasive methods of vascular assessment help determine the severity of peripheral vascular disease and may predict the likelihood of wound healing following surgical intervention. Test/Measure

Normal Values

Abnormal Findings

Capillary refill time

Elevation of limb 20 s Return to dependent position Pressure on toe or nail Blanch, then refill in 1–2 s

Delayed refill or persistent blanching Rubor of dependency

Refill after occlusion

Inflation of blood pressure cuff at thigh for 5 min On release, flush to normal skin color at toes within 10 s

>10 s: impaired arterial perfusion

Venous refill time

Elevation of the limb 2 min Return to dependent position Veins on dorsum of foot refill in 10 s

>10 s: impaired arterial perfusion 400 cm/s indicates >75% stenosis

pulse volume recording, and duplex ultrasound may also be considered. (Refer to Chapter 18 for a detailed description of noninvasive assessment strategies.) Imaging modalities that outline the specific arterial anatomy are magnetic resonance angiography and computed tomography angiography (CTA) (Fig. 19.1).28,29 In addition to the work-up of chronic vascular disease, CTA is a valuable tool in the evaluation of suspected vascular injury in the setting of an acute trauma (Fig. 19.2A and B).30 Finally, conventional arteriography is indicated in symptomatic patients being considered for revascularization procedures. This invasive strategy involves local surgical placement of a catheter into the femoral artery in the groin (or alternatively, the axillary, radial, or subclavian arteries), followed by introduction of radiopaque dye into the arterial tree and exposure to radiation.31 Although this method generally provides excellent visualization of vascular anatomy, drawbacks include difficult delineation in distal or heavily calcified vessels and the risk of kidney injury with nephrotoxic contrast agents.25

Indications for Amputation Versus Revascularization PAD disease or DM may result in a nonviable or threatened limb due to occlusive vascular disease, neuropathic related reasons, or, frequently, a combination of both.18,32 The management and prognosis for each of these groups are somewhat different. Vascular bypass surgery,33 percutaneous endovascular stents,34 or the use of thrombolytic intervention35 may preserve the limbs of those with large-vessel vascular disease without significant microvascular dysfunction or neuropathy. Persons with a combination of diabetes and vascular disease are the most likely to require amputation; advanced age and multiple comorbidities (e.g., cardiovascular and

Fig. 19.1 Results of a computed tomography angiography in an individual with intact circulation.

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Fig. 19.2 (A) Coronal computed tomography of lower extremity in a patient who sustained a blast injury. (B) Axial cross section of computed tomography angiography proximal to the zone of injury, at the zone of injury, and distal to the zone of injury. Note the absence of flow to the distal vasculature in the limb. Vascular repair in this patient was not successful, resulting in a transtibial amputation.

cerebrovascular disease, kidney disease, and visual impairment) provide additional challenges for healing, early mobility after amputation, and the prosthetic rehabilitation process. Furthermore, chronic wounds resulting from either vascular insufficiency or neuropathy further jeopardize the viability of the extremity by providing an avenue for infection. When infected neuropathic or vascular wounds fail nonoperative management, amputation may be indicated, sometimes on an urgent or emergent basis.36-38 The management of PAD is a complex undertaking, and consultation with a vascular surgeon is advised to determine revascularization options and which amputation level is most likely to heal. This complexity is reflected by the numerous classification systems that have been designed to describe the disease process and, in limited cases, direct therapy.39 Without timely revascularization, amputation rates approach 40%, and population-based studies have shown amputation rates for critical limb ischemia to be highest in regions of the country with the least intensive vascular care.40-42 The optimal approach to critical limb ischemia (endovascular vs. open surgical techniques) has yet to be defined; however, national trends have recently reported an increase in the proportion of endovascular procedures as compared with open procedures, as well as a decrease in major amputations performed.43 The best evidence is likely to emerge from the ongoing multicenter randomized

controlled trial Best Endovascular versus Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI).44 Amputation is often the best option when arterial anatomy precludes bypass or if severity of disease is such that bypass cannot salvage irreversibly ischemic and gangrenous tissue. Patients with complex medical conditions at high risk for intraoperative and postoperative complications may also be considered for amputation to minimize the risk of serial vascular procedures.45 Revascularization can also be considered as an adjunct to amputation in an attempt improve healing and preserve amputation level.46 However, given the systemic nature of the disease process and associated comorbidities, revision to a more proximal amputation level commonly occurs. Reamputation rates vary by amputation level—approximately 34% of foot and ankle amputations and 15% of transtibial amputations progress to a more proximal level of limb loss.2 Because vascular and neuropathic disease are systemic illnesses, these patients are at risk for compromise of both lower limbs.47 After amputation of one limb, careful monitoring of vascular status and skin condition and appropriate conservative care of the intact limb and foot are essential. This is particularly true in the postoperative-preprosthetic period when there is single limb ambulation with assistive devices, as well as in the months and years following initial amputation.48,49

19 • Amputation Surgeries for the Lower Limb

TRAUMA Incidence and Patient Population In the United States, trauma accounts for up to 6% of all lower extremity amputations, with the most common causes being motor vehicle accidents, falls, firearms, or machinery; however, due to the greater life expectancy of trauma-related amputees, approximately 20% of persons living with lower limb loss experienced amputations due to trauma.9,50 In areas of the world where there is current or recent armed conflict, traumatic amputations are more likely to be the result of improvised explosive devices, land mines, grenades, shrapnel, or direct gunfire.51 Many of the injuries sustained by coalition personnel during the recent conflicts in Iraq and Afghanistan involve limbthreatening trauma.52-54 Since the beginning of combat operations in 2001, nearly 1700 major limb amputations have been sustained by U.S. military personnel.55 In contrast to amputations performed in the setting of vasculopathy, amputations following trauma are more likely to be performed on young, otherwise healthy individuals.9 As a result, these patients often have the potential to return to a high level of function following amputation and are likely to be reliant on their residual limb and prosthesis for many years following their injuries. Evaluation of the Threatened Limb Depending on the mechanism of injury, trauma may result in an acute amputation or (more commonly) in open fractures with limb-threatening soft tissue damage (Fig. 19.3). Open fractures result in a high likelihood of infection as a consequence of introduced environmental microorganisms, ischemia caused by vascular compromise, and tissue necrosis due to direct damage.56 The most commonly used classification scheme for open fractures, the Gustilo-Anderson classification, uses both wound size and vascular status to

Fig. 19.3 Clinical photograph of a Gustilo-Anderson type 3B distal femur fracture with external fixation in place. This patient ultimately required transfemoral amputation.

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Table 19.3 Gustilo-Anderson Classification of Open Fractures Type

Description

1

Open clean wound 1 cm and 10 cm with extensive soft tissue damage but able to be closed

3B

Open wound that requires rotational or free tissue transfer for bony coverage

3C

Associated vascular injury that requires repair for viability of the limb

Adapted from Gustilo RB, Anderson JT. Prevention of Infection in the treatment of one thousand and twenty-five open fractures of long bone, retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58 (4):453–458.

stratify the severity of the injury (Table 19.3). Although originally developed for open tibia fractures only, it is commonly applied to all extremity fractures and provides a common language to describe open injuries. The threatened limb must undergo a thorough assessment of both limbspecific and patient factors prior to proceeding with amputation or limb salvage. Considerations include severity of bone and soft tissue loss, adequacy of arterial blood supply, neuromotor and sensory function of the extremity, potential for prosthetic use, recovery time, and anticipated long-term functional status and quality of life.

Limb Salvage Versus Reconstruction Advances in trauma care and surgical techniques, including microsurgery and bone transport, have increased the likelihood that a traumatized limb can be preserved. However, not all limbs can or should be saved, which presents the surgeon and patient with an often difficult decision to make. Although there are a number of decision-making models available that attempt to quantify the factors involved when such a difficult decision is necessary (e.g., Predictive Salvage Index, Mangled Extremity Severity Score, Limb Salvage Index, Hanover Fracture Scale), few accurately predict the fate of an injured extremity, although specificity in predicting successful limb salvage is fair to good.57-60 Suggested absolute indications for amputation include blunt or contaminated traumatic amputations, a mangled extremity in a critically injured patient in shock, or a limb with a warm ischemia time of greater than 6 hours.61,62 The best available evidence to guide decision-making comes from the Lower Extremity Assessment Project (LEAP), a multicenter, prospective observational study that tracked outcomes for 601 patients with limb-threatening injuries who underwent either limb salvage or amputation.63 In light of important limitations, such as the lack of randomization, the study remains controversial and has been cited by advocates of both limb salvage and amputation. What the LEAP data have shown is that long-term outcomes (e.g., return to work, perceived health status) are generally poor for both primary amputation and successful limb salvage and reconstruction patients. Furthermore, outcomes are often driven more by economic,

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social, and personal resource factors rather than the initial treatment selected.63,64 A multivariate analysis of factors influencing surgeons’ decision to perform a primary amputation in the LEAP study found a clear hierarchy with degree of soft tissue injury by far the most important component, followed by nerve function, vascular status, and extent of bony injury.65 However, the mere absence of plantar sensation, once thought to be an important indicator of the need for amputation, has been found not to impact outcomes as the majority of patients regain sensation by 2 years after injury, and some of those with allegedly normal sensation on presentation lose this function.65,66 Overall complication rates for both limb salvage and amputation groups are significant; however, the complication profiles (and the expected surgical course) differ between the two.67 Given the need for multiple reconstructive procedures, patients undergoing limb salvage generally have much higher rates of rehospitalization and can expect complications to occur for up to a year following initial injury.67 In contrast, complications in patients undergoing amputation generally resolve within 6 months. Individuals and their families must be informed of the pros and cons of limb salvage versus amputation, including risk of infection and failure, as well as intensity and time frame for rehabilitation and likelihood of returning to premorbid functional levels.68 In terms of the cost of care, early expenditures for both limb salvage and reconstruction were found to be similar. As might be expected due to the frequent need for multiple surgical procedures associated with limb salvage, rehospitalization costs were much higher in the reconstruction group. However, the substantial cost of prosthetic devices resulted in overall higher costs at 2 years for the amputation group. The lifetime cost of amputate care is estimated to be three times higher, again primarily due to prosthesis-related expenses.69

Considerations Unique to Traumatic Amputations Initial management of trauma patients with a limbthreatening injury should focus on patient stabilization, resuscitation, and control of hemorrhage followed by thorough d
ebridement of all contaminated wounds. An aggressive initial d
ebridement should be performed, with removal of all devitalized muscle, skin, and bone that is devoid of soft tissue attachments. Wounds are then irrigated with normal saline, using gravity or low-flow irrigation.70 In the vast majority of cases, definitive closure should not be attempted at the time of initial d
ebridement. Serial d
ebridement allows for nonviable tissue to declare itself, thus allowing for judicious removal and preservation of soft tissue that can help to preserve the length of the residual limb.56 Accordingly, guillotine-style amputations should be avoided in most instances because this unnecessarily sacrifices soft tissue coverage. Diligent preservation of viable soft tissue may result in flaps of viable muscle and skin that do not fit classically described flaps for amputation closure and thus are considered atypical flaps or “flaps of opportunity.” In general, irrigation and d
ebridement are performed every 48 to 72 hours until the wound is considered clean and devoid of nonviable tissue and the patient is medically stable and suitable for attempted closure. Negative pressure wound therapy is a

Fig. 19.4 Patient with bilateral traumatic transtibial amputations with negative pressure wound therapy in place. This technique allows for efficient management of open wounds in between multiple surgical d
ebridement. Note also the elastic vessel loops in place on each wound, allowing for continuous tension to prevent retraction of the skin edges and preserve maximal soft tissue coverage.

useful tool in managing open wounds during frequent trips to the operating room (Fig. 19.4), and local antibiotic delivery via antibiotic-impregnated polymethylmethacrylate (i.e., bone cement) beads is a common tactic used in the hope of mitigating infection.56,71 The timing of wound closure is a matter of clinical judgment, and, in certain cases, definitive closure may include the use of splitthickness skin grafts, local flaps, or free tissue transfers in an effort to preserve amputation length.72 Although associated with high complication rates, fixation of fractures proximal to a traumatic amputation can performed to preserve functional joint level or salvage residual limb length.73

NEOPLASM Incidence and Patient Population Neoplasm represents the least common indication for lower extremity amputation, with less than 1% of amputations performed for malignant or locally aggressive bone or soft tissue tumors.2 The term sarcoma refers to malignant tumors that arise primarily from embryonic mesoderm and can be broadly categorized into tumors of bone or soft tissue. Seventy-five percent of all extremity sarcomas are observed in the lower extremities.74,75 The incidence of tumors of bone and soft tissue demonstrate two age peaks: the first occurs in adolescents and young adults (e.g., osteosarcoma, Ewing sarcoma), with a second peak in mid- and late-life adults (especially metastatic).76 Advances in diagnostic imaging, chemotherapy, radiation therapy, and reconstructive surgical techniques have made limb salvage a viable option in the treatment of many tumors. Currently, consideration of amputation as a treatment option is limited to only the most aggressive tumors. Rates of amputation at tertiary centers for extremity sarcoma are reported to be less than 10%.77 Evaluation of the Patient The initial evaluation of a patient with a suspected bone or soft tissue tumor includes a detailed history, physical

19 • Amputation Surgeries for the Lower Limb

477

Fig. 19.5 Coronal T1 postcontrast sequence of the knee demonstrating a malignant neoplasm (osteogenic sarcoma) of the proximal tibia.

examination, and plain radiographs of the anatomic region of concern. Further cross-sectional imaging with magnetic resonance imaging (MRI, ideally) and/or computed tomography helps to characterize the lesion location, size, extent, and relationship to vital neurovascular structures (Fig. 19.5). Other studies such as bone scan or positron emission tomography may be indicated in certain cases. Although a select few types of lesions can be diagnosed by imaging alone, many will require biopsy to obtain a tissue diagnosis.78 Patients requiring biopsy should be referred to an orthopedic oncologist. Prior studies have demonstrated significantly higher rates of diagnostic error for biopsies performed at referring institutions. Moreover, biopsies not performed by the treating surgeon frequently result in alterations to treatment and an ultimate change in the patient’s clinical course.79 The optimal care of patients with a musculoskeletal tumor requires a team of professionals including an orthopedic oncologist and a radiologist, pathologist, radiation oncologist, and medical oncologist. Therapists must also be aware of the impact of chemotherapy and radiation treatments on healing soft tissue and bone; on peripheral sensation; and on physiologic response to exercise and activity, as well as the individual’s overall health status, immune response, prognosis, and level of energy.80,81 The most successful rehabilitation programs are individualized and adapt to any adverse effects of concurrent therapeutic interventions. Individuals with recent diagnosis of bone cancer often find significant support in interacting with others who have previously rehabilitated from limb-sparing or amputation surgery.82

Limb-Sparing Surgery Versus Amputation Historically, most tumors of bone were managed by amputation with adjunctive chemotherapy or radiation.83 In the modern era, current reconstruction techniques using allograft bone, endoprostheses, and arthroplasty, along with a combination of multiagent chemotherapy, radiation, or

Fig. 19.6 Postoperative lateral radiograph of the same patient’s knee shown in Fig. 19.4, now with a custom megaprosthesis used for limbsparing surgery.

isolated limb perfusion with tumor necrosis factors, may be used in an effort to preserve the limb (Fig. 19.6).84-87 These strategies have significantly reduced the number of tumor-related amputations performed each year. Amputation may be necessary when there is large, multifocal, high-grade, sarcoma, pathologic fracture, or significant involvement of neurovascular structures or if the tumor is chemoresistant.88-91 Amputation may also be indicated in the case of local recurrence following previous limb salvage.91 The decision to perform limb salvage or amputation is multifactorial but centers around four important considerations: impact of treatment choice on patient survival, short- and long-term morbidities, the function of a salvaged limb versus a prosthesis, and psychosocial impact on the patient.92 The potential for recurrent disease and subsequent metastases or death has been the primary concern over attempts at limb salvage surgery in the setting of malignant disease. However, a landmark study published in 1982 found no difference in overall or disease-specific survival in patients with soft tissue sarcoma that were randomized to major amputation or limb-sparing surgery with adjuvant radiotherapy.93 Subsequent studies for other types of sarcoma have confirmed that limb salvage surgery does not jeopardize survival. Indeed, multiple recent meta-analyses of amputation versus limb salvage for osteosarcoma found a higher 5-year survival rate for limb salvage procedures without an increased risk of local recurrence.94-96 In the modern era, patients who undergo primary amputation for an extremity sarcoma are more likely to have had loss of function of the limb due to tumor involvement or lacked a feasible salvage option due to the need to remove critical limb structures or to achieve appropriate tumor margins.77

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Patients should be counseled in regard to morbidity associated with limb-sparing surgery and with amputation. Although limb-sparing surgeries can vary drastically, these procedures generally are associated with a higher rate of perioperative morbidity than amputation. Many complications are related to large endoprosthetic implants used to reconstruct resected bone. Frequently encountered complications include aseptic loosening, deep infection, instability, and implant or periprosthetic fracture.85 Infection rates following endoprosthetic reconstruction of lower extremity tumors are approximately 10% and have been reported as high as 25% in some series, far higher than for conventional arthroplasty.97 Nearly 10% of patients who undergo limb salvage initially may ultimately require an amputation, most commonly due to local recurrence or infection.98 Objective measures such as survival or local recurrence are relatively straightforward to collect. In contrast, the effect of treatment choice on an individual’s function or quality of life is far harder to measure. In general, no studies have demonstrated a difference in functional outcomes for limb salvage or amputation for oncologic indications.99 However, more proximal levels of amputation (i.e., proximal to the knee) are generally associated with greater functional limitations. Limb salvage, rather than amputation, at these levels has been shown to result in better measures of gait efficiency, but the impact on a patient’s perception of quality of life is less clear.100,101

of the limb to more complex such as surgical distraction procedures to lengthen bone, conversion to a conventional level of amputation or disarticulation, or, in select instances, reconstruction involving a combination of surgical reorientation and arthrodesis.106-109 By way of example, children with severe partial longitudinal deficiency of the femur (proximal focal femoral deficiency) may be managed with a Van Nes procedure, known as a rotationplasty in which the tibia is repositioned 180 degrees and fused to the residual femur (if present) or pelvis so that the reversed ankle can function as a knee joint (Figs. 19.7 and 19.8).110 Alternatively, isolated arthrodesis of the knee and ankle disarticulation can achieve a weighttolerant residual limb that closely resembles a traditional transfemoral residual limb.107 Deficiencies of the fibula or tibia may be managed, depending on the severity of the

LIMB DEFICIENCY DISORDERS Limb deficiency disorders encompass a wide range of congenital anomalies that involve hypoplasia or aplasia of one or more of the bones of the appendicular skeleton. Lower limb deficiency disorders are estimated to occur in approximately 2 per 10,000 live births.102 Nearly half of patients with lower limb deficiency are born with major anomalies of the internal organs, axial skeleton, or central nervous system.102,103 Deficiencies are broadly categorized as transverse or longitudinal.104 Transverse deficiencies are perpendicular to the long axis of the limb, thus resulting in the amputation of the limb at the level of the deficiency, such as the congenital absence of a foot. In contrast, longitudinal deficiency affects the long axis of the limb, as in the absence of a fibula. Transverse deficiencies are the most common type, often due to amniotic bands.102 The rehabilitation, prosthetic, and eventual elective surgical management of children with limb deficiency is linked to age-appropriate developmental status, with the goal of enhancing function while minimizing deformity.105 The reader is referred to Chapter 29 for in-depth information on developmentally appropriate preprosthetic and prosthetic activities for mobility and skill, as well as discussion of the therapist’s and prosthetist’s roles in counseling and educating the family and child about rehabilitation and prosthetic alternatives. Orthopedic management of children with congenital limb deficiency focuses on enhancing appropriate growth of the residual limb, maintaining relatively equal limb length or proximal joint levels, enhancing joint function, and ensuring appropriate prosthetic fit. Surgical treatment options include a wide variety of interventions, ranging from relatively simple such as minor revisions to optimize the shape

Fig. 19.7 Clinical photograph of patient who underwent right lower extremity rotationplasty for a malignant neoplasm in the right thigh. Note the right ankle has been rotated 180 degrees from its native orientation to function as a knee joint.

Fig. 19.8 Radiograph of same patient in Fig. 19.6 demonstrating fixation of tibia to the proximal residual femur. The ankle has been positioned at the same level as the contralateral knee.

19 • Amputation Surgeries for the Lower Limb

defect and resulting deformity, by custom footwear and shoe lift, epiphysiodesis, corrective osteotomy, limb lengthening, ankle disarticulation, or conversion to traditional transtibial amputation.111,112 Regardless of the treatment option selected, the goal is to maximize ambulatory capability by creating a functional limb that is equal to the contralateral side.

Surgical Principles of Amputation DETERMINING THE LEVEL OF AMPUTATION Determination of the appropriate level of amputation is guided by two principles: soft tissue coverage and preservation of residual limb length. An adequately vascularized soft tissue envelope must be present to ensure successful healing.113 Preoperative physical examination and other previously mentioned measures such as the ABI, transcutaneous oximetry, and angiography provide key information about the adequacy of blood flow to the threatened portion of the extremity. In the setting of traumatic amputations, repeat examination of remaining soft tissue during serial irrigation and d
ebridement prior to definitive closure aids in the determination of viable tissue.56 Residual limb length plays an important role in the mechanical work able to be performed, as well as with prosthesis options and fit. Furthermore, as many functional anatomic joints as reasonably possible should be preserved. The energy required for ambulation increases significantly with more proximal amputations.114,115 Remaining muscles and joints must compensate for the absence of muscle function distal to the level of amputation. For example, patients with transfemoral amputation adapt to limb loss with trunk and pelvic movement asymmetries to facilitate weight transfer during walking. In contrast, patients with transtibial amputations do not demonstrate the need for such adaptations.116 At times, tension occurs between the goals of length preservation and adequate soft tissue coverage. For example, for individuals with plantar neuropathic ulcers and osteomyelitis, a transmetatarsal amputation (TMA) has the potential to preserve the ankle joint and permit functional gait without prosthesis and is often less difficult for individuals to accept psychologically.117 However, if there is delayed or failed healing, the risks of complications associated with limited activity and bed rest (e.g., further deconditioning, pneumonia, deep venous thrombosis, decubitus ulcer), and repeated anesthesia if surgical revisions to more proximal levels become necessary, can be significant.118 In these instances an initial surgery at the transtibial level might improve the chances for optimal rehabilitation outcome.119 In individuals with traumatic crush injury to the proximal tibia but an intact knee joint, an extremely short transtibial residual limb may actually be more difficult to manage prosthetically than a long transfemoral residual limb: the reduced surface area around a short residual tibia and fibula for weight bearing within the socket increases pressure on skin and soft tissue of the residual limb, reducing functional wearing time of the prosthesis despite the advantage of preservation of the anatomical knee joint. Put succinctly, limb length should be preserved so long as it does not result in a nonhealing, painful, or dysfunctional residual limb. This includes atypical, novel, or extra-long amputations such

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as a transtibial amputation below the level of the midtibia. Due to both poor soft tissue coverage and limited space available for prostheses, these levels risk leaving the patient with the limitations of both the more proximal and more distal amputation levels, without the full benefits of either.

TECHNICAL CONSIDERATIONS Bone Following amputation, the residual bone of the limb will be required to transmit force between the body and the prosthetic device. This transmission of force may occur either through the end of a resected bone as in a transfemoral amputation or through a disarticulated joint as in a Syme amputation. To accommodate this function, residual bone should be surgically contoured to allow for a smooth weight-bearing surface. Bony prominences not covered by adequate soft tissue should be resected. Soft Tissue and Muscle Careful management of skin and muscle at the site of amputation allows for the creation of a durable soft tissue envelope that can withstand the stress of weight bearing and prosthetic fit. Furthermore, appropriate muscle coverage can allow for improved control and alignment of the residual limb.120,121 In general, there are two ways of securing muscle about the end of a residual limb: myoplasty or myodesis. Myoplasty involves suturing of a residual muscle to its antagonist over the end of the residual limb to create physiologic tension between the two muscle groups. However, this is generally not recommended in isolation because tension may not be achieved, and deep bursa formation may occur as a result of the unstable muscle mass.56,120 Myodesis involves suturing residual muscle and fascia directly to bone through drill holes or to the periosteum. This technique results in the most structurally stable construct and allows for secure soft tissue padding, preserved muscle bulk, and functional muscle use during ambulation.122,123 In the absence of myodesis, residual muscles are likely to experience greater atrophy, and contractures may result from unbalanced muscle units. Skin flaps should be kept as thick as possible, particularly in the setting of dysvascular amputations as the underlying subcutaneous tissue provides blood flow to the skin. In certain patients without compromised circulation, split-thickness skin grafts, local rotational flaps, or free tissue transfer can be used in “heroic” efforts to preserve length and amputation level, particularly just distal to the knee or elbow.72,124 Patients should be counseled that, although these techniques result in successful preservation, they are associated with frequent complications. Although it is important to achieve adequate soft tissue coverage, this effort should not be taken to the extreme. Excessive, often hypermobile skin and soft tissue at the end of the limb should be avoided as it interferes with both prosthesis wear and control. Nerve Following transection of a peripheral nerve, regenerating axons from the proximal portion form a disorganized mass of abnormal nerve as they attempt to reconnect with the distal stump. Although presumably all transected nerves form a neuroma, not all are symptomatic. Ebrahimazed

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et al. found a 13% rate of symptomatic neuromata in transtibial amputations and a 32% rate in transfemoral amputations.125,126 Surgical management is frequently required—symptomatic neuromata were the indication for 11% of revision procedures in a retrospective review of 300 consecutive combat-related lower extremity amputations.127 A neuroma is most likely to be symptomatic when it forms in an anatomic region where it is exposed to pressure, stretch, or vascular pulsations. A multitude of both prophylactic and therapeutic techniques have been described to address symptomatic neuromata; however, there is no clear “gold standard” treatment or prevention option.128-130 At present, the most commonly performed and simplest procedure is a traction neurectomy in which the nerve is pulled distally and then transected.131 Upon transection, the nerve retracts into the limb, ideally in an area of robust soft tissue coverage. This does not prevent neuroma formation but rather is intended to place the transected nerve end in an area with robust soft tissue padding well away from ligated vessels and the end of the residual limb. Recently, there have been a number of promising techniques for nerve management in the setting of amputation, as discussed later.

Vessels Special attention should be paid to hemostasis and management of blood vessels. The use of tourniquet during the procedure allows for improved visualization and hemostasis intraoperatively and has not been shown to result in increased healing complications, even in the case of severe PAD.132,133 Major vessels should be identified and ligated with nonabsorbable suture. Larger blood vessels, such as the popliteal artery, should be double ligated, particularly in patients with normal blood flow. The tourniquet should be deflated prior to closure and meticulous hemostasis obtained. Suction drains are routinely used to prevent accumulation of a hematoma postoperatively.

Postoperative Care DRESSINGS The completion of the surgical procedure is but the first stage of the intervention. A multidisciplinary team of physical medicine specialists, physical therapists, occupational therapists, and prosthetists is required to achieve the ultimate goal of restoring function via fitting of an appropriate prosthetic limb. The average time to prosthetic fitting varies widely, depending on the level of amputation and patientand health care system–related factors. For transtibial amputations, the time to prosthetic fitting following amputation has been reported to range between 19 and 76 days.134 Our preference is to fit most traumatic, oncologic, and congenital amputations between 4 and 6 weeks postoperatively. This period is substantially longer for dysvascular patients, to ensure that adequate superficial and deep wound healing, which is slower in such patients, has occurred. The primary concerns in the transition from amputation to functional residual limb are adequate wound healing, edema control, prevention of joint contractures, and rapid

Fig. 19.9 Postoperative lateral radiograph of transtibial amputation demonstrating rigid plaster of Paris splint, molded to keep knee in an extended position. Note that the splint material stops short of the patella, an area with prominent subcutaneous bone that is prone to ulceration with rigid dressings.

return to activity. Toward those ends, a number of philosophies exist with regards to postoperative dressings and wound care. For the most part, patients are kept non– weight bearing on the involved extremity until the wounds are healed. Commonly used dressing techniques include soft dressing, rigid dressings, and immediate postoperative prosthesis (IPOP). When a soft dressing is used, a sterile dressing is applied to the surgical incision and the limb is wrapped in a compressive bandage. The limb is kept elevated, and, depending on the amputation level, elastic shrinkers are applied as soon as postoperative drains are removed. Alternatively, rigid dressing consists of a well-padded plaster of Paris splint or cast that is applied to the limb at the conclusion of surgery (Fig. 19.9). Potential advantages of rigid dressings include edema control, prevention of joint contractures, and a shorter time to prosthetic fitting.134 In contrast, soft dressing may be better suited for amputations with tenuous skin closure because it allows for greater ease of wound inspection and decreased risk of pressure ulceration. Removable rigid dressings (RRDs) may provide the best of both techniques by providing the benefits of a rigid dressing with regard to contracture prevention and protection from external trauma, while at the same time providing ease of access for regular wound inspection.135 Regardless of the selected technique, the goals remain the same: reduced edema, controlled pain, contracture prevention, and a stable limb volume that is healed and amenable to prosthetic fitting. As suggested by the name, a patient with an IPOP is fitted with a temporary prosthesis immediately following surgery. Reported advantages include early ambulation and rehabilitation, which may reduce the sequelae of prolonged immobilization, as well as providing a psychological

19 • Amputation Surgeries for the Lower Limb

benefit.136-138 However, the success of this technique has been demonstrated in primarily nontraumatic-related amputations, and concerns persist regarding wound healing and early detection of infection that may preclude early mobilization.56

PAIN MANAGEMENT Patients undergoing lower extremity amputation commonly experience significant acute postoperative pain, with studies reporting moderate to severe residual limb pain (RLP) in 30% to 53% of patients.139,140 Patients with acute postoperative pain are thought to be at higher risk for developing chronic RLP; thus much effort has been devoted to optimizing postoperative pain management following amputation.140 Current recommended strategies include a multimodal approach using interventional methods with perineural regional or epidural analgesia and pharmacologic agents including acetaminophen, nonsteroidal anti-inflammatories, gabapentin, ketamine, and opioid therapy, as well as so-called alternative measures (e.g., acupuncture, biofeedback) as needed.141 Given the complexity of analgesic techniques and the multiple classes of medication involved, consultation with a pain medicine specialist should be strongly considered, both for optimization of perioperative pain control and for management of potential chronic pain issues.

Complications Unfortunately, complications frequently occur following lower extremity amputations. Complications can range from minor, such as superficial wound necrosis, to major, such as the need for reamputation at a more proximal level or death. A study of 2879 patients who underwent a major amputation following trauma found a 27.5% rate of major postoperative complications.50 Data from the LEAP study further lend insight into complication profiles after trauma-related amputations. Over the course of 24 months following surgery, a total of 128 complications were reported in 149 patients who underwent amputation during the initial hospitalization. Wound infection (34.2%), wound necrosis (13.4%), phantom limb pain (PLP) (13.4%), and “stump” complications (10.7%) were most frequently reported.67 Complications following amputations for vascular insufficiency are also regrettably common, with one multicenter prospective clinical database study finding an overall complication rate of 43%, with nearly 20% of patients being readmitted to the hospital within 30 days of the index procedure.142 Minor amputations are also subject to complicated postoperative courses. One retrospective study of 717 patients undergoing toe amputations and TMAs found a readmission rate of 13.9%, with infection, ischemia, and nonhealing wounds as the leading causes. Nearly all (95%) of those with complications underwent reamputation, with almost two thirds (64%) requiring a transtibial or more proximal amputation.143 Risk factors for readmission were largely nonmodifiable, including hypertension, PAD, and renal insufficiency.

WOUND HEALING If wound healing problems are encountered, the initial step in evaluation should be re-evaluation of the amputation

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level. This is of particular relevance for dysvascular amputations. Previously mentioned objective measures including ABI and transcutaneous oxygen levels should be used to determine healing potential.144 Two other key and potentially modifiable risk factors include nutrition and smoking status. Multiple authors have cited a cutoff of less than 3.5 g/dL albumin and total lymphocyte count less than 1500 cells per cubic millimeter as markers of malnutrition and a potential risk factor for wound healing following amputation.145-148 At a minimum, nutritional intake should be optimized in the postoperative period and, if possible, preoperatively. Smoking compromises cutaneous blood flow velocity, increases the risk of microthrombi, and has been shown to be associated with a 2.5 times higher risk of infection and reamputation in smokers as compared with nonsmokers.149 Similarly, being a current smoker predicted more complications (OR, 1.8) in transfemoral amputations performed due to critical limb ischemia.150 In the trauma patient population, current smokers with limb-threatening open tibia fractures were found to be twice as likely to develop an infection compared with nonsmokers.151 Although often difficult, the topic of smoking cessation should be discussed with patients undergoing amputation. Patients may benefit from counseling, nicotine replacement therapy (itself a vasoconstrictor), and pharmacologic agents such as antidepressants.152

FLUID COLLECTIONS The risk of developing a postoperative hematoma can be mitigated by meticulous hemostasis during the procedure, the use of a drain, and adequate compression via either soft or rigid dressings. Surgical dogma suggests that a hematoma can compromise wound healing by serving as a culture medium for bacterial infection and may require evacuation in the operating room. However, the presence of an acute postoperative fluid collection is not indicative of an infection in and of itself. In a study of patients with combat-related amputations, more than half demonstrated fluid collection within the early (¼40 years of age with and without diabetes: 1999-2000 national health and nutrition examination survey. Diabetes Care. 2004;27(7):1591–1597. 14. Stern JR, Wong CK, Yerovinkina M, et al. A Meta-analysis of Longterm Mortality and Associated Risk Factors following Lower Extremity Amputation. Ann Vasc Surg. 2017;42:322–327. 15. Karam J, Shepard A, Rubinfeld I. Predictors of operative mortality following major lower extremity amputations using the National Surgical Quality Improvement Program public use data. J Vasc Surg. 2013;58(5):1276–1282.

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19 • Amputation Surgeries for the Lower Limb 258. Hagberg K, Brånemark R, Gunterberg B, Rydevik B. Osseointegrated trans-femoral amputation prostheses: prospective results of general and condition-specific quality of life in 18 patients at 2-year followup. Prosthet Orthot Int. 2008;32(1):29–41. 259. Hagberg K, Hansson E, Brånemark R. Outcome of percutaneous osseointegrated prostheses for patients with unilateral transfemoral amputation at two-year follow-up. Arch Phys Med Rehabil. 2014;95(11):2120–2127. 260. Windrich M, Grimmer M, Christ O, Rinderknecht S, Beckerle P. Active lower limb prosthetics: a systematic review of design issues and solutions. Biomed Eng Online. 2016;15(Suppl 3):140. 261. Souza JM, Fey NP, Cheesborough JE, Agnew SP, Hargrove LJ, Dumanian GA. Advances in tranfemoral amputee rehabilitation: Early experience with targeted muscle reinnervation. Curr Surg Rep. 2014;2(51):9. 262. Tucker MR, Olivier J, Pagel A, et al. Control strategies for active lower extremity prosthetics and orthotics: a review. J Neuroeng Rehabil. 2015;12:1. 263. Hargrove LJ, Young AJ, Simon AM, et al. Intuitive control of a powered prosthetic leg during ambulation: a randomized clinical trial. Jama. 2015;313(22):2244–2252. 264. Kuiken TA, Li G, Lock BA, et al. Targeted muscle reinnervation for real-time myoelectric control of multifunction artificial arms. JAMA. 2009;301(6):619–628. 265. Hargrove LJ, Simon AM, Young AJ, et al. Robotic leg control with EMG decoding in an amputee with nerve transfers. N Engl J Med. 2013;369(13):1237–1242. 266. Stalberg E. Propagation velocity in human muscle fibers in situ. Acta Physiol Scand Suppl. 1966;287:1–112. 267. Herberts P, Kadefors R, Kaiser E, Petersen I. Implantation of microcircuits for myo-electric control of prostheses. J Bone Joint Surg Br. 1968;50(4):780–791. 268. Kamavuako EN, Scheme EJ, Englehart KB. On the usability of intramuscular EMG for prosthetic control: a Fitts’ Law approach. J Electromyogr Kinesiol. 2014;24(5):770–777. 269. Pasquina PF, Evangelista M, Carvalho AJ, et al. First-in-man demonstration of a fully implanted myoelectric sensors system to control an advanced electromechanical prosthetic hand. J Neurosci Methods. 2015;244:85–93. 270. Kuiken TA, Marasco PD, Lock BA, Harden RN, Dewald JP. Redirection of cutaneous sensation from the hand to the chest skin of human

271.

272. 273. 274. 275. 276.

277.

278. 279. 280. 281.

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amputees with targeted reinnervation. Proc Natl Acad Sci U S A. 2007;104(50):20061–20066. Hebert JS, Olson JL, Morhart MJ, et al. Novel targeted sensory reinnervation technique to restore functional hand sensation after transhumeral amputation. IEEE Trans Neural Syst Rehabil Eng. 2014;22 (4):765–773. Urbanchek MG, Kung TA, Frost CM, et al. Development of a Regenerative Peripheral Nerve Interface for Control of a Neuroprosthetic Limb. Biomed Res Int. 2016;2016. 5726730. Larson JV, Urbanchek MG, Moon JD, et al. Abstract 17: prototype sensory regenerative peripheral nerve interface for artificial limb somatosensory feedback. Plast Reconstr Surg. 2014;133(3 Suppl):26–27. Irwin ZT, Schroeder KE, Vu PP, et al. Chronic recording of hand prosthesis control signals via a regenerative peripheral nerve interface in a rhesus macaque. J Neural Eng. 2016;13(4). 046007. Ortiz-Catalan M, Hakansson B, Branemark R. An osseointegrated human-machine gateway for long-term sensory feedback and motor control of artificial limbs. Sci Transl Med. 2014;6(257). 257re256. Souza JM, Cheesborough JE, Ko JH, Cho MS, Kuiken TA, Dumanian GA. Targeted muscle reinnervation: a novel approach to postamputation neuroma pain. Clin Orthop Relat Res. 2014;472 (10):2984–2990. Bowen JB, Wee CE, Kalik J, Valerio IL. Targeted Muscle Reinnervation to Improve Pain, Prosthetic Tolerance, and Bioprosthetic Outcomes in the Amputee. Adv Wound Care (New Rochelle). 2017;6(8): 261–267. Agnew SP, Schultz AE, Dumanian GA, Kuiken TA. Targeted reinnervation in the transfemoral amputee: a preliminary study of surgical technique. Plast Reconstr Surg. 2012;129(1):187–194. Dumanian GA. Targeted Reinnervation as a Means to Treat Neuromas Associated With Major Limb Amputation (TMR). NCT02205385, https://clinicaltrials.gov/ct2/show/NCT02205385. Pet MA, Ko JH, Friedly JL, Mourad PD, Smith DG. Does targeted nerve implantation reduce neuroma pain in amputees? Clin Orthop Relat Res. 2014;472(10):2991–3001. Woo SL, Kung TA, Brown DL, Leonard JA, Kelly BM, Cederna PS. Regenerative Peripheral Nerve Interfaces for the Treatment of Postamputation Neuroma Pain: A Pilot Study. Plast Reconstr Surg Glob Open. 2016;4(12). e1038.

20

Postoperative and Preprosthetic Care TAMARA GRAVANO and MICHELLE M. LUSARDI

LEARNING OBJECTIVES

On completion of this chapter, the reader will be able to do the following: 1. Plan a comprehensive examination for an individual with recent lower extremity amputation, selecting appropriate tests and measures and documentation strategies. 2. Use information gathered in the examination, evidence from the clinical research literature, and knowledge of postoperative care to evaluate individuals with recent lower extremity amputation. 3. Formulate an appropriate physical therapy (PT) movement dysfunction diagnosis and prognosis for rehabilitation for individuals with recent lower extremity amputation. 4. Develop appropriate short- and long-term goals and estimate duration, frequency, and intensity of care in the postoperative, preprosthetic care of an individual with recent lower extremity amputation. 5. Develop an appropriate PT plan of care for single limb mobility, residual limb care and wound healing, and preprosthetic rehabilitation. 6. Describe strategies to monitor progress and to adapt and advance the plan of care during the preprosthetic period of rehabilitation. 7. Describe strategies to evaluate outcomes of postoperative, preprosthetic rehabilitation.

Patient-Client Management After Amputation INDIVIDUALS WITH NEW AMPUTATION In the early days following surgery, the person with a new amputation is likely to experience acute surgical pain and is likely to be grieving the loss of his or her limb. The immediacy of pain combined with a sense of loss may make it difficult for those with recent amputation to recognize their potential for a positive rehabilitation outcome.1 Older persons with dysvascular or neuropathic limb loss may have had time to physically and psychologically prepare for an elective amputation after a prolonged period of managing a poorly vascularized foot or nonhealing neuropathic ulcer and therefore may be somewhat less distressed about the loss of their limb than younger persons who have suddenly lost a limb in a traumatic accident or other medical emergency. However, whatever the circumstances leading to amputation, the loss of one’s limb requires significant psychological adjustment.2 Early education and discussion about the process of rehabilitation and the person’s ultimate goals are extremely important.3

PATIENT-CENTERED CARE AND MULTIDISCIPLINARY TEAMS In response to the numbers of military personnel with traumatic amputation and to older veterans with 504

dysvascular amputation, the Departments of Defense and of Veterans Affairs have adopted interdisciplinary, patient-centered care as the ideal model for rehabilitation of persons with amputation.4–6 The physical therapist and prosthetist, as members of the rehabilitation team, will interact with surgeons, patients, and family members as decisions about surgical levels, plans for postoperative care, potential for prosthetic use, and prosthetic rehabilitation plans are made. For persons facing elective amputation because of dysvascular disease, a period of physical therapy (PT) intervention prior to surgery can positively impact on postoperative outcomes.6 In the days immediately after amputation, this initial stage of acute care and early rehabilitation sets the stage for eventual return to functional mobility, ability to return to valued activities, and participation in key family and social roles.4 Although the immediate goals of each member of the interdisciplinary team vary, all ultimately lead toward the independence and return to the preferred lifestyle of the person with a newly amputated limb. To accomplish this, the team must use a holistic and comprehensive approach to address the person’s comorbid burden of illness and psychological and developmental needs, as well as his or her long-term functional, vocational, and leisure goals. Surgical and medical members of the team are most concerned about the healing suture line and overall health status, especially for individuals with vascular insufficiency and for those at risk of infection after traumatic amputation.7 Nursing professionals provide general medical and wound care as the suture line heals and

20 • Postoperative and Preprosthetic Care

administer medications for pain management.7,8 Registered dieticians assess the patient’s nutritional needs related to wound healing and exercise demands.9 Physical and occupational therapists focus on enhancing the patient’s early single limb mobility, self-care, assessment of the potential for prosthetic use, control of edema and pain management, donning and doffing dressings and shrinkers for optimal shaping of the residual limb, and prevention of secondary complications.10,11 The prosthetist may fabricate an immediate postoperative prosthesis (IPOP) or an early postoperative prosthesis (EPOP) or a semirigid dressing (SRD) and begins to consider which prosthetic components and suspension systems will ultimately be most appropriate, given the individual’s characteristics, abilities, and functional needs.11,12 The person with new amputation and his or her family are often most concerned about pain management and what life will be like without the lost limb.13 A psychologist, social worker, vocational counselor, or school counselor is involved as needed to help with psychological adjustment and to organize long-term rehabilitation care or community resources in preparation for discharge.11,14 A spiritual leader, such as a priest or rabbi, can also be a valuable resource for the person with new amputation, the family, and the team. Although the multidisciplinary team can vary in size, depending on patient needs and practice settings, the members at the center are the individual with new amputation and his or her caregivers.15 Coordinated communication among all team members, including the opportunity for the amputee and his or her family members to ask questions and voice concerns, is more important in this early postoperative and preprosthetic period than it is during the process of prosthetic prescription and training later in the rehabilitation process. This early period sets the stage

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for the individual’s expectations, and ultimately success, as a person with an amputation.15 The unique training, clinical expertise, and individual roles of each team member contribute, in a collaborative process, to the development of a plan for rehabilitation that best meets the needs and optimizes the potential of the individual who has lost a limb.6 The team must come to agreement on the timing and prioritization of specific rehabilitative interventions to meet the goals defined for each patient. Effective communication and strong relationships among the surgeons, orthopedists, or trauma teams who perform the majority of amputations and the rehabilitation team substantially improve the quality of patient care and assist the rehabilitation process. This chapter focuses on the roles of rehabilitation professionals who work with persons with new amputation in the days and weeks immediately after surgery. It explores how surgical pain and phantom sensation are managed, strategies for controlling postoperative edema, and methods to assess a patient’s readiness for prosthetic fitting. Interventions that help a person with new amputation gain competence with single limb mobility tasks and exercises that provide the foundation for successful prosthetic use are identified. The strategies for patient management are organized around the model outlined in the American Physical Therapy Association’s Guide to Physical Therapist Practice (Fig. 20.1).16

Examination Ideally, for those undergoing a “planned” or “elective” amputation, the rehabilitation team will meet with the individual and caregivers before surgery to begin collecting information that will be used to guide intervention and provide

Outcomes Determine impact of intervention on: • Active pathology • System-level impairments • Functional limitations and capacity • Degree of disability or handicap • Prevention of secondary problems • Patient/client satisfaction with care

Examination Gathering evidence: • Current complaint • Medical, psychological, and social history • Systems review and screening • Use of appropriate tests and measures

DOCUMENT Evaluation Integrating the evidence: • Clinical judgment and expertise • Research literature • Patient’s goals and expectations

COMMUNICATE

Intervention Provision of skilled physical therapy care: • Implementation of plan of care • Monitor patient progress and re-evaluate • Adapt and advance plan of care

REFER AS APPROPRIATE Diagnosis Defining movement dysfunction: • Classify primary problems • Identify potential confounding factors • Identify possible secondary problems Fig. 20.1 The components of a systematic and effective patient-client management process. (Adapted from http://guidetoptpractice.apta.org/, with permission of the American Physical Therapy Association. Who are Physical Therapists? Guide to Physical Therapist Practice. © American Physical Therapy Association. All rights reserved.)

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information about the rehabilitation process. In some instances, input from rehabilitation professionals may be sought by trauma surgeons to assist patients and families in making informed decisions when faced with amputation after severe injury of the limb. Preoperative interaction may not always be possible, especially when amputation occurs subsequent to failed revascularization, acute and severe limb ischemia, severe infection, or civilian or combat-related traumatic injury. If preoperative assessment is not possible, referral to rehabilitation should be made as

soon after surgery as possible; delaying referrals often leads to contracture formation, further cardiovascular and musculoskeletal deconditioning, delayed prosthetic fitting and training, a greater risk of dependency, and a higher risk of reamputation, institutionalization, and mortaltity.17,18 Box 20.1 summarizes the components of a comprehensive assessment for persons with lower extremity amputation. Whenever the first contact with the individual and family occurs, the rehabilitation team begins by gathering baseline information that will guide planning for and implementing

Box 20.1 Comprehensive Assessment for Patients with Lower Extremity Amputation History (Data Collected From Chart Review and Interview) Demographics Social history Occupational history Developmental status Living environment Current condition Past medical history Family history Medications

Age, gender, primary language, race/ethnicity Family and caregiver resources, other social support systems Employment or retirement status, typical work and leisure activities Physical/motor, perceptual, cognitive, and emotional dimensions Characteristics and accessibility of “home” environment, projected discharge destination Reason for referral, current concerns/needs, previous medical/surgical interventions for current condition Prior hospitalizations and surgeries; smoking, alcohol, or drug use (past and present) Health risk factors for vascular and cardiac disease Prescription medication for current and other medical conditions Over-the-counter medications typically used Functional status Current and prior abilities and functional limitations (ADLs/IADLs) Systems Review (Concurrent/Comorbid Disease and Impairment Related to Prognosis for and Participation in Rehabilitation) Cardiopulmonary and cardiovascular systems Endocrine and metabolic systems Musculoskeletal system Neuromuscular system Gastrointestinal and genitourinary systems Tests and Measures (Areas for Specific Assessment) Pain

Anthropomorphic characteristics

Skin/integument

Circulation

Range of motion/muscle length Joint integrity Muscle performance

Motor function Upper extremity function

Presence of phantom limb sensation or pain Postoperative pain and pain management strategies Muscle soreness related to altered movement patterns Joint pain related to motion or comorbid arthritis, etc. Residual limb length (bone length, soft tissue length) Residual limb girth, redundant tissue (“dog ears,” adductor roll) Residual limb shape (bulbous, cylindrical, conical) Assessment of type and severity of edema Effectiveness of edema control strategy being used Overall height, weight, body composition Assessment of surgical wound healing Assessment/management of adhesions and existing scar tissue Other skin problems (other incisions, grafts, psoriasis, cysts, etc.) Integrity of remaining foot/limb, especially if neuropathic or dysvascular etiology of amputation Palpation/auscultation of lower extremity pulses, residual and intact limbs Skin temperature and presence of trophic changes, residual and intact limbs Skin color and response to elevation or dependent position, residual and intact limbs Claudication time and distance, impact on function Range of motion, soft tissue length, and joint contracture Ligamentous integrity or joint instability Structural alignment or joint deformity Integrity or inflammation of synovium, bursae, cartilage Current muscle strength of upper extremity, trunk, lower extremity Muscular power for functional activity Muscular endurance for functional activity Potential for improvement Motor control, including dexterity, coordination, agility, tone Motor learning, including previous use of ambulatory aids, prostheses Power and strength of upper extremity and of trunk Ability to use upper extremity in functional activities

20 • Postoperative and Preprosthetic Care

507

Box 20.1 Comprehensive Assessment for Patients with Lower Extremity Amputation (Continued) Aerobic capacity Attention/cognition/ emotion

Sensory integrity Mobility Postural control Transfers Assistive/adaptive equipment Ambulation and locomotion Gait and balance

Posture Self-care Community/work reintegration

Prosthetic requirements

Blood pressure, heart rate, respiratory rate (at rest, as well as during and following activity) Perceived exertion, dyspnea, angina, during functional activity Overall level of physical fitness and functional capacity Level of consciousness, sleep patterns Ability to learn and preferred learning style Cognitive dysfunction screening (delirium, depression, dementia) Motivation, attention/distractibility, learning styles Protective sensation of residual and remaining limb Superficial sensation: light touch, sharp/dull, pressure, temperature Proprioception: kinesthesia, position sense Changing position in bed (rolling, scooting, coming to sitting) Static, anticipatory, reactionary balance, in sitting, standing, during functional activities Ability to transfer to/from bed, toilet, wheelchair, mat, tub/shower Assistive devices/adaptive equipment currently being used Ability to use ambulatory aid safely for single limb gait Ability to use wheelchair safely Adaptations/equipment necessary for patient’s living environment Assessment of postural control in quiet standing, reaching, ability to stop/start, change direction, and alter velocity while walking Reaction to unexpected perturbation, at rest and during activity Observational gait assessment, identification of gait deviations Kinematic gait assessment (e.g., speed, stride length, cadence) Energy cost or efficiency of locomotion/gait, perceived exertion and dyspnea Ability/safety to manage uneven terrain, stairs, ramps, etc. Resting posture in sitting, standing, other positions Alteration in posture due to loss of limb segment Ability to perform basic ADLs Ability to perform IADLs Availability of assistance and preparation of caregivers Analysis of roles/activities/tasks Functional capacity analysis, determination of essential functions Analysis of environment, safety assessment Assessment of need for adaptation Potential for functional prosthetic use Readiness for prosthetic fitting/prescription Appropriate prosthetic design, components, suspension

ADLs, Activities of daily living; IADLs, instrumental activities of daily living. Adapted from The Guide to Physical Therapy Practice; Pattern K: Impaired gait, locomotion, and balance, and impaired motor function secondary to lower extremity amputation. Guide to Physical Therapist Practice 3.0. Alexandria, VA: American Physical Therapy Association; 2014. Available at: http://guidetoptpractice.apta.org/content/1/SEC2.body. Accessed January 30, 2019. American Physical Therapy Association. All rights reserved.

of the rehabilitation process. This initial information is gathered in three ways: developing a complete patient-client history, performing a review of physiologic systems to identify important comorbidities that will affect the rehabilitation process, and using appropriate tests and measures to identify impairments and functional limitations to be addressed in the rehabilitation plan of care.19 The volume and complexity of information needed to guide planning for prosthetic rehabilitation means that information gathering is a somewhat continuous process and must be integrated with early mobility training in preparation for the individual’s discharge from the acute care setting. Examination in the acute care setting likely focuses on four priorities: initial healing of the surgical site, pain management and volume control of the residual limb, bed mobility and transfers, and readiness for single limb ambulation. Examination later in the preprosthetic period (in an outpatient, home care, or subacute setting) would add more detail to determine potential for prosthetic prescription.

PATIENT-CLIENT HISTORY AND INTERVIEW Rehabilitation professionals use several strategies to gather information about an individual’s medical history. In the acute care setting, the process usually begins with a review of the individual’s current medical record or chart, as well as previous medical records (if available). The chart review process provides a broad overview of the individual’s health, comorbidities, current medications, previous and current functional status, and details about the surgical procedure. Data that other members of the health care team have generated in their examination and evaluative processes are quite relevant to PT care, not only to avoid redundancy in examination but also in planning what additional information will be necessary to collect during subsequent interviews and discussion with the individual and family caregivers. The interview process provides key information about the individual’s priorities and concerns so that they can be appropriately integrated into the plan of care. The physical

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therapist may also choose to gather supplementary information from the clinical research literature at this point to assist in the subsequent development of prognosis and plan or care, especially if the individual’s situation is unusual or complex.20

Demographic and Sociocultural Information The information gathered when reviewing history often begins with basic demographics such as age, gender, race/ ethnicity, primary language, and level of education. These data help us to appropriately target communication during our interaction with an individual with recent amputation. It is also important to build an understanding of the individual’s sociocultural history including beliefs, expectations and goals, preferred behaviors, and family and caregiver resources, as well as access to and quality of informal and formal support systems.21–23 There is some evidence regarding the benefits of a formal peer support system for new amputees.24 A comprehensive examination includes assessment of both physical and psychological components regarding the amputation and use of a new prosthetic.22 Each factor is a potentially important influence on the individual’s engagement in the rehabilitation process. Rehabilitation professionals also gather information about the individual’s employment status and task demands, roles and responsibilities within the family system, and leisure interests and hobbies, as well as previous and preferred involvement in the community (access, transportation, and key activities). In addition, information about smoking, alcohol intake, and other previous substance use/abuse, as well as the individual’s coping style and preferred coping strategies help the team to better understand how the individual may behave in the postoperative period. This information is important in developing a prognosis and plan of care; it helps rehabilitation professionals to better define the long-term goals and anticipated outcomes of rehabilitation. Developmental Status Another piece of information that informs an appropriate rehabilitation plan of care is the physical, cognitive, perceptual, and emotional developmental status of the individual and his or her caregivers, as well as an understanding of the family system as an organization.25–27 Although the relevance of developmental status is most obvious when the individual being examined is a child, the perspective afforded by understanding of life span development is valuable for individuals with recent amputation of any age. Examples of factors that evolve over the life span that affect an individual’s participation in rehabilitation include postural control, motor abilities, perceptual abilities, willingness to take risks, problem solving, coping styles and strategies, and limb dominance. Observation and interchange during the interview process help the therapist to determine if further clinical examination of developmental status will be necessary. Living Environment Rehabilitation professionals gather information about the characteristics of an individual’s physical living environment.28 They ask about getting into and out of the house (e.g., how far is it from the car to the house? What kind of surfaces will be encountered moving from the car to the house? Are there steps and railings at the entry? What

are the distances between the major living areas that the person will have to navigate? How accessible and functional are each of the major living areas in the home for those using ambulatory aids or a wheelchair for mobility? Is it possible to adapt the home if necessary? What adaptive equipment is already available? What type of assistance is likely to be routinely available? What type of equipment is likely to be acceptable for the individual and family?). Asking about the individual’s ability to drive, access to public transportation, or plans for alternatives for transport once discharged from the acute care setting is important. This may determine what services will be necessary and where they will be provided. Will the individual be returning to his or her home environment on discharge from acute care? If so, will he or she require home care or is transportation available for follow-up appointments with physicians and for outpatient rehabilitation? Alternatively, will the individual have an interim stay in another health care facility for further rehabilitation? This information will help to set rehabilitation priorities and begin the process of discharge planning.

Health, Emotional, and Cognitive Status During the interview the rehabilitation professional’s impression of the individual’s general health status that initially developed during chart review broadens. The rehabilitation professional asks questions to discern how the person perceives his or her health and his or her ability to function in self-care, family, or social roles. They assess the individual’s understanding of the current situation and prognosis, as well as expectations about the rehabilitation process. They may explore the person’s coping style and response to stress, as well as preferred coping skills and strategies.29,30 This conversation also provides an indication about the individual’s current emotional status, ability to learn, cognitive ability, and memory function. A person who undergoes an amputation may struggle with body image and express difficulties in maintaining satisfaction with his or her quality of life.31 Because increased levels of depression, anxiety, and body image issues are associated with sexual dysfunction in individuals with lower limb amputation, the therapist should screen for depression and be prepared to select appropriate referral sources.30 Because rehabilitation involves physical effort, it is important to understand the person with recent amputation’s usual level of activity and fitness, as well as his or her readiness to be involved in exercise. Is physical activity a regular part of the preamputation lifestyle? Has there been a period of prolonged inactivity prior to surgery?32 Will any additional health habits, such as smoking and use of alcohol or other substances, affect the individual’s ability to do physical work and ability to learn or adapt?33 Medical, Surgical, and Family History Potentially important medical conditions that may influence the postoperative/preprosthetic rehabilitation include diabetes, cardiovascular disease, cerebrovascular disease, obesity, neuropathy, renal disease, congestive heart failure (CHF), uncontrolled hypertension, and preexisting neuromuscular or musculoskeletal pathologic conditions or impairments, such as stroke or osteoporosis.34–36 Each of these has a potential impact on wound healing, functional

20 • Postoperative and Preprosthetic Care

mobility, and exercise tolerance during rehabilitation. Healing and risk of infection are also concerns for those with compromised immune system function, whether from diseases such as human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS), those on transplantation medications, those involved in chemotherapy or recent stem cell transplantation, or those using medical steroids.37 Wound healing, skin condition, and endurance may be issues for persons who are currently undergoing chemotherapy or radiation treatments for cancer.38,39 Review of the individual’s past surgical history provides additional information that helps rehabilitation professionals to anticipate what the individual’s response to physical activity might be like. Has the individual had a cardiac pacemaker or defibrillator implanted? Has there been previous amputation of toes or part of the foot of either the newly amputated or “intact” limb? Are there recent surgical scars to be aware of (e.g., following revascularization before amputation)? Has there been total joint replacement or lower extremity fracture that might affect rehabilitation activities and prosthetic component selection? The “laundry list” of comorbidities and previous surgeries identified in chart review does not necessarily mean that the individual is in poor health.40 Many individuals manage chronic illnesses and conditions quite effectively, and, although they may have less functional reserve than those without a pathologic condition, they have the potential for positive rehabilitation outcomes.41 Physical therapists must also be aware of the results of tests and diagnostic procedures that other team members have undertaken as part of their examination and evaluation. These might include preoperative cardiac or peripheral vascular studies, electrocardiogram (ECG), stress tests, pulmonary function tests, radiographs, CT, MRI, urinalysis, and laboratory tests for various components of blood (e.g., hemoglobin [Hb], cell counts, cultures). Physical therapists must recognize potential physiologic signs and symptoms that may occur when a laboratory value is out of range.42 Comparison of the individual’s test results to established norms provides an index of overall health status and tolerance of levels of activity. Monitoring laboratory test values (e.g., white blood cell [WBC], hematocrit [HCT], Hb, platelet, international normalized ratio [INR], partial prothrombin time [PPT], glycosylated Hb, and blood glucose levels) and oxygen saturation levels provide ongoing information about general health status and exercise/activity tolerance, allowing the therapist to adapt intervention to the individual’s potentially changing condition.43,44 Because many of the medications used to manage postoperative pain affect thinking and learning, it is crucial to understand what pain management strategies are in place and when medication is typically administered.45,46 Given the likelihood of cardiovascular comorbidity in older adults with vascular disease and diabetes, it is also important to understand what cardiac medications are being administered and how these medications affect response to physical activity and position change.47–49 It is not unusual for persons who have been immobile or on bed rest to be at risk of postural (orthostatic) hypotension, especially if they are taking medications to manage hypertension.50 In addition, given the stress of the surgery and hospital environment, especially if the amputation was performed under general

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anesthesia, there is the possibility of a temporary postoperative delirium or difficulty with learning and memory.51 If confusion is observed, it is important to clarify typical preoperative cognitive status by speaking with family and caregivers.

Current Condition Review of the operating room report in the medical record provides information about surgical procedure, drain placement, method of closure, and planned postoperative wound and limb-volume strategies being used (Chapter 19 provides an overview of the most common surgical procedures at the transtibial and transfemoral levels). This information, when combined with knowledge of pain management strategies and demographic information, guides early postoperative/preprosthetic care. Physical therapists use this information to identify potential issues with healing, determine educational needs for the person with new amputation, develop strategies for early positioning of the residual limb, identify potential issues affecting prosthetic fit, and prepare the residual limb for wearing a prosthesis. Determining how comorbidities and injuries are being actively managed is also important because these affect readiness for early mobility, learning, and memory. Impressions of the individual’s psychological state, fears, and expectations round out the baseline with which the person will begin early rehabilitation.

SYSTEMS REVIEW In the acute care setting, there has likely been a fairly comprehensive review of physiologic systems as a component of preoperative work-up (or emergency care in the case of traumatic injury). Rehabilitation professionals find the results of such review in the physician notes and intake forms in the medical record. The therapist may choose to screen or evaluate in more detail if the information in the record is insufficient in depth or detail as it relates to functional status and response to increasing activity and exercise. Review of systems must include anatomic and physiologic status of the cardiovascular, cardiopulmonary, integumentary, musculoskeletal, and neuromuscular systems, as well as communication, affect, cognition, language, and learning style.52 Ongoing screening as rehabilitation progresses will help to identify the onset of secondary problems and postoperative complications that require medical intervention or referral to other members of the team. Deterioration in cognitive status or onset of new confusion over a relatively short period of time is especially important to watch for because it is often the first indication of dehydration, adverse drug reaction, or infection (e.g., pneumonia, urinary tract infection, infection of surgical construct) in older adults.53

TEST AND MEASURES In the postoperative, preprosthetic period, physical therapists use a variety of objective tests and measures to determine the severity of impairment and functional limitation and to establish a baseline that will be used to determine PT movement–related diagnosis, determine prognosis, and assess outcomes of the rehabilitation process.54

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Table 20.1 lists examples of tests and measures appropriate for the postoperative, preprosthetic period. Although most strategies are similar to those used in general PT practice, some may need to be adapted to accommodate the condition

or length of the residual limb (e.g., the point of application of resistive force during manual muscle testing of knee extension strength after transtibial amputation). However, whenever measurement technique is altered, the reliability and

Table 20.1 Examples of Tests and Measures Important in the Postoperative, Preprosthetic Period Category

Examples of Test or Measurement Strategy

Pain

Description of nature or type of pain Visual analog scale for intensity of pain Body chart for location of painful areas Description of factors to increase/decrease discomfort

Anthropometric characteristics

Residual limb length Residual limb circumference Description of edema type and location

Integumentary integrity

Condition of the incision Nature and extent of drainage Condition of “intact” limb Skin color, turgor, temperature

Circulation

Palpation of peripheral pulse Skin temperature

Arousal, attention, cognition

Mini-Mental State Examination, Mini-Cog Delirium scales Depression scales (e.g., Geriatric Depression Scale, Centers for Epidemiologic Studies Depression scale) Saint Louis University Mental Status (SLUMS) Montreal Cognitive Assessment (MOCA)

Sensory integrity

Protective sensation (Semmes-Weinstein filament) Proprioception and kinesthesia Visual acuity, figure-ground, light/dark accommodation Vestibulo-ocular function during position change Hearing impairment (acuity, sensitivity to background noise)

Aerobic capacity, endurance

Heart rate at rest, % maximal attainable in activity Arm ergometry, single limb bicycle ergometry, combined upper extremity/lower extremity ergometry Respiratory rate at rest, during activity Ratings of perceived exertion or dyspnea

Mobility

Observation of bed mobility (e.g., rolling) Observation of transitions (e.g., supine-sit) Observation of description of level of assistance, cueing required transfers (various surfaces, heights)

Balance

Static postural control (various functional positions) Anticipatory postural control in functional activity Reaction to perturbation Specific balance tests (e.g., Berg, Functional Reach)

Gait and locomotion

Use of assistive devices Level of independence, cueing or assistance required Time and distance parameters (velocity, cadence, stride) Pattern and symmetry Perceived exertion and dyspnea

Joint integrity and mobility

Manual examination of ligamentous integrity Documentation of bony deformity

Neuromotor function

Observation of quality of motor control in activity Observation of efficiency of motor planning Determination of stage of motor learning with new or adapted tasks Muscle tone Reflex integrity

Muscle performance

Strength: manual muscle test, handheld dynamometer Power: isokinetic dynamometer, manual resistance through range at various speeds of contraction Endurance: 10 repetitions maximum, or maximum number contractions, time to fatigue

Range of motion/muscle length

Goniometry Functional tests (e.g., Thomas test, straight-leg raise)

Self-care and home management

Observation of BADLs and IADLs BADL and IADL rating scales

BADLs, Basic activities of daily living; IADLs, instrumental activities of daily living.

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validity of the data collected may be questionable and the data generated less precise. Therapists often begin with examination at the level of impairment and then move into functional assessment.

Assessing Acute Postoperative Pain The individual with new amputation is likely to be coping with significant acute postoperative pain and may be distressed by the sense that the limb is still in place (phantom sensation) after amputation. Pain is a subjective sensation; each person defines his or her own level of tolerance. Physical therapists have a number of strategies available to document the nature of pain, location of pain, and the

intensity of discomfort that the individual is experiencing. These include descriptors generated by the individual with recent amputation or circled on a pain checklist, body maps, visual analog scales, provocation tests, or specific pain indices or questionnaires developed for postsurgical patients (Fig. 20.2).55,56 It is also important to assess how severely that pain interferes with functions, what activities or conditions increase the pain, and what positions or strategies have been helpful in managing the postoperative pain. Documentation of pain management strategies is also important: narcotic and opioid medications potentially impact on attention, ability to learn, and response time during movement and balance activities.57,58

McGill Pain Questionnaire Part 1: Where is Your Pain?

Part 2: What Does Your Pain Feel Like? Some of the words below describe your PRESENT pain. Circle ONLY those words that best describe your pain right now. Leave out any category that is not suitable. Use only a single word in the appropriate category—the one that applies the best.

Part 3: How Does Your Pain Change With Time?

2. What kind of things relieve your pain? 3. What kind of things increase your pain?

Part 4: How Strong is Your Pain? People agree that the following five words represent pain of increasing intensity. They are: 2 3 1 Discomforting Distressing Mild

4 Horrible

5 Excruciating

To answer each question below, write the number of the most appropriate word in the space beside the question.

Fig. 20.2 Examples of tools used to document pain and discomfort. (A) McGill Pain Questionnaire. Descriptor groups: sensory (1–10), affective (11–15), evaluative (16), and miscellaneous (17–20). (B) The visual analog scale. ([A] Modified from Melzack R. The McGill pain questionnaire; major properties and scoring methods. Pain. 1975;1(3):277–299. [B] From Bijur PE, Silver W, Gallagher EJ. Reliability of the visual analog scale for measurement of acute pain. Acad Emerg Med. 2001;8(12): 1153–1157.)

1. 2. 3. 4. 5. 6.

Which word describes your pain right now? Which word describes your pain at its worst? Which word describes it when it is least? Which word describes the worst toothache you ever had? Which word describes the worst headache you ever had? Which word describes the worst stomach-ache you ever had?

___________________ ___________________ ___________________ ___________________ ___________________ ___________________

A No pain at all

Worst possible pain 100 mm

B

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Phantom Sensation and Phantom Pain Commonly, persons with recent amputation experience a sense that the amputated limb remains in place in the days and weeks after surgery.59 Research reports indicate that from 54% to 99% of persons with new amputation have noticeable phantom limb sensation.60–63 Phantom sensations are typically described as a sense of numbness, tingling, tickling, or pressure in the missing limb, and some complain of itchy toes or mild muscle cramps in the foot or calf.60 In contrast, phantom pain is described as shooting pain, severe cramping, or a distressing burning sensation that may be localized in the amputated foot or present throughout the missing limb. A smaller percentage (46%–63%) of those with new amputation experience phantom pain.60–63 Fortunately, fewer than 15% of those experiencing phantom pain rate it as severe or constant; most experience transient mild to moderate discomfort that does not interfere with usual activity. Phantom pain is more likely in those with longstanding and severe preoperative dysvascular pain and for those requiring amputation after severe traumatic injury.60,63 In most cases, if the individual reports significant phantom sensation or pain, careful inspection of the residual limb helps to rule out other potential sources of pain, such as a neuroma or an inflamed or infected surgical wound. A neuroma may form any time a nerve is cut, and despite multiple surgical techniques to prevent neuromas, such as electrocautery, perineural closure, and silastic capping, most surgeons will cut the nerve proximal to the bone stump and allow it to retract into the stump, hoping to avoid a painful neuroma.64 Phantom limb sensation and pain tend to decrease over time whether the amputation was the result of a dysvascular/neuropathic extremity or a traumatic injury.60–63 A variety of medications (e.g., amitriptyline, tramadol, carbamazepine, ketamine, morphine) can be used if phantom pain is disabling; however, efficacy appears to be low.65 Recent studies of ketamine for phantom pain indicate its effectiveness for acute and chronic postsurgical pain.66,67 Use of epidural anesthesia during surgery and/or perineural infusion of local anesthetic for several days following surgery may help to reduce development of phantom pain.68,69 Although a number of models or theories for phantom limb sensation and phantom pain have been proposed, the neurophysiologic mechanism that underlies this phenomenon is not well understood.70,71 The likelihood of postoperative phantom limb sensation must be discussed with the individual and family before amputation surgery, as well as in the days immediately after operation. Phantom limb sensation is quite vivid; its realistic qualities can be disturbing and frightening to those with recent amputation. Candid discussion about phantom limb sensation as a normally anticipated occurrence helps to reduce an individual’s anxiety and distress should phantom sensation occur. It also alerts the individual to issues of safety in the immediate postoperative period. Individuals with recent amputation are at significant risk of falling when they awaken from sleep and attempt to stand and walk to the bathroom in the middle of the night, thinking in their semialert state that both limbs are intact. Ecchymosis or wound dehiscence sustained during a fall can lead to major delays in rehabilitation and prosthetic fitting; some fall-related injuries require surgical revision or closure.

Assessing Residual Limb Length and Volume The length and volume of the residual limb are important determinants of readiness for prosthetic use, as well as socket design and components chosen for the training prosthesis.72–74 Initial measurements can be made at the first dressing change. Changes in limb volume are tracked by frequent remeasurement during the preprosthetic period of rehabilitation. This is important because discomfort from the poorly fitting socket is the most common reason for clinical visits for new amputees.72 The two components of residual limb length are the actual length of the residual tibia or residual femur and the total length of the limb including soft tissue. Measurements are taken from an easily identified bony landmark to the palpated end of the long bone, the incision line, or the end of soft tissue. In the transtibial limb the starting place for measurement is most often the medial joint line of the knee; an alternative is to begin measurement at the tibial tubercle (Fig. 20.3A). In the transfemoral limb the starting place for measurement can be the ischial tuberosity or the greater trochanter (see Fig. 20.3B). Clear notation must be made

TT

MJ line

A

GT

B Fig. 20.3 (A) Medial view of a left transtibial residual limb. Limb length is measured to the end of the tibia (solid arrow) and to the end of soft tissue (dotted arrow) from a bony landmark such as the medial joint (MJ) line or tubercle of the tibia (TT). (B) Lateral view of a right transfemoral residual limb. Limb length is measured from the greater trochanter (GT) or ischial tuberosity to the end of bone (solid arrow) and to the end of soft tissue (dotted arrow).

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Table 20.2 Residual Limb Lengths and Associated Prosthetic Consequences Segment

Level

Preserved

Inches

Centimeters

Functional Outcome

Adult tibia72

Intact

100%

14.5
1.2

36.9
3.0

Effective walking ability

Transtibial residual limb73,74

Short

upper extremity) Two-point discrimination Cutaneous pain Temperature detection Passive movement/joint position sense (lower extremity > upper extremity)

Pathologic Conditions Affecting the Visual System Cataract Age-related maculopathy/macular degeneration Diabetic retinopathy Glaucoma Homonymous hemianopsia consequent to cerebrovascular accident Auditory System Age-Related Changes Gradual progressive bilateral hearing loss, beginning with high frequencies Diminished sensitivity to low-volume sounds Increasing pure tone auditory threshold Diminished ability to screen background noise Diminished discernment of speech sounds Diminished word and sentence recognition Decreased ability to accommodate to rapid speaking rates Distortion of sound/sensitivity to shouting and emotional cues Functional Consequences

Functional Consequences Reduced ability to monitor environmental conditions Less-efficient postural responses Increased risk of tissue damage under low-load, repetitive conditions Pathologic Conditions Affecting Somatosensory Systems Diabetic neuropathy Entrapment neuropathy (e.g., carpal tunnel syndrome) Toxic neuropathy (e.g., chronic alcoholism) Sensory and perceptual impairment consequent to cerebrovascular accident

Less efficient listening, especially in noisy environments

inspection and wound care, as well as decisions about appropriate socket-limb interface for prosthetic prescription. Screening for proprioceptive and kinesthetic awareness at intact joints provides information that will be useful when designing interventions for postural control and, eventually, prosthetic gait training. Sensory testing requires that the individual be able to concentrate and focus so as to respond when a stimulus is presented. The reliability of sensory testing is diminished in individuals with confusion or delirium or if the examiner uses a consistent (predictable) pattern or rhythm during

testing.155 To minimize the likelihood of “lucky guesses” in those with suspected sensory impairment, it may be helpful to test specific sites multiple times, in random order and uneven timing, documenting the number of accurate responses versus number of times stimulated (e.g., 0/3, 1/ 3, 2/3, or 3/3) at each testing site. Noting how the individual with new amputation perceives the residual limb is also important; is the individual willing to look at the limb, watch it during dressing changes, touch it, or freely move it? One challenge in the preprosthetic period is to assist the incorporation of this “different”

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limb in the person’s body image and self-perception.22,23,156 Some individuals with dysvascular-neuropathic disease continue to perceive their limb as fragile and needing protection. Those with traumatic amputation may become emotionally distressed when confronted with the real evidence of their loss. These situations may interfere with readiness to wear and use a prosthesis effectively. Awareness of the person’s emotional response to his or her altered body guides the therapist in patient education and intervention activities aimed to accomplish adaptation of body image necessary for effective prosthetic use.

Assessing Mobility, Locomotion, and Balance An individual with recent amputation may find that simple mobility tasks (rolling over, coming to sitting/returning to supine, transitioning from sitting to standing) are more difficult than anticipated following surgery. With the reduction of body mass that results from lower extremity amputation, for example, the individual’s functional center of mass (COM) shifts slightly upward and to the opposite side of the body; the degree of the shift is directly related to the amount of body mass removed during amputation surgery.157 When this alteration in body mass is paired with deconditioning associated with bed rest, performance of mobility tasks degrades. It is important to document baseline functional status and to discern how much that altered body mass, altered muscle performance, and even fear of pain or of falling may be contributing to difficulty in moving. These alterations in COM may require adaptation of strategies used before surgery for postural control; most persons with recent amputation can effectively adapt their postural control mechanisms by practicing activities that require them to anticipate or respond to postural demands. One of the most worthwhile aspects of preoperative assessment is determination of the usual (previous) and current (postoperative) ambulatory status of the person with new amputation. The therapist is interested in the individual’s familiarity with the use of assistive devices (e.g., walker, crutches, canes), need for assistance to assume standing and while walking, typical distances walked before surgery, the overall effort (energy cost) of walking, the frequency of walking, any other factors or comorbidities that limit walking, and the type of walking environment that the person is most likely to encounter after discharge from acute care (e.g., level inside, uneven outside, stairs and ramps). Self-reports and direct observation of walking provide this information. Preamputation ambulatory status is a very strong predictor of functional postoperative prosthetic use.158,159 At this early point in rehabilitation the priority is safety and functionality of walking, rather than quality and preciseness of the gait pattern. Detailed observational gait analysis is typically deferred until training with the prosthesis begins. Quantitative kinematics (e.g., cadence, gait speed, step or stride length) and ratings of perceived exertion can be used to establish a baseline early in the postoperative period as a benchmark for progression and readiness for discharge. Individuals with new amputation must be able to use a step-to or swing-through gait pattern with the type of walker or crutches that provides adequate stability and energy efficiency with the least activity restriction.160

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Once gait training with the prosthesis begins, the strategies of resisted gait and functional training were found to be more effective that supervised walking to improve gait performance.161 In acute care settings, initial examination and training of gait is likely to focus on level, predictable surfaces in a relatively closed environment. The ability to manage on a variety of surfaces in active and open environments is examined as care progresses; discharge from acute care approaches; and preprosthetic rehabilitation continues at home, in subacute settings, or on an outpatient basis. The individual with recent amputation using an assistive device in single limb ambulation must be able to walk forward, sideways, and backward, change direction, and turn, in addition to managing stairs and inclines so as to be safe and functional in the home environment. Familiarity with and effectiveness of propulsion and maneuverability of a wheelchair are likely to be important in the preprosthetic period for both the individual and family caregivers. Determining the effectiveness of the individual’s postural control is also key. This includes stability in quiet sitting and standing; anticipatory postural adjustments in reaching, in transitions from sitting to standing, and during locomotion; and reactionary postural adjustments when there is unexpected perturbation or unpredictable environmental conditions (e.g., a wet area on the floor, an area rug that may shift when stepped on). Although objective mobility measures such as the Tinetti Performance Oriented Mobility Assessment and Berg Balance Scale are used clinically for persons with recent amputation, the reliability, validity, and norms for safe or impaired performance are not well documented in the research literature.162–164 However, the Functional Reach test has been shown to be a valid and specific measure of balance for individuals at the definitive prosthetic phase after lower limb amputation, and it correlates with the Timed Up and Go (TUG) test.165 Subjective assessment of postural control (poor, fair, good, excellent) is somewhat influenced by the therapist’s level of experience and comfort with allowing an individual to move toward his or her limits of stability.166 Objective measurements of balance and postural control provide the therapist with more information to help develop a specific plan of care to address balance deficits. One study found differences in limits of stability between patients with vascular and nonvascular unilateral transtibial amputation (UTA) and patients without amputation. When center of gravity excursion end points were measured across all three groups, the patients with vascular UTA had substantially reduced limits of stability compared with patients without amputation and the patients with nonvascular UTA.167 The Amputee Mobility Predictor (AMP) (Fig. 20.11) may be a useful tool to establish baseline preprosthetic balance and walking abilities, as well as an outcome measure for preprosthetic rehabilitation.168–170 Minimal detectable change (MDC) for the AMP is reported to be 3.5 points.171 Providing an opportunity for the individual to practice moving from sitting to standing and ambulation with an appropriate assistive device allows the therapist to identify potential problems with balance and postural control. This also helps the individual to anticipate what mobility will be like while the residual limb heals and while awaiting the

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Fig. 20.11 Items of the Amputee Mobility Predictor scale. (Modified from Gailey RS, Roach KE, Applegate EB, et al. The amputee mobility predictor: an instrument to assess determinants of the lower limb amputee’s ability to ambulate. Arch Phys Med Rehabil. 2002;83(5):613–627.)

prosthesis. The AMP has two subcategories: Amputee Mobility Predictor with prosthesis (AMPPRO) and Amputee Mobility Predictor without prosthesis (AMPnoPRO). The scores on the AMPPRO range from 0 to 42 (47 if assistive device is included) and on the AMPnoPRO from 0 to 38 (43 if assistive device is included). Higher scores indicate better mobility.168,169,172 Because the AMP is used for persons with unilateral limb amputation, the AMPBilateral (AMP-B) was created. The AMP-B has been shown to predict mobility and functional capabilities of service members with bilateral lower limb loss and is

correlated with the 6-Minute Walk Test.173 AMP-B scores range from 0 to 47, and it is based on modifications to the original AMP scoring.173 A self-reported mobility scale, the Prosthetic Limb Users Survey of Mobility (PLUS-M) has been shown to have good construct validity among people with lower limb amputation and may be related to AMP scores and TUG test times.174 For those individuals with high levels of mobility, the Comprehensive High-Level Activity Mobility Predictor (CHAMP) has been shown to correlate with the 6-Minute Walk Test for service members with lower-limb loss.175,176

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Assessing Posture, Ergonomics, and Body Mechanics In the assessment of symmetry of alignment in sitting and standing, the physical therapist must differentiate habitual or preferred postures from fixed postures, malalignments, and deformities.177 This might be accomplished by noting whether a particular postural orientation is maintained during different functional activities, as well as whether the individual with new amputation can change position or alignment when so directed. Quantitative measures to document abnormalities in posture and alignment include comparison with vertical and horizontal using plumb line and grids, goniometry and angle assessment, and passive movement. Given the typical age group of persons with dysvascularneuropathic etiology of amputation, there may be kyphosis associated with osteoporosis, especially if there is history of pathologic compression fractures of the spine.177 Assessing the health and function of the lumbar spine in standing and during reaching and lifting activity (including excursion of hamstrings and flexibility of hip flexors and adductors) is important because of the likelihood of developing low back pain with the use of a prosthesis if there is contracture. This is especially true for individuals with a transfemoral or any bilateral amputation level.178 Considering back health early in the preprosthetic program is a health promotion/wellness activity that is a worthwhile investment in time and effort. Over time, persons with amputation are likely to develop osteopenia or osteoporosis of the residual limb; those with transfemoral amputation may be at increased risk of pathologic hip fracture as they age.179,180 Assessing Self-Care and Environmental Barriers In the acute care setting and in many acute rehabilitation centers, the Functional Independence Measure (FIM) is commonly used to determine how much assistance an individual with new amputation requires for self-care, toileting, transfers, and locomotion and with cognition-related aspects of task performance (Table 20.4).181,182 Each item on the FIM is rated between 1 (complete dependence) and 7 (complete independence); possible FIM scores range between 18 and 126 points, with low scores indicating that greater assistance is required. Because the FIM was designed to measure burden of care in hospital settings, many of the criteria used to indicate independence for mobility items do not necessarily represent level of function required for community living. In the early postoperative, preprosthetic period, use of the FIM is appropriate; later during preprosthetic care or during prosthetic care, there is likely to be a ceiling effect that makes it less sensitive to change in functional status.183,184 FIM scores may not be particularly useful as indicators of improvement once an individual has reached relative modified independence, especially on the locomotion and mobility subscales.172 Whether using the FIM or other measures of function, the individual’s ability to transfer to and from the toilet, in and out of the shower or bathtub, and in and out of a car, bus, or subway; to manage stairs, elevators and escalators; and to get up from the floor (in case of a fall) should be examined as the preprosthetic period advances. This is

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Table 20.4 Dimensions of the Functional Independence Measure Self-Care Subscale (8–56 points)

1. Eating 2. Grooming 3. Bathing 4. Dressing the upper body 5. Dressing the lower body 6. Toileting 7. Bladder management 8. Bowel management

Mobility Subscale (5–35 points)

9. Transfers: bed to chair or wheelchair 10. Transfers: to and from toilet 11. Transfers: in and out of bathtub or shower 12. Locomotion: walking or wheelchair propulsion 13. Stairs

Cognition Subscale (5–35 points)

14. Communication: comprehension (auditory and visual) 15. Communication: expression (verbal and nonverbal) 16. Social interaction 17. Problem solving 18. Memory

Total FIM Score

Range 18–126 points

NOTE: The Functional Independence Measure (FIM) is a proprietary measurement tool of the Uniform Data System for Medical Rehabilitation (270 Northpointe Parkway, Suite 300, Amherst, NY 14228, www. [email protected]). Readers are encouraged to contact the UDSMR for detailed information about administering, scoring, and interpreting the tool.

part of the assessment of readiness to return to the home environment or determine the need for continued rehabilitation. The rehabilitation team must also consider the individual’s ability to dress, perform self-care and grooming activities, inspect his or her residual and remaining limbs, and function in typical food preparation roles and other instrumental activities of daily living (IADLs). A brief, preprosthetic instruction in activity of daily living (ADL) performance should be incorporated in the rehabilitation plan.184 The team assesses the family caregiver’s ability to provide appropriate and effective assistance at home if the individual needs help or guarding during functional activities. Discussion about what work and leisure activities are important for the individual to resume once home will guide selection of appropriate adaptive equipment and adaptive movement strategies necessary to carry out important tasks and roles before receiving the prosthesis. Finally, information about the accessibility of the person’s living environment must be gathered to determine whether it is feasible to return home to function on a single limb during the preprosthetic period. The therapist may ask family members to measure doorway widths, determine whether there is adequate space for maneuvering a wheelchair, and consider the need for installation of ramps to make entering/exiting the home both less effortful and safer. Readers are referred to Cameron and Monroe (2007) for more information.184a

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Monitoring for Postoperative Complications Many individuals undergoing amputation, whether related to an infected diabetic foot wound, peripheral vascular disease, or traumatic injury, carry a high comorbid burden of illness. Physical therapists must be aware of potentially life-threatening and rehabilitation-delaying complications in the postoperative, preprosthetic period. In-hospital mortality following amputation is estimated to be from 4% to 20%.185–187 Predictors of mortality during this vulnerable time include significant renal disease, chronic obstructive pulmonary disease and CHF, previous MI or ischemic stroke, liver dysfunction, and an age of 75 years or older.184–187 Transfemoral amputation and older age were found to have a higher proportion of early postoperative mortality.187 Patients who require blood transfusion during or following surgery tend to have both more postoperative complications and a greater risk of mortality.188 There is high risk of morbidity during the immediate postoperative period as well. The stress of surgery may contribute to problematic hyperglycemia and need for insulin in persons with diabetes, even those who had not

previously required insulin.189 Cardiac complications for persons with diabetes, PAD, and coronary artery disease in the postoperative period include arrhythmia (with associated risk of cerebral embolism), exacerbation of CHF, and new MI or stroke.185,186,190–192 Bed rest and inactivity are associated with risk of deep venous thrombosis and associated pulmonary embolism, risk of developing pneumonia, and risk of developing decubitus (pressure) ulcer on the heel of the intact limb or sacrum.193,194 Placement of catheter for collection of urine increases risk of urinary tract infection.195 Infection of the surgical wound has been reported to be between 10% and 26% in dysvascular disease and 34% in those with amputation as a consequence of trauma.194,196,197 Pneumonia, urinary tract infection, or infection of the wound may contribute to development of sepsis and eventual multisystem organ failure.198,199

Case Example 20.1a An 89-Year-Old Woman Facing “Elective” Transtibial Amputation for Severe Arterial Occlusive Disease of Her Right Foot N. H. is a slight but energetic woman who is referred to your interdisciplinary team for preoperative examination and education about the rehabilitation program she will be involved in after her planned transtibial amputation. She stands 5 feet 2 inches tall with slight kyphosis and weighs 101 lb. She rises to standing by scooting to the edge of her wheelchair (used for community mobility), then rocking back and forth several times to build momentum. She tells you that she spends her days reading the New York Times, writing to grandchildren and the few long-term friends still alive, cooking (with help to assemble ingredients and take things in and out of the oven), and talking to other “shut ins” from her church on the phone. N. H. lives in the home of her youngest son, a 67-year-old who has recently undergone quadruple coronary artery bypass grafting and is recovering from an embolic stroke that left him with mild left hemiparesis. Grandchildren and great-grandchildren visit fairly often. According to her chart, N. H. has hypertension controlled by β-blockers, had a mild MI 15 years ago, has never smoked cigarettes, and enjoys a glass of wine with her evening meal. She had lens implants for cataracts bilaterally but still wears glasses to read. Over the past year, claudication has become an increasing problem, making it uncomfortable for her to walk from her bedroom at one end of the ranch-style home to the kitchen and family room at the other. When presented with the choice of revascularization versus amputation, she decided that, in the long run, she would rather take her chances with amputation surgery with spinal anesthesia than bypass graft with general anesthesia. She expresses concern that she is “very out of shape” because her walking has been so limited by ischemic pain. She has a good friend whose husband used a transtibial prosthesis for many years after losing his foot in a lawnmower accident; this has assured her that a prosthesis will allow her adequate mobility and function once she heals after surgery. She tells you she has come through many difficult times

during her long life, and, although sad at the prospect of losing her leg, she looks forward to being free of claudication pain and anticipates she will muster the determination necessary to get back on her feet. QUESTIONS TO CONSIDER

▪ What additional data might you want to gather from the

medical record to build your understanding of her current condition and medical prognosis? ▪ What are the most important questions to ask during your interview with N. H. and her son as you begin to formulate her PT diagnosis and plan of care? ▪ Given her age and general health status, what additional review of physiologic systems would be important to carry out before surgery? Why have you chosen these systems? How might they affect her ability to participate in rehabilitation? ▪ What specific tests and measures, at an impairment level, will be important to do during your physical examination? How long do you think the assessment might take? How might you prioritize if your time with N. H. is limited? How reliable are the strategies that you have chosen? How precise does the information you are collecting at this preoperative visit need to be? ▪ What functional activities would you choose to assess before her surgery? What tests and measures will you use to document her functional status? ▪ What information would be important for you to share with N. H. and her son about the first few days after her surgery? Before discharge from acute care? During the preprosthetic period until she is ready to be casted for her initial prosthesis? ▪ Given the limited information currently available to you, what impression or expectations do you have about her postoperative care? How might this be different if she had a medical diagnosis of type 2 diabetes?

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Case Example 20.2a A 25-Year-Old Man With Bilateral Traumatic Transtibial Amputations Sustained in a Construction Accident P. G. is a construction worker who was pinned between the fenders of two vans when the driver of one van put the vehicle in reverse as P. G. was walking between them. He sustained severely comminuted and open fractures of the mid tibia and fibula and significant damage to soft tissue and neurovascular structures. Tourniquets were placed on his limbs by emergency medical technicians responding to the 911 call. In the emergency department, trauma surgeons determined that neither of P. G.’s limbs met criteria for limb salvage. Because the limbs were contaminated by dirt and debris from the job site, the surgeon performed bilateral open transtibial amputations to allow for frequent wound inspection. P. G. was placed on intravenous antibiotics. Three days after the operation, there is no sign of infection in either limb. Revision and closure of his residual limbs is scheduled for tomorrow, using an equal anterior and posterior flaps closure, leaving approximately 5 inches of residual tibia in length. Adjustable polypropylene, removable semirigid dressings (SRDs) are planned for compression and protection of the wound postoperatively. Review of the medical record indicates that P. G. was in generally good health before his injury, although he has been a pack-per-day smoker since the beginning of high school. He was 6 feet 4 inches tall, weighing 210 lb before his injury. His only previous hospitalization was at age 17, for openreduction, internal fixation of a midshaft right femoral fracture sustained in a motorcycle accident. P. G. has been married for slightly more than 1 year, and his wife is 7 months pregnant. They live on the third floor of a three-family home in the ethnic city neighborhood in which they grew up. Extended family members have kept vigil at the hospital since the accident to support P. G. and his wife. When not working, P. G. is an avid motorcycle and quad rider, competing locally in both speed and distance events. He also participates in an intracity adult basketball league. Pain management has been via a morphine pump; even with this, P. G. reports typical pain levels of 5 to 6 out of 10, increasing in severity during dressing changes. When you come to discuss his postoperative rehabilitation with him, he is in a semireclined position in bed, with both lower limbs abducted and externally rotated at the hip, resting in apparent 20 degrees of knee flexion. He is anxious and quite angry over the situation, stating that he “can’t believe this has happened” and “doesn’t

Process of Evaluation, Diagnosis, and Prognosis Understanding an individual’s rehabilitation needs emerges as baseline data are collected and integrated with health professionals’ clinical expertise and judgment, as well as evidence from the clinical research literature. As part of the evaluative process, the team weighs factors that are likely to influence the rehabilitation program and begins to formulate a plan of care to address the individual’s specific needs. The team identifies key problems that will need to be addressed, formulates a PT (rehabilitation) movement dysfunction diagnosis, estimates the level of function that will likely be reached and the time and intensity of

want to end up in a wheelchair” unable to work. The only experience he has with persons with amputation is an uncle with poorly controlled diabetes who had successive amputations of multiple toes as a consequence of vascular insufficiency, subsequently revised to transmetatarsal because of osteomyelitis of a neuropathic wound, and then to transtibial because of delayed healing. P. G.’s uncle’s rehabilitation was complicated by a significant stroke a week after transtibial amputation, and, although he wears a prosthesis, his mobility limitations keep him homebound. QUESTIONS TO CONSIDER ▪ What additional data might you want to gather from the medical record to build your understanding of P. G.’s current condition and medical prognosis? ▪ What are the most important questions to ask during your interview with P. G. and his family as you begin to formulate his PT diagnosis and plan of care? ▪ What additional review of physiologic systems would be important to carry out before surgery? Why have you chosen these systems? How might they affect his ability to participate in rehabilitation? ▪ What specific tests and measures, at an impairment level, will be important to do during your physical examination? How long do you think the assessment might take? How might you prioritize if your time with P. G. is limited? How reliable are the strategies that you have chosen? How precise does the information you are collecting at this preoperative visit need to be? ▪ What functional activities would you choose to assess before his surgery? What tests and measures will you use to document his functional status? ▪ What information would be important for you to share with P. G. and his family about the first few days after the next surgery? Before discharge from acute care? During the preprosthetic period until he is ready to be casted for his initial prostheses? ▪ Given the limited information currently available to you, what impression or expectations do you have about his postoperative care? How might P. G.’s care be similar to or different from that of his uncle and the older woman in the previous case?

intervention necessary to reach it, specifies measurable goals that will be used to judge progression over time, and prioritizes interventions to be carried out as part of the rehabilitation program. Readers are referred to the Guide to Physical Therapist Practice to review for details about the patientclient management process and the practice patterns applicable to PT care of persons with recent amputation (http://www.apta.org/Guide/) (Box 20.3).

PHYSICAL THERAPY DIAGNOSIS The PT diagnosis reflects the problems with body structure and function (impairments) and activity (functional limitations) that the person with recent amputation encounters as a consequence of their surgery and current health status.

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Box 20.3 Guide to Physical Therapist Practice Patterns Relevant for Individuals With Amputation Musculoskeletal System Impaired motor function, muscle performance, range of motion, gait, locomotion, and balance associated with amputation Neuromuscular System Impaired motor function and sensory integrity associated with acute or chronic polyneuropathies Cardiovascular/Cardiopulmonary System Primary prevention/risk reduction for cardiovascular/pulmonary disorders or Impaired aerobic capacity/endurance associated with deconditioning Integumentary System Primary prevention/risk reduction for integumentary disorders Impaired integumentary integrity associated with skin involvement extending into fascia, muscle, or bone and scar formation

The PT diagnosis differs from the medical diagnosis in that it focuses on the functional consequences of a condition at the level of the system and, more importantly, at the level of the whole person.7 The models used to frame the rehabilitation process have evolved from the process of disablement200 to a focus on enablement, based on the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF).201–203 The models provide a way of organizing information collected in the patient-client interview and examination process, to facilitate development of a PT movement diagnosis, prognosis and goals, and plan of care. For students and new therapists, it may be helpful to complete an organizational table on the basis of the ICF model that lists all relevant descriptors of active disease/ comorbidity, the impairments and resources of body structures and function, and the activity and participation level issues that need to be addressed during the episode of care (Table 20.5). The entries in each column in the table can be prioritized, with notations about which issues are likely to improve or change and which will require adaptive equipment or alternative strategies. The statement of PT diagnosis for the particular individual begins with a prioritized list of activities to be addressed during the episode of care, followed by the contributing impairments of body systems and structures related to or resulting from the individual’s constellation of active pathologic conditions and comorbidities. Formulating the PT diagnosis in this way clearly guides establishment of goals and appropriate interventions.

PLAN OF CARE: PROGNOSIS Forecasting the length of the proposed episode of PT care and the potential for prosthetic replacement and rehabilitation can be challenging. Decisions must be informed by several factors:

1. The overall health, cognitive, and preamputation functional status of the individual; 2. The level of amputation as it affects prosthetic control and the energy cost of walking; 3. The likely contribution of prosthetic use to perform basic and IADLs for the individual or for the caregivers who will be assisting and managing daily function; 4. The resources (financial and instrumental) available to the individual during the entire rehabilitation process; and 5. Knowledge of typical length of stay for patients with amputation in the setting in which care if being provided (acute care, inpatient rehabilitation, subacute care, home care, or outpatient care). The premorbid factors that tend to predict successful prosthetic use (i.e., rehabilitation potential) include the ability to walk functional distance in the months prior to surgery, overall level of physical fitness, requiring little assistance in ADLs, and the ability to maintain single limb stance without assistance.204 Persons of advanced age often require a longer period of rehabilitation but eventually become functional prosthetic users. Delayed wound healing (which delays prosthetic fitting), as well as knee and hip flexion contracture, reduce the likelihood of successful prosthetic use.205 A long list of past or chronic illnesses does not predict poor rehabilitation potential: Approximately 75% of persons with amputation are able to return to independent living, managing multiple chronic conditions effectively to become highly functional prosthetic users.206 Premorbid health conditions that make prosthetic use less likely (odds ratio > 2.0) include moderate to severe dementia, end-stage renal disease, and advanced coronary artery disease.207 Persons with very low body mass (underweight) may have more difficulty with prosthetic ambulation and functional independence than those who are overweight and obese, given a similar comorbid burden of illness.206 Hip extensor strength is a powerful contributor to overall function with a prosthesis for persons with both transtibial and transfemoral amputation.208 Difficulty learning has more of an impact during the postoperative and preprosthetic period than does depression or anxiety.209 The sooner an individual is fit for a prosthesis and begins rehabilitation following amputation, the more likely the individual will become a functional prosthetic user.210 Long-term outcome of function and survivorship following amputation is more difficult to forecast: The relatively high morbidity and mortality for patients with amputation secondary to vascular disease have been well documented.211–213 Unless there is clear evidence that ambulation will not be possible and that provision of prosthesis will not improve the patient’s mobility (e.g., reducing the amount of assistance that is necessary to transfer), prosthetic replacement should and must be considered. A key component of prognosis is delineation of the frequency, intensity, and duration of the episode of care. In the acute care setting, hospitalization for an uncomplicated amputation may be 4 to 7 days and PT may occur for 30 to 45 minutes, once or twice daily. For frail or chronically ill older adults coping with multiple comorbidities, length of stay often increases to 21 or more days. For individuals with amputation as a result of trauma affecting multiple systems, the period of hospitalization

Table 20.5 Application of the WHO International Classification of Functioning, Disability and Health (ICF) Model, Completed Postoperatively, for Case Example 20.1a: N. H., an 89-YearOld Woman, Following with Elective Transtibial Amputation Secondary to Severe Peripheral Arterial Disease Overall Health Status

Body Structure and Function (Physiological Systems)

Activity (Overall Functional Status)

Participation (Ability to Engage in Social Roles)

Buffers or Confounding Factors

Effective management of chronic conditions prior to surgery Intact cognitive status and effective executive function preoperatively Self-rated health “good” other than claudication

Effective vision and hearing Effective communication Highly motivated: determined to eventually return to own home

Previous use of walker and wheelchair Able to ambulate independently with assistive device functional (in home) distances Self-selected walking speed 0.85 m/s preoperatively Independent in self-care (toileting, bathing with tub seat and handheld shower, dressing) Independent in stair management, step up to step pattern, with rail

Active and engaged in community (church) Able to manage food preparation and cleanup with minimal assistance

Knowledge of successful prosthetic use by friend Understanding of the rehabilitation process: previous participation in cardiac rehabilitation Lives in one-story home, with ramp at entry Significant emotional and instrumental support available by a number of family caregivers

Active problems (examination findings)

Medical diagnosis: Peripheral arterial disease with critical limb ischemia Status post right transtibial amputation, posterior flap (2/15/12) Removable rigid dressing 200 square ecchymosis suture line Moderate amount of serosanguineous drainage at mid suture line Postoperative pain (morphine pump) Comorbid conditions Hypertension (βblockers) Status post MI (1997) Cataract (lens implants 6/12/07) Recent fall in hospital bathroom (2/17/12) Mild postoperative delirium with sundown syndrome Stress incontinence Possible osteoporosis Possible sarcopenia

Postoperative pain (4/10 VAS) Phantom sensation (cramping) Potential for delayed healing because of injury to surgical site sustained in fall Postoperative edema Limited excursion right knee flexion and hip extension ROM Less than 3/5 muscle strength right knee extension, hip abduction, hip extension Diminished functional core and upper extremity muscle strength Limited muscular endurance Limited cardiovascular endurance Limited short-term memory and distractibility (MMSE preoperation 28/30, postoperation 18/30) Hypersensitivity to touch and pressure bordering suture line Inadequate protective sensation left forefoot Impaired postural control in single limb support (static and dynamic)

Difficulty with transitions Effortful but functional rolling side to side Minimal assistance to shift upward in bed (difficulty sustaining “bridge” position) Minimal assistance supine to/from sitting with directional cueing Moderate assistance sit to stand, with directional cueing Maximal assistance stand to sit with poor eccentric control upper extremity and left lower extremity Inability to ambulate functionally Moderate assist of 1, hop-to pattern in parallel bars, requires consistent cueing Step length 6 inches, perceived exertion 7/10, distance 10 ft Diminished exercise and activity tolerance Difficulty with toileting, dressing, and other self-care activities Quickly becomes frustrated and agitated when encounters difficulty with mobility and selfcare tasks Possible difficulty with carryover of new learning from session to session until delirium clears Difficulty self-monitoring status of residual limb and remaining limb

Inability to function in typical premorbid roles in interactions with family at home Inability to function in premorbid roles in interactions with members of her communities (church, friends, extended family)

Left lower extremity claudication may limit activity

Physical Therapy Diagnosis: N. H. has difficulty with functional activity (mobility and transfers, ambulation, and self-care activities) secondary to postoperative dysfunction of body structure and systems (transient cognitive impairment, pain, impaired muscle strength and motor control, diminished endurance, limited range of motion of at key lower extremity joints, impaired postural control) related to recent transtibial amputation, postoperative delirium, and various comorbidities. MI, Myocardial infarction; MMSE, Mini Mental Status Exam; ROM, range of motion; VAS, visual analog scale.

20 • Postoperative and Preprosthetic Care

Resources (preoperative)

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depends on the severity of damage across all systems, so that duration of care may be longer. Postacute care occurs in inpatient rehabilitation settings (approximately 55%), subacute rehabilitation settings (approximately 21%), or by discharge to home with referral for in-home nursing and rehabilitation services (approximately 24%).214 Discharge location is determined by overall health status and need for care, availability and capacity of family caregivers, the type of rehabilitation settings or care that is available in the area, and insurance and financial considerations. In subacute settings, for those on Medicare, the rehabilitation stay may be for a month or more, and care is much more intense, with PT typically occurring twice daily with an hour or more of PT and occupational therapy planned each day. Care provided at home and in outpatient settings may be somewhat less intense, occurring three times a week for an hour or more but is certainly supplemented by an active home program.

PLAN OF CARE: DETERMINING APPROPRIATE GOALS Goals to be achieved during a particular episode of care are influenced by the setting in which care is provided. Although the overall goal of the preprosthetic period is to prepare the individual for prosthetic fitting and training, the specific goals of the acute care setting may be to achieve primary wound closure, initiate an effective strategy for compression, and achieve supervision or minimal assist in transfers and in locomotion using a wheelchair or ambulatory device on level surfaces during the days or week that the person is hospitalized. In subsequent subacute, home care, and outpatient settings, goals expand to include strengthening of core and key muscle groups; ensuring adequate ROM for prosthetic use; improving cardiovascular fitness; and achieving more advanced ADLs, IADLs, and mobility skills over a longer period of intervention.215 An effective goal is directly linked to the impairments and

Case Example 20.2b Determining a Physical Therapy Diagnosis for P. G. Following Revision of Bilateral Transtibial Amputations

▪ You have collected the following information in your chart

review, interview, and brief initial examination: ▪ Surgery: Underwent revision and closure of bilateral open amputation 2 days ago (under general anesthesia) with equal anterior and posterior flaps closures; 5.25-inch residual tibia on left, 4.75-inch residual tibia on right. Placed in bulky dressing and Ace wrap for compression, then into bilateral adjustable prefabricated semirigid dressings to hold knees in full extension and protect surgical construct. Moderate serosanguineous drainage noted at first dressing change. Wound edges slightly inflamed consistent with operative trauma. No dehiscence noted. Proximal circumference at joint line 10.25 inches bilaterally, distal circumference (4 inches below) of right residual limb 11.25 inches and of left residual limb 11 inches. ▪ Postoperative health: Elevated temperature postoperatively, with diminished breath sounds in posterior bases of lungs bilaterally. Radiograph suggests early pneumonia. Cough nonproductive. ▪ Cognition/affect: Signs of agitation and distress in recovery room, being mildly sedated for combination of pain relief and calming. Currently lethargic and somewhat distractible, requiring consistent cueing to stay on task during examination. ▪ Pain/phantom sensation: Reports postoperative pain at 7 out of 10 level. Complains of shooting pains in phantom right lower extremity and is distressed by “itchy” toes on phantom left lower extremity. Currently intravenous narcotics every 3 hours for pain management. ▪ ROM/muscle length: Reports “pulling” behind knees when head of bed elevated into long sitting position. Requests time out of semirigid dressing to allow knee flexion and to be more comfortable. ▪ Muscle performance/motor control: Able to actively extend both knees to approximately 10 degrees from full extension; stops because of “pulling” behind knee. ▪ Upper extremity function and transfers: Able to “push up” to lift body weight when assisted to bedside chair, requiring contact guard/minimal assist, using a sliding board to transfer.

▪ Aerobic capacity/endurance: Reports transfer effort 6 out of 10

on perceived exertion scale. Reports dyspnea 5 out of 10 immediately following transfer. ▪ Rolls independently: Able to come to sitting from side-lying with minimal assistance. ▪ Postural control: Maintained static sitting balance on edge of bed 2 minutes. Able to reach forward 7 inches, sideward more than 10 inches bilaterally, reluctant to turn and reach behind because of discomfort. Effective postural responses to mild perturbations forward and backward, moderate perturbations sideways. QUESTIONS TO CONSIDER ▪ List all of the active pathologic conditions and comorbidities that will influence P. G.’s postoperative/preprosthetic care. ▪ List and prioritize the impairments, across physiologic systems and from a psychological perspective, that should be directly addressed or considered in his rehabilitation plan of care. ▪ List and prioritize the functional limitations that will be addressed during his acute care stay. Suggest additional functional limitations that will be addressed as his rehabilitation progresses at home or at a subacute or rehabilitation facility. ▪ List and prioritize disabilities that P. G. is likely to be concerned about and that the rehabilitation team will be attempting to minimize over the course of his care. ▪ Develop a definitive PT diagnosis for P. G. on the basis of the disablement model. ▪ Develop a rehabilitation prognosis for P. G. and explain or justify your expectations. ▪ Develop a list of prioritized goals for P. G. for the next 2 weeks in the acute care hospital. Expand these goals as if care would continue after discharge in a rehabilitation center, at home, or on an outpatient basis. What will frequency, duration, and intensity of his rehabilitation sessions be? How will you judge if he is making progress toward achieving these goals?

20 • Postoperative and Preprosthetic Care

Box 20.4 Acute Care Goals for Case Example 20.1a N. H. is an 89-year-old woman with recent transtibial amputation secondary to peripheral arterial disease. By the conclusion of this episode of care (projected 4–5 days), N. H. will be able to do the following: ▪ Actively participate in inspection of her surgical wound during dressing changes and of her remaining limb. ▪ Describe and recognize signs of inflammation, dehiscence, ecchymosis, and infection along her incision site and of inflammation or developing neuropathic or vascular ulceration of her remaining extremity. ▪ Direct caregivers in the proper application of her compressive dressing and removal of her rigid dressing. ▪ Safely perform rolling and bridging activities, without assistance, for effective bed mobility with perceived exertion of no more than 3 out of 10. ▪ Demonstrate active contraction into full-knee extension in supine and seated positions. ▪ Demonstrate understanding of proper stretching and flexibility for knee extension and hip extension in multiple functional positions. ▪ Safely rise and return from sitting to standing position from a standard arm chair or wheelchair with minimal assistance and occasional verbal cues, with perceived exertion of 4 out of 10. ▪ Ambulate with contact guard and occasional cues, using a hopto pattern using a standard walker for 25 feet, with a perceived exertion of 4 out of 10. ▪ Direct caregivers in assisting her with toilet transfers and clothing management during toileting and other self-care activities.

functional limitation identified in the PT diagnosis and is stated in measurable terms so that progression can be assessed as postoperative and preprosthetic care continues (Box 20.4).

Interventions for Persons With Recent Amputation After amputation surgery the focus shifts to preparation for prosthetic use.216 Strategies for control of edema, pain management, and facilitation of wound healing are implemented. The person with a new amputation and his or her caregivers receive instruction and the opportunity to practice single limb mobility with an appropriate assistive device. A recent study indicates that a majority of patients who undergo transtibial amputation due to diabetic complications report improved quality of life at least 1 year after the surgery.217 This may be due to decreased pain and improved mobility compared with the previously nonfunctional lower extremity. For persons with dysvascular or diabetes-related amputation, the condition of the remaining foot must be carefully monitored as single limb mobility training begins.215 Handling of the residual limb during dressing changes and skin inspection, as well as the consistent use of compression devices, helps to desensitize the residual limb, enhancing readiness for prosthetic use.

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Exercises to strengthen key muscle groups in the residual and remaining limb and to assist effective postural responses are implemented to assist function and prepare for prosthetic gait. Functional training in self-care and transfers begins in the acute care setting and is followed up in home care, subacute, or outpatient settings. The therapist may use a combination of manual therapy, therapeutic exercise, facilitation techniques, physical agents, and mechanical or electrotherapeutic modalities to help manage pain, assist healing, minimize risk of soft tissue contracture, and enhance mobility. A rigid dressing or temporary socket may be fabricated or adapted to protect the residual limb while it heals.

POSTOPERATIVE PAIN MANAGEMENT In addition to reducing acute discomfort, effective postoperative pain management is key for several other reasons. Pain is a significant physiologic stressor that affects homeostasis and the patient’s ability to concentrate and learn.8,9,127 In the early postoperative period, persons with recent amputation are faced with learning how to care for their new residual limb, including monitoring for signs of infection, using strategies to control edema, and appropriate positioning to minimize the risk of contracture formation. They must also learn a variety of new motor skills including exercises to preserve strength and ROM and how to protect their healing suture while moving around with crutches or a walker on their remaining limb. If postoperative discomfort and pain are kept to a minimum, they can better learn and retain these new cognitive and motor skills. Similarly, preoperative anxiety and depression have been shown to influence pain intensity postoperatively, as well as chronic postamputation pain.218 Health care professionals should be aware of these factors when designing a plan of care. Pain can also be fatiguing and demoralizing; those with significant pain may be reluctant to participate fully in active rehabilitation programs because they fear that movement will only increase their pain. Individuals with significant pain may be erroneously labeled as unmotivated or uncooperative, when their primary goal is to find a way to escape their discomfort. Importantly, although certain types of pain medications (opioid and narcotic analgesics) are effective in providing relief, they may compromise cognitive function or increase the risk of postural hypotension.57 Therapists must be aware of the actions and side effects of the pain medication being used. In the days immediately after amputation the goal is to minimize the severity of acute postoperative pain. Because prevention is more effective than reduction of significant pain, those with recent amputations are encouraged to request pain medication before pain becomes severe.58 Preoperative and intraoperative pain management also affects postoperative pain: In patients undergoing amputation due to vascular insufficiency who receive epidural analgesia before surgery, problematic phantom limb pain after amputation may be less likely to develop.68,69 Effective management of postoperative edema is an important element in the control of postoperative pain as well.

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DEALING WITH PHANTOM LIMB SENSATION AND PHANTOM PAIN A variety of pharmacologic and nonpharmacologic interventions have been used for individuals with significant phantom limb sensation or pain, although management of phantom pain is often challenging and frustrating for all involved.59,65,71,219–221 Table 20.6 summarizes the results of a recent Cochrane Review focused on efficacy of pharmacologic management of phantom limb pain.222 Current best evidence is, at best, limited as a result of differences in study methodology and design, insufficient control groups, and acuity/chronicity of the pain. Readers are encouraged to follow developing evidence from future randomized controlled trials of pharmacologic agents in the management of phantom limb pain. One strategy designed to impact development of phantom limb pain in the postoperative period is continuous analgesic infusion to control the severity of phantom limb pain in the immediate postoperative period; the success of this intervention varies with pharmacologic agents and the rate of their administration.69,70,223 Pulse radiofrequency ablation224 and botulinum toxin type A injection225 are being investigated as possible interventions for severe longstanding phantom limb pain that has not been responsive to more conservative approaches. Sympathetic blocks appear to reduce pain intensity over the short term (up to 1 week) but not over the long term (up to 8 weeks).226 Implantation of spinal cord stimulators has been explored for persons with severe, intractable phantom limb pain; however, results appear to be equivocal and complications of the implantation worrisome.227

Physical Therapy for Postoperative and Phantom Pain The success of early rehabilitation is influenced by the effectiveness of postoperative pain management; for this reason, physical therapists must be aware of medications being used and be involved in assessing the effectiveness of the pain management strategy and its impact on patient learning and function.228 When epidural anesthesia has been used during surgery or in the immediate postoperative period, it is imperative that the patient’s cognitive, autonomic, sensory, and motor function is carefully evaluated before transfer training and single limb mobility activities are begun. In whatever setting PT care is provided, it is important that administration of medications be timed so that pain control is optimal during PT activities. If the patient is experiencing phantom sensation or pain, the physical therapist plays an important role in educating the patient and family about these sensations. Noninvasive alternatives such as relaxation techniques, imagery, desensitization, hypnosis, therapeutic touch, or virtual reality activities may be effective adjuncts for pharmacologic interventions aimed at pain reduction.229,230 Virtual reality and other simulation experiences are beginning to show promise in relief of phantom pain.230,231 Transcutaneous electrical nerve stimulation (TENS) is an effective adjunct for pain management for patients with acute postsurgical pain.232–234 TENS may also play a role in the management of troubling phantom sensation or pain in the immediate postoperative period; however, its efficacy in the prevention or management of phantom limb pain over time is not well supported in the clinical research

Table 20.6 Results of a Cochrane Review of Prescription Medications Used in the Management of Moderate to Severe Phantom Limb Pain and Their Side Effects

a

Medication

Class

Primary and Secondary Outcomesa

Adverse Effects Reported

Oral or IV morphine

Opioid

Short-term decrease in pain intensity Better sleep No impact on mood Satisfaction higher in oral versus IV

Sedation, fatigue, dizziness/vertigo, constipation, sweating, difficulty voiding, itching, respiratory depression

Ketamine or dextromethorphan

N-methyl-Daspartate (NMDA) receptor antagonists

Short-term decrease in pain intensity Better sleep Better sense of well-being No impact on functional status

Sedation, hallucinations, loss of consciousness, hearing impairment, balance problems, insobriety

Gabapentin

Anticonvulsant

Trend toward short-term decrease in pain intensity No impact on mood No impact on functional status No impact on sleep

Somnolence, dizziness, headache, nausea

Amitriptyline

Tricyclic antidepressant

No impact on pain intensity No impact on mood No impact on functional status Negative impact on sleep

Dry mouth, drowsiness, blurred vision, dizziness, constipation, altered sleep, nausea/vomiting/ diarrhea, tinnitus, urinary retention

Calcitonin infusion

Polypeptide hormone

Trend toward decreased intensity and frequency of phantom limb pain in persons with recent amputation

Facial flushing, nausea, sedation, dizziness

Lidocaine; bupivacaine

Anesthetics

No different than morphine

Stinging sensation at injection site

Primary outcomes: change in phantom limb pain intensity; possible secondary outcomes: changes in mood (depression), functional status, quality of sleep, patient satisfaction with intervention, severity of adverse effects. Adapted from Alviar MJ, Hale T, Dungca M. Pharmacologic interventions for treating phantom limb pain. Cochrane Database Syst Rev. 2011;(12):CD006380.

20 • Postoperative and Preprosthetic Care

literature.235–237 There is limited evidence for the use of TENS to reduce phantom limb pain using low-frequency and high-intensity settings, although more studies are needed.221 Additional PT interventions that have been used to manage on postoperative pain include mechanical stimulation (massage, vibration, percussion) and superficial heat (ultrasound, hot packs, cryotherapy) or cold; although there are clinical reports of short-term pain relief, there are few studies that have carefully evaluated their efficacy.237 For any PT intervention in the postoperative/preprosthetic period, it is imperative to pay careful attention to the healing status of the wound: wound closure must not be compromised by any intervention that is aimed at reducing discomfort or pain. Energy-based medicine therapies (e.g., mind-body connection approaches, therapeutic touch, eye-movement reprocessing and desensitization, and motor imagery) may be alternative approaches to the management of acute and chronic phantom limb pain, although there are few welldesigned and well-controlled studies of their efficacy.238,239 Mirror box therapy is being investigated as a strategy to minimize the development and severity of phantom pain after amputation.221,240,241 This approach attempts to facilitate cortical reorganization by accessing the mirror motor and sensory neuron systems and prefrontal cortex in the brain.242–244 In the most commonly used paradigm, persons with amputation attempted to move their “missing” limb while simultaneously moving and observing reflected image of the movement of the intact limb.245 The degree of severity of phantom limb pain has been shown to positively correlate with the onset of relief, with the lowest levels of pain experiencing relief in the fewest number of sessions and the highest pain levels requiring the most amount of sessions before relief.246 Although preliminary evidence suggests that mirror box therapy may be helpful,221,245,247–249 more carefully designed and controlled studies are necessary before it can be widely adopted for clinical use. Mirror therapy is not without adverse effects: Some individuals experience dizziness and disorientation, sense irritation in their residual limb, or do not tolerate the intervention, especially if mirror therapy is concurrent with traditional prosthetic training.250 Still, despite all of the various forms of treatment for phantom limb pain, there appears to be no first line treatment, indicating a need for further study.251

LIMB VOLUME, SHAPING, AND POSTOPERATIVE EDEMA The management of postoperative edema is important for four reasons: Edema control strategies are essential components of pain control, enhance wound healing, protect the incision during functional activity, and assist preparation for prosthetic replacement by shaping and desensitizing the residual limb.7 A variety of postsurgical dressing and edema control strategies are available. These include soft dressings with or without Ace wrap compression, SRDs, various removable rigid dressings (RRDs) applied over soft dressings, or the application of a rigid cast dressing in the operating room.252,253 An IPOP or EPOP is a rigid dressing with an attachment for a pylon and prosthetic foot.254,255 Pneumatic IPOP/EPOP options are also available for early

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ambulation. Each option contributes to pain control, wound healing and protection, and preparation for prosthetic use in a significantly different way. The choice of strategy is determined by the etiology and level of amputation, the condition of the skin, the medical and functional status of the patient, access to prosthetic consultation and care, the preference and experience of the surgeon, and established institutional protocol. Table 20.7 compares characteristics of the most commonly used postoperative/ preprosthetic options.252–254

Soft Dressings and Compression The traditional postoperative edema-control and woundmanagement strategy is a soft dressing with or without compression wrap. A nonadherent dressing is placed over the suture line, sterile absorbent gauze fluff is then placed over this, and one or more rolls of gauze is loosely overwrapped in figure-of-eight pattern around the residual limb. A compressive Ace bandage wrap may then be used in an effort to control some of the postsurgical edema. Although this method continues to be the most frequently used immediate postsurgical option for patients with transfemoral amputation or when significant wound drainage and a high risk of infection are present, soft dressings with Ace wraps are ineffective for limiting postoperative edema.118,252,253 Soft dressings cannot protect a healing incision from bumps, bruising, or shearing during activity or from fall-related injury. The other practical disadvantage of elastic Ace bandage compression of the residual limb is the need for frequent reapplication: Movement during daily activities quickly loosens the bandages, compromising the effectiveness of the compression. Most rehabilitation professionals suggest that Ace bandages should be removed and reapplied every 4 to 6 hours and should never be kept in place for more than 12 hours without rebandaging.256 Effective application of an Ace wrap requires practice, manual dexterity, and attention to details if the desired distal-to-proximal pressure gradient is to be achieved (Figs. 20.12 and 20.13).74,256,257 It may be difficult for patients with limited vision, arthritis of the hands and wrist, limited trunk mobility, or compromised postural control to master this technique for independence in control of edema. Nurses, residents, surgeons, therapists, prosthetists, and family members (and anyone else who may be taking down the soft dressing to care for the wound) must be consistent and effective in reapplication of the Ace bandage if maximal control of edema is to be achieved. Ineffectively applied elastic wraps can lead to a bulbous, poorly shaped residual limb, which is likely to delay prosthetic fitting.257 Tight circumferential wrapping can significantly compromise blood flow, compromising healing of the incision and even leading to skin breakdown.257 Some patients with bulbous or pressure-sensitive residual limbs do not tolerate Ace wrap for compressions. An alternative to these patients, as well as for those with limited dexterity, is application of an elasticized stockinet or Tubigrip sock (Seton Health Care Group TLC, Oldham, England). Both materials are available with various levels of elasticity; minimal to significant compression can be achieved, depending on the patient’s tolerance of pressure. The double-layer method starts with careful application of a long piece of elastic stockinet or Tubigrip over the transtibial

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OUTCOMES Protection from Trauma

Degree of Postoperative Edema

Postoperative Pain

Knee Flexion Contracture Risk

Time to First Prosthetic Fitting

Strategy

Cost

Ease of Application

Wound Healing

Soft gauze dressing without Ace wrap

Inexpensive

Not difficult

Little impact on primary or secondary healing

None

Significant

Often severe

Very high

Prolonged

Soft gauze with Ace wrap

Inexpensive

Figure-of-eight wrap requires skill, frequent reapplication

Little impact on primary or secondary healing

None

Significant

Often severe

Very high

Prolonged

“Shrinker” garment

Low to moderate cost

Requires UE strength, dexterity

Used after primary healing has occurred

Minimal

Moderate

Somewhat less

Very high

Slightly shortened

Rigid dressing (above knee cast)

Low cost

Requires training; MD or CP

Reduces time to primary healing

Excellent

Minimal

Minimized

Extremely low

Shortened

RRD (below knee) Plaster/custom

Low to moderate cost

Requires training; PT or CP

Reduces time to primary healing

Very good

Minimal

Minimized

Moderate

Shortened

RRD Prefabricated (thigh level)

Moderate cost

CP custom fits

Reduces time to primary healing

Very good

Minimal if worn consistently

Minimized if worn consistently

Extremely low

Shortened

IPOP Rigid dressing Plaster/custom

Low to high cost

CP applies in the OR, or fabricates

Reduces time to primary healing if protected WtB only

Very good when worn, protected WtB only

Reduced if worn consistently

Minimized if worn consistently

Low if worn consistently

Shortened

IPOP: pneumatic

Moderate to high cost

PT uses as part of rehabilitation

Less evidence about impact on healing available

Very good when worn, protected WtB only

Reduced if shrinker worn between IPOP use

Depends on options in place between IPOP use

Moderate if not in thigh RRD between use

Shortened

CP, Certified prosthetist; IPOP, immediate postoperative prosthesis; MD, physician; OR, operating room; PT, physical therapist; ROM, range of motion; RRD, removable rigid dressing; UE, upper extremity; WtB, weight bearing. Data from Nawijn SE, van der Linde H, Emmelot CH, Hofstad CJ. Stump management after transtibial amputation: a systematic review. Prosthet Orthot Int. 2005;29(1):13–26; Smith DG, McFarland LV, Sangeorzan BJ, et al. Addendum 1: post-operative dressing and management strategies for transtibial amputations: a critical review. J Prosthet Orthot. 2004:16(S3):15–25; and Walsh TL. Custom removable immediate postoperative prosthesis. J Prosthet Orthot. 2003;15(4):158–161.

Section III • Prostheses in Rehabilitation

Table 20.7 Comparison of Various Postoperative Options for Management of New Transtibial Residual Limbs Following Amputation

20 • Postoperative and Preprosthetic Care

1

2

3

4

5

6

537

Fig. 20.12 The application of an effective Ace wrap to a transtibial residual limb uses successive diagonal figure-of-eight loops between the distal residual limb and thigh to create a distal-to-proximal pressure gradient. This creates a distal-to-proximal, tapering, cylindrical residual limb with minimal excess distal soft tissue. (Modified from Karacollof LA, Hammersley CS, Schneider FJ. Lower Extremity Amputation. Gaithersburg, MD: Aspen; 1992:16–17.)

residual limb to midthigh level (Fig. 20.14). The remaining length of elastic stockinet or Tubigrip is turned or twisted 180 degrees (to minimize pressure over the new incision) and rolled over the residual limb as a second layer of compression. As residual limb volume decreases and the limb becomes more pressure tolerant, a stockinet or Tubigrip with progressively narrower diameters is used to increase compressive forces and assist limb shrinkage and maturation. These materials are relatively inexpensive, but they are not as durable as commercially available elastic shrinker socks.

Pressure Garments: “Shrinkers” Once the suture line has healed sufficiently, many prosthetists and therapists recommend the use of a commercially manufactured elasticized “shrinker” pressure garment whenever the prosthesis is not being worn (Fig. 20.15A and B).90,257 These garments are designed to apply significant distal to proximal graded compressive force to the residual limb, and it may be difficult for individuals with limited manual dexterity or upper extremity strength to apply them. Patients with recent amputation must be careful to minimize or avoid excessive shear forces over the incision as the shrinker is being applied. Although shrinkers are effective for control of edema and limb volume, it is not possible to create “relief” for bony prominences or pressure-vulnerable areas on the residual limb. As with

other soft dressings, commercial shrinkers cannot protect the residual limb from trauma during daily activities or in the event of a fall. It is not unusual for patients to continue to use a shrinker for limb volume control, whenever they are not wearing their prosthesis, for 6 months to a year after amputation.90 Although a number of edema control options are available for persons with transtibial amputation, those with transfemoral residual limbs have fewer strategies from which to choose. Commercially manufactured shrinkers are more convenient to don and are more likely to remain in place than the more cumbersome Ace wraps, but those who choose this option must be just as careful to capture all the soft tissue high in the groin within the shrinker to avoid the development of an adductor roll, redundant tissue that may make prosthetic fitting more challenging. Another alternative for those with transfemoral amputation is a custom-fit Jobst pressure garment. Jobst garments can be fabricated either as a half-pant or full pant garment; the full pant garment achieves a more consistent suspension and compression, especially for patients who are obese. A Jobst garment may be the only effective alternative for patients with short transfemoral amputation. Because shrinkers, Tubigrip, and prosthetic socks worn over a healing residual limb are permeable, they absorb perspiration from the skin of the residual limb, as well as any drainage from the suture line. For this reason, they must

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Section III • Prostheses in Rehabilitation

1

2

4

6

3

5

7

9

8

10

Fig. 20.13 The application of an effective Ace wrap to a transfemoral limb also strives to create a distal-to-proximal pressure gradient using a modified figure-of-eight pattern. For patients with transfemoral amputation, the wrap is anchored around the pelvis and applied to pull the hip toward hip extension and adduction. Note the importance of capturing soft tissue high in the groin within the Ace wrap to reduce the risk of developing an adductor roll of noncompressed soft tissue. (From May BJ. Amputation and Prosthetics: A Case Study Approach. Philadelphia, PA: F. A. Davis; 1996:84.)

Fig. 20.14 One strategy to control edema and manage limb volume is to use a double layer of an elastic stockinet or Tubigrip to apply compressive forces to the limb. After the initial layer (A) has been smoothly applied, the stockinet is twisted closed (B) at the end of the limb and the excess is applied (C) as a second layer of compression.

be laundered daily in warm water and a mild soap. Cotton, wool, or elasticized materials do not tolerate the heat and turbulence of a clothes dryer; most prosthetists recommend that shrinkers and socks be smoothed out on a flat surface to

dry. The person wearing the garment must have a sufficient number available to apply compression around the clock. In addition, sock changes are less frequent during the weekdays than on the weekends, and use of a daily “sock log”

20 • Postoperative and Preprosthetic Care

A

B

Fig. 20.15 Examples of commercially available transfemoral (A) and transtibial shrinkers (B) used for edema control and shaping of the residual limb. (From www.juzo.com.)

Fig. 20.16 A plaster or fiberglass cast, applied immediately after amputation in the operating room, is an effective method of edema control, protection of the residual limb, and prevention of knee flexion contracture.

may help to facilitate proper sock use for volume management and comfort.258

Nonremovable Rigid Dressings Many surgeons opt to use a cylindrical plaster or fiberglass cast placed on the new transtibial residual limb in the operating room immediately after amputation (Fig. 20.16).79,90,259,260 Rigid dressings accomplish three very important postoperative goals: (a) control of immediate postoperative edema (and subsequently, reduction of postoperative pain); (b) protection of the vulnerable newly sutured residual limb from inadvertent trauma during bed mobility, transfers, and single limb ambulation; and (c) prevention of postoperative knee flexion contracture. All three of these goals help to reduce time to initial prosthetic fitting.98,259,261 A rigid dressing is a simple postoperative cast applied in the same way as a cast that is used to immobilize a fracture

539

of the proximal tibia or distal femur. The newly sutured surgical construct is dressed with gauze, and a cottonette or Tubigrip “sock” is pulled over the residual limb. A layer of cast padding is applied smoothly over the stockinette, and extra cushioning is placed to protect the patella and femoral condyles. The knee is placed in as close to a fully extended position as possible, and fast-drying plaster of Paris or fiberglass casting material is wrapped around the limb, at least to the level of upper thigh (2–4 inches below the perineum). The stockinette is then folded over the proximal edge of the newly applied cast and is incorporated into one or two addition wraps of casting material to finish the proximal border of the cast. Modifications of the cast as it is setting or drying, such as molding it to fit closely over the supracondylar thigh, are used to aide suspension. A strip of webbing may be incorporated on the anterior surface for attachment to a waist belt to further aide to suspension. If the cast is to be used as the base for an IPOP (discussed in more detail later), the prosthetist modifies the cast as in a patellar tendon–bearing socket to ensure that weight-bearing forces are directed to pressure tolerant areas of the limb and that bony prominences and the suture line are well protected. The initial rigid dressing stays in place on the residual limb for 2 to 5 days postoperatively (or more), depending on the patient’s condition and the surgeon’s preference.90,98,252,253 When the cast is removed, the status of the wound is carefully inspected. If the wound is healing well, the physician may opt for reapplication of the cast for an additional period, which varies by protocol used, of between 5 and 21 days. If the status of the wound is questionable or risk of infection high, an alternative method of edema control that allows more frequent wound inspection and care must be used. Some physicians opt to replace a thigh-encasing rigid dressing with an RRD after the first cast is taken off, regardless of wound status. Application of a rigid cast, especially if it is the base of an IPOP (discussed later) requires careful attention to anatomy and alignment, well-developed manual skills, and a clear understanding of prosthetic principles. A poorly applied or inadequately suspended rigid dressing can lead to skin abrasions or pressure-related ulcerations over bony prominences, delaying prosthetic fitting until wound healing occurs. Pistoning or rotation of the rigid dressing on the residual limb can apply distracting forces over the suture line, compromising healing and increasing the risk of ecchymosis or dehiscence. A major criticism of thigh-level non-RRDs is that the cast prevents visual inspection and monitoring of the new surgical wound and limits access for wound care.259 For this reason a non-RRD may not be appropriate for those with significant risk of infection, especially if wounds were potentially contaminated during traumatic injury. Wound status can be monitored only indirectly, using body temperature, WBC count, size and color of drainage stains on the cast, and patient reports of increasing discomfort and pain as indicators of a developing infection. There are several strategies that physicians and prosthetists have to address to assess healing, while providing the protection and other benefits of non-RRD. One is to

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Section III • Prostheses in Rehabilitation

Fig. 20.17 AmpuShield removable rigid dressing. (From Reichmann JP, Stevens PM, Rheinstein J, Kreulen CD. Removable rigid dressings for postoperative management of transtibial amputations: a review of published evidence. PMR. 2018;10(5):516–523. DOI: https://doi.org/10.1016/j. pmrj.2017.10.002.)

bivalve the cast so that it can be removed for short periods to allow wound care. Prefabricated rigid dressings, custom fit by the prosthetist to the individual with new amputation, are also available.262

Removable Rigid Dressings The RRD is a “cap” cast worn over a soft or compressive dressing (Fig. 20.17).263 This edema-control strategy effectively protects the healing residual limb and helps to limit the development of edema. RRDs are used in three circumstances. For some individuals managed with a non-RRD applied in the operating room, the next step in postoperative edema control may be fabrication of an RRD. For others the RRD is applied instead of a cylindrical cast in the operating room. The RRD can also be fabricated after surgery for those initially managed with soft dressings and elastic bandages. The physical therapist may be responsible for fabrication of the RRD, working in collaboration with the surgeon, surgical nurse, or prosthetist. The RRD has been shown to be more beneficial than soft dressings for reducing limb edema, increasing healing time, limb contouring, reduced external limb trauma, and prevention of knee contractures.264 One of its major advantages, when compared with a cylindrical cast, is the ability to doff (remove) and don (apply) the RRD quickly and easily to monitor wound healing and provide daily wound care. Use of an RRD also assists residual limb shaping and shrinkage; patients who wear RRDs are often ready for prosthetic fitting more

quickly than those managed with soft dressings or Ace wraps alone.265,266 Because the RRD limits the development of edema, it is an important adjunct in the management of postsurgical pain. The protective cap limits shearing across the incision site as the person recovering from amputation surgery moves around in bed or during therapy; this soft tissue immobilization can assist wound healing. The RRD is not as likely to become displaced or dislodged during activity when compared with Ace wrap compression. The ease of donning and doffing means that individuals with new amputation can quickly become responsible for this task component of caring for their residual limb. Because the RRD is removed and reapplied several times a day for wound care, the residual limb quickly becomes desensitized and tolerant of pressure, which assists transition to prosthetic wear. Fabrication and use of an RRD provide the opportunity to educate those new to prosthetic use about the fabrication of a preparatory prosthesis and the use of prosthetic socks to obtain and maintain socket fit. The RRD is most appropriate for patients whose transtibial incision appears to be in the initial stages of healing. Although the wound may be inflamed secondary to the trauma of surgery, no signs of infection, significant ecchymosis, or large areas of wound dehiscence should be present. Those with substantial drainage from their surgical wound requiring bulky soft dressings and frequent dressing changes are not good candidates for RRD; it is difficult to accommodate distally placed bulky dressings within the RRD shell. Those with fluctuating edema secondary to CHF or dialysis can be managed with an RRD if it is fabricated when limb volume is high: Layering prosthetic sock ply over the limb before putting on the RRD accommodates for volume loss. The RRD works best if distal residual limb circumference is no more than ½ inch larger than its proximal circumference. Compressive dressings may be more appropriate for patients with extremely bulbous residual limbs. The residual limb is prepared for casting by first placing a protective layer of gauze fluff over the suture line.263,267 The limb can be loosely wrapped in plastic wrap to assist removal of the completed RRD after casting. Next, a “sock” made from elasticized cotton stockinet or Tubigrip is applied over the limb, with particular care to avoid shearing across the suture line. Pieces of Webril or a similar filler material are layered around the limb to create reliefs within the RRD for bony prominences (tibial crest, fibular head, distal tibia) and the hamstring tendons. When the distal residual limb has a larger circumference, additional padding is added proximally to ensure that the RRD will be cylindrical and easily donned. A long sock made from regular cotton stockinet is carefully donned over the padding; this will be the inner layer of the finished RRD. The outline of the patella marked on the stockinet will serve as a guide for trim lines after the cast has dried. Typically, two rolls of fast-setting plaster cast material are sufficient for an RRD. The residual limb is supported in full knee extension, and successive layers of plaster are smoothed into place, building a cast with an anterior trim line at midpatella and a slightly lower posterior trim line to allow knee flexion without tissue impingement.

20 • Postoperative and Preprosthetic Care

The cotton stockinet sock is then folded down over the cast at the knee, and several additional circumferential layers of plaster are used to finish and reinforce the proximal brim (to ensure that the RRD can subsequently withstand repeated donning/doffing). An Ace wrap can be applied to provide additional compression while the plaster sets. Once the RRD has hardened sufficiently, the patient is asked to flex the knee slightly and the cast is carefully removed from the residual limb. The extra Webril or padding is pulled out of the RRD, and the inner surface is inspected for potentially problematic rough areas or ridges. Because the RRD is almost cylindrical, it is helpful to mark the front of the cast to ensure that it is correctly donned. Before the completed RRD is applied, one or two gauze pads are placed over the suture line for protection. A prosthetic sock, Tubigrip, elasticized stockinet sock, or commercially manufactured “shrinker” is carefully donned, with minimal shear stress across the suture line. Additional ply of prosthetic socks are used as needed to ensure a snug fit within the RRD. A small amount of Webril or other fluffy padding is placed in the distal anterior RRD to protect the distal tibia and suture line; then the RRD is carefully slipped onto the residual limb, aligning the markings on the front of the RRD with the patella for optimal fit. A small foam filler or cushion can be placed between the anterior brim and residual limb to minimize the risk of friction during activity. The outer Tubigrip or stockinet suspension sleeve is then rolled over the RRD and onto the thigh, the supracondylar strap is secured in place, and the sock is folded back down over the strap to minimize the risk of loss of suspension. The skin must be inspected within the first 60 to 90 minutes of initial fitting with an RRD to assess skin integrity and identify potential pressure-related problems. If no skin problems develop, routine wound inspection once per nursing shift is usually adequate. The RRD is designed to be worn continuously, even when sleeping, except during routine wound care or bathing. If the individual with recent amputation is expecting to be out of the RRD for more than several minutes, another form of compression such as a shrinker or several layers of Tubigrip must be available to minimize the development of edema. The individual wearing an RRD must be encouraged to report any localized pain or discomfort as signs of potential problems with RRD fit or function. Layers of prosthetic sock are added, over time, as the residual limb “shrinks.” There is some evidence that polymer gel socks worn under an RRD may help to control edema and associated pain and reduce the time to prosthetic fitting.268 Sometimes short distal socks are necessary to provide for distal compression without excessive proximal bulkiness that can prohibit donning. The consistent use of 12- to 15-ply socks to achieve appropriate fit usually indicates the need for fabrication of a smaller RRD. Significant change in the shape or configuration of the residual limb also requires fabrication of a new RRD. The referral for fabrication of the initial (preparatory or training) prosthesis can occur within 12 to 17 days of surgery if the incision has healed sufficiently. Many individuals continue to use their RRD in conjunction with a shrinker for control of edema and limb protection whenever they are not wearing their prosthesis for as long as 6 months after surgery.

541

Removable Polyethylene Semirigid Dressings An alternative to a plaster RRD is a removable polyethylene SRD.269 Like the RRD, the SRD is an effective strategy for control of edema, protection of the healing incision, and shaping of the residual limb.270 However, unlike the RRD, the SRD requires the skill of a prosthetist for fabrication. The prosthetist may take a negative mold of the patient’s residual limb while in the operating room or when the rigid dressing is removed on the third or fourth postoperative day. A positive model is created using the negative mold and is modified to incorporate reliefs for pressure-intolerant areas of the residual limb. The polyethylene is heated and vacuum molded over the positive model in the same way that a thermoplastic socket would be. The polyethylene SRD is often ready for delivery in 2 or 3 days after casting. When someone is initially casted for a polyethylene SRD in the operating room before being placed in a plaster or fiberglass cast, the SRD may be delivered on the day that the rigid plaster dressing is removed. The polyethylene SRD has several advantages when compared with the plaster of Paris RRD. First, polyethylene is easier to clean; as a result, hygiene of the residual limb may be improved. The polyethylene SRD is lighter in weight and somewhat more durable than a plaster RRD; it does not melt if exposed to liquids. The flexibility of the material makes it easier to don and doff than the stiff plaster RRD. Because the polyethylene SRD closely resembles a transtibial socket, greater carryover about proper use of prosthetic socks for optimal fit in the socket of the initial (preparatory, temporary, or training) prosthesis is likely. The major disadvantage of a polyethylene SRD is the cost associated with casting and fabrication. Because most residual limbs become progressively smaller with maturation in the weeks and months after amputation, several successfully smaller SRDs may need to be fabricated as the limb shrinks. In some settings, plaster RRDs are used until the initial prosthetic fitting. At that point the prosthetist makes a polyethylene SRD, in addition to the socket, for the training prosthesis. Some companies now offer a prefabricated adjustable SRD with Velcro closures as an alternative to the custom-molded polyethylene SRD. Zinc Oxide–Impregnated Semirigid Dressing Another postoperative strategy is the fabrication of an SRD using a zinc oxide–impregnated Unna bandage. Unna is most often used in the management of chronic venous stasis ulcers (Unna boot)271; because it appears to enhance healing, it has also been used as a strategy to control edema and facilitate healing following transtibial amputation.272 As the Unna dressing dries, it provides nonelastic external support to the residual limb, preventing development of edema. The Unna dressing is basically a roll of gauze impregnated with zinc oxide, triglycerine, calamine, and gelatin. This pasty dressing easily adheres to the skin on application, drying to a semirigid leathery consistency within 24 hours. Typically, an Unna dressing would be applied to the residual limb immediately after wound closure in the operating room.272 Although not as rigid and protective as an RRD or SRD, Unna paste dressings are more effective in limiting postoperative edema than are soft dressings and Ace

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Section III • Prostheses in Rehabilitation

wrapping.272 An Unna SRD can be left on for as long as 5 to 7 days; if more frequent wound inspection is desired, it can be easily removed with bandage scissors. Because the Unna dressing remains in place for an extended period, fewer opportunities are available for limb desensitization and patient education about socket fit compared with those for the RRD and polyethylene SRD.

Pneumatic Compression for Early Ambulation The deconditioning associated with inactivity is a particular concern in the postoperative and preprosthetic periods. However, ambulation on a single limb can be quite challenging for persons with a high comorbid burden of illness. Although pneumatic compression (such as the air splints use for immobilization following acute fracture) is relatively inexpensive and can be quickly removed and reapplied for wound inspection, the compression tends to be uneven, so shaping of the residual limb is not as effective as other methods. The splint can be uncomfortably hot if worn for more than 20 to 30 minutes. However, its major benefit is that it allows early protected weight bearing on the residual limb; this is especially beneficial for individuals who are physically or functionally frail.273 The air splint provides limited mobility for patients who would not otherwise be ambulatory and may be a useful means of assessing the potential for prosthetic rehabilitation. Several air-filled early prosthetic options exist for compression in the postoperative and preprosthetic periods.274–277 However, because regulation of the amount of weight bearing allowed within a pneumatic compression splint is difficult to control, the therapist must weigh the risks of placing too much pressure on the surgical wounds as compared with limited mobility. For this reason, many prosthetists prefer a non–weight-bearing rigid residual dressing.278,279 Another option is the bent-knee prosthesis, which, when used with an RRD, removes weight bearing from the incision site yet does not prohibit ambulation (see Fig. 20.18).280 When donning a pneumatic compression device for early ambulation, the suture line is covered with smooth gauze pads for protection. Prosthetic socks, stockinet, or Tubigrip is then applied over the residual limb before the air splint is inflated. Felt pads are strategically placed over the residual limb’s soft dressing, or a shrinker loads pressure-tolerant areas (medial tibial flare and patellar tendon) while protecting pressure-sensitive areas (crest of the tibia and fibular head) after inflation of the air splint. The sleeve is zipped into place around the limb, and the limb is positioned in the frame before inflation. The sleeve is inflated with a hand or foot pump to an air pressure of 35 to 40 mm Hg. This low pressure sustains toe touch to partial weight without compromising capillary blood flow to the healing suture line. Recently a variety of prefabricated pneumatic immediate postoperative prostheses, with inflatable air bladders within an adjustable closure polyethylene “socket,” has become available.281–284 Rigid Dressing as a Base for Immediate Postoperative Prostheses When a non-RRD is to be used as an IPOP, a prosthetist joins the surgical team in the operating room during cast

Fig. 20.18 Bent-Knee Prosthesis. (Courtesy of Hanger Inc., Austin, TX.)

application to incorporate the features of a patellar tendon–bearing socket and an attachment for a pylon into the cast (Fig. 20.19).285 Several felt or gel pads are positioned on the limb to direct and distribute weight-bearing forces more effectively onto pressure-tolerant areas (e.g., medial tibial flare, anterior muscle compartment, patellar tendon). The residual limb is then supported with the knee extended, and several layers of elastic or nonelastic plaster of Paris or fiberglass casting material are applied. The proximal edges of the cast are finished at the upper thigh (2–4 inches below perineum) level. Modifications of the cast (as it is setting) are used to aid suspension or, for an IPOP, to ensure that weight-bearing forces are directed to pressure-tolerant areas. Pressure applied to the outside of the cast just above the femoral condyles captures normal femoral anatomy to create supracondylar suspension. For an IPOP, the prosthetist incorporates a patellar tendon bar, a broad “shelf” for the medial tibial flare, and a stabilizing popliteal bulge by applying manual pressure to these areas as the cast begins to set. The prosthetist also incorporates a point of attachment and alignment into the distal cast for subsequent attachment of a pylon and prosthetic foot. Finally, the prosthetist or surgeon can incorporate a suspension attachment, which will connect to a waist belt, into the proximal anterior surface of the cast. In a retrospective study of individuals who underwent a below-knee amputation, at 60 days postamputation 58% of those who received a rigid plaster or plastic IPOP were ready for prosthesis casting compared with 38% of those who received a soft dressing.279,286 The early mobility afforded by application of an IPOP may be important physically and psychologically for individuals with new

20 • Postoperative and Preprosthetic Care

A

B Fig. 20.19 (A and B) Incorporation of a pylon and features of a patellar tendon–bearing socket in an immediate postoperative prosthesis (IPOP) can facilitate early mobility in selected patients. (From Ali MM, Loretz L, Shea A, et al. A contemporary comparative analysis of immediate postoperative prosthesis placement following below-knee amputation. Ann Vasc Surg. 2013;27(8):1146–1153.)

amputation who would otherwise be unable to achieve single limb ambulation with a walker or crutches, especially those who are at significant risk of functional decline, physiologic deconditioning, or atelectasis and pneumonia secondary to inactivity and immobilization.287 Although an IPOP replaces the amputated limb with a pylon and prosthetic foot, limited and protected weight bearing is essential in the early postoperative period: most physicians suggest toe touch or partial weight bearing. Shearing forces that result from excessive weight shift and repeated loading of the residual limb in an IPOP can compromise or delay wound healing.285 Because of this risk, an IPOP is inappropriate for frail or confused individuals who are likely to be unreliable about limiting weight bearing. Many proponents of IPOP suggest that gradual controlled application of mechanical stress to healing connective tissues actually assists tissue modeling for better tolerance of the mechanical stresses of prosthetic wear and ambulation. Although the early application of mechanical stresses is apparently well tolerated by wounds with adequate blood supply, ischemic wounds tolerate only minimum stress in their healing phase.

Selecting the Appropriate Compression Strategy In deciding which edema control and limb-shaping strategy is most appropriate, the rehabilitation team should consider the following questions:

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1. Can the person don/doff the device independently? If not, is a family member available who can assist with this task? 2. Given the individual’s physical characteristics and likely level of activity, will the device remain securely in place on the residual limb? 3. Will the device apply enough compression for effective progressive limb shrinkage? 4. Will the device apply enough compression for symmetric shaping of the residual limb? 5. Will the device protect the skin and healing suture line during daily activities, and does use of the device carry any risk of skin irritation or breakdown? 6. Is the device comfortable for the patient to use or wear over the long periods of time that are required for effective control of edema and limb shaping? 7. Is the device relatively cost effective in terms of fabrication, modification, and replacement? Monitoring tissue tolerance and potential areas of pressure closely in whatever edema control method is chosen is very important, especially in the first few days and weeks after amputation. Although rigid dressings, IPOPs, and Unna dressing remain on the limb for extended periods, each other method of edema control and shaping should be removed and reapplied a minimum of three times each day to ensure appropriate fit and tissue tolerance in the acute phase of healing. When a rigid cast or IPOP is removed, it must be quickly replaced with an alternative compression device so that limb volume does not increase substantially. Individuals with recent amputation must wear the compression device at all times unless walking in a training prosthesis (even time out of compression during bathing should be as short as possible). Most people find that a compression device is necessary to maintain the desired limb volume for 6 months to a year after surgery. Some persons with mature residual limbs who have fluctuation in volume because of concurrent medical conditions continue to require compression well beyond the first postoperative year. Many people with amputation experience a transient increase in residual limb volume after showering or bathing; they often choose to bathe in the evening so that volume change does not interfere with prosthetic use. Those who prefer to bathe in the morning may need to use a compression device immediately after bathing to achieve optimal prosthetic fit and suspension, especially if suction suspension (which requires consistent limb volume) is used. Those who use prosthetic socks may require a few less ply of sock immediately after bathing but need to add a few more ply after a few hours as limb volume decreases.

SKIN CARE AND SCAR MANAGEMENT It is important that the healing incision move without adherence to underlying deep tissue or bone as healing progresses. There must be sufficient gliding between skin and underlying layers of soft tissue after healing so that shear forces will be minimal while the prosthesis is donned and used for function. An adherent scar at the distal tibia can

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be quite problematic: If a point of adherence is present along an incisional scar, the mobility of tissues will be compromised. The resulting traction and shear forces are likely to lead to discomfort, skin irritation, and often recurrent breakdown of soft tissues with prosthetic use. Once primary healing has been established, the person with recent amputation learns to use gentle manual massage to enhance tissue mobility in preparation for prosthetic use. At first, this is performed above and below, but not across, the incision to minimize the risk of dehiscence. When the wound is well closed and Steri-Strips are no longer necessary to support and protect the incision, gentle mobilization of the scar itself can begin. Handling of the limb during soft tissue mobilization and massage not only minimizes adhesion formation but also helps the individual to adapt his or her body image to include the postamputation residual limb and prepare for the sensory experience of prosthetic use.288,289 Persons with new amputation may have surgical scars from previous vascular bypass or from harvesting veins for coronary artery bypass surgery. These may require carefully applied soft tissue mobilization or friction massage to free adhesions and restore the mobility of the skin. Those with traumatic amputation may have healing skin grafts or abrasions from road burn, thermal injury, or electrical burn. In such cases, wound care and d
ebridement are important components of preprosthetic rehabilitation. For individuals with healing burns or skin graft, the use of an appropriate compression garment or shrinker assists healing and maturation of skin, controls postoperative edema, and shapes the residual limb. Once the sutures have been removed, normal bathing resumes and a routine for daily skin care is established. Most physicians, prosthetists, and therapists recommend daily cleansing of the residual limb with a mild, nondrying soap. Patting or gently rubbing the limb with a terry cloth towel until it is fully dry also helps to desensitize it in preparation for prosthetic use. A small amount of moisturizer or skin cream can be applied if the skin of the residual limb is dry or flaky. A limb with soft, healthy pliable skin is much more tolerant of prosthetic wear than a limb with tough, dry, easily irritated skin. Persons with new amputation and their caregivers are taught to inspect the skin of the entire residual limb carefully, using a mirror if necessary to visualize difficult-to-see areas. Areas over bony prominences that may be vulnerable to high pressure within the socket are especially important to assess. Persons with amputation are as likely to have other dermatologic conditions such as eczema or psoriasis as the general population.290–292 Those with hairy limbs or easily irritated skin may be more at risk of folliculitis and similar inflammatory skin conditions once the prosthesis is worn consistently. Effective early management of skin irritation or other skin problems is important: Serious skin irritation or infection precludes prosthetic use until adequate healing has occurred. Some persons with new amputation mistakenly assume that something must be used to “toughen” the skin in preparation for prosthetic use. They may opt to rub the skin with alcohol, vinegar, salt water, or even gasoline, erroneously thinking that this will make the skin thicker and more pressure tolerant. In fact, these “treatments” can damage the

skin, making it more susceptible to pressure-related problems. Patient and family education about effective cleansing and skin care strategies is essential in the early postoperative/preprosthetic period.

RANGE OF MOTION AND FLEXIBILITY Persons with transtibial amputation are at significant risk of developing both knee and hip flexion contractures. Those with transfemoral amputation are very likely to develop hip flexion and external rotation contracture. Such contractures cause substantial problems for prosthetic fit and alignment, as well as on efficiency of walking with a prosthesis. Impairment of extensibility of two joint muscles, such as the hamstrings and rectus femoris, may not be obvious when an individual is seated but may have profound impact on comfort when wearing a prosthesis during functional activities. For this reason, proper positioning is a key component of preprosthetic rehabilitation. Prolonged dependence of the residual limb held in knee flexion when sitting also leads to development of distal edema, which can delay readiness for prosthetic fitting. Persons with transtibial amputation must maintain the knee in as much extension as possible, whether in bed, sitting in a wheelchair or lounge chair, or during exercise and activity. Although it may be comfortable to place a pillow under the knee when sitting or lying in bed, a more effective strategy is to position a small towel roll under the distal posterior residual limb to encourage knee extension (Fig. 20.20). Use of a wheelchair with elevating leg rests on the side of the amputation helps to keep the residual limb in an extended position, although a “bridge” between the seat and calf

A

B Fig. 20.20 The optimal position for individuals with recent transtibial amputation is in full extension. (A) A small rolled towel, bolster, or pillow placed under the distal posterior residual limb encourages knee extension, whereas (B) support under the knee makes development of knee flexion contracture more likely.

20 • Postoperative and Preprosthetic Care

Fig. 20.21 Prone positioning for stretching of the posterior soft tissue and prevention of knee flexion contracture. A small towel roll placed just above the patella elevates the residual limb from the surface of the mat or bed. The therapist can use hold-relax or contract-relax techniques, or the patient can actively contract the quadriceps to assist elongation of the hamstrings and posterior soft tissues.

support may be necessary for those with short residual limbs. In some settings the therapist fabricates a posterior trough splint from low-temperature thermoplastic materials; this splint supports the limb in knee extension when the individual with recent amputation is resting in bed or sitting in a wheelchair. If the individual is able to assume prone position, the weight of the limb can be used to assist elongation of the hamstring muscles and soft tissue of the posterior knee (Fig. 20.21). A small towel roll positioned just above the patella effectively positions the limb for elongation. Although there is little conclusive evidence in the research literature about contracture management in persons with recent lower limb amputation, evidence from studies of soft tissue contracture following total knee arthroplasty suggest that prolonged stretching, dynamic splinting, and manual therapy may be effective following amputation as well.293–295 Stretching programs also have a positive impact on the quality and efficiency of gait in older adults.296 What is not well understood is the intensity necessary if stretching is to prevent or minimize degree of contracture formation, especially if there is also evidence of central nervous system dysfunction.297–299 Intervention strategies currently used to target joint ROM and flexibility include proprioceptive neuromuscular facilitation (PNF) hold-relax or contract-relax300,301 and myofascial release.302 Although the strength of the clinical research evidence on interventions for stretching and flexibility following lower limb amputation is low, the consequences of not attending to risk of contracture development are substantially negative. Converging recommendations by experts strongly support that interventions aimed at contracture prevention or minimization are essential in the postoperative/preprosthetic period.303–307 Readers are referred to Stretching and Strengthening for Lower Extremity Amputees (Miami, FL: Advanced Rehabilitation Therapy, 1994) and to Facilitated Stretching (Champaign, IL: Human Kinetics, 2014) for more detailed information about designing exercise programs for stretching and flexibility. Persons with recent amputation are instructed how to perform exercises (done at the bedside while an inpatient or at home while an outpatient) that are designed to elongate muscles and soft tissue to counteract the tendency to develop tightness, especially in two-joint muscles.

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Performed independently or with the assistance of a family member or caregiver several times a day, these stretching exercises are as important as individualized PT sessions during preprosthetic and prosthetic rehabilitation. Significant hip flexion contracture can render a person with transfemoral amputation ineffective in controlling a prosthetic knee unit and walking with a prosthesis. Persons with recent transfemoral amputation tend to hold their residual limb diagonally outward when seated, unconsciously and automatically increasing their seated base of support to enhance postural stability. If they spend significant amounts of time in a seated position, development of hip flexor, abductor, and external rotator tightness is almost inevitable. PT interventions that elongate these soft tissues, including manual stretching, active exercise, and functional postural training, are used to counteract the tendency for tightness to develop.303–309 Resting in a prone position with a towel roll under the distal anterior residual limb provides prolonged elongation for tight hip flexors. However, care must be taken to maintain a neutral pelvis or slight posterior tilt when lying prone. Excessive hip flexor tightness leads to lordosis of the lumbosacral spine.

MUSCLE PERFORMANCE Most individuals do not achieve sufficient activity levels after lower limb amputation. A recent study found that 61% of lower limb amputees did not achieve the recommended 150 minutes of activity per week and that 33% were sedentary.310 Rehabilitation professionals must promote physical activity participation beyond minimal functional levels but also encourage strength and aerobic conditioning to maximize health benefits. Strengthening programs have two goals: (a) remediation of specific weaknesses detected in the examination and (b) maximization of overall strength and muscular endurance for safe, energy-efficient prosthetic gait. Because functional activities require use of muscles at varying lengths and types of contraction, effective preprosthetic exercise programs include concentric, holding (isometric), eccentric, and co-contraction activities in a variety of positions and muscle lengths.303–309 In the immediate postoperative period the specific strengthening program is often a combination of isometric and active isotonic exercise within a limited ROM of the joint just proximal to the amputation.303–309 This strategy minimizes stress or tension across the incision while preserving and improving the strength of key muscle groups. It is as critical to include strengthening exercise for the intact (nonamputated limb) as for the residual limb. Core stability also needs to be addressed. Incorporation of controlled exhalation during isometric contraction minimizes the risks to cardiac function and fluctuations of blood pressure that are associated with the Valsalva maneuver.310 For persons with transtibial amputation, exercises to strengthen knee extension that are initiated within the first week of amputation might include “quad sets” in the supine position or “short arc quads” performed in the supine or sitting position. For those with transfemoral amputation, “glut sets” in the prone or supine position or “short arc” hip extension and abduction in a gravity-eliminated position would be initiated. Gailey and

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Gailey306 recommend an exercise strategy of slow, steadily controlled, 10-second muscular contractions, followed by 5 to 10 seconds of rest, for 10 repetitions as one that is easily learned and physiologically sound. As wound healing is accomplished, exercises can be progressed to include active exercises through larger arcs of motion, active resistive exercise (using weights or manual resistance), or isokinetic training. Application of manual resistance during functional activities, as in PNF, allows the therapist to provide appropriate resistance as muscle strength varies throughout the active ROM while providing facilitation and augmented sensory feedback to the patient.215,311 Progressive resistive exercise for strength development (low repetition–high load) and muscular endurance (high repetition–low load) are key and should also be included.312–315 Readers are referred to American College of Sports Medicine’s (ACSM’s) Exercise Management for Persons with Chronic Disease and Disability (Champaign, IL: Human Kinetics, 2016),314 Therapeutic Exercise: Foundations and Techniques (Philadelphia, PA: F.A. Davis, 2018), and Essentials of Strength Training and Conditioning (Champaign, IL: Human Kinetics, 2016) for information on designing progressive resistive exercise programs of adequate intensity and duration. Isokinetic exercise, involving both concentric and eccentric contraction, allows the patient to develop muscle strength and control at a variety of movement velocities and has a marked positive impact on functional ability.314–318 Isokinetic exercise, if prescribed properly, is well tolerated by older adults, even at speeds of 180 degrees per second angular velocity.319 For individuals with transtibial amputation, attachments of the quadriceps and hamstrings are typically intact and preprosthetic strengthening exercises emphasize control of the knee, as well as hip extensor and abductor strength for stability in stance. There is evidence that older men who are unable to develop knee extension force greater than 1.13 Newton-meters (Nm)/kg (measured by handheld isokinetic dynamometer, normalized by body weight) and older women who are unable to develop knee extension force greater than 1.01 Nm/kg have a high risk for functional decline, morbidity, and mortality.320 These strength values may represent the minimum threshold for community function and could serve as evidence-based functional goals for persons recovering from transtibial amputation (both limbs) and transfemoral amputation (remaining limb). Those with transtibial amputation are also very likely to have deficits in muscle performance around the hip; strengthening programs must include hip abductors (for stance phase stability) and hip extensors,321 much like those who are receiving rehabilitation following total knee arthroplasty.322,323 Persons with transfemoral amputation must develop strong hip extension capabilities to control the prosthetic knee unit. They must also have effective hip abduction power if the pelvis is to remain level during stance.321 It is vital to recognize that the distal attachments of the hamstrings, rectus femoris, sartorius, tensor fasciae latae/iliotibial band, adductor longus, and adductor magnus are relocated by myodesis or myoplasty or are lost entirely

(for patients with short residual limbs) during transfemoral surgery. The combination of an altered line of pull and loss of muscle mass often creates an imbalance of muscle action around the hip.324–326 The gluteus maximus, gluteus medius, and iliopsoas, with their intact distal attachments, are more powerful in determining resting hip position than the altered adductor group. If the tensor fasciae latae/iliotibial band and gluteus maximus become secondarily shortened, function of the adductor group is further compromised. Because of this imbalance, the physical therapist must consider activities that strengthen the remaining hip adductors, as well as hip extensors and hip abductors, to prepare the patient for effective postural control in sitting and standing and stance phase stability in prosthetic gait.326 Readers are referred to Stretching and Strengthening for Lower Extremity Amputees (Miami, FL: Advanced Rehabilitation Therapy, 1994) for more examples of postoperative, preprosthetic strengthening activities. General strengthening exercises for the trunk and upper extremities are also essential components of an effective preprosthetic exercise program. Back extensors and abdominal muscles play a principal role in postural alignment and postural control. Activities that involve trunk rotation or diagonal movements activate trunk and limb girdle muscles in functional patterns, addressing strength and flexibility for functional activities and enhancing reciprocal arm swing and pelvic control in gait. Upper extremity strengthening, targeting shoulder depressor and elbow extensors, enhances the patient’s ability to use an assistive device for single limb ambulation before prosthetic fitting.

ENDURANCE Many older adults with dysvascular amputation begin rehabilitation with compromised cardiopulmonary endurance because of the effects of comorbid cardiac and pulmonary diseases and on deconditioning associated with inactivity and bed rest.327 In persons with significant peripheral vascular disease without amputation, endurance training on treadmill improved endurance (6-Minute Walk distance) and physical function (Short-Form 36 physical functioning values).328 In deconditioned individuals, a 2-minute walk test may be a more appropriate test of aerobic conditioning than the 6-Minute Walk Test because it has been shown to be predictive of 6-Minute Walk Test distance for individuals with lower extremity amputations.329 A distance of 113 m is necessary for patients to be likely to walk at least 300 m in the 6-Minute Walk Test to show potential as community ambulators.329 Although treadmill training is not appropriate in the preprosthetic period, other strategies, such as cycle ergometer driven by the intact limb, upper extremity ergometer, or cycle/recumbent combined upper and lower extremity ergometers (e.g., NuStep Inc, Ann Arbor, MI) (Fig. 20.22), can be safely and successfully used for persons with lower limb amputation.330–332 Endurance and physical conditioning are predictors of prosthetic use: the ability to exercise at or greater than 50% of age-predicted maximum volume of oxygen consumption (VO2max) differentiated between persons with amputation able to walk

20 • Postoperative and Preprosthetic Care

Fig. 20.22 Example of a combined upper and lower extremity recumbent ergometer appropriate for endurance exercise as part of the preprosthetic program for persons with amputation. (Courtesy NuStep Inc., Ann Arbor, MI.)

functional distances (100 m) with a prosthesis and those who were unable to do so.333–335 Because energy cost of walking with a prosthesis increases as limb length decreases, endurance training is particularly important for persons with transfemoral amputation.336–338 Energy expenditure increases with the level of amputation from transtibial to bilateral transfemoral, as much as 20% to 200%.338,339 Persons with amputation can substantially improve level of fitness (VO2max) and, with that, their potential for physical activity and prosthetic use.337 Readers are referred to the ACSM’s Guidelines for Exercise Testing and Prescription, 9th edition (Philadelphia, PA: Wolters Kluwer, Lippincott Williams & Wilkins, 2013)340 and ACSM’s Exercise Management for Persons with Chronic Disease and Disabilities, 4th edition (Champaign, IL: Human Kinetics, 2016)314 for additional information about exercise testing and endurance exercise prescription.

POSTURAL CONTROL Loss of a limb shifts the position of the body’s COM, moving it slightly upward, backward, and toward the remaining or intact extremity; the magnitude of this shift is determined by the extent of limb loss. The shift may have relatively little impact on postural control and functional ability in patients with partial foot or Syme amputation. However, it may have a significant impact on sitting balance, transitions between sitting and standing, and single limb ambulation for persons with transtibial, transfemoral, or hip disarticulation amputation. An effective preprosthetic program incorporates activities that challenge patients to improve core stability, postural control, and equilibrium responses, learning how to control the repositioned COM effectively over an altered base of support. In sitting, this can be accomplished using a variety of reaching tasks including forward reaching, diagonal reaching across and away from the midline, reaching down to a lower surface or objects, reaching up and away

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from their center, and turning to reach behind them. Anticipatory and reactive postural responses can also be practiced by throwing and catching games that require an automatic weight shift as part of the activity. The difficulty of the task can be advanced by progressively shifting the location of the catch or toss away from the midline of the patient’s trunk; alternating locations from side to side or upward or downward; increasing the speed of the activity; increasing the weight of the object or ball that is being used; or performing the activity on a less stable seating surface (e.g., TheraBall, large bolster, or air-filled balance cushion). Similar activities can be implemented in single limb stance, initially within the parallel bars with physical guarding to insure safety. Such opportunity to practice anticipatory and reactionary postural control in single limb stance lays the foundation for the postural control necessary for single limb ambulation with an assistive device, as well as for eventual prosthetic use. Readers are referred to Balance, Agility and Coordination for Lower Extremity Amputees (Miami, FL: Advanced Rehabilitation Therapy) for more activities that can be used to enhance postural control. The effectiveness of postural responses is influenced by efficiency of the somatosensory system and visual systems, flexibility and strength of the trunk and limb girdles, and the length and power of the residual limb.208,341,342 The prosthetic replacement of a missing limb increases the functional base of support in sitting; for some individuals the weight of the prosthesis serves as a stabilizing anchor during functional activity. For those with limited flexibility or strength, such a replacement might be essential for effective postural responses and the ability to reach, even if the potential for functional ambulation is small.

WHEELCHAIRS, SEATING, AND ADAPTIVE EQUIPMENT Many patients with amputation rely on a wheelchair for at least some of their mobility needs during the postoperative, preprosthetic period.343 Some patients with short transfemoral amputation, hip disarticulation, or bilateral amputation prefer the relative energy efficiency of wheelchair mobility to ambulation with or without a prosthesis.344,345 For others, comorbid cardiovascular or cardiopulmonary dysfunction precludes ambulation and the wheelchair becomes their primary mode of locomotion.346 The shift in COM after amputation has important implications in choice of wheelchairs. The design of many standard or traditional wheelchairs is based on the anthropomorphic characteristics of an “average” adult male with intact lower extremities. With the loss of a limb, the COM shifts in a posterior and lateral direction; when the patient is seated in a wheelchair, this moves the COM closer to the axis of rotation of the chair’s wheels. If the patient with lower extremity amputation turns or reaches backward during a functional activity, the COM shifts even farther toward, or even beyond, the wheel axis, and the chair may tip backward. The provision of simple antitip devices reduces the risk of posterior tipping during functional activities. For those with transfemoral or bilateral

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amputation, a wheelchair with wheels that can be offset posteriorly is recommended. Patients with recent amputation must also be aware of altered dynamics when they reach forward while sitting in a wheelchair: High downward pressure on the wheelchair foot plate by the intact limb when reaching forward is likely to lead to anterior tipping. Specific wheelchair assessments and prescription are warranted for all individuals who will be using a wheelchair as their primary means of locomotion and mobility (see Chapter 16). This individual evaluation and prescription process ensures that the wheelchair will provide adequate support of the thighs to increase seating stability and reach, effective seating with an appropriate cushion for pressure distribution, and configuration of components that provides ease of wheelchair locomotion. Wheelchair skills to be mastered by persons with new amputation and their caregivers include effective propulsion over level, carpeted, and uneven ground; turning and backing up; positioning of the wheelchair for safe bed, toilet, bathtub, furniture, and car transfers; ascending and descending thresholds, curbs, and ramps; and getting the wheelchair into and out of the family’s motor vehicle. In addition, practice getting to and from the floor and opportunity to react to a controlled fall (lowering backward to the ground) may allay concerns about aftermath of falls. Readers are referred to textbooks on spinal cord injury rehabilitation, which contain chapters on wheelchair skill development that can be applied to persons with amputation.347,348 Along with a wheelchair, many persons with new amputation would benefit from provision of adaptive equipment for their homes (e.g., tub benches, grab bars, toilet frames, raised toilet seats, handheld shower adapter) and installation of temporary (or permanent) ramps to entrance/egress to the home. Consideration must also be given to access to sinks, as well as to using insulated coverings of exposed hot water and drain pipes. In some cases, if the individual is likely to use the wheelchair for a long period of time as primary means of mobility, modification of the home may be recommended for both safety and efficiency of function. Although these concerns are more typically addressed in inpatient and subacute rehabilitation settings, many patients with new amputation may be discharged to home to await sufficient healing prior to beginning prosthetic rehabilitation. Therapists in acute care must consider referral to home care services if there is insufficient time to address wheeled mobility and accessibility during hospitalization. Once again, textbooks on spinal cord injury are good sources of information about durable medical equipment and home modifications for accessibility.349,350

BED MOBILITY AND TRANSFERS In the acute care setting, PT intervention at the bedside includes instruction about optimal positioning of the residual limb and activities to assist the patient’s ability to change position in bed and move to or from a seated position. Early mobility and activity significantly reduce the risk of

atelectasis, pneumonia, and further physiologic deconditioning.351 However, the therapist must be aware of the risk of postural hypotension and of postoperative complications, including deep venous thrombosis and pulmonary embolism. Assessment and monitoring of the patient’s vital signs (pulse, respiratory rate, blood pressure, pulse oximetry) are recommended as bed mobility and out-of-bed activity begin.352 Care must also be taken to minimize the risk of trauma to the newly amputated limb during activity, exercise, or transfers. Many individuals with recent amputation can roll from supine to or from the prone position without great difficulty, although those with transfemoral amputation of the dominant limb may need to develop an adapted movement pattern or sequence. The strategies for transition into sitting are not substantially different from preferred preoperative strategies; however, efficiency of postural responses may be challenged by the alteration in body mass after amputation. Those who have become deconditioned by inactivity in the days and weeks before amputation may find bed rails, a trapeze, bed ladders, or other devices helpful early in rehabilitation. Strategic placement of a bed table or walker near the bedside at night serves as a reminder of the amputation for individuals who are likely to get up during the night to go to the bathroom (without otherwise fully awakening), reducing the risk of falling. A primary goal of postoperative, preprosthetic rehabilitation is development of the ability to move between seating surfaces or from sitting to standing as safely and independently as possible. The majority of falls for persons with new amputation in acute care settings occur during self-transfer between wheelchair and bed or toilet.353 Depending on the individual’s preamputation level of activity, transferring between seating surfaces may require some degree of assistance or use of adaptive devices or may be accomplished relatively smoothly and easily. Those who are deconditioned or who have previous neuromuscular-related postural impairment may require a mechanical lifting aid, multiperson lifting, or some level of assistance in the early postoperative period. Others may benefit from a strategically placed transfer board as they develop their ability to perform a pivot transfer on their remaining limb. Some persons require a walker or crutches for extra stability in single limb stance in the midst of their pivot transfers. Still others quickly master scooting in sitting and pivoting on their remaining limb to become independent in transfers. Persons with single limb amputation initially prefer transferring toward their remaining limb but should be encouraged to master moving in either direction. Individuals with bilateral limb loss or injury that precludes weight bearing on the remaining limb can scoot across a sliding board to a wheelchair or commode that is positioned diagonally from the bed. Those with bilateral transfemoral amputation (and those with bilateral transtibial amputation who have sufficient hamstring excursion) may prefer the surface-to-surface stability that is provided when the entire anterior edge of the wheelchair seat abuts the side of the bed, allowing them to scoot directly forward. Some individuals who require significant assistance to

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transfer without a prosthesis become nearly independent in pivot transfers when a prosthesis is worn: The sensory feedback that is provided to the residual limb within the socket when there is contact between the prosthetic foot and the floor enhances sitting balance during sliding board or pivot transfers. Persons with transfemoral amputation must learn that, although they can wear a prosthesis when seated, the prosthesis cannot be counted on for stability during transfers. Readers are referred to Patient Care Skills, 6th edition (Upper Saddle River, NJ: Prentice-Hall, 2010)354 for suggestions about interventions to enhance bed mobility, transfers, and ambulation with assistive devices. Mastery of single limb or non–weight-bearing transfers in the postoperative period is the foundation for functional transfers whenever the person with amputation is not wearing his or her prosthesis. At times in the future, mechanical problems with the prosthesis, skin problems on the residual limb, or a medical problem (e.g., CHF or renal failure) may affect socket fit, temporarily precluding prosthetic use. Providing opportunities for patients to practice transferring between surfaces at different levels (e.g., wheelchair to stool to floor) in the postoperative, preprosthetic period is very important, especially if delayed prosthetic fitting is anticipated.

AMBULATION AND LOCOMOTION Single limb ambulation with an appropriate assistive device provides an opportunity to enhance postural control and to build strength and cardiovascular endurance, in addition to allowing patients with recent amputation to move about in their environment. A number of factors (e.g., safety, balance and postural control, endurance, lower extremity muscle performance, fear of falling) must be considered in recommending an ambulator assistive device.354,355 Although use of a standard or rolling walker may be appropriate in the initial PT sessions, many individuals with new amputation quickly master a two- or three-point swing-through pattern with crutches on level surfaces and are ready to build advanced gait skills on uneven surfaces, inclines, and stairs. Others are fearful of using crutches, preferring the stability provided by a walker to the mobility of crutches. A walker may be appropriate for patients with limited endurance and balance impairment who would otherwise be limited to wheelchair use. However, therapists must be aware of the potential long-term limitation in gait patterns imposed by walkers: The halting hop-to gait pattern interrupts forward progression of the COM. Individuals who have adapted to this pattern of motion before receiving a prosthesis may have difficulty developing a smooth step-through pattern or becoming comfortable with a less supportive ambulation aid once they are using their prosthesis. Walkers are also more difficult to use on inclines and are dangerous to use on stairs. Whenever possible, patients are encouraged to use crutches.354,355 Table 20.8 summarizes the progressive single limb ambulation skills for preprosthetic rehabilitation. Individuals with limited endurance or poor balance spend much time practicing a hop-to or swing-through gait in the

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parallel bars before they acquire the confidence and motor skill necessary to move out of the parallel bars with a walker or crutches. Indeed, single limb ambulation with an assistive device is often more energy intensive than walking with a prosthesis.346,356 Achievement of functional single limb ambulation is not a prerequisite for prosthetic fitting.357 All individuals who can stand and use an assistive device to walk should be encouraged to ambulate as much as possible, even if they are walking for aerobic exercise rather than to accomplish a functional task. For those with single limb amputation, wheelchair use should be reserved for long-distance transportation unless ambulation is not medically advisable. Wheelchairs are appropriate for patients with bilateral amputation; self-propulsion provides some aerobic conditioning and an energy-efficient means of locomotion.358

PATIENT AND FAMILY EDUCATION: CARE OF THE REMAINING LIMB Patient and family education begins in the initial interview process and continues throughout the acute hospital stay, as illustrated in the preceding discussions of positioning, residual limb care, remaining/intact limb care, and enhancing motor performance and functional training. Patient education about the risk of decubitus ulceration and strategies to reduce this risk are also key components of early postoperative care. Individuals with vascular disease and neuropathy are particularly at risk, with the heel and lateral border of the remaining foot most vulnerable.359 Those with dysvascular limbs may have barely enough circulation to support tissue health in an intact or noninjured foot; once a wound has occurred, circulation may be inadequate for tissue healing. An open wound on the remaining limb would preclude single limb ambulation, increasing the risk of inactivity-related postoperative complications and making prosthetic rehabilitation even more challenging. Pressurerelated wounds significantly delay rehabilitation, increase disability, and multiply health care costs for patients with amputation. Vulnerability to pressure increases with sensory impairment; altered mechanical characteristics of injured, calcified, or scarred tissues; poor circulatory status; microclimate of the skin; and (in combination with these factors) advanced age.360 For those who have limited ability to change position, a pressure-distributing mattress and welldesigned, carefully applied heel protectors can reduce the risk of decubitus ulcer formation. A routine of frequent position change, weight shifting, and exercise reduces weightbearing pressures and enhances circulation to vulnerable tissues. Before discharge, the rehabilitation team must ascertain how close to functional independence the individual and caregivers are in a variety of self-care activities, in mobility and locomotion, and in performance of preprosthetic exercises (Fig. 20.23). As the program progresses, the ability of the individual and family in these areas is a key determinant of discharge readiness and placement (home with home care, home with outpatient follow-up, or to a rehabilitation or subacute facility).

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Case Example 20.1b Amputation

Interventions for N. H., an 89-Year-Old Woman With “Elective” Transtibial

N. H. is now 4 days postsurgery, and her delirium is clearing. She is conversing with her typical sense of humor with family and staff. Her casted fiberglass rigid dressing was removed yesterday; the surgical wound is draining moderate amounts of serosanguineous fluid; edges are closely approximate. An area of pressure-related abrasion and inflammation at the anterior distal tibia was noted when the cast was removed; granulation is now evident. N. H. can transfer to a bedside chair with moderate assistance of one person, with noted moderate impairment of postural control. N. H. tolerates being up in a bedside chair for 45 minutes. She rates her postoperative pain as 4 out of 10, except at dressing change, when it increases to 6 out of 10. She laughs but feels concern that she feels mild cramping in the instep of the limb that is no longer there, wanting to stretch her foot and toes into dorsiflexion to relieve her discomfort. She is somewhat reluctant to look at or to touch her residual limb but does not mind if nurses, physicians, or PT staff handle it during dressing changes or functional activities. She transferred sitting to standing with a walker at bedside with moderate assistance of one person, complaining of dizziness after standing for more than a minute and requesting to return to sitting. She tells you that she is “ready to get going” and wants to return to her own home to use her wheelchair as soon as possible. QUESTIONS TO CONSIDER

▪ Given her postoperative pain and phantom sensation, what

PT interventions would be appropriate at this time for N. H.? Why would these be most appropriate from among available options? What are the pros and cons of each, with respect to attention, memory, and ability to learn? ▪ Given the status of her wound and condition of her residual limb, what strategies for management of edema and limb shaping would you recommend? What are the pros and cons that you considered when deciding among options for compression and residual limb protection? Why do you think the option you selected is the most appropriate? How would this be similar or different if her amputation was at the transfemoral level? ▪ What strategies for intervention and patient-family education would you implement for skin care and scar management for N. H.? What issues or factors will assist or inhibit her ability to take responsibility for her skin care? ▪ What specific strategies for intervention and patient-family education aimed at ROM and flexibility do you recommend for N. H.? What impairments or functional limitations are you particularly concerned about for N. H.? What activities will you engage her in? What positions? For what period of time? With what equipment? What would you emphasize if her amputation was at a transfemoral level? What issues or

factors will assist or inhibit her ability to take responsibility for exercises aimed at ensuring adequate ROM and flexibility in preparation for prosthetic use? ▪ What specific strategies for intervention and patient-family education aimed at improving muscle performance do you recommend for N. H.? How do you address strengthening of key muscle groups of extremities and trunk? How do you address power and muscle endurance? How do you address concentric, isometric, and eccentric control and performance? What issues or factors must be considered regarding exercise tolerance, intensity, frequency, and duration during her acute care stay? How will you address her concerns about her low level of aerobic fitness and conditioning? ▪ What specific strategies for intervention and patient-family education aimed at improving static, dynamic, and reactionary postural control during functional activities do you recommend for N. H.? During which activities is postural control most likely to be problematic? What apparatus, equipment, and activities might you use to assist her postural control? ▪ What are your concerns about seating and wheelchair mobility for N. H.? Do you think that a standard wheelchair will adequately meet her needs? Do you think she will be able to propel her chair? What tasks does she need to master if the wheelchair will be her primary source of mobility during the preprosthetic period? ▪ What types of bed mobility and transfer activities are important for N. H. and her family caregivers to master? What specific intervention and patient-family education strategies will you use to help her move toward safe and, hopefully, independent performance of bed mobility and transfer activities? How will you vary environmental conditions and task demands to ensure that she can adapt her strategies and skills? ▪ What strategies for intervention and patient-family education will you use to get her up and walking? What assistive or ambulatory device do you feel would be most appropriate? Why have you chosen this particular device from among available options? What gait pattern will she use? For what other dimensions or ambulatory skills (in addition to walking forward) will you provide instruction and opportunity for N. H. to practice? How will you address the likelihood that she will experience a fall at some point in her preprosthetic period? What is “functional distance” for ambulation for N. H. and her family? ▪ Are there any additional interventions that would be appropriate for N. H. at this point in her postoperative, preprosthetic rehabilitation? ▪ How will you determine her readiness for prosthetic fitting?

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Case Example 20.2c Interventions for P. G., an Individual with Recent Amputation of Both Lower Extremities Following a Construction Accident Now 3 days postoperation, P. G. is beginning his rehabilitation in preparation for discharge to home until there is adequate healing for prosthetic fitting and prosthetic training. Pain continues to be a serious concern, generally reported as 5 or 6 out of 10 on the visual analog scale. Postoperative agitation has cleared, although P. G.’s wife reports he is more subdued in affect than usual, and she is concerned about possible depression. Low-grade temperature persists, but white cell counts are within normal limits. P. G. can actively flex and extend both knees to within 10 degrees of full ROM, with effort and a “tight pulling sensation” behind the knee, when out of his semirigid dressing (SRD) for dressing changes and wound inspection. Although he reports feeling “weak as a baby” and is quickly fatigued, P. G. can use upper extremity and body strength for contact guard sliding board transfers to and from bed to a bedside chair. Moving between sitting and supine is effortful and fatiguing, but P. G. manages these transitions with occasional standby assistance. He was previously involved in both aerobic and strengthening exercise at the local YMCA, but he is not sure how to use the weights and equipment now that he has lost his limbs. Plans are being made to move temporarily to his parent’s home, on the first floor of a three-family house (although there are six steps to reach a front porch and entryway) because it is more accessible than his third-floor walk-up apartment. In the meantime, family and friends are apartment hunting for housing that will be less challenging for P. G. in the months ahead. P. G.’s major goal is to achieve independent mobility with a wheelchair before the birth of his child. QUESTIONS TO CONSIDER

▪ Given his postoperative pain and phantom sensation, what

PT interventions would be appropriate at this time for P. G.? Why would these be most appropriate from among available options? What are the pros and cons of each, with respect to attention, memory, and ability to learn? ▪ Given the status of his wound and condition of his residual limb, what strategies for management of edema and limb shaping would you recommend? What are the pros and cons that you considered when deciding among options for compression and residual limb protection? Why do you think the option you selected is the most appropriate? How would this change if his amputations were at the transfemoral level? ▪ What strategies for intervention and patient-family education would you implement for skin care and scar management for P. G.? What issues or factors will assist or inhibit his ability to take responsibility for his skin care? ▪ What specific strategies for intervention and patient-family education aimed at ROM and flexibility do you recommend

for P. G.? What impairments or functional limitations are you particularly concerned about for P. G.? What activities will you engage him in? What positions? For what period of time? With what equipment? How would these be similar or different if his amputations were at the transfemoral level? What issues or factors will assist or inhibit his ability to take responsibility for exercises aimed at insuring adequate ROM and flexibility in preparation for prosthetic use? ▪ What specific strategies for intervention and patient-family education aimed at improving muscle performance do you recommend for P. G.? How do you address strengthening of key muscle groups of extremities and trunk? How do you address power and muscle endurance? How do you address concentric, isometric, and eccentric control and performance? How would this be similar or different if his amputations were at the transfemoral level? What issues or factors must be considered regarding exercise tolerance, intensity, frequency, and duration during his acute care stay? How will you address his concerns about low level of aerobic fitness and conditioning? ▪ What specific strategies for intervention and patient-family education aimed at improving static, dynamic, and reactionary postural control during functional activities do you recommend for P. G.? During which activities is postural control most likely to be problematic? What apparatus, equipment, and activities might you use to assist his postural control? ▪ What are your concerns about seating and wheelchair mobility for P. G.? Do you think that a standard wheelchair will adequately meet his needs? Do you think he will be able to propel his chair? What tasks does he need to master if the wheelchair will be his primary source of mobility during the preprosthetic period? ▪ What additional bed mobility and transfer activities do you think are important for P. G. and his family caregivers to master? What specific intervention and patient-family education strategies will you use to help him move toward safe and, hopefully, independent performance of bed mobility and transfer activities? How will you vary environmental conditions and task demands to ensure that he can adapt his strategies and skills? ▪ How will you address the likelihood that he will experience a fall at some point in his preprosthetic period? ▪ Are there any additional interventions that would be appropriate for P. G. at this point in his postoperative, preprosthetic rehabilitation to assist with his coping and adjustment to his limb loss? ▪ How will you determine his readiness for prosthetic fitting?

Table 20.8 Progressive Strategies for Preparing for and Mastering Single Limb Mobility After Amputation Phase

Purpose

Preparation

Strengthening

Target

Examples of Activity Progression All activities: concentric, holding, eccentric contraction All activities: intact limb and residual limb

Hip extensors Hip interior and exterior rotators Hip abductors

Bridging; uniplanar, diagonal antigravity, with resistance Gluteal sets Hip extension in prone, in standing, adding resistance, open chain, closed chain Hip abduction side-lying, in standing, adding resistance, open chain, closed chain Continued

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Section III • Prostheses in Rehabilitation

Table 20.8 Progressive Strategies for Preparing for and Mastering Single Limb Mobility After Amputation (Continued) Phase

Stability in standing

Mobility

Purpose

Target

Examples of Activity Progression

Knee extensors

Quad sets, short arc quads Sit to stand at varying heights and speeds Progressive resistive exercise Low load, high repetition (endurance) High load, low repetition (strength)

Ankle dorsiflexors

Toe raises in standing Manual resistance of active movement

Flexibility

Hip flexor tightness Knee flexor tightness Tensor fascia lata/ iliotibial band Plantar flexor tightness

Prolonged passive stretching, positioning antigravity Thomas test position or prone Proprioceptive neuromuscular facilitation: hold-relax/contract-relax followed by concentric exercise in new ROM Active stretching in various positions

Rising to standing

Control of COM during transition

Part-to-whole practice progressing to serial practice of sit-to-stand transition Scooting to edge of seating surface Forward lean with trunk extension (anterior weight shift) Weight transfer onto foot Extension into upright position Achieving stability in upright position Controlled lowering back into sitting position Practice with varying speeds Adding appropriate resistance for sensory feedback and/or strengthening Practice with higher to lower seating surfaces Practice with various seating surfaces (firm to soft chair, toilet seat, tub seat) Practice with transfers into/out of car

Postural control in single limb stance

Discovering limits of stability Developing postural control

Static: standing in parallel bars Bilateral upper extremity support, single upper extremity support, no upper extremity support Anticipatory: directional reaching Forward, diagonal toward stance limb, diagonal away from stance limb Throwing activities: lightweight to heavier weighted balls; forward to diagonal directions; various distances Reactionary: gentle unexpected perturbations; catching activities; lightweight to heavier weighted balls; toward body center, away from body center; various speeds and distances All activities: initially standing on firm surface, progressing to compliant surface

Ambulation

Forward progression Changing direction Backing up Sideward stepping

In parallel bars to over ground with appropriate assistive devices Over simple (tile) surface to more challenging (carpet, grass, etc.) surfaces In closed (predictable) environment, to open (unpredictable) environment Over level surfaces, inclines (ascend and descend)

Stair management

Bilateral railings, to railing and one crutch Low to standard height steps Provide opportunity for family caregiver to practice guarding

Managing environmental challenges

Opening doors: away from self, toward self, weighted doors, revolving doors Managing thresholds Managing curbs Environmental scanning: avoiding obstacles in walking path Home safety evaluation Crossing the street at times crosswalks

Fall management

At least: demonstration/observation of chair to floor, stand to floor transition Discussion of risk factors for falls from wheelchair, from standing, on stairs Develop plan of action should fall occur Practice chair-to-floor and stand-to-floor transitions in controlled circumstances

COM, Center of mass; ROM, range of motion.

Preprosthetic Outcome Assessment Current models of health care practice (and reimbursement) require assessment of the efficacy of intervention that has been provided, often by comparing information

collected at initial and discharge examinations. A number of tools and measures can be used to assess outcome of intervention in the preprosthetic period; Table 20.9 provides examples of such measures. The selection of the most appropriate tools from among those available can be challenging.361 The first consideration is to determine which “population” the tool has been designed and validated

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INDICATOR

Wound Inspection ____ Individual or caregiver is able to independently inspect status of incision and residual limb Individual or caregiver is able to describe signs of inflammation, infection, dehiscence, bleeding, orecchymosis requiring contact/visit with health professional ____ Individual or caregiver is able to effectively inspect and care for intact limb ____ Supervision or assistance by a health professional is necessary for wound inspection and care of either residual limb or intact limb Residual Limb Care ____ Individual or caregiver is able to change wound dressings effectively, maintaining clean environment ____ Individual or caregiver is able to appropriately cleanse and care for residual limb ____ Individual or caregiver is able to safely effectively self-mobilize skin around incision site ____ Individual or caregiver is able to apply appropriate compression strategy (circle: Ace wrap, removable rigid dressing or semirigid dressing, commercial shrinker garment, other) ____ Individual with transtibial amputation is able to maintain limb in extended knee position Mobility ____ Individual is able to move around in bed as needed Level of assistance ________________ Equipment used ________________ ____ Individual is able to transition from supine to sitting and return Level of assistance ________________ Equipment used ________________ ____ Individual is able to transfer from bed or chair to wheelchair and return Level of assistance ________________ Equipment used ________________ ____ Individual is able to transfer sit to single limb standing and return Level of assistance ________________ Equipment used ________________ ____ Individual is able to transfer to toilet and return Level of assistance ________________ Equipment used ________________ ____ Individual is able to transfer to shower or tub and return Level of assistance ________________ Equipment used ________________ Locomotion ____ Individual is able to ambulate on level surfaces using appropriate assistive device Level of assistance ________________ Assistive/ambulatory device used ________________ Gait pattern ________________ Distance ________________ Perceived exertion ________________ ____ Individual is able to ascend/descend stairs using railing and appropriate assistive device Level of assistance________________ Assistive/ambulatory device used________________ Gait pattern ________________ Number of steps________________ Perceived exertion________________ ____ Individual is able to ambulate on inclines and outdoor surfaces Level of assistance________________ Assistive/ambulatory device used________________ Gait pattern ________________ Distance________________ Perceived exertion________________ ____

Fig. 20.23 Example of checklist of key patient and family knowledge and skills after lower limb amputation.

for. Some measures have been evaluated for use with older adults who are hospitalized, and others have been evaluated specifically for persons with lower limb amputation.362,363 The next concern is the domain that the tool evaluates: outcomes can be assessed at the level of body structure and function (e.g., wound healing, limb volume); activity ability or limitation (e.g., ability to ambulate, complete ADLs); or at the level of participation (e.g., quality of life, ability to participate in meaningful social roles).364,365 The physical therapist must understand the level of measurement of the tool, so as to be able to interpret findings.366

The various scales and tools may provide descriptive/categorical information (e.g., Medical Functional Classification Levels), ordinal information (e.g., ranking, severity, FIM scores), or robust continuous data (e.g., walking speed, limb circumference, functional reach distances). How the information is collected is also a factor: tools may be based on self-report, observation of performance, or they may require use of precise measurement tools. Given all of these aspects of measurement, it becomes obvious that there is no single “perfect” outcome measure for preprosthetic rehabilitative care; instead the rehabilitation team should collectively

554

Section III • Prostheses in Rehabilitation ____

____

Self-Care Activities ____

____

____

____

Exercise Program ____

____

____

____

Follow-Up Care

____ ____ ____

Individual is able to ambulate on inclines and outdoor surfaces Level of assistance________________ Assistive/ambulatory device used________________ Gait pattern ________________ Distance________________ Perceived exertion________________ Individual/caregiver is able to safely propel wheelchair functional distances Level of assistance________________ Distance________________ Perceived exertion________________ Individual is able to manage clothing during activities of daily living and dressing activities Level of assistance________________ Positions ________________ Adaptive equipment needs________________ Perceived exertion________________ Individual is able to manage bathing and grooming activities Level of assistance________________ Positions ________________ Adaptive equipment needs ________________ Perceived exertion________________ Individual is able to manage key instrumetal activities of daily living Level of assistance________________ Types of activities________________ Adaptive equipment needs________________ Perceived exertion________________ Sufficient and safe transportation is available Type of transportation ________________ Level of assistance________________ Equipment used________________ Perceived exertion________________ Individual and caregiver demonstrate mastery of stretching/flexibility component of program Positions/activities ________________ Assistance required________________ Equipment used________________ Repetitions and frequency________________ Individual and caregiver demonstrate mastery of strengthening component of program Positions/activities ________________ Assistance required________________ Equipment used________________ Repetitions and frequency________________ Individual and caregiver demonstrate mastery of aerobic conditioning component of program Positions/activities ________________ Assistance required ________________ Equipment used ________________ Repetitions and frequency________________ Individual and caregiver demonstrate mastery of balance/coordination components of program Positions/activities ________________ Assistance required________________ Equipment used ________________ Repetitions and frequency________________ Plans for return to surgeon for post-op visit are in place Plans for continued rehabilitation care are in place Additional services are in place as appropriate Nursing ________________ Dietician ________________ Counseling________________ Home health ________________ Others________________

Fig. 20.23, cont’d

select those measures that best meet the needs of the patient, therapeutic goals, and expectations of the practice environment.367–369 Although it would be wonderful to have professional consensus of the type and scope of data that should be routinely collected, the reality is that outcome measurement in rehabilitation, although not in its infancy, is at least in its troubling teenage years! What makes a good outcome measure for preprosthetic rehabilitation? The selection of measures should be based on the primary goals of the setting in which care is provided

and the specific patient-centered goals that have been defined for the individual: What concepts, functions, or attributes need to be measured? In choosing an outcome measurement tool, we look for evidence of the following:

▪

Reliability: Can we trust the numbers that the tool provides? Is the tool consistent in measurement over time? Do different raters tend to come up with similar scores? How much measurement error might be present in the “score”?

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Table 20.9 Examples of Outcome Measures for Preprosthetic Rehabilitation Tool

Purpose

Level of Measurement

Comments

Activity Measure for Post-Acute Care (AM-PAC)

Assess limitations in three ICF Activity domains: 1. Physical and Movement 2. Personal Care and Instrumental 3. Applied Cognitive

Ordinal (raw score) Interval (standardized score) Paper and computerized instruments available

Physical and Movement and Personal Care and Instrumental subscales have minimal ceiling effect as compared with Functional Independence Measure (FIM)362,381,382

Amputee Mobility Predictor–no prosthesis (AMP-noPRO)

Sitting balance, transfers, standing balance, gait, stairs, use of assistive device

Ordinal scale 21 items in 6 domains Score range: 0–42 Performance-based MDD ¼ 3.4

Predicts likelihood of prosthetic use; also used as outcome measure in preprosthetic period168,171,172

Barthel Index (BI)

Activities of Daily Living

Ordinal 10 items; weighted ratings 0–100 range Performance based or by interview (self-report)

Developed initially for persons with neurologic problems; applied to those with amputation. Ceiling effect possible as rehabilitation progresses383,384

FIM181–185

Burden of care, activities of daily living

Ordinal 18 items for 6 categories Score range: 18–126 Performance based or self-report (interview)

Marked ceiling effect; does not reflect community function. May be more appropriate in acute care than for intensive rehabilitation385–387

Office of Population Consensus and Surveys Scale (OPCS)

WHO International Classification of Impairments, Disabilities, Handicaps–based measure of functional capacity

Ordinal 108 items over 13 disability categories Weighted overall “Disability Score” (requires computer)

Developed for assessment community-living individuals with disability; useful for inpatient rehabilitation388

Patient Generated Index (PGI)

Impact of amputation (or other medical event) on quality of life

Ordinal Respondents identify 5 activities impacted by amputation, rate severity and importance of impact on quality of life Overall score (0–10) mathematically derived Patient Specific Functional Scale: rate current ability to

Can be challenging for patients to understand389,390

Patient Specific Functional Scale (PSFS)

Impact of amputation (or other medical event) on functional performance of important activities

Ordinal Respondents identify 3–5 activities impacted by amputation then rate their ability to perform (0–10) Mean of items used as PSFS score MDD: 3–4.5 per item

Effective measuring change for the individual patient391,392

Prosthetic Profile of the Amputee (PPA)

Assesses predisposing, enabling, and facilitating factors for eventual prosthetic use

Nominal and ordinal data 38 questions in 6 sections Self-report or interview Requires training to score (computer)

For adults with unilateral amputation Recommended for use in research, rather than clinical settings383,393,394

Rivermead Mobility Index (RMI)

Capacity to perform mobility activities

Ordinal 15 Items Forced choice format Self-report or interview

Poor ceiling effects in late preprosthetic and prosthetic rehabilitation124a,395,396 Recommended for research, rather than clinical settings396

Short Form-36 or ShortForm-12

Health-related quality of life

Ordinal 8 subscales over 2 domains (physical and mental functioning) Self-report or interview MDD for SF-36 Health: 17.1 MDD for SF-36 Physical Functioning: 34.2 MDD for SF-36 Physical Role: 26.3

Designed for general population; has not been specifically evaluated for use with persons with amputation397,398

Continued

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Section III • Prostheses in Rehabilitation

Table 20.9 Examples of Outcome Measures for Preprosthetic Rehabilitation (Continued) Tool

Purpose

Level of Measurement

Comments

Function Component of the Late Life Function and Disability Instrument (LLFDI)

Function and disability in community-living older adults

Ordinal Interview or self-report 32 questions: rated 1–5 8 additional questions if assistive device is routinely used Raw score transformed to scaled score (0–100) Overall function score Upper extremity subscale Basic lower extremity subscale Advanced lower extremity subscale

High scores ¼ better function Has been used for a variety of conditions and health care settings but not fully evaluated for persons with amputation399–402

Walking Speed (selfselected and/or fast)

Overground mobility Proxy for overall health/functional status

Continuous Performance–based MDD range: 0.10–0.2 m/s for most medical diagnoses

Minimal equipment: stopwatch and hallway Use of assistive device during testing possible 4-m walk protocol effective (6–8 m total walkway) comparable to 10 m (20 m total walkway)403 Norms available for healthy adults by decade of age and gender404

2-Minute Walk Test (Brooks)

Cardiovascular endurance

Continuous Performance based Distance (m) covered in 2-min period Minimal Detectable Change: 34.3 meters or 112.5 feet (90% confidence)171 Excellent correlation with 6-Minute Walk Test329

Developed as alternative to exercise stress test for persons with CHF; applied to wide variety of medical diagnoses405,406

Wheelchair Skills Test Version 4.1

Assessment of performance and safety of manual wheelchair use

Ordinal Performance or questionnaire 32 items Indoor use Community use Advanced skills Scoring: performance: pass/fail Safety: safe/unsafe

Used to assess ability of users of manual wheelchair, caregivers, and power chairs407,408

CHF, Congestive heart failure; ICF, International Classification of Functioning, Disability, and Health; MDD, minimal detectable difference; WHO, World Health Organization.

▪

Validity: How well does the tool measure what it intends to measure? Is it designed for patients like the ones that we provide care for? How well do scores on the measure discriminate between persons with and without the problem that the measure attempts to examine? ▪ Responsiveness: How well can this measure capture change? What is the minimal change in status or function that it can predict (minimal detectable difference [MDD] or MDC)? Do we understand what a clinically meaningful change might be (minimal clinically important difference)?171 Readers are referred to Portney and Watkins (2009)409 for more information on the process of measurement and to Stokes (2011)410 as a resource for evaluating and selecting outcome measures.

Summary Early rehabilitation in the postoperative, preprosthetic period lays the foundation for prosthetic rehabilitation. Initial emphasis is placed on wound healing and control of edema, essential prerequisites for prosthetic use. Early in the process, the individual with new amputation and family

caregivers become actively involved in the rehabilitation process and decision making, assuming responsibility for limb compression, skin care, and desensitization. The therapist is alert for postoperative medical complications such as postural hypotension or deep venous thrombosis, as early mobility begins. The therapist implements strategies to prevent secondary impairments and functional limitations such as further deconditioning and contracture formation. Strengthening exercises targeting the residual limb and overall fitness begin in the acute or subacute setting and continue as an aggressive home program to prepare the individual for prosthetic training. Persons with new amputation are encouraged to become as independent as possible in transfers, single limb gait, and wheelchair mobility, depending on their medical status and functional capability. As the wound heals and edema subsides, the individual with new amputation, family caregivers, therapist, prosthetist, and physician begin discussion about future prosthetic rehabilitation. The postoperative, preprosthetic period is a time of transition in which many individuals mourn the loss of their limb and question their future yet are challenged and encouraged by the possibilities offered by prosthetic replacement of their limb. If the consensus is that prosthetic fitting is not viable, emphasis shifts to development of

20 • Postoperative and Preprosthetic Care

wheelchair mobility skills and adaptation of the patient’s environment as rehabilitation continues. If the consensus is that prosthetic fitting is likely, rehabilitation during this time focuses on building the physical and psychological resources that will ensure the person with new amputation will become a successful prosthetic user.

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20 • Postoperative and Preprosthetic Care 384. Treweek SP, Condie ME. Three measures of functional outcome for lower limb amputees: a retrospective review. Prosthet Orthot Int. 1998;22(3):178–185. 385. Stineman MG, Shea JA, Jette A, et al. The Functional Independence Measure: tests of scaling assumptions, structure, and reliability across 20 diverse impairment categories. Arch Phys Med Rehabil. 1996;77:1101–1108. 386. Masedo AI, Hanley M, Jensen MP, et al. Reliability and validity of a selfreport FIM (FIM-SR) in persons with amputation or spinal cord injury and chronic pain. Am J Phys Med Rehabil. 2005;84:167–176. 387. Panesar BS, Morrison P, Hunter J. A comparison of three measures of progress in early lower limb amputee rehabilitation. Clin Rehabil. 2001;15(2):157–171. 388. McPherson K, Sloan RL, Hunter J, Dowell CM. Validation studies of the OPCS scale—more useful than the Barthel Index? Office of Population Census’s and Surveys. Clin Rehabil. 1993;7(2):105–112. 389. Callaghan BG, Condie ME. A post-discharge quality of life outcome measure for lower limb amputees: test-retest reliability and construct validity. Clin Rehabil. 2003;17(8):858–864. 390. Martin F, Camfield L, Rodham K, et al. Twelve years’ experience with the Patient Generated Index (PGI) of quality of life: a graded structured review. Qual Life Res. 2007;16(4):705–715. 391. Stratford PW, Gill C, Westaway M, Binkley J. Assessing disability and change on individual patients: a report of a patient specific measure. Physiother Can. 1995;47:258–263. 392. Kowalchuk Horn K, Jennings S, Richardson G, et al. The patientspecific functional scale: psychometrics, clinometrics, and application as a clinical outcome measure. J Orthop Sports Phys Ther. 2012;42 (1):30–42. 393. Streppel KR, Vries J, Van Harten WH. Functional status and prosthesis use in amputees, measured with Prosthetic Profile of the Amputee (PPA) and the short version of the Sickness Impact Profile (SIP68). Int J Rehabil Res. 2001;24(3):251–256. 394. Gauthier-Gagnon C, Grise M. Tools to measure outcome of people with a lower limb amputation: update on the PPA and LCI. J Prosthet Orthot. 2006;18(1 S):61–67. 395. Ryall NH, Eyres SB, Neumann VC, et al. Is the Rivermead Mobility Index appropriate to measure mobility in lower limb amputees? Disabil Rehabil. 2003;25(3):143–152. 396. Franchignoni F, Brunelli S, Orlandini D, et al. Is the Rivermead Mobility Index a suitable outcome measure in low limb amputees?—A psychometric validation study. J Rehabil Med. 2003;35 (3):141–144.

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397. Pezzin LE, Dillingham TR, Mackenzie EJ. Rehabilitation and the long term outcomes of persons with trauma-related amputations. Arch Phys Med Rehabil. 2000;81(3):292–300. 398. de Godoy JM, Braile DM, Buzatto SH, Longo O, Fontes OA. Quality of life after amputation. Psychol Health Med. 2002;7(4):397–400. 399. Jette A, Haley S, Coster W, et al. Late life function and disability instrument: I. Development and evaluation of the disability component. J Gerontol A Biol Sci Med Sci. 2002;57A: M209–M216. 400. Haley S, Jette A, Coster W, et al. Late life function and disability instrument: II. Development and evaluation of the function component. J Gerontol A Biol Sci Med Sci. 2002;57A:M217–M222. 401. Denkinger MD, Igl W, Coll-Planas L, et al. Evaluation of the Short Form of the Late-Life Function and Disability Instrument in geriatric inpatients-validity, responsiveness, and sensitivity to change. J Am Geriatr Soc. 2009;57(2):309–314. 402. Jette AM, Haley SM, Kooyoomjian JT. Late Life FDI Manual. Boston, MA: Roybal Center for the Enhancement of Late Life Function, Boston University; 2006. 403. Peters DM, Fritz SL, Krotish DEPT. Assessing the reliability and validity of a shorter walk test compared to the 10 meter walk test for measurements of gait speed in healthy, older adults. J Geriatr Phys Ther. 2013 Jan-Mar;36(1):24–30. 404. Chui KK, Lusardi MM. Spatial and temporal parameters of selfselected and fast walking speeds in healthy community-living adults aged 72–98 years. J Geriatr Phys Ther. 2010;33(4):173–183. 405. Brooks D, Hunter JP, Parsons J, et al. Reliability of the two-minute walk test in individuals with transtibial amputation. Arch Phys Med Rehabil. 2002;83(11):1562–1565. 406. Miller WC, Deathe AB, Harris J. Measurement properties of the Frenchay Activities Index among individuals with a lower limb amputation. Clin Rehabil. 2004;18(4):414–422. 407. Wheelchair Skills Test Manual. Version 4.2. http://www. wheelchairskillsprogram.ca/eng/documents/WST_Manual_ version_4.2.1_approved.pdf;2013. Accessed 4 March 2018. 408. Lindquist NJ, Loudon PE, Magis TF, et al. Reliability of the performance and safety scores of the Wheelchair Skills Test Version 4.1 for manual wheelchair users. Arch Phys Med Rehabil. 2010;91 (11):1752–1757. 409. Portney LG, Watkins MP. Foundations of Clinical Resarch: Applications to Practice. 3rd ed. Upper Saddle River, NJ: Prentice Hall; 2009. 410. Stokes EK. Rehabilitation Outcome Measures. Philadelphia: Elsevier: Churchill Livingstone; 2011.

21

Understanding and Selecting Prosthetic Feet KEVIN CARROLL, JOHN RHEINSTEIN, and ELICIA POLLARD

LEARNING OBJECTIVES

On completion of this chapter, the reader will be able to do the following: 1. Define the Medicare functional levels and how they relate to the provision of a prosthesis and prosthetic feet. 2. Explain key factors analyzed when prescribing a prosthetic foot. 3. Define the fundamental characteristics of the different types of prosthetic feet. 4. Formulate a prescription recommendation for a prosthetic foot based on a person’s needs.

Just as every person is unique, every person with a lower limb amputation presents a different set of characteristics that should be considered in the design of their prosthesis and especially when selecting a prosthetic foot. This selection should be made carefully because safety, performance, and satisfaction can be impacted if the foot is not well matched to the user.1 To make an effective foot selection among the multitude of choices, it is important to thoroughly consider each individual’s current and potential abilities and needs. The rehabilitation team should carefully review each person’s current and expected physical capabilities and prosthetic history while keeping in mind the performance features, specifications, and appearance of available feet. Published research and evidence provide the basis for general clinical practice guidelines based on users’ functional abilities and needs but does not yet provided complete prescriptive pathways to individual foot selection.2–6 The aim of providing a prosthetic foot is to maximize every person’s rehabilitation potential so that they may reach their goals for their activities and function at a level comparable with their peers. Ideally, the function of a prosthetic foot should match that of an anatomic human foot.7 It should offer shock absorption, compliance to uneven terrain, push-off, and ground clearance during the appropriate points in the gait cycle, all in a lightweight, low-maintenance package. Although modern prosthetic feet have many of these capabilities, in reality, no foot currently available matches the human foot in all these characteristics. The final choice is always a compromise because no prosthetic foot performs optimally for all activities and conditions. The most appropriate foot is one that best serves the present and future unique needs of the individual. It is incumbent upon the rehabilitation team to select the management strategies that (1) are consistent with each patient’s needs, capabilities, and potential; (2) protect the patient from progressive overuse symptoms; and (3) avoid overuse and underuse of medical resources. Once a foot model is selected, it must be ordered to meet the specific weight and activity level of each person so it will 566

respond appropriately under load. If a person experiences significant changes in their weight or activity level, the foot should be replaced to match their new functional needs. For example, a weight gain of 20 or more pounds, and/or a substantial increase in activity, or loads carried may result in the foot being too compliant. Under these conditions the foot can no longer provide the necessary amount of support or energy return and may also result in catastrophic failure of the structural elements. All the parts of a prosthetic system, especially feet, should be checked every 6 months for wear and tear. Visible cracks or noises are signs of structural failure and warnings that the foot should be replaced. It is difficult to predict the useful life span of a foot because of the wide range of users and the way in which they are used. Most feet have a manufacturer’s warranty of 2 to 3 years.

Factors in Selecting a Prosthetic Foot When designing an appropriate prosthesis, the rehabilitation team in consultation with the user should consider the following multiple factors that influence component selection. By understanding the function and features of the chosen foot, alignment and training can be targeted to maximize its functional benefits.

FUNCTIONAL LEVEL Medicare guidelines define five functional levels (also known as “K levels”) for unilateral lower limb amputees that are widely accepted by most payers. This classification system determines the medical necessity for feet and knees based on the patient’s current and potential functional abilities. Medicare policy states, “A determination of the medical necessity for certain components/additions to the prosthesis is based on the beneficiary’s potential functional abilities. Potential functional ability is based on the reasonable

21 • Understanding and Selecting Prosthetic Feet

expectations of the prosthetist and treating physician, considering factors including, but not limited to: 1. The beneficiary’s past history (including prior prosthetic use if applicable) 2. The beneficiary’s current condition including the status of the residual limb and the nature of other medical problems 3. The beneficiary’s desire to ambulate Clinical assessments of beneficiary rehabilitation potential must be based on the following classification levels: Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility. Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulator. Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs, or uneven surfaces. Typical of the limited community ambulator. Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete. The records must document the beneficiary’s current functional capabilities and his/her expected functional potential, including an explanation for the difference, if that is the case. It is recognized, within the functional classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level classifications.”8 It should also be noted that the use of a mobility aid is not a determinant in assessing functional level. Ideally, the rehabilitation team examines and interviews the prosthetic candidate and reaches a consensus as to the potential functional level they are most likely to achieve. The key word in reaching such a decision is “potential,” which challenges the team to predict future outcomes based on past performance, stated goals, and other unknowns. However, it can be easy to jump to conclusions because a clinical practice guideline recommends, “Neither patient age nor amputation etiology should be viewed as primary considerations in prosthetic foot type.”2 The functional level classification has real implications for the prosthetic user because it determines what type of foot they will receive. Therefore, if the rehabilitation team believes that a person currently performing at functional level 2 will reach level 3, they should receive a level 3 foot straightaway. Not only does this allow the person to train with and use a foot that supports his or her higher activity level, but it will save cost over the long run by eliminating the need to purchase two different feet. In addition to the factors mentioned later, there are a number of performance-based and self-reported outcomes measure that can assist in the determination of

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current and potential functionality.9 For example, the Amputee Mobility Predictor instruments (AMPPRO and AMPnoPRO) are designed to measure ambulatory potential of lower limb amputees.10 The Prosthetic Limb Users Survey of Mobility (PLUS-M) is a self-report instrument for measuring mobility of adults with lower limb amputation and can also be used to compare an individual with other amputees and to monitor a person’s progress and satisfaction over time.11,12

ACTIVITIES OF DAILY LIVING, VOCATIONAL, AND WORK REQUIREMENTS No single foot usually meets a person’s needs in all situations. By determining all of their current and future activities, a balance of performance features can be achieved. For example, for someone who works in an office during the week and who also plays golf on weekends, a foot with a multiaxial ankle would be recommended to accommodate uneven terrain.

BODY WEIGHT Foot sizes and strengths are available for people ranging from a baby to adults weighing up to 500 pounds. A small prosthetic foot for children is shown in Fig. 21.1. Because a growing population of people are overweight, manufacturers are offering prosthetic feet for those heavier individuals. A prosthetic foot expected to support heavier weights must be specially crafted for increased strength and durability; consequently, the prosthesis itself is larger and heavier because of the additional materials included in the foot, pylon, and socket. The user’s weight should be recorded at every encounter to ensure that his or her foot is still appropriately matched. Obesity makes prosthetic fitting more difficult; however, the results achieved by overweight people can be very inspirational. In one study, body mass index was not a significant independent predictor of failure for any outcome parameter measured. Interestingly, “there were significantly poorer outcomes for underweight patients.”13 Even people weighing more than 300 pounds should not give up hope.

Fig. 21.1 A very small children’s foot. (Courtesy Hanger Clinic, Austin, TX.)

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Although initially confined to a nursing home bed, rehabilitation teams that work with overweight individuals can fit them with a prosthesis, assist them with standing, begin therapy, and within just a few months have the same bedridden patients walking on their own. It is common for functional K1 level patients to progress to K2 level with appropriate care and therapy. People are often deconditioned from the illnesses that precipitated their amputation and can make great strides as long as they are motivated and do the physical and occupational therapy needed to succeed.

RESIDUAL LIMB Foot selection can bear directly on the health of the person’s residual limb. Ground reaction forces that are transmitted through a person’s body can be stressful or damaging to their residual limb, knee, hip, and/or back.14 People with short or painful residual limbs are generally fit with feet that are softer to attenuate ground force transmission through the prosthesis. Choosing a foot with compliant heel action or vertical shock absorption features can reduce these impact forces.

COMORBIDITIES Comorbid health conditions such as diabetes and peripheral vascular disease should be considered relevant only to foot selection to the degree to which they effect a person’s functional abilities. Keep in mind that patients are often deconditioned from weight-bearing restrictions prior to amputation and can recover once they receive a prosthesis and physical therapy. The deflection dynamics and alignment of a foot can have an effect on the health and well-being of a person’s joints. “Patients at elevated risks for overuse injury (i.e., osteoarthritis) to the sound side lower limb and lower back are indicated for an energy storage and return (ESAR) foot to reduce the magnitude of the cyclical vertical impacts experienced during weight acceptance.”2 Excessive toe stiffness can cause hyperextension of the knee, and a prosthesis that is too short or long may cause back pain.15

ENVIRONMENTAL EXPOSURE AND DURABILITY People exposed to extreme environments need a foot that will not fail under wet or dirty conditions. An additional specially designed prosthesis with a solid foot or drain holes should be provided for water use if it is needed for bathing, swimming, or water sports. Sand and dirt are especially destructive to feet.

A

B

€ Fig. 21.2 (A) Heel height–adjustable foot. (B) Cover for foot. (© Ossur.)

gait and energy-storing capability in any height position. Although a heel-height–adjustable foot can flatten for barefoot walking, the rubber foot shell will wear out quickly if it is used without a shoe. A prosthesis without a heel-height– adjustable mechanism cannot be worn with shoes of different heel heights unless adjustment wedges are placed in the shoes to make the effective heel height the same among all the user’s shoes. It is important to note, when a heel wedge is added to the prosthetic side shoe, another must be added to the contralateral side to avoid changing the overall length of the prosthesis. However, a wedge may be added under the ball of the prosthetic foot with no effect on the overall length. Seasonal changes in shoes are also important; providing a split between the big toe and its neighbor may not seem important in the fall or winter, but is very noticeable in the summer when the user wants to wear thong sandals (Fig. 21.3). If a prosthetic foot is too wide, it may prove difficult to get into a shoe, and a foot that is too narrow may move around in the shoe causing instability. Asking the person to bring to the clinic all the shoes he or she intends to wear can reduce uncertainty about foot size and shape. Individuals who have been prescribed a diabetic shoe should be encouraged to wear only those shoes.

SHOE CHOICES (HEEL HEIGHTS AND SHOE SHAPE) A heel-height–adjustable foot (Fig. 21.2) can make a significant difference for someone who wants to wear high heels or switch between different heel-height shoes, depending on the occasion or work requirements. People who enjoy a versatile shoe wardrobe can switch from a tennis shoe or casual slipper into a dressy high-heeled shoe easily, by pushing a button on the side of the ankle, concealed by the cosmetic covering. The ankle is allowed to bend into the desired position and then safely locked. The foot still provides normal

Fig. 21.3 Foot cover with split toes. (Courtesy Hanger Clinic, Austin, TX.)

21 • Understanding and Selecting Prosthetic Feet

INTERACTION WITH OTHER PROSTHETIC COMPONENTS The foot is part of a closed chain in which ground reaction forces are transmitted through the prosthesis. The characteristics of the foot will affect the way a prosthetic knee and hip joint respond to ground forces. For example, a foot with a stiff heel will send more flexion force to the knee at heel strike causing less knee stability. In addition, the anterior/posterior and medial/lateral placement, transverse rotation, and the dorsi-plantarflexion alignment of a foot relative to the other prosthetic components affect the way it functions and feels to the wearer, as well as the resulting gait. For example, moving a foot anterior relative to a prosthetic socket or plantarflexing it would increase forefoot stiffness and support while decreasing heel stiffness and support. Alignment changes also result in changes in socket pressures on a user’s residual limb. Small alignment changes can produce dramatic changes in the biomechanics of a prosthesis and should be undertaken with care under the guidance of a certified prosthetist.

PRIOR PROSTHETIC FEET AND GAIT HABITS People who have become accustomed to the characteristics of a particular foot over many years may have difficulty adapting to a different one. When a change is warranted, a period of adjustment is expected. Physical therapy is recommended any time a new prosthesis, foot, or component is provided. Exercises and gait training for balance, weight transfer, and loading and releasing the forefoot should be tailored to the functional dynamics of each foot.16

PSYCHOLOGICAL INFLUENCES AND PERSONALITY TRAITS The wearer’s age has less to do with the choice of prosthesis than the wearer’s attitude. For example, an 80-year-old might be running marathons, whereas a 45-year-old with less determination remains wheelchair-bound. The difference may lie solely in their state of mind. A prosthesis wearer’s personal preferences, practical goals, and lofty ambitions should all be considered when selecting a foot. Many people are able to expand their capabilities and motivation dramatically once they are fit with an appropriate prosthesis that allows them to improve their range of activities. Peer support can be an important element in helping to motivate someone who is not progressing to their potential.17

SKIN TONE Each of the feet described in this chapter is available with a rubber cover or foot shell that gives the appearance of a foot, in addition to protecting its structural elements. Current foot shells have a more natural appearance and greater durability than their predecessors, but they will still wear out faster than the structural element of the foot and thus should be checked every 6 months and replaced as needed. Most have toes and are available in three basic flesh tones. Flexible skins can be added that closely approximate each person’s skin tone.

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COST Foot choices may be limited by insurance coverage and the person’s ability to pay. In general, higher-functional-level feet cost more; however, people with higher function and who fall less as a result of an appropriate prosthesis will likely incur less overall medical cost. Work by Dobson et al. states, “The results of our analysis indicate that patients who received lower extremity prostheses were more likely to receive extensive outpatient therapy than comparison group patients.18 The receipt of physical therapy was associated with fewer acute care hospitalizations, emergency room admissions, and less facility-based care (P < .05), which nearly offset the cost of the prosthetic. As a result, patients who received prosthetics had comparable cumulative Medicare payments over 12 months than those who did not ($728, or just 1 percent higher). Results suggest that the device was nearly amortized by the end of 12 months and the patient could experience better quality of life and increased independence compared with patients who did not receive the prosthetic at essentially no additional cost to Medicare or the patient.”19

BILATERAL LIMB LOSS People missing both legs at the same amputation level generally receive a matched pair of feet. Outcomes for individuals with bilateral transfemoral amputations are improved if they are first trained to use very short prostheses with small rigid feet known as “stubbies.”20 All of the factors mentioned previously should be considered when narrowing the selection of appropriate prosthetic choices. It is important to thoroughly discuss with the person the choices available to them. Everyone on the rehabilitation team should understand the person’s wishes and his or her plans for future or potential activities. Each person has different values as to what is important to him or her. Many manufacturers have short trial periods during which a foot can be returned if it is not working well for the wearer.

Performance Features and Appearance of Available Prosthetic Feet FUNCTIONAL LEVEL 1 FEET The solid-ankle, cushion-heel (SACH) (Fig. 21.4) foot is the most basic prosthetic foot available. It is recommended only for those with limited functional ability and potential to ambulate. The SACH foot is provided primarily for transfers and limited ambulation. This foot’s immovable ankle and soft heel give it the ability to absorb the impact of heel strike but provides minimal energy return and anterior support. There are numerous manufacturers who produce a version of the SACH foot that is simply crafted from a wooden or plastic block with a soft cushion under the heel segment and rubber toes. Because the SACH foot has no moving parts, little maintenance is required until the foot is worn out, at which time it should be replaced. However, no device is indestructible, and, with our increasingly overweight

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providing smooth transitioning from heel strike to toe-off. These feet have foam-rubber cushions that assist the wearer with soft plantarflexion by providing a smooth transition from heel strike to midstance. The feet also allow for some transverse rotation. The flexibility of the ankle on most of these feet can be softened or stiffened by changing the rubber cushions. More features and adjustments also mean that more attention and maintenance must be provided. People at functional level 2 should be reassessed regularly by the rehabilitation team to determine whether they can progress to functional level 3. Additional physical therapy and motivation may be all that is needed to push them to the next level. Fig. 21.4 K1 functional level foot: the solid-ankle, cushion-heel foot. (Courtesy Hanger Clinic, Austin, TX.)

society, care should be taken to provide a foot with the appropriate weight category to avoid damage or failure. A carbon composite foot (see “K3 Feet” later) may be required if a SACH foot cannot be made strong enough to support an extremely heavy-weight person. Single axis feet with a pivoting ankle joint are also appropriate for K1 ambulators. A recent Clinical Practice Guideline consolidated available evidence and recommended that, “For patients ambulating at a single speed that require greater stability during weight acceptance due to weak knee extensors or poor balance, a single axis foot should be considered.”2 By moving quickly from heel strike to foot flat, less force is transmitted to the user’s residual limb and to their knee, which makes their prosthesis more stable than with a SACH foot. Single axis feet have moving parts and require periodic maintenance.

FUNCTIONAL LEVEL 2 FEET There is an array of different feet suitable for people with amputation at functional level 2 who are able to walk inside their homes and outside in the community at a slow pace (Fig. 21.5). Most level 2 feet are lightweight, have a flexible keel and a multiaxial ankle, and provide some energy return. A full-length toe mechanism lends stability while

Fig. 21.5 K2 functional level foot. Otto Bock 1M10. (Courtesy Hanger Clinic, Austin, TX.)

FUNCTIONAL LEVEL 3 FEET Functional level 3 feet are appropriate for people with the ability or potential to perform daily activities beyond simple locomotion and to walk with variable cadence. Known as ESAR, these feet are fabricated from lightweight flexible materials such as carbon fiber and more recently fiberglass, which are very responsive and extremely durable. Compared with a SACH foot, they reduce energy consumption, offer increased ankle motion, reduce sound side loading, and store and return more energy. ESAR feet should be considered for patients at elevated risks for overuse injuries. Individuals walking at faster speeds are subjected to higher ground reaction forces and can benefit from the way ESAR feet reduce the magnitude of the cyclical vertical impacts experienced during weight acceptance.2 Initial studies indicate that fiberglass feet offer additional power generation over carbon fiber feet.21 There are numerous designs available in this category, which vary based on the shape of the carbon fiber or fiberglass and the addition of other materials to absorb shock and rotational forces. They can be fitted with or without an integrated pylon. Although most are designed with no moving parts and need little maintenance, carbon fiber and fiberglass feet should be checked every 6 months for wear tear, as well as to (1) clean out or replace the foot shell, (2) replace the inner protective sock, and (3) determine if the foot still meets the needs of the wearer. The integrated pylon foot (Fig. 21.6) is the lightest of all foot prostheses. It is one continuous composite material unit

Fig. 21.6 K3 functional level foot with integrated pylon—Ossur Variflex. (Courtesy Hanger Clinic, Austin, TX.)

21 • Understanding and Selecting Prosthetic Feet

from the toe to the top of the pylon, with a separate heel segment. Plantarflexion and dorsiflexion are achieved by deflection of the structural material of the foot. Some of these feet also provide inversion/eversion by way of a longitudinal split that bisects the foot, a urethane cushion, or a floating sole plate. These feet cannot be used for individuals with long residual limbs. In addition, alignment capabilities are somewhat limited by the integrated pylon foot as adjustments can be made only just below the socket rather than at the ankle. Alignment wedges can be added to the foot or shoe to compensate for this shortcoming. Energy-storing feet without the integrated pylon (Fig. 21.7) offer the same features as those described previously and are indicated for those individuals with long residual limbs. They also allow the prosthetist to perform alignment adjustments at the ankle where the foot is joined to a separate pylon. Feet with shock and torsion absorption are especially important for high-activity people and those performing repetitive motions. These features reduce the vertical and sheer forces that are transmitted to the residual limb by allowing these motions to take place in the foot rather than inside the socket (Fig. 21.8). Hydraulic damping is another ankle feature that permits increased fluidity of sagittal plane

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Fig. 21.9 Foot with hydraulic ankle—Freedom Innovations Kinterra. (Courtesy of Hanger Clinic, Austin, TX)

Fig. 21.10 Foot with integrated vacuum pump—RUSH—EVA. (Courtesy Hanger Clinic, Austin, TX.)

Fig. 21.7 K3 functional level foot with integrated pyramid—Ossur LP Pro-Flex LP. (Courtesy of Ossur, Foothill Ranch, CA)

Fig. 21.8 K3 dynamic response foot with vertical shock and torque absorption—Ottobock Triton VS. (Courtesy of Otto Bock Health Care, www.ottobockus.com.)

movement (Fig. 21.9) and are available in both level 3 and level 2 versions. A number of feet are designed to generate vacuum from the motion of walking for elevated vacuum sockets (Fig. 21.10). These sockets provide volume management and reduce movement between the residual limb and the socket.22–24 Microprocessor feet are the most recent development in prosthetic foot technology and have opened an exciting new spectrum of possibilities for many people with lower extremity amputation. In contrast to traditional prosthetic feet which are passive, microprocessor feet actively respond and adapt to changes in the environment such as changes in inclines, walking speed, and shoes. If the wearer ascends an incline, the foot automatically provides dorsiflexion and continues to do so for the extent of the incline. Similarly, the foot automatically responds with plantarflexion during the descent on a downhill grade. The Freedom-Innovations Kinex, Endolite Elan, Ossur Proprio, Fillaurer Raize, Ottobock Triton Smart Ankle, and Ottobock Meridium all perform these functions (Fig. 21.11A–F). Microprocessor feet are heavier than most other feet. They are powered by an onboard battery that requires nightly recharging. The range of motion of microprocessor feet is thus far limited to this single-axis capability, but inversion and eversion flexibility are likely to be available in the future. They are indicated for functional level 3 users who encounter inclines in their activities of daily living.

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Fig. 21.11 Microprocessor feet. (A) Freedom innovations—Kinex. (Courtesy Freedom Innovations, Irvine, CA.) (B) Endolite Elan. (Courtesy of Blatchford, € blatchford.co.uk.) (C) Ossur Proprio. (© Ossur.) (D) Fillauer Raize. (Courtesy of Fillauer Companies, Inc, Chattanooga, TN.) (E) Ottobock Smart Ankle. (Courtesy of Otto Bock Health Care, www.ottobockus.com.) (F) Ottobock Meridium. (Courtesy of Otto Bock Health Care, www.ottobockus.com.) (G) Ottobock Empower Ankle. (Courtesy of Otto Bock Health Care, www.ottobockus.com.)

21 • Understanding and Selecting Prosthetic Feet

Fig. 21.12 Fillauer running blade. (Courtesy Fillauer Companies, Inc, Chattanooga, TN.)

Contraindications for microprocessor feet are very high activity, heavy body weight, and frequent exposure to water, dirt, and extremes of temperature. The Empower Ankle is the only microprocessor foot designed to actively replace the propulsive function of the gastrocsoleus muscles (see Fig. 21.11G). This foot generates power during plantarflexion, propelling the person forward. Research demonstrated a significant reduction in metabolic cost, which allows people with amputation to walk with less energy and better gait symmetry.25 In spite of these benefits, adoption has been slow due to the high weight and cost of this foot.

FUNCTIONAL LEVEL 4: HIGH ACTIVITY AND SPECIALIZED FEET A number of specialized prosthetic feet are available for the serious athlete and weekend warriors. Sprinting feet are designed for powerful bursts of speed, such as in a 100-meter or 200-meter race (Fig. 21.12). They do not have a heel component. Running feet are softer than sprinting feet for longer distance running up to marathon or halfmarathon challenges and have a heel (Fig. 21.13A and B). Choice of design depends on the person’s activities and special interests. Running or sprinting feet are not recommended for everyday wear. Running feet are also available

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Fig. 21.14 Pediatric running foot. (Courtesy Hanger Clinic, Austin, TX.)

for children (Fig. 21.14). Specialized activity feet are available for a variety of sports (Fig. 21.15A–C). A swim foot is available that can be locked in plantarflexion for use with a swim fin. A short, rock climbing foot is designed for use with a specialized climbing shoe, and a skiing foot clips directly into the binding without a ski boot.

Summary Selecting the most appropriate prosthetic foot can be a complex clinical decision because of a variety of factors, including a person’s current and potential functional level, specific needs, the wide array of available choices, and cost. A miscalculation in the selection process can make a significant difference in outcome and level of success. Rehabilitation team professionals, together with the wearer, family members, and caregivers, should analyze and evaluate the best prosthetic options for advancing mobility that is functional, efficient, practical, and safe for people with lower extremity amputation. Advances in energy-storing materials and microprocessor technology offer people with lower extremity amputation improved function in daily activities as well as high-activity performance in sports such as running, swimming, golfing, biking, hiking, skiing, and rock climbing.

Fig. 21.13 Running feet. (A) Ottobock Challenger. (Courtesy of Otto Bock Health Care, www.ottobockus.com). (B) Fillauer allPro. (Courtesy Fillauer Companies, Inc, Chattanooga, TN.)

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Fig. 21.15 Specialized activity feet. (A) Swim foot with moveable ankle. (Courtesy of Freedom Innovations, Irvine, CA.) (B) Adult climbing foot. (Courtesy TRS, Inc, Boulder, CO.) (C) Skiing foot. (Courtesy Freedom Innovations, Irvine, CA.)

Case Example 21.1 An Individual With a Transtibial Amputation A. J., a former marine soldier, was 20 years old when he endured traumatic injuries after driving his motor vehicle over a landmine. He was one of three people who survived the explosion. A. J. was flown to Germany for emergency surgery and later transferred to a military medical center in Washington, D.C. He severely injured his left leg, incurred damage to his right tympanic membrane, and lost his left thumb. After multiple surgeries, bone infection in his left leg, and months of rehabilitation, doctors decided to amputate his leg below the knee. A. J. was offered an honorable discharge because of his injuries. He accepted the discharge and returned to his hometown where he continued rehabilitation. In high school, A. J. had been a competitive athlete for his track team, and he maintained an average weight of 180 pounds. One year after the accident, the 5-foot 11-inches-tall former soldier weighs 206 pounds and is ambulating independently with a transtibial prosthesis. A. J. has accepted the loss of his left leg and is ready to return to a “normal” life. He is determined to run again and plans to enroll at a local college. A. J. currently lives with his mother in a small one-story house in a

rural community and has not driven a vehicle since the accident. QUESTIONS TO CONSIDER ▪ To what extent would A. J.’s age, height, weight, and lifestyle impact the selection and maintenance of a prosthetic foot? ▪ What prosthetic foot design would be most appropriate for athletic challenges? ▪ What environmental challenges might A. J. encounter on a college campus? What environmental challenges might he encounter in a rural community? ▪ How does a prosthetic foot simulate the functional characteristics of a human foot? ▪ How does a prosthetic foot’s function during gait differ during running? ▪ What social issues might A. J. face as he enters college? How would a prosthetic foot affect his psychosocial health? ▪ What specific recommendations should be given to meet A. J.’s needs and to assist him in meeting his goals?

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Case Example 21.2 An Older Adult with Amputation Due to Infected Nonhealing Neuropathic Ulcer Mrs. R. T. is a 79-year-old woman with long-standing diabetes and peripheral artery disease who developed a neuropathic ulcer at the first metatarsal head of her right forefoot 6 months ago. Despite conservative attempts to heal the wound using a total contact cast and subsequent vascular bypass surgery to restore blood flow to the distal extremity, the wound failed to heal and osteomyelitis developed. Mrs. R. T. underwent standard transtibial amputation 2 months ago and managed postoperatively with removable rigid dressing to protect the surgical site and control postoperative edema. Although the surgical incision was slow to heal, her surgeon has determined that it is now safe to begin prosthetic training, and she has been referred for prosthetic prescription. Until the development of her neuropathic ulcer, Mrs. R. T. lived independently in a second-floor apartment of an urban retirement community in a small city, drove her own car to a nearby park to walk for exercise at least three times each week, and participated in many activities at her local senior center. Since her surgery, she has been living with her daughter in a nearby suburb, using a wheelchair (propelling it herself) for mobility, and receiving home care physical therapy to build her strength and endurance. She reports that she is able to transfer between bed and wheelchair independently but requires assistance to get into and out of the car. She looks forward to receiving a prosthesis but wonders if she will have the

ACKNOWLEDGEMENT

Thank you to Laura Rheinstein and Phil Stevens for their editorial assistance.

References 1. Powers CM, Torburn L, Perry J, et al. Influence of prosthetic foot design on sound limb loading in adults with unilateral below-knee amputations. Arch Phys Med Rehabil. 1994;75(7):825–829. 2. Stevens P, Rheinstein J, Wurdeman S. Prosthetic Foot Selection for Individuals with Lower Limb Amputation: A Clinical Practice Guideline. J Prosthet Orthot. Accepted, pending publication 3. van der Linde H, Hofstad CY, Geurts AC, et al. A systematic literature review of the effect of different prosthetic components on human functioning with a lower-limb prosthesis. J Rehabil Res Dev. 2004;41:555–570. 4. Cummings DR, Kapp S. State-Of-The-Science Conference on prosthetic feet and ankle mechanisms. http://www.oandp.org/jpo/library/index/ 2005_04S.asp. 5. Czerniecki JM. Research and clinical selection of foot-ankle systems. J Prosth Orthot. 2005;17(4S):358. 6. Highsmith MJ, et al. Prosthetic interventions for people with transtibial amputation: Systematic review and meta-analysis of high-quality prospective literature and systematic reviews. J Rehabil Res Dev. 2016;53 (2):157–184. 7. Perry J. Gait Analysis: Normal and Pathological Function. Thorofare, NJ: Slack; 1992. 8. CMS LCD L33787. www.cms.gov. 9. Kaluf B, Stevens P. Outcome Measures in Lower Limb Prosthetics. In: Krajbick J, Pinzur M, Potter B, Stevens P, eds. Atlas of Amputations and Limb Deficiencies. 4th ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2016:645–652. 10. Gailey RS, Roach KE, Applegate EB, et al. The amputee mobility predictor: an instrument to assess determinants of the lower-limb amputee’s ability to ambulate. Arch Phys Med Rehabil. 2002;83(5):613–627. 11. Hafner BJ, Morgan SJ, Askew RA, Salem R. Psychometric evaluation of self-report outcome measures for prosthetic applications. J Rehabili Res Dev. 2016;53(6):797–812.

ability to return to community ambulation without the need of an assistive device. Mrs. R. T. is 5 feet, 3 inches tall and weighs 150 pounds. She admits that her memory “is not what it used to be” and has recently been diagnosed with mild cognitive impairment, but she has no clinical signs of dementia. She has significant osteoarthritis of her fingers and wrists, as well as in both of her hips. QUESTIONS TO CONSIDER ▪ To what extent would Mrs. R. T.’s age, height, weight, and lifestyle impact the selection and maintenance of a prosthetic foot? ▪ What K level best reflects Mrs. R. T.’s functional potential? Why have you selected this K level? ▪ What prosthetic foot design would be most appropriate for Mrs. R. T.’s first prosthesis? ▪ What environmental challenges might Mrs. R. T. encounter if she is able to resume her preulcer activities? How might the challenges be similar or different in an urban versus suburban community? ▪ How does the prosthetic foot that you have chosen simulate the functional characteristics of a human foot? ▪ What are the effects of a prosthetic foot on gait? ▪ What specific recommendations should be given to meet Mrs. R. T.’s needs and assist her in meeting her goals?

12. Wurdeman SR, Stevens PM, Campbell JH. Mobility Analysis of AmpuTees (MAAT I): Quality of life and satisfaction are strongly related to mobility for patients with a lower limb prosthesis. In: Prosthet Orthot Int. 2017. 13. Kalbaugh CA, et al. Does obesity predict functional outcome in the dysvascular amputee? Am Surg. 2006 Aug;72(8):707–712. https://www. ncbi.nlm.nih.gov/pubmed/16913314. 14. Snyder R, et al. The effect of five prosthetic feet on the gait and loading of the sound limb in dysvascular below-knee amputees. Journal of Rehabilitation Research and Development; Washington. Nov 1995;Vol. 32(Iss. 4):309–315. 15. Lower Limb Amputees and Low Back Pain. https://www.physio-pedia. com/Lower_Limb_Amputees_and_Low_Back_Pain. 16. Gailey R, Gaunaurd I, Laferrier J, Krajbick J, Pinzur M. Physical Therapy Management of Adults with Lower Limb Ampuations. In: Potter B, Stevens P, eds. Atlas of Amputations and Limb Deficiencies. 4th ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2016:597–620. 17. Reichmann J, Bartman K. An Integrative Review of Peer Support For Patients Undergoing Major Limb Amputation. J Vasc Nurs. 2018;36:34–39. 18. Dobson A, et al. Economic Value of Prosthetic Services Among Medicare Beneficiaries: A Claims-Based Retrospective Cohort Study. Mil Med. 2016 Feb;181(2 Suppl):18–24. https://doi.org/10.7205/MILMED-D15-00545. https://www.ncbi.nlm.nih.gov/pubmed/26835740. 19. Dobson A, et al. Economic Value of Prosthetic Services Among Medicare Beneficiaries: A Claims-Based Retrospective Cohort Study. Mil Med. 2016 Feb;181(2 Suppl):18–24. https://doi.org/10.7205/MILMED-D15-00545. https://www.ncbi.nlm.nih.gov/pubmed/26835740. 20. Carroll C, Rheinstein J, Richardson R. Bilateral Lower Limb Amputation: Prosthetic Management. In: Krajbich I, Pinzur M, Potter B, Stevens P, eds. Atlas of Amputations and Limb Deficiencies. 4th ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2016:631–643. 21. Kaufman K, Bernhardt K. Comparative Performance of a Fiberglass Dynamic Elastic Response Foot. Boston, MA: The American Orthotics & Prosthetics Association 2016 National Assembly; 2016. September 8-11.

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22. Board WJ, Street GM, Caspers C. A comparison of trans-tibial amputee suction and vacuum socket conditions. Prosthetics and Orthotics International. 2001;25:202–209. 23. Beil TL, Street GM. Comparison of interface pressures with pin and suction suspension systems. Journal of Rehabilitation Research and Development. 2004;41(6A):821–828.

24. Beil TL, Street GM, Covey SJ. Interface pressures during ambulation using suction and vacuum-assisted prosthetic sockets. Journal of Rehabilitation Research and Development. 2002;39(6):693–700. 25. Esposito E, et al. Step-to-step transition work during level and inclined walking using passive and powered ankle-foot prostheses. In: Prosthet Orthot Int: 2015 Jan 27.

22

Postsurgical Management of Partial Foot and Syme Amputation☆ JONATHAN DAY and MILAGROS JORGE

LEARNING OBJECTIVES

On completion of this chapter, the reader will be able to do the following: 1. Differentiate among the various joint disarticulation and transosseous surgeries used when amputation of the forefoot, midfoot, or rearfoot is necessary. 2. Describe usual gait performance and limitations of individuals with a partial foot and with Syme amputations. 3. Compare the advantages and disadvantages of prosthetic options for individuals with partial foot amputation. 4. Compare the advantages and disadvantages of the various prosthetic designs for persons with Syme amputation, including donning and pressure tolerance. 5. Compare how the various nonarticulating and dynamic response Syme prosthetic feet mimic the three rockers of gait. 6. Describe typical static and dynamic alignment variables or issues affecting gait for patients with a Syme or partial foot prosthesis. 7. Use knowledge of prosthetic options to suggest prosthetic prescriptions and plans of care for patients with partial foot and Syme amputation.

Partial foot and Syme amputations present advantages and challenges to the patient and the rehabilitation team. Preservation of the ankle and heel (in partial foot amputation) and most of the length of the lower limb (in Syme amputation) has an important advantage of distal weight-bearing capability: The individual with partial foot or Syme amputation is often able to ambulate without a prosthesis if necessary. However, the prosthesis provides protection for the vulnerable distal residual limb for patients with vascular compromise and neuropathy. The length and shape of the residual limb present three challenges for successful fitting and prosthetic training for patients with partial foot or Syme amputation: suspension of the prosthesis on the residual limb, distribution of weight-bearing forces within the prosthesis, and attachment and alignment of the prosthetic foot. Improved communication combined with patient-centered care can have a positive influence on patient acceptance and adherence of prosthetic treatment.1 This chapter defines the most common partial foot and Syme amputations and reviews the prosthetic management options currently available. Also identified are specific indications and contraindications for the various prosthetic designs.

☆

The authors extend appreciation to Edmond Ayyappa and Heather Worden, whose work in prior editions provided the foundation for this chapter.

Partial Foot Amputations Until the advent of antibiotics, disarticulation through the joints of the foot reduced the risk of sepsis and shock and improved the prognosis for healing compared with amputations that transected bone. The earliest partial foot amputation was recorded in 434 BC by the Greek historian Herodotus,2 who told of a Persian warrior who escaped death while in the stocks by disarticulating his own foot. He hobbled 30 miles to a nearby town, where he was nursed to health until he could construct a prosthesis for himself. Later he became a soothsayer for the Persian army but ultimately was recaptured by the Spartans and killed. At present, distal partial foot amputations include a wide variety of ray resections, digit (phalangeal) amputations, and metatarsal transections (Fig. 22.1). Midfoot amputations include surgical ablation at the Chopart and Lisfranc levels (Fig. 22.2).3 Chopart disarticulation involves the talocalcaneonavicular joint and separates the talus and navicular, as well as the calcaneus and cuboid.4 Lisfranc disarticulation separates the three cuneiform bones and the cuboid bone from the five metatarsal bones of the forefoot. The three hindfoot amputations are the Pirogoff, Boyd, and Syme. The Pirogoff amputation is a wedging transection of the calcaneus, followed by bony fusion of the calcaneus and distal tibia with all other distal structures removed. In a Boyd amputation, the calcaneus remains largely intact rather than being wedged before arthrodesis with the tibia. 577

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A B

C

C

B A

Fig. 22.1 Examples of amputations involving the forefoot. A, This digit (phalangeal) amputation involves disarticulation of the phalanx at the metatarsal joint. More distal digit amputations remove either the distal phalanx or the middle and distal phalanges. B, In this complete transmetatarsal amputation, transection occurred just proximal to all five metatarsal heads. C, Ray resections involve disarticulation of one or more metatarsals and their phalanges from the tarsal and neighboring metatarsals. Ray resections often require skin graft to achieve adequate tissue closure.

A

B C

Fig. 22.2 In a Chopart amputation (A), there is disarticulation of the midfoot from the hindfoot at the level of the talus and calcaneus. In a Lisfranc amputation (B), there is disarticulation of the forefoot (metatarsals) from the midfoot (tarsals). (C), In a transmetatarsal amputation, there is transaction through the length of one or more metatarsals, usually just proximal to the metatarsal heads.

Fig. 22.3 A, The Syme amputation involves removal of the inferior projections of the tibia and fibula and all bone structures distally while preserving the natural weight-bearing fat pad of the heel. B, The Chopart amputation preserves the talus and calcaneus. C, The Lisfranc amputation has disarticulation of metatarsals from the midfoot.

Currently, the Pirogoff and Boyd amputations are infrequently performed on adult patients. Neither provides an easy fit with a prosthesis. The Boyd amputation has received positive clinical reviews when used in the management of congenital limb deficiencies in children in which the amputated limb is shorter than the sound limb.5,6 In this case, there are usually fewer postoperative complications, such as scarring and heel pad migration, and less susceptibility to the bony overgrowth common in children with congenital limb deficiencies. In children, the longer the remnant limb or foot, the better the functional outcome.7 The Syme amputation is performed more frequently in adults because of the ease of prosthetic management at this level (Fig. 22.3). Because of the length of the residual limb in Pirogoff and Boyd amputations, the attachment of a prosthetic foot lengthens the limb when a prosthesis is worn. A heel lift on the contralateral sound limb is usually necessary to counteract this artificially long prosthetic limb. Proximal partial foot amputations often result in equinus deformities because of muscular imbalance created by severed dorsiflexors and intact triceps surae.8-10 Nevertheless, many individuals with a partial foot amputation function extremely well. In one survey, physicians and prosthetists reported that patients with partial foot amputation function better than those with the Syme amputation.11 Although surgeons and prosthetists have long supported the Syme amputation in preference to the Lisfranc or Chopart amputations, many patients with midfoot amputation achieve high levels of function and long remnant limb durability.12

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For example, Jack Dempsey, a professional football player with a midfoot amputation, set several all-time field goal records wearing a custom-designed kicking boot.13 Patients with diabetes, particularly those with diabetic foot syndrome, have persistent high rates of limb amputation and mortality.14 Minor amputations in patients with diabetic foot problems can be effective in limb salvage and can reduce morbidity and mortality.15 Quality of life is influenced by age, time with diabetes, and presence of retinopathy—not level of amputation.16 Functional benefits of partial foot amputation with a disproportionate risk of revision versus determining amputation level based on minimized risk of reulceration have to be considered prior to surgery.17

GAIT CHARACTERISTICS AFTER PARTIAL FOOT AMPUTATION A person with a partial foot amputation typically has vascular insufficiency, is usually between the ages of 60 and 70 years, has compromised proprioception and sensation, and has weak lower limb musculature. After a Syme or partial foot amputation, a patient may be able to ambulate without a prosthesis but has a loss of the anterior lever arm in ambulation and an inefficient, somewhat dysfunctional gait. The primary need immediately after amputation is to protect the remaining tissue, which is vulnerable to vascular or neuropathic disease. The neuropathic walker developed at Rancho Los Amigos Medical Center locks the ankle in a custom-molded, foam-lined, thermoplastic ankle-foot orthosis (AFO) (Fig. 22.4). A rocker bottom is contoured to promote a smooth rollover as a substitute for the second and third rockers of gait, and the orthosis provides optimum protection for the insensate residual foot. For patients with adequate protective sensation, the risk of tissue breakdown is less and a custom shoe insert with in-depth or postoperative shoes often provides adequate protection. A review of gait in partial foot case histories showed variations in single-limb support time directly related to the reduction of the forefoot lever arm of a partial foot and subsequent increase in the force concentration on the distal end

A

B

Fig. 22.4 The neuropathic walker, or CROW boot, provides maximum protection for the denervated foot at risk for amputation. The combination of custom-molded multidurometer liner, locked neutral ankle, and rocker bottom permits a rollover with minimal plantar pressure and shear. (A) Side view of custom CROW Walker. (B) Inside view of custom CROW Walker.

% Gait cycle in single-limb support

22 • Postsurgical Management of Partial Foot and Syme Amputation

100 90 80

70

70 60 50

54

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Level of amputation Fig. 22.5 Percent of the gait cycle spent in single-limb support for patients with midfoot Chopart or Lisfranc amputations and forefoot transmetatarsal amputation. Healthy older adults with intact feet typically spend between 65% and 75% of their gait cycle in single-limb support.

during terminal stance, reflected as reduced time in singlelimb support on the limb with amputation (Fig. 22.5).18 Uneven step lengths result from this reduced single-limb support, long ipsilateral and short contralateral steps referencing the amputated side. In a person with a whole foot, a fully intact anterior lever arm preserves elevation of the center of mass at terminal stance. With normal quadriceps strength and eccentric control, slight knee flexion (15–20 degrees) provides shock absorption as weight is rapidly transferred onto the limb during loading response (Fig. 22.6). Some people with a dysvascular partial foot and a Syme amputation demonstrate significant weakness of the quadriceps. This functional weakness threatens eccentric control of the usual knee flexion angle that occurs during loading response. To compensate, the patient may keep the knee extended during loading response. This strategy shifts the ground reaction force vector to a position anterior to the knee joint axis, thus reducing the workload of the quadriceps. Although this compensatory strategy enhances early stance phase stability, it sacrifices the shock absorption mechanism at the knee and hip joints, increasing the likelihood of cumulative joint trauma at both joints (see Fig. 22.6B). Neuropathic impairment of proprioception and sensation may further complicate control of the knee in early stance. In addition, compromised forefoot support increases center of gravity displacement, which results in higher energy expenditure. A study of the gait of persons with partial foot amputation included 18 patients with transmetatarsal amputations, 11 with one or more metatarsal amputations, 15 with ray resections, and 2 with either a Lisfranc or a Chopart amputation.18-20 One portion of the analysis focused on the mechanics of the residual limb rockers. Partly because of a delay in the forefoot rocker, patients with all types of partial foot amputations walked with a significantly slower velocity than control subjects with healthy, intact feet (Fig. 22.7). Peak ankle dorsiflexion was also significantly delayed for all three partial foot groups compared with those with intact feet. Although the control group with intact lower limbs reached peak ankle dorsiflexion at a point

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100

100

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90 % of normal mean velocity

Normal quad strength

80 70

62

60

57

61

MT

TM

50 40 30 20 10 0

RR

NC

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Impact of limb loading

Fig. 22.7 Reduced gait velocity in patients with partial foot amputations. On average, patients walked at 62% of gait velocity of control subjects with intact lower limbs. MT, Metatarsal amputation of one to four rays; NC, normal control subjects; RR, ray resection; TM, complete transmetatarsal amputation.

A

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B Fig. 22.6 (A) During loading in normal gait, knee flexion provides a significant shock absorption mechanism to protect the proximal joints. (B) The patient with weakness associated with dysvascular disease avoids knee flexion to increase stability, with a penalty of increased trauma to the proximal joints as a consequence of repeated higher impact loading.

43% into the gait cycle, patients with partial foot amputation did not reach peak dorsiflexion angle until nearly the halfway point of the gait cycle (Fig. 22.8). This delay in reaching peak dorsiflexion subsequently delays forward progression over the shortened stance limb and the transition to double-limb support. The rise rate of the vertical ground reaction force is the amount of force that occurs in 1% of the gait cycle and can be expressed as Newtons divided by the percent of the gait cycle. After controlling for variation in velocity, the rise

Fig. 22.8 For persons with partial foot amputations, maximum dorsiflexion is delayed during stance phase of the gait cycle. Although control subjects with intact feet achieved a maximum dorsiflexion angle at a point 43% into the gait cycle, those with partial foot amputation did not reach the maximum dorsiflexion angle until halfway through the cycle. The consequence of this delay is a slowed forward progression of the body’s center of mass and transition to the subsequent period of double-limb support. MT, Metatarsal amputation of one to four rays; NC, normal control subjects; RR, ray resection; TM, complete transmetatarsal amputation.

rate of the vertical ground reaction force from midstance to terminal stance (as the force pattern nears its F2 peak) was significantly lower for all three amputation groups compared with the control group (Fig. 22.9). Peak vertical ground reaction forces were significantly higher for the sound limb than the affected limb, likely reflecting an abrupt unloading of the partial foot amputation limb. The forefoot lever arm of the trailing limb typically provides anterior support and results in adequate terminal stance support time (Fig. 22.10). This results in appropriate step length of the advancing limb. By contrast, inadequate anterior support of the trailing limb with partial foot amputation reduces the lever arm, resulting in premature toe break and forefoot collapse. The step length of the advancing limb may be correspondingly reduced (see Fig. 22.10B).

22 • Postsurgical Management of Partial Foot and Syme Amputation

14.0

Peak vertical GRF (N/% gait cycle)

12.0

11.3

11.9 11.0 9.7

10.0 8.0 6.0 4.0 2.0 0.0

RR

MT

TM

NC

Level of amputation Fig. 22.9 Comparison of peak vertical ground reaction force (GRF) of the intact limbs of patients with partial foot amputations and persons without amputation, expressed as Newton (N) divided by percent of gait cycle. MT, Metatarsal amputation of one to four rays; NC, normal control subjects; RR, ray resection; TM, complete transmetatarsal amputation.

An inverse relation exists between surface area and peak pressure when body weight is loaded on the foot during stance. This relation is especially important for individuals with partial foot amputation during terminal stance. As the plantar surface area of the supporting forefoot is reduced, the magnitude of the pressure is increased.18-20 The reduced forefoot lever arm also creates abrupt weight transfer to the contralateral side and can reduce step length, stride length, and velocity. Without prosthetic support, the advancing sound-side step length diminishes. Fear, insecurity, and pain aggravated by increased pressure near the amputation site collectively create an abrupt transfer of weight to the sound side, thus increasing the magnitude of the initial vertical force peak.21

In normal gait, the weight line is positioned more and more anterior to the knee joint as the gait cycle moves from midstance into terminal stance and preswing phases (Fig. 22.11). As a result, the limb is held in a passive, energy-efficient extended knee position, effectively supporting body weight and increasing stability in late stance. The length of the forefoot lever arm is one of the key determinants of this support. For persons with partial foot amputation, the lever arm of the foot is greatly reduced, leading to a less effective, premature loss of support at the end of stance phase. This shorter lever places the ground reaction force closer to or behind the knee in late stance (see Fig. 22.11B). Because much of the passive stability provided by a normal forefoot lever in late stance is absent, the quadriceps must contract to maintain stance phase stability, contributing to an increased energy cost of walking for persons with partial foot amputation. Pinzur and colleagues22 described a functional relation between gait velocity and the level of amputation at the foot. As the amputation level becomes more proximal (as the length of the residual foot decreases), changes in temporal and kinetic gait characteristics include reduced sound-side step length, decreased velocity, increased energy cost, and increased vertical load on the sound side. An inverse relation exists between the length of the remaining portion of the forefoot and the time spent in single-limb support on the amputated side.21 When the level of amputation is proximal to the metatarsal heads, medial support is lost at loading response. This may require orthotic “posting” to limit resultant valgus deformity. Patients with partial foot amputation frequently have plantarflexion contracture develop from muscle imbalance. Any plantarflexion contracture, in turn, increases pressure at the distal residual limb during terminal stance, causing discomfort, pain, and risk of ulceration.23 A contracture is even more problematic for individuals with Hansen disease or diabetic neuropathy, because they

Normal toe break

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arm Lever ed reduc

al Norm rm a r e lev

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581

Normal step length

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Step length reduced

Fig. 22.10 (A) The forefoot lever arm contributes to a normal step length. (B) Reduction of the forefoot support after partial foot amputation produces a consequent reduction in contralateral step length.

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Single limb support

Single limb support

Resultant passive knee support

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Increased quad activity

Locked ankle limits excessive dorsiflexion

A

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B

Short lever arm

Fig. 22.11 (A) Normal energy-efficient passive knee support in late stance relies on a locked or rigid forefoot that limits further dorsiflexion at the ankle and a normal forefoot lever arm to maintain the ground reaction force anterior to the knee during late stance. (B) After partial foot amputation, the reduced forefoot lever arm often leads to increased quadriceps activity to compensate for reduced passive knee support and ensure stability in late stance.

already have compromised sensation.24,25 Shoes worn without prosthetic replacement of the missing forefoot quickly become disfigured, collapsing at a displaced toe break, further endangering the vulnerable areas of the residual limb.26 The areas of the residual foot most vulnerable to tissue damage during walking include the distal end, first and fifth metatarsal heads, navicular, malleoli, and tibial crest. The longitudinal and transverse arches, the heel pad, and the area along the pretibial muscle belly are pressure-tolerant areas for loading in a custom shoe or prosthesis.

PROSTHETIC MANAGEMENT During the 1800s, digit amputations were fitted by a wood or cork sandal with a leather ankle lacer.27,28 Partial foot amputations were sometimes fitted with a socket and keel fashioned from one piece of carefully chosen root wood, the grain of which followed the curve of the ankle. This was referred to as the natural crook technique. Another commonly used historical design incorporated steel-reinforced leather sockets.29 In recent decades, a wide variety of prosthetic options for individuals with partial foot amputation have emerged. The prescribing physician and patient care team must familiarize themselves with the broad array of options available in prosthetic components and design so that prescription considerations can best accommodate the special needs of each patient. Because of variability in level of amputation, sensitivity or insensitivity of the residual limb, concurrent foot deformity, and patient activity, no single prosthetic prescription can be used for all patients with foot amputation.30 As the amputation level becomes more proximal and the length

of the residual foot decreases, prostheses should incorporate supramalleolar-, AFO-, and patella tendon-bearing designs. This is especially true as a patient’s activity level increases. Prosthetic treatment approaches include toe fillers placed inside the shoe, an arch support with a foam spacer, the University of California Biomechanics Laboratory (UCBL) shoe insert maximum-control foot orthosis with a toe filler, which provides better control of the heel position, and a boot or slipper made of flexible urethane resin (Smooth-On, Easton, PA). Cosmetic restoration of silicone and several variations of AFOs are also in common use. The length and degree of flexibility of the prosthetic forefoot affect the anterior lever arm and consequently foot and ankle motion. The biomechanical goal of prosthetic treatment is to provide anterior support of the remnant limb and a controlled fulcrum of forward motion as the foot-ankle complex pivots over the area of the amputation level in the third rocker of late stance. An additional goal is to minimize pressure at the distal end and balance the weight-bearing forces on the remnant limb within the socket or shoe.

Toe Fillers and Modified Shoes Historically, if a simple toe filler was prescribed, an extended steel shank or band of rigid spring steel was also placed within the sole of the shoe, extending from the calcaneus to the metatarsal heads. Currently, carbon fiber plates are designed in a variety of styles and degrees of stiffness that can be incorporated into prosthetic treatment. The challenge that faces the prosthetist is to match the appropriate degree of forefoot flexibility to the needs of each patient. For an energy-efficient and cosmetic gait, relative plantar rigidity should give way to at least 15 degrees of forefoot

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Case Example 22.1 A Patient With a Unilateral Hallux (Great Toe), Second Toe, and Distal First Metatarsal Head Amputation with Rotated Skin Flap for Soft Tissue Coverage J.C. is an 84-year-old male with a 34-year history of type II diabetes. He has controlled his diabetes but has lost protective sensation due to neuropathy. On October 10, 2017, J.C. was working with his zero turn mower (ZTR) on his property. He left the engine and mower blades running and positioned himself in front of the mower, needing to move the ZTR only approximately 12 to 18 inches forward. The ZTR got stuck on a tree root and did not come straight forward; it wiggled and then broke free as J.C. fell. J.C. watched both feet go under the deck of the mower. His left foot ended up by the discharge chute, and his right foot got wedged and staled the mower blades, preventing more extensive injuries as the mower deck

came to rest on his right hip. J.C. was emergently taken to the operating room, and his right great toe, second toe, and distal first metatarsal head were amputated. A local skin flap had to be rotated for soft tissue coverage. By rotating this local skin flap, a split-thickness skin graft is not necessary (Fig. 22.12A–I). Partial foot amputations combined with split-thickness skin grafts usually require subsequent revision to a more proximal level.43 The referring surgeon kept J.C. non–weight bearing on his right foot until mid-December, when he was released to begin the fitting of his partial foot prosthesis. There continues to be an area of healing on the dorsum of his right foot, which is expected to heal by secondary intention over time (Fig. 22.13).

Fig. 22.12 (A–I) The progress of healing after J.C. suffered his traumatic partial foot amputation.

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Case Example 22.1 A Patient With a Unilateral Hallux (Great Toe), Second Toe, and Distal First Metatarsal Head Amputation with Rotated Skin Flap for Soft Tissue Coverage (Continued)

Fig. 22.12, cont’d

QUESTIONS TO CONSIDER ▪ Considering his medical situation and awareness of his diabetic condition, what concerns might exist about the residual foot? Which part of the foot is most vulnerable to future complications? ▪ What is the primary mechanism for an increase in energy consumption with any digit amputation, and what is particularly concerning about a great toe (hallux) amputation?

▪ How will his shortened foot affect progression throughout the

gait cycle with respect to each phase of gait and the specific three rockers of the foot? ▪ What would be the most optimal prosthetic recommendation? What are the primary goals of the prosthesis? How should the rehabilitation team assist him in caring for his new amputation, as well as in prevention of future more proximal amputations?

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Case Example 22.1 A Patient With a Unilateral Hallux (Great Toe), Second Toe, and Distal First Metatarsal Head Amputation with Rotated Skin Flap for Soft Tissue Coverage (Continued)

Fig. 22.12, cont’d

Fig. 22.14 (A and B) The right remnant limb of J.C. with his partial foot prosthesis and toe filler.

Fig. 22.13 The right remnant limb and intact foot of J.C. at delivery of his first prosthesis.

RECOMMENDATIONS After obtaining all additional health information from J.C. and from all medical sources concerning J.C., it was noted that he had medically significant bilateral callusing of his heels and on the plantar surface of his feet over metatarsals 1, 3, and 5 on his left and 3 and 5 on his right. He had hammer toes bilaterally. His skin was thin, shiny, and frail. He was wearing appropriately sized tennis shoes. His right foot was considerably swollen relative to his left foot. After reviewing his medical history and completing his physical exam, the treatment team recommended a custom

partial foot prosthesis with toe filler and carbon plate. The custom partial foot prosthesis consisted of a great, second, and medial foot filler, diabetic compliant trilaminate foam, medial longitudinal arch support, and relief at the metatarsal heads (Fig. 22.14A and B). The carbon plate was left independent for use as needed to stiffen flexible shoes. After fitting him with his new shoes and right partial foot prosthesis, J.C. was able to ambulate with relatively equal step lengths. He stated, “I am glad to be walking again and not having to use the wheelchair.” At his follow-up visit in January of 2018, J.C. had discontinued his use of the carbon plate because he felt he walked better and was more comfortable in these shoes without it (Fig. 22.15A and B). Continued on following page

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Case Example 22.1 A Patient With a Unilateral Hallux (Great Toe), Second Toe, and Distal First Metatarsal Head Amputation with Rotated Skin Flap for Soft Tissue Coverage (Continued)

Fig. 22.15 A, J.C.’s partial foot prosthesis with the carbon fiber foot plate. B, J.C. wearing his prosthesis and shoes walking for the first time.

flexibility distal to the metatarsal heads. The steel shank (carbon plate) is helpful in providing a limited degree of buoyancy that substitutes for the lost anterior support of the foot.31 Stiffening the sole with a spring steel shank (carbon fiber) increases the lever arm support but often at the expense of additional pressure on the distal end of the residual limb.32 For a patient with a more complex partial foot amputation, a rocker bottom shoe modification distributes force over a greater area and advances stance more quickly and efficiently. A curved roll or buildup on the plantar surface of the shoe encourages tibial advancement while minimizing weight-bearing pressures on the distal amputated end. For optimal function the plantar contour of a rocker bottom should follow a radius originating from the knee joint center but break or roll more abruptly just distal to the metatarsal heads. Although a rocker bottom assists rollover, it also compromises symmetry of gait. It is often prescribed for individuals with chronic pain or in conjunction with a custom-molded accommodative interface for those with a neuropathy-related risk of reamputation. Extradepth shoes have 6 to 8 mm or more of space inside the shoe on the plantar surface to accommodate an orthotic insert or prosthesis and may be useful for patients with digit or ray amputations.30 Custom-molded shoes, when used in conjunction with a filler and carbon plate, improve the comfort level and reduce the risk of ulceration in many dysvascular patients with amputation. They are not as subject to forefoot collapse, provide major protection to the endangered foot, and may last longer than stock shoes.33

Partial Foot Inserts and Toe Fillers A custom-molded, flexible, plantar shoe insert is one of the options for individuals with amputation of the hallux or first ray. This partial foot prosthetic approach is typically used in combination with extra-depth shoes. The goals are to provide a flexible anterior extension to compensate for a missing or shortened first ray to improve the third rocker and to support and protect the amputation site during the simulated metatarsophalangeal hyperextension in late stance and preswing.34 This provides some relief for metatarsal head pressure, supports the arch, and probably assists in normalizing the ground reaction force pattern during terminal stance and preswing. It may incorporate a toe filler to prevent premature forefoot shoe collapse and migration of remaining toes.35-37 Partial foot inserts should be fabricated to support subtalar neutral to minimize remnant limb tissue stress.38 Toe fillers consist of soft foam material such as roomtemperature vulcanized elastomer, which fills the voids in the toe box of the shoe. They provide limited extension of the shoe life and a moderate degree of cosmesis. They also act as spacers, keeping adjoining toes properly positioned and reducing abnormal motion that can otherwise lead to ulceration. The toe filler alone provides limited mechanical advantage. An appropriately stiff carbon plate placed inside the shoe under the partial foot insert can further improve gait. An alternative to the spring steel shank and carbon plate is a longitudinal support built into a flexible custom insole. Either support device must end at the metatarsal heads or allow proper hyperextension of the metatarsophalangeal joints. A partial foot insert with arch support and filler is

22 • Postsurgical Management of Partial Foot and Syme Amputation

preferable to the simple filler because it can be used in different shoes and because it provides plantar support to an already compromised weight-bearing surface.39 Custom partial foot insoles can also be made from a sawdust and epoxy resin instead of foams and thermoplastics as a base structure. The UCBL orthosis, a foot orthosis that encapsulates the calcaneus, was developed at the UCBL during the 1960s and was comprehensively described in 1969.40,41 The UCBL orthosis is designed to provide better control of subtalar and forefoot position than are custom-made shoe inserts, reducing motion and thus friction with a closer fit or purchase over the calcaneus and forefoot.42 The UCBL orthosis design can be effectively incorporated into a custom partial foot prosthesis with toe filler for persons with partial foot amputation.

Cosmetic Slipper Designs The slipper, one variation of which has been referred to as the slipper-type elastomer prosthesis, is fabricated from semiflexible urethane elastomer.44 A similar design in silicone may not provide adequate forefoot support without the addition of an extended steel shank in the patient’s shoe or incorporation of a carbon plate. Another similar variation is made from a combination of silicone Silastic (Dow Corning, Midland, MI), polyester resin, and prosthetic (polyurethane) foam. These designs provide much of the support and control of the UCBL approach but with added cosmesis. These designs may be appropriate for individuals with transmetatarsal and metatarsal disarticulation (Lisfranc) amputations. They are ideal for swimming or water sports because most are water impervious, cosmetic, and capable of providing a flexible whip action, which is useful with swim fins. Some slipper-type prostheses are cosmetic restorations made of silicone or vinyl and based on a “life cast” or on an alginate impression of a human model (Fig. 22.16). This prosthesis is made for patients who consider cosmesis paramount. This custom prosthesis is most often produced in special manufacturing centers and frequently requires a considerable amount of time for delivery. It can be ordered

Fig. 22.16 The life cast prosthesis provides excellent cosmesis with little or no biomechanical assistance. Without additional reinforcement a silicone slipper-style prosthesis does not provide adequate forefoot support. Stiffer silicone durometers can be incorporated to provide better biomechanical function.

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with hair and freckles and in a large variety of skin tones; however, it is most often a less-than-perfect match when compared with the intact contralateral foot. The patient should always share responsibility in the color swatch selection. The material itself is easily stained and changes color with time when exposed to sunlight. The cosmetic restoration provides little ambulation advantage but does increase shoe life. It may be appropriate for patients with transmetatarsal amputations who place a premium on cosmesis but is not always covered by insurance and may be the patient’s financial responsibility.

Prosthetic Boots The prosthetic boot, with laced or hook-and-loop material ankle cuff closures, has greater proximal encompassment to reduce distal motion and increase control (Fig. 22.17). This design is appropriate for individuals with a Lisfranc or metatarsal disarticulation amputation. One variation, the Chicago boot, or Imler partial foot prosthesis, combines a thermoplastic UCBL-type heel cup with a flexible urethane prosthetic forefoot.45,46 Other designs incorporate urethane with a modified solid-ankle, cushion-heel (SACH) foot. Some are fabricated from leather, laminated plastic, Silastic elastomer (Dow Corning), or Plastazote (Bakelite Xylonite Ltd, London, UK) combinations as an insert for a boot or as an outer boot with inner filler to accommodate bony prominences.47-50 Such boots often have an anterior or medial tongue and laces or some other means of obtaining a firm purchase above the ankle.51-54 Some variation of the prosthetic boot may be the general prosthesis of choice for most patients with midfoot amputations.

Fig. 22.17 A prosthetic boot, composed of epoxy-modified acrylic resin combined with supramalleolar containment and free motion, single-axis ankle joints may be helpful at the transmetatarsal level. Without the circumferential containment above the ankle, patients often report joint pain toward the end of the day.

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stability and control because of its high proximal trim line. It has been an excellent solution for many patients with partial foot amputation and may be the prosthesis of choice for the active patient with a Chopart or Lisfranc amputation. Prefabricated carbon AFOs and custom-fabricated carbon AFOs can also be incorporated into partial foot prosthetic designs. Supramalleolar thermoplastic or laminated versions are fit with Tamarack (Blaine, MN) or Gillette (Gillette Children’s Specialty Healthcare, St. Paul, MN) joints to provide free plantar and dorsiflexion motion. This biomechanical solution is popular for the higher activity level of midfoot amputations. In the presence of acute ankle pain, a patient with a Chopart amputation was successful with a rear-entry ground reaction force AFO with a rigid solid ankle design. AFO designs incorporating an interior tibial shell, clamshell, or panel distributes the toe lever forces during the terminal stance phase of gait.56 Partial foot prostheses designed with a stiff forefoot and restricted dorsiflexion can manage the center of pressure of the remnant limb with less excursion.56,57 This type of partial foot prosthesis, with articulated clamshell AFO, can affectively restore the foot length.57

Fig. 22.18 A posterior leaf spring partial foot prosthesis with toe filler and anterior strap is successful for many patients with partial foot amputation.

Partial Foot Prostheses Incorporating an Ankle-Foot Orthosis Individuals with reduced mobility may benefit from partial foot prostheses that extend above the ankle, incorporating an AFO design.55 The polypropylene or copolymer shell supports the plantar aspect of the foot, incorporates the heel, and extends up the posterior leg to the belly of the gastrocnemius (Fig. 22.18). A circumferential anterior strap stabilizes the limb in the AFO. As an alternative, metal uprights may be attached to a shoe but have obvious cosmetic drawbacks. The AFO, whether metal or plastic, provides advantages of the arch support/UCBL orthosis and boot with maximum containment and a lever arm for support and substitution of the rocker mechanism. It offers enhanced

Chopart Prostheses Chopart socket designs are similar to Syme amputations, but there is no room for Syme prosthetic feet because the leg lengths of the patient remain the same after this level of partial foot amputation. Prosthetic manufacturers have developed Chopart plates that can be directly laminated onto the plantar surface of the socket to minimize the leg length increase and to provide more dynamic function when compared with an AFO design. Otto Bock (Minneapolis, MN) has developed three Chopart plates; 1E80, 1E81, and 1E82 with heel heights of 0 (flat), 9 mm, and 19 mm, respectfully, and all three of these plates have a patient weight limit of 300 lb (136 kg). Ossur (Aliso Viejo, CA) has developed a Chopart plate that has a 10-mm heel height and a patient weight limit of 324 lb (147 kg). Ability Dynamics (Tempe, AZ) has designed a Chopart plate that has a 10-mm heel height and a patient weight limit of 360 lb (163 kg). All these plates are fixed once laminated to the distal socket and do not allow any alignment changes if the patient improves his or her strength, balance, and gait during rehabilitation.

Case Example 22.2 A 4-Year-Old With Traumatic Injuries Requiring Amputation of Right Foot K.J. is a 29-year-old mother of two children with a 25-year history of right lower limb amputation. K.J. was run over by a lawn mower when she was 4 years of age. K.J. was a healthy, normally developing child without any medical comorbidities to consider when determining her optimal surgical and rehabilitative treatment. The limb-threatening injury ultimately required an amputation because the foot could not be salvaged. QUESTIONS TO CONSIDER ▪ Given her pediatric medical history, what level of amputation would be best? ▪ Would you recommend a surgery that transects bone or disarticulates a joint? ▪ Would a Boyd, Syme, or transtibial amputation provide the best long-term outcome for a pediatric patient?

▪ Would a leg length discrepancy be created by any of these

amputation techniques? What is her risk for additional surgeries as she grows? ▪ Should an epiphysiodesis be performed at her initial amputation, later during her development, or not at all? ▪ How will her shortened lower extremity biomechanically progress through the gait cycle? ▪ Will she have functional compromise during any of the three gait rockers from initial contact through loading response, loading response through midstance, and midstance through terminal stance? ▪ What are the major goals for surgical and prosthetic intervention for K.J.? ▪ What specific recommendations should be made and why? ▪ What is her prognosis for functional ambulation? ▪ How should the efficacy of intervention be assessed?

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Case Example 22.2 A 4-Year-Old With Traumatic Injuries Requiring Amputation of Right Foot (Continued) RECOMMENDATIONS At 4 years of age, K.J. underwent a Syme amputation. K.J. was treated with a Syme prosthesis almost annually due to growth, with a variety of functional prosthetic feet based on the available space or leg length difference compared with the contralateral side. By age 8, the plantar calcaneal fat pad that was placed distal to her tibia and fibula during her amputation surgery had started to migrate. By age 12, the fat pad had migrated completely off the distal end of her remnant limb (Fig. 22.19 through Fig. 22.22). The uncovered distal end suffered recurrent callous and would not tolerate end bearing. The socket had to be elongated to reduce distal pressure, further limiting prosthetic foot options due to decreased space for her foot. In February of 2012, K.J. underwent a transtibial amputation due to pain and recurrent distal remnant limb skin breakdown (Fig. 22.23). Her Syme amputation got her through childhood and delayed surgical revision until she reached skeletal maturity and adulthood. Based on my clinical experience, a Boyd and epiphysiodesis would have been the preferred treatment originally. The Boyd amputation technique leaves the natural calcaneal attachment of the plantar heel fat pad, and the epiphysiodesis would provide remnant limb shortening over time to improve prosthetic foot options. Fat pad migration risk would

have been reduced, decreasing the potential need for revision surgery. (See Figs. 22.20 and 22.21.) K.J. has been an independent community ambulator with all her prostheses. Her prosthetic feet provided biomechanical function throughout her gait cycle. Growing up, K.J. participated in sports and has continued her active lifestyle into adulthood. Her step lengths are equal, and her timing and gait symmetry approach normal. When K.J. is wearing jeans, public observers do not know she has any lower extremity impairment.

Fig. 22.21 K.J. demonstrating end bearing of her remnant limb into the exam table.

Fig. 22.19 K.J. right Syme residual limb showing the fat pad migration and tapper of her limb at 13 years of age.

Fig. 22.20 Distal end of K.J.’s remnant limb.

Fig. 22.22 K.J.’s distal remnant limb with skin over bone and no fat pad coverage to protect the bone during weight bearing.

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Case Example 22.2 A 4-Year-Old With Traumatic Injuries Requiring Amputation of Right Foot (Continued)

Fig. 22.23 K.J.’s distal limb with skin breakdown, which resulted in revision to the transtibial level during early adulthood.

Syme Amputation In 1867, E.D. Hudson, the Surgeon General of the United States, described the Syme amputation with a litany of superlatives: “No amputation of the inferior extremity can ever compare in value with that of the ankle joint originated by Mr. Syme. Twelve years of experience with that variety of operation have afforded me assurance that it is a concept which is complete in itself and not capable of being improved in its general character.”58 The Syme, or tibiotarsal, amputation is a disarticulation of the talocrural joint. The entire foot is completely removed, but the fat pad of the heel is preserved and anchored to the distal tibia. This allows distal end bearing and some degree of ambulation without a prosthesis (see Fig. 22.3).59 It gained popularity during the late 1800s primarily because the likelihood of survival with this technique was substantially greater than with other surgical choices, given the reduced degree of sepsis and shock that occurred when bone was not severed.60 Two possible problems exist in amputations at the Syme level: migration of the distal heel pad (which may be surgically avoidable) and poor cosmetic result (which can sometimes be partially addressed by decreasing the mediolateral dimension of the malleoli during surgery). For a positive outcome, the vascular supply must be adequate to ensure healing. The current resurgence of popularity of the Syme amputation is from an increased awareness of its energy efficiency in gait compared with transtibial levels, as well as improved vascular evaluation techniques and medical procedures that increase the likelihood of more distal primary wound healing.61,62 In addition, the dramatic weightbearing potential of a well-performed Syme surgery (with or without a prosthesis) has always been considered.63

Pressure-sensitive areas of the Syme residual limb include the tibial crest, lateral tibial flair, fibula head, and the bony prominence around the distal expansion.64,65 Pressuretolerant areas include the midpatella tendon, medial tibial flair, and anterior tibialis.

POSTOPERATIVE CARE: WALKING CASTS To avoid migration of the heel pad in the postoperative period, gait training and other therapy that involve weight bearing should be encouraged only after delivery of the prosthesis. The prosthesis is designed to hold the prosthetic foot and bulbous distal tissue of the remnant limb in an appropriate relation. A fully mature residual limb is less likely to displace. Early prosthetic fitting may involve a definitive prosthesis or a temporary walking cast with a patten bottom. The temporary walking cast may be especially preferred if the patient has edema, is obese, or has other medical conditions in which significant volume loss is anticipated. The initial walking cast should be applied as soon as the sutures have been removed, usually within 2 weeks of surgery. The successful application of the Syme walking cast requires a more thorough knowledge base in prosthetics than might be readily appreciated, and the rehabilitation team all have to work together to prevent complications. Application of a walking cast should be done by a clinician with a solid prosthetic background.

PROSTHETIC MANAGEMENT The prosthesis for the Syme amputation must be strong enough at the ankle section to withstand the forces of tension and compression that are produced by the long tibial lever arm throughout the gait cycle and at the same time

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provide an acceptable degree of cosmesis over the bulbous expansion at the ankle. All prosthetic designs strive to encompass the tibial section above the distal expansion firmly and still permit donning and doffing. Although prostheses designed for Syme amputations may be appropriate for Pirogoff and Boyd amputations, use of such prostheses may require that a lift be placed on the contralateral side to achieve bilateral limb length symmetry and a properly level pelvis during stance. Before World War II, most patients with Syme amputations were fit with anterior lacing wooden sockets or leather sockets supported by a superstructure of heavy medial and lateral steel sidebars.65,66 The prostheses most frequently fabricated nowadays include the Canadian, medial opening, sleeve suspension, and flexible wall (bladder) designs.

Canadian Syme Prostheses The Canadian Syme prosthesis design was introduced during the 1950s as the first major improvement over the traditional steel-reinforced leather.67-70 When viewing the ankle in the coronal plane, no obvious buildups, windows, or hardware is present to increase the ankle diameter. The Canadian Syme prosthesis has a removable posterior panel to facilitate donning and doffing. This donning window extends from the apex of the distal expansion, moving proximal as far as necessary to provide clearance for the bulbous end.71 Breakage may be higher than with other Syme prostheses because the ankle area, which undergoes the most compression and tension during ambulation, is weakened by the window cutout around the ankle in the posterior region. Modern carbon fiber and acrylic lamination materials and techniques have aided in meeting this challenge.72,73 The Canadian prosthesis is a relatively cosmetic approach, but more recent options have limited its use. Medial Opening Syme Prostheses The medial opening Syme prosthesis, also known as the Veterans Administration Prosthetic Center Syme prosthesis, followed the introduction of the Canadian Syme prosthesis. Developed at the New York City Veterans Administration Medical Center in 1959, it has a removable donning door that extends proximally from the distal expansion to a level approximately two thirds of the height of the tibial section on the medial side.74,75 Like the Canadian design, the medial opening prosthesis is relatively cosmetic at the ankle and compares favorably with the Canadian design. The medial placement of the donning panel provides much more opportunity for anteroposterior strengthening of the prosthesis. All other factors being equal, this design is stronger than the Canadian design and is the approach of choice for many patients with Syme amputation. Sleeve Suspension Syme Prostheses The sleeve suspension Syme prosthesis is sometimes referred to as the stovepipe Syme prosthesis because of the cylindrical appearance of its removable liner. This design is appropriate for pediatric patients (Fig. 22.24A and B). It is constructed with an inner flexible insert or sleeve that has filler material in the areas just proximal to the distal expansion.76,77 Before slipping into the outer shell or socket, the wearer first pulls on the flexible liner.78 The outside sleeve then telescopes within the outer prosthetic shell (Fig. 22.25). In another

Fig. 22.24 (A and B) Two views of a Syme prosthesis showing the laminated socket and foam liner separately.

version the leather and foam inner sleeve does not cover the entire residual limb but wraps around the leg and fills up the void areas above the expansion.79 The sleeve suspension prosthesis is bulky and not very cosmetic, but its strength is significantly better because no window is present to create a structural weakness. It is often chosen for the obese or very heavy-duty wearer or for the patient with recurring prosthetic breakage with other designs. It is more adjustable and forgiving than the other Syme designs and is often chosen when major fitting problems are anticipated.

Expandable Wall Prostheses The flexible, expandable wall, and bladder Syme prostheses, of which several varieties are available, vary more by materials

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superstructure of laminated thermosetting plastic. The use of flexible thermosetting plastics and silicone elastomer for expandable wall sockets has gradually eclipsed the use of Surlyn (DuPont, Wilmington, DE) and other thermoplastics as a material of choice for the inner liner. Expandable wall Syme prostheses are slightly bulkier and less cosmetic at the ankle than their Canadian or medial opening counterparts because they require a flexible inner socket and a rigid exterior superstructure. The fabrication process is more involved, and fitting adjustments to the flexible inner socket can be difficult. Creating either a silicone elastomer or a Surlyn inner socket flexible enough for comfortable donning and doffing may significantly limit its durability. The Syme residual limb presents greater pressure distribution challenges to a prosthetist than do other types of lower-limb prosthetics. A test socket is especially recommended for all Syme prostheses. Because the act of donning and doffing with this system is relatively simple, it may be the prosthesis of choice for patients with upper limb dysfunction or cognitive impairment. Fig. 22.25 Residuum, foam liner, and Syme prosthesis

used than by mechanism of action. All are based on the concept of an inner socket wall just proximal to the distal expansion that is elastic or expandable enough to allow entry of the limb into the prosthesis and still provide a level of total contact around the ankle once donned.80,81 This design normally requires a double prosthetic wall. The original bladder Syme prosthesis, described by Marx in 1969, obtained expansion by using flexible polyester resin in the neck area.82 The more recent Rancho Syme prosthesis uses a flexible inner socket, supported by a frame or

Tucker-Winnipeg Syme Prostheses The Tucker-Winnipeg Syme prosthesis, rarely seen in the United States, ignores the traditional requirement of comprehensive total contact by introducing lateral and medial donning slots.83 The design is well suited for children. It is contraindicated for patients with severe vascular disease and for others who are prone to window edema. A loss of total contact can also affect proprioception and control of the prosthesis. In general, the method permits a prosthesis that is relatively cosmetic, easy to don, and not prone to the noises that are sometimes created by rubbing at the window covers of the medial opening on Canadian Syme prostheses.

Case Example 22.3 A Patient With Bilateral Dysvascular Partial Foot Amputation L.P. is a 66-year-old man with a 23-year history of type II diabetes. He has comorbid history of diabetic retinopathy, hypertension, hyperlipidemia, peripheral neuropathy, stage III kidney disease, vascular complications associated with type II diabetes, bilateral foot ulcers, and vision changes. Five years ago, a right hallux amputation failed to heal and became infected, necessitating a right transmetatarsal amputation in 2013. After healing, he became proficient with a partial foot prosthesis, ambulating functional distances without assistive devices. In 2015 a large neuropathic wound developed under the metatarsal heads of his left foot. The wound failed to heal despite several attempted treatments. L.P. and his surgeon agreed that a transmetatarsal amputation on the left would allow him to heal, improve his functional status, and allow him to maintain his independence. The left transmetatarsal amputation failed to heal and became infected, leading to revision of his left partial foot back to a midtarsal level of amputation. His right residual limb is well healed, and the left is almost healed (Figs. 22.26A–C and 22.27A and B). The clinical team has agreed he is ready to return to prosthetic use and prescribes new prostheses. QUESTIONS TO CONSIDER

▪ Given his medical history, what concerns exist about the condition of his residual feet?

▪ What areas are most vulnerable to pressures from repetitive loading during walking in prostheses?

▪ What types of muscle performance at his knee and hip are important to assess?

▪ What measures should be used to assess muscle function and strength?

▪ How will any impairments be addressed? ▪ How does the transmetatarsal and transtarsal amputation affect progression through the gait cycle?

▪ How might a prosthesis substitute for compromise of the three rockers of the gait cycle?

▪ How might these amputations affect step and stride length of the opposite swing limb?

▪ What are the major goals for prosthetic intervention for L.P.? ▪ What specific recommendations should be made for socket design, suspension, and biomechanical function?

▪ What options should be chosen from among those available? ▪ What is his prognosis for functional ambulation? ▪ Is an assistive device recommended for long-term use? Why or why not?

▪ How should the efficacy of intervention be assessed? RECOMMENDATIONS The clinical team determines L.P. is a candidate for bilateral limited motion, articulated ankle-foot orthosis style partial foot prostheses with toe fillers (Fig. 22.28A–C). L.P. currently ambulates with a rolling walker and is happy not to be using a wheelchair. He is receiving physical therapy and hopes to ambulate without any assistive devices again in the future. After delivery of the prostheses, L.P. reports immediate improvement of his balance and walking (Fig. 22.29A and B).

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Case Example 22.3 A Patient With Bilateral Dysvascular Partial Foot Amputation (Continued)

Fig. 22.26 (A) L.P.’s bilateral partial foot amputations. (B) Left transtarsal and (C) right transmetatarsal remnant feet.

Continued on following page

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Case Example 22.3 A Patient With Bilateral Dysvascular Partial Foot Amputation (Continued)

Fig. 22.27 (A) Right and (B) left plantar surface of L.P.’s remnant limbs.

Fig. 22.28 (A–C) L.P.’s articulated ankle-foot orthosis design prostheses with toe fillers and dorsiflexion limiters.

22 • Postsurgical Management of Partial Foot and Syme Amputation

Case Example 22.3 A Patient With Bilateral Dysvascular Partial Foot Amputation (Continued)

Fig. 22.28, cont’d

Fig. 22.29 L.P. wearing his prostheses for the first time while sitting (A) and walking (B).

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PROSTHETIC FEET FOR SYME PROSTHESES One of the challenges in selecting prosthetic components for patients with a Syme amputation is fitting a prosthetic foot within the very limited space under the residual limb while still maintaining equal leg lengths and a level pelvis. The rare exception to this is when bilateral ankle disarticulation has occurred; bilateral Syme amputation allows many more choices of foot designs to be considered for improved function. When there is unilateral Syme amputation, great care must be given to the minimal amount of space available between the distal end and shoe so that a heel lift on the contralateral side would not be necessary.

Determining the Prosthetic Clearance Value In determining whether a particular Syme foot can accommodate a patient, the available space between the distal end of the residual limb and the floor is measured with the pelvis level and the anatomic clearance value is derived. Syme feet can be directly attached to the socket in the lamination by Syme nut (a threaded disk that is laminated into the socket) or using a variety of endoskeletal alignable lamination components. The nut, shaped to approximately match the contours of the distal residual limb, is approximately 5⁄8 inch tall, and this height must be considered when constructing the prosthesis. To determine the applicability of a particular foot for a patient, the space between the bottom of the heel of the foot and the top of the foot is added to height of the selected lamination component to ensure the prothesis will not create a leg length discrepancy. This measurement is the prosthetic clearance value and should be less than or equal to the anatomic clearance value. Nonarticulating Syme Feet Many prosthetic feet used for transtibial amputation have been adapted for the Syme amputation. The first was the SACH foot, patented in 1863 by Marks and further developed at the University of California at Berkeley after World War II. It was introduced as a component of the Canadian Syme prosthesis in the 1950s. The Syme SACH is distributed in the United States primarily by Kingsley (Kingsley, Costa Mesa, CA). It is available in a regular men’s shoe heel height and a running shoe heel height. The SACH foot design simulates plantarflexion as the patient rolls over a compressible heel, but because of a rigid wooden (typically maple) keel, it is neither flexible nor elastic in late stance. The SACH-type Syme foot was the historical foot of choice for patients with a Syme amputation in previous decades but is currently limited in use due to more functional options. The stationary-ankle flexible-endoskeletal (SAFE) Syme foot has the advantage of providing a modest inversion and eversion component of motion through elasticity of the forefoot, and it is useful for uneven terrain ambulation. Not including the thickness of the Syme’s nut, the SAFE II (CampbellChilds, White City, OR) Syme foot requires 1⅜ inches of space between the distal end and the floor or shoe with pelvis leveled. The SAFE II was also used historically and is currently more limited in use due to lighter and more functional prosthetic feet options.

Dynamic Response Syme Feet A variety of dynamic response foot designs have emerged for more active Syme walkers. The Impulse Syme’s Foot (Ohio Willow Wood, Mt. Sterling, OH) has a Kevlar (DuPont, Wilmington, DE) keel with carbon deflection toe-spring plates and a weight limit of up to 250 lb (113 kg). The toe spring is a carbon-epoxy composite. A unique manufacturing technique allows carbon fibers to be optimally oriented and avoid wrinkling, buckling, and deformation. The most interesting part of the foot is alignment adjustability. Ohio Willow Wood also has a Carbon Copy II Syme foot available in two heel heights and with all the toe resistances and sizes of the standard (non-Syme) Carbon Copy II. The Carbon Copy II is available with a medium heel density for patient weights up to 250 lb (113 kg). The Steplite Foot (Kingsley) provides a compressible heel design with the buoyancy of a carbon keel. It is quite durable and applicable to almost every patient with a Syme amputation because it requires only 1⅝ inches of prosthetic clearance value. That accounts for 1 inch for the foot itself and ⅝ inch for the nut and socket thickness. The low-profile version accommodates a typical man’s heel height. The “Strider” is made for a man’s running shoe, and “Flattie” is a narrow foot for females that accommodates a flat heel. The Steplite provides a buoyant elastic forefoot but, like many Syme feet, is limited in its heel compression. Ossur (Aliso Viejo, CA) offers a low-profile carbon Syme foot version for a very active prosthetic wearer weighing up to 285 lb (129 kg). The same foot can be worn by a low-activity level user weighing up to 365 lb (165.5 kg). The Ossur Low Profile requires 2 inches of clearance from the floor to the distal end of the socket and is designed with a flexible double-spring keel. It uses a fenestrated heel that allows greater compression, thus reducing shock. The upper spring bumper is coated with Teflon (DuPont), which reduces squeaks, a characteristic not uncommon to feet with more than one keel in the forefoot. Another Syme foot that may be used for patients up to 500 lbs (227 kg) is the Vari-Flex (Ossur), which requires only 1¾ inches of space under the socket and is attached using epoxy filler and lamination. Freedom Innovations (Irvine, CA) has developed the Pacifica (FS2) and LP Pacifica (FS4) with 10-mm heel height and build heights ranging from 1⅞ to 2½ inches depending on the foot size. Freedom Innovations also designed an LP Syme (LP2) laminated Syme foot with a heel height of 10 mm and a build height of 1¾ to 2⅛ inches, depending on foot size. All three of these feet can be used to treat patients weighing up to 365 lb (166 kg). Ability Dynamics (Tempe, AZ) developed the Rush Rover with a unique design, moving the foot attachment to the socket more anterior, thus changing the biomechanics of the foot. Another dynamic elastic foot choice for the active individual is the Seattle Light Foot (Seattle Orthopedic Group, Seattle, WA). Almost all prosthetic feet for Syme prostheses have ankles that are essentially locked. This characteristic results in increased work for the quadriceps for controlled knee flexion during loading response. Incorporation of several degrees of adjustable articulated plantarflexion (at the risk of increasing the weight of the prosthesis) might improve function for certain patients.

22 • Postsurgical Management of Partial Foot and Syme Amputation

Alignment Issues With most prosthetic feet, the small area between the distal residual limb and floor limits the prosthetist’s ability to refine the special relation between the socket and foot in the dynamic alignment phase. Chopart plates are laminated directly to the bottom of the socket and have no alignment adjustability (Figs. 22.30B, 22.31C, 22.32A). Adjustable alignment devices, similar to those available for transtibial prostheses, have historically not been compact enough to fit in the available space between the prosthetic foot and the end of the socket. Two component options have been introduced with the goal of addressing this limitation. The SL Profile and the Lo Rider Syme feet (Otto Bock, Minneapolis, MN) provide angular adjustability by a

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pyramid. Unfortunately, the height of the pyramid may preclude their use on many patients with a Syme amputation. The newest and very promising addition is the 1 C20 ProSyme’s (Otto Bock), which can be fit on most patients and is a moderately dynamic urethane carbon fiber foot for Syme amputees up to 275 lb (125 kg). It has a wide range of alignment adjustability, as well as heel height changes. Several alignable feet with various heel heights, weight limits, and functional benefits are currently being manufactured: Ability Dynamics makes the Rush Rover; Ossur makes LP Vari-Flex and Pro-Flex LP; Freedom Innovations makes Pacifica and Pacifica LP; and Otto Bock makes Axtion, Lo Rider, Triton Low-Profile, and Triton K2 (Figs. 22.30 through 22.33).

Fig. 22.30 (A) Ability Dynamics foot shell examples with (B) Rush Chopart plate and (C) Rush Rover feet.

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Fig. 22.31 Otto Bock feet and foot shell options. (A) Axtion. (B) Pro Syme. (C) Chopart plate. (D) Lo Rider. (E) Split toe foot shells. (F) 2C66 foot shell. (G) Pro Syme foot shell. (H) Foot shells. (I) Triton Low Profile. (J) Triton K2.

Placing the Syme foot in slight dorsiflexion relative to the shin section mimics normal gait patterns, encourages a smooth cosmetic and energy-efficient rollover during stance phase, and optimizes the weight-bearing potential of the socket contours. For individuals with quadriceps weakness, the dorsiflexion angle can be reduced to minimize excessive demands on the quadriceps. The telltale clinical sign of excessive demand is trembling of the knee during

midstance. Although early alignment recommendations placed optimal initial dorsiflexion up to 12 to 15 degrees, current practice is to set the foot at a smaller angle of approximately 5 degrees.84 The long Syme residual limb does not easily accommodate itself, cosmetically or functionally, to more than 5 degrees of dorsiflexion. Alignment can be significantly compromised when knee flexion contracture is present. To prevent breakage and

22 • Postsurgical Management of Partial Foot and Syme Amputation

599

Fig. 22.31, cont’d

premature wear from the anterior lever arm, the degree of anterior (linear) displacement of the socket over the foot is generally reduced from that of a transtibial prosthesis. The Syme socket is positioned in an angle of adduction that matches the anatomic adduction angle of the tibia. The adduction of the socket should be positioned to create

as smooth a transition as possible at the ankle and knee so that the prosthetic foot rolls over with the sole flat on the floor. The optimal spatial relation in the coronal plane is one that creates a slight varus moment. Socket adduction angle, foot eversion angle, and linear displacement affect the external varus moment at the knee during midstance. For an efficient and cosmetic gait, the knee must displace

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Fig. 22.31, cont’d

Fig. 22.32 Ossur feet and foot shells. (A) Chopart plate. (B) Flex Syme. (C) LP Variflex. (D) Proflex LP. (E) LP Variflex attachment options. (F) Foot shells.

approximately 12 mm laterally at midstance. Insufficient displacement implicates malalignment, most often at an inadequate eversion angle. Excessive displacement may be the result of malalignment or lateral collateral ligament laxity at the knee. The most successful strategy to address chronic weight-bearing ulceration at the knee that has not responded to a silicone liner, or to address major laxity of the collateral ligaments, is the addition of orthotic

components (external knee joints and a thigh lacer) to provide extra support and protection.

Summary This chapter explores the options for prosthetic management for patients with partial foot and Syme amputations.

22 • Postsurgical Management of Partial Foot and Syme Amputation

601

Fig. 22.32, cont’d

Because of the variability in surgical procedures, condition of the residual limb, and altered biomechanics of the residual limb in gait, no single best option exists for prosthetic design. More scientific research is needed to improve our understanding of biomechanics of ambulation after partial foot amputation to better guide the clinical judgement of the rehabilitation team.85 For now, the characteristics of each patient (weight, skin condition, desired activity level, and length of residual limb) must be carefully considered in

prosthetic prescription. The goal is to find the best match of the person’s status and needs from the growing array of prosthetic design options for the partial foot and Syme amputations. This places an increasing demand on the knowledge base of medical professionals. More than ever, the physician, physical therapist, and prosthetist are challenged to function as a cohesive team, drawing on each other’s strengths to achieve the best possible outcome for each patient.

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Fig. 22.33 Freedom Innovations feet and foot shells. (A) Foot shell examples. (B) LP Syme. (C) Pacifica LP.

References 1. van Netten JJ, et al. Communication techniques for improved acceptance and adherence with therapeutic footwear. Prosthetics & Orthotics International. 2017;41(2):201–204. 2. Herodotus. Library IX, 37, Loeb Classical Edition. Vol 4. London: Heinemann; 1924. 3. Bowker JH. Partial foot and Syme amputations—an overview. Clin Prosthet Orthot. 1988;12(1):10–13. 4. Bahler A. The biomechanics of the foot. Clin Prosthet Orthot. 1986;10 (1):8–14. 5. Frankovitch KF, Farrell WJ. Syme and Boyd amputations in children. ICIB J Assoc Childrens Prosthet Orthot Clin. 1984;19(3):61. 6. Oglesby DG, Tablada C. The child amputee: lower limb deficiencies: prosthetic and orthotic management. In: American Academy of Orthopaedic Surgeons, ed. Atlas of Limb Prosthetics. 2nd ed St. Louis: Mosby; 1992:837.

7. Greene WB, Cary JM. Partial foot amputations in children. A comparison of the several types with the Syme amputation. The Journal of bone and joint surgery American volume. 1982;64(3):438–443. 8. Burgess EM. Prevention and correction of fixed equinus deformity in mid-foot amputations. Bull Prosthet Res. 1966;10(5):45–47. 9. Pritham CH. Partial foot amputation—a case study. Clin Prosthet Orthot. 1977;1(3):5–7. 10. Wagner FW. Partial Foot Amputations. In: American Academy of Orthopaedic Surgeons, ed. Atlas of Limb Prosthetics. St. Louis: Mosby; 1981:315–325. 11. Wilson AB. Partial foot amputation results of the questionnaire survey. Newsletter Prosthet Orthot Clin. 1977;1(4):1–3. 12. Brown ML, Tang W, Patel A, Baumhauer JF. Partial foot amputation in patients with diabetic foot ulcers. Foot & ankle international. 2012;33 (9):707–716. 13. Kay HW. Limb deficits no bar to record performance. Int Clin Info Bull. 1970;10(3):17.

22 • Postsurgical Management of Partial Foot and Syme Amputation 14. Malyar NM, Freisinger E, et al. Amputations and mortality in inhospital treated patients with peripheral artery disease and diabetic foot syndrome. Journal of Diabetes & Its Complications. 2016;30 (6):1117–1122. 15. Nather A, Lin Wong K. Distal amputations for the diabetic foot. Diabetic foot & ankle. 2013;4(1):21288. 16. Quigley M, Dillon MP, Duke EJ. Comparison of quality of life in people with partial foot and transtibial amputation: A pilot study. Prosthetics and orthotics international. 2016;40(4):467–474. 17. Dillon MP, Fatone S. Deliberations about the functional benefits and complications of partial foot amputation: do we pay heed to the purported benefits at the expense of minimizing complications? Archives of physical medicine and rehabilitation. 2013;94(8):1429–1435. 18. Dorostkar M, Ayyappa E, Perry J. Gait Mechanics of the Partial Foot Amputee, Rehabilitation Research & Development Final Report. Project #A861-RA -2000. Long Beach, CA: VA National Prosthetic Gait Laboratory; July 11, 1999. 19. Dorostkar M, Ayyappa E, Perry J. Gait Mechanics of the Partial Foot Amputee. Project #A861-RA. JRRD Progress Reports. Vol 35:. Long Beach, CA: VA National Prosthetics Gait Laboratory; July 1998;17–18. 20. Dorostkar M, Ayyappa E, Perry J. Gait Mechanics of the Partial Foot Amputee. Project #A861-RA. JRRD Progress Reports. Vol 36. Long Beach, CA: VA National Prosthetics Gait Laboratory; July 1999. 21. Ayyappa E, Moinzadeh H, Friedman J. In: Gait Characteristics of the Partial Foot Amputee: Proceedings of the 21st annual meeting and scientific symposium of the American Academy of Orthotists and Prosthetists; 1995. New Orleans, March 21–25. 22. Pinzur MS, Gold J, Schwartz D, et al. Energy demands for walking in dysvascular amputees as related to the level of amputation. Orthopedics. 1992;15(9):1033–1037. 23. New York University Post Graduate Medical School. Lower Limb Prosthetics. New York: New York University; 1979. 24. Enna CD, Brand PW, Reed JK, Welch D. The orthotic care of the denervated foot in Hansen’s disease. Orthot Prosthet. 1976;30(1):33–39. 25. Menon PBM. A new type of protective footwear for anesthetic feet. Int Soc Prosthet Orthot Bull. 1976;18:4. 26. Veterans Administration Prosthetics Center. Semiannual report of the VA Prosthetics Center. Bull Prosthet Res. 1965;10(3):142–146. 27. Marks AA. Manual of Artificial Limbs. New York: AA Marks; 1931. 28. Marks GE. A Treatise on Artificial Limbs with Rubber Hands and Feet. New York: AA Marks; 1888. 29. American Academy of Orthopaedic Surgeons. Orthopedic Appliance Atlas. Vol 2: Artificial Limbs. Ann Arbor, MI: J.W. Edwards; 1960. 30. Cestaro JM. Comments on partial foot amputations. Newslett Prosthet Orthot Clin. 1977;1(3):7. 31. Levy SE. Total contact restoration prosthesis for partial foot amputations. Orthot Prosthet. 1961;15(1):34–44. 32. Lunsford T. Partial foot amputations: prosthetic and orthotic management. In: American Academy of Orthopaedic Surgeons, ed. Atlas of Limb Prosthetics. St. Louis: Mosby; 1981:320–325. 33. Staros A, Peizer E. Veterans Administration Prosthetic Center research report. Bull Prosthet Res. 1969;10(12):340–342. 34. Zamosky I. Shoes and their modifications. In: Light S, Kampuetz H, eds. Orthotics Etcetera. 2nd ed. Baltimore: Williams & Wilkins; 1980: 368–431. 35. Potter JW, Stockwell JE. Custom foamed toe filler for amputation of the forefoot. Orthot Prosthet. 1974;28(3):57–60. 36. Young RD. Functional positioning toe restoration. Orthot Prosthet. 1985;39(3):57–59. 37. Young RD. Special Chopart prosthesis with custom molded foot. Orthot Prosthet. 1984;38(1):79–85. 38. Paul S, Vijayakumar R, Mathew L, Sivarasu S. Finite element model– based evaluation of tissue stress variations to fabricate corrective orthosis in feet with neutral subtalar joint. Prosthetics and orthotics international. 2017;41(2):157–163. 39. Platts RGS, Knight S, Jakins I. Shoe inserts for small deformed feet. Prosthet Orthot Int. 1982;6(2):108–110. 40. Henderson WH, Campbell JW. UC-BL shoe insert, casting and fabrication. Bull Prosthet Res. 1969;10(11):215–235. 41. Inman VT. UC-BL dual axis ankle control system and UC-BL shoe insert; biomechanical considerations. Bull Prosthet Res. 1969;10 (11):130–145. 42. Quigley MJ. The present use of the UCBL foot orthosis. Orthot Prosthet. 1974;28(4):59–63.

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43. Wood MR, Hunter GA, Millstein SG. The value of stump split skin grafting following amputation for trauma in adult upper and lower limb amputees. Prosthetics and orthotics international. 1987;11(2):71–74. 44. Stills M. Partial foot prosthesis/orthosis. Clin Prosthet Orthot. 1988;12 (1):14–18. 45. Imler CD. Imler partial foot prosthesis IPFP—the Chicago boot. Orthot Prosthet. 1985;39(3):53–56. 46. Imler CD. Imler partial foot prosthesis IPFP “Chicago boot.” Clin Prosthet Orthot. 1988;12(1):24–28. 47. Wilson MT. Clinical application of TRV elastomer. Orthot Prosthet. 1979;33(4):23–29. 48. Fillauer K. A prosthesis for foot amputation near the tarsal-metatarsal junction. Orthot Prosthet. 1976;30(3):9–12. 49. Pullen JJ. A low profile pediatric partial foot. Prosthet Orthot Int. 1987;11(3):137–138. 50. Rubin G, Danisi M. A functional partial-foot prosthesis. ISPO Bull. 1972;3(7):6. 51. Collins JN. A partial foot prosthesis for the transmetatarsal level. Clin Prosthet Orthot. 1988;12(1):19–23. 52. Rubin G, Danisi M. Functional partial-foot prosthesis. Bull Prosthet Res. 1971;10(16):149–152. 53. Staros A, Goralnik B. Lower limb prosthetic systems. In: Atlas of Limb Prosthetics, ed. American Academy of Orthopaedic Surgeons. St. Louis: Mosby; 1981:293–295. 54. LaTorre R. The total contact partial foot prosthesis. Clin Prosthet Orthot. 1987–1988;12(1):29–32. 55. Spaulding SE, Chen T, Chou LS. Selection of an above or below-ankle orthosis for individuals with neuropathic partial foot amputation: a pilot study. Prosthetics and orthotics international. 2012;36(2): 217–224. 56. Stefania Fatone PhD BPO. Effect of prosthetic design on center of pressure excursion in partial foot prostheses. Journal of rehabilitation research and development. 2011;48(2):161. 57. Dillon MP, Barker TM. Can partial foot prostheses effectively restore foot length? Prosthetics and orthotics international. 2006;30(1):17–23. 58. Hudson ED. Mechanical Surgery; Artificial Limbs, Apparatus for Resections, by U.S. Soldiers. New York: Commission of the Surgeon-General; 1867 [Library of Congress Call No. RD 756.H86]. 59. Jansen K. Amputation—principles and methods. Bull Prosthet Res. 1965;10(4):19–20. 60. Harris RI. The History and Development of the Syme’s Amputation: Selected Articles from Artificial Limbs. Huntington, NY: Krieger; 1970. 61. Burgess EM, Romano RL, Zettl JH. The Management of Lower-Extremity Amputations. Washington, DC: U.S. Government Printing Office; 1969. 62. Wagner FW. The Syme amputation: surgical procedures. In: Atlas of Limb Prosthetics, ed. American Academy of Orthopaedic Surgeons. St. Louis: Mosby; 1981:326–334. 63. Quigley M. The Rancho Syme prosthesis with the Regnell foot. Clin Prosthet Orthot. 1988;12(1):33–40. 64. Hanger HB. The Syme and Chopart Prostheses. Chicago: Northwestern University Prosthetic-Orthotic Center; 1965. 65. Wilson AB. Prostheses for Syme amputation. Artif Limbs. 1961;61 (1):52–75. 66. Leimkuehler J. Syme’s prosthesis—a brief review and a new fabrication technique. Orthot Prosthet. 1980;34(4):3–12. 67. Foort J. The Canadian type Syme prosthesis. UCBL Technical Reports. 1956;30:75–76. 68. Murphy EF. Lower extremity components. In: Orthopedic Appliance Atlas, ed. American Academy of Orthopaedic Surgeons. Ann Arbor, MI: J.W. Edwards; 1960:212–217. Vol 2. 69. Voner R. The Syme amputation: prosthetic management. In: Atlas of Limb Prosthetics, ed. American Academy of Orthopaedic Surgeons. St. Louis: Mosby; 1981:334–340. 70. Boccius CS. The plastic Syme prosthesis in Canada. Artif Limbs. 1961; 6(1):86–89. 71. Department of Veterans Affairs. Syme Amputation and Prosthesis. Toronto: Department of Veterans Affairs, Prosthetic Services Centre; 1954. 72. Dankmeyer CH, Doshi R, Alban CR. Adding strength to the Syme prosthesis. Orthot Prosthet. 1974;28(3):3–7. 73. Radcliffe CW. The Biomechanics of the Syme Prosthesis: Selected Articles from Artificial Limbs. Huntington, NY: Krieger; 1970. 74. Schwartz RE, Bohne WO, Kramer HE. Prosthetic management of below knee amputation with flexion contracture in the child. J Assoc Childrens Prosthet-Orthot Clin. 1986;21(1):8–10.

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75. Iuliucci L, Degaetano R. V.A.P.C. Technique for Fabricating a Plastic Syme Prosthesis with Medial Opening. New York: New York University Medical School; 1969. 76. Byers JL. Fabrication of Cordo, Plastizote, or Pelite removable liner for closed Syme sockets. Bull Prosthet Res. 1972;10(18):182–188. 77. Warner R, Daniel R, Lesswing A. Another new prosthetic approach for the Syme’s amputation. Int Clin Info Bull. 1972;12(1):7–10. 78. Byers JL. The closed Syme socket with removable liner. ISPO Bull. 1973;7:4–5. 79. McFarlen JM. The Syme prosthesis. Orthot Prosthet. 1966;20(3):23–27. 80. Eckhardt AL, Enneberg H. The use of a Silastic liner in the Syme’s prosthesis. Int Clin Info Bull. 1970;9(6):1–4.

81. Meyer LC, Bailey HL, Friddle D. An improved prosthesis for fitting the ankle-disarticulation amputee. Int Clin Info Bull. 1970; 9(6):11–15. 82. Marx HW. An innovation in Syme prosthetics. Orthot Prosthet. 1969;23(3):131–141. 83. Lyttle D. Tucker-Syme prosthetic fitting in young people. Int Clin Info Bull. 1984;19(3):62. 84. Hanger of England. Prosthesis for Below-Knee Amputation—Roelite Instruction Manual. Bath, UK: Trowbridges; 1982. 85. Dillon MP, Fatone S, Hodge MC. Biomechanics of ambulation after partial foot amputation: a systematic literature review. JPO: Journal of Prosthetics and Orthotics. 2007;19(8):P2–P61.

23

Transtibial Prosthetics☆ TODD DEWEES

LEARNING OBJECTIVES

On completion of this chapter, the reader will be able to do the following: 1. Describe the principles underlying current transtibial socket design. 2. Recognize key components of a transtibial prosthesis. 3. Discuss the pros and cons of the various options for prosthesis suspension. 4. Identify key weight-tolerant and pressure-intolerant surfaces of a typical transtibial residual limb. 5. Identify key determinants of appropriate transtibial prosthesis alignment. 6. Recognize and differentiate the various factors that may lead to gait deviations with a transtibial prosthesis. 7. Suggest appropriate strategies to address transtibial gait deviations.

Evaluation for a Prosthesis When a candidate is being evaluated for a transtibial prosthesis, a comprehensive physical examination including a detailed history or interview is essential to determine his or her needs and limitations. The interview assesses the individual’s cognitive level, age, health history, vocation, avocation, support system, and home living status. A typical physical examination includes inspection, palpation, sensory testing, and skin integrity assessment. The examination should also include manual muscle testing, an evaluation of muscle performance using both active and passive range-of-motion (ROM) testing. This is also an ideal time to discuss rehabilitation goals with the person with amputation and the rest of his or her clinical team. Setting challenging yet realistic goals offers opportunities for incremental victories, which can go a long way toward reaching a successful outcome. Each member of the clinical team— the person with amputation, the therapist, the physician, and the prosthetist—has information and input that can be useful in the rehabilitation process. The best outcome will be achieved through a collaborative endeavor involving all team members. There are no hard-and-fast rules to determine an individual’s rehabilitation potential. The decision to move ahead with fitting a prosthesis is made on an individual basis. When the candidate for a prosthesis is being interviewed, the individual’s motivation and belief in his or her ability to walk with such an aid will be the deciding factors. The rehabilitation process will require both physical and mental effort; sometimes it will involve working through pain, discomfort, and weakness. When persons with amputation have the desire and drive to walk again, it is rare that they will not succeed in attaining that goal. Alternatively, if a person does not believe that walking will be possible, all ☆

The author extends appreciation to David Knapp, whose work in prior editions provided the foundation for this chapter.

efforts to enhance that person’s recovery may be in vain. Involving the person with recent amputation in an amputee support group or asking a local prosthetist to arrange for a peer visit by another person with amputation can provide inspiration. Encouragement from therapists, family members, or prosthetists who have not experienced amputation may not have the same impact. Peer visitors are individuals of similar age, gender, and amputation level who have been through the rehabilitation process and have successfully reintegrated into their communities (work, leisure, and/or social). Peer visitors are often available to spend time with those with recent amputations and to share their experiences. The internet hosts a variety of organizations that provide support and information for persons new to amputation and the use of prostheses; it can serve as a way of finding local groups that may be helpful to the patient. Because amputation is often the result of trauma or disease, there may be comorbidities that can complicate the overall management of the person with amputation. A variety of options are available to the prosthetist to provide a functional prosthesis even when the condition of a residual limb is not ideal. Mild to moderate knee flexion contractures and weakness, for example, may be accommodated by altering the alignment of the prosthesis. Skin issues, such as adherent scarring and eczema, can be addressed by selecting the appropriate interface material. Pressure on skin and soft tissue over prominent bones can be relieved by altering the socket shape. There are also options for those with severe upper-limb dysfunction that will enable the individual to don and doff a prosthesis independently. It is only with careful consideration of the persons complete profile that the clinical team can recommend the components and design that will lead to an optimal outcome. This clinical analysis includes choosing the features that are most appropriate for the individual’s current status and the anticipated level of function. The most appropriate prosthesis is the prosthesis that suits the person’s individual requirements. One size does not fit all: the ideal prosthesis for one person may be completely unsuitable for another. 605

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Prosthesis design is often a compromise of weight versus function. Adding features that may seldom be used will increase the weight and maintenance requirements of the device. Increased weight leads to increased energy expenditure and premature fatigue.1 On the other hand, exclusion of features that the patient will need on a regular basis may lead to excessive stresses on the limb, premature component wear or breakdown, and inefficient gait, resulting in the inability to attain optimal function. The clinical team should agree on the individual’s goals so that the prosthesis can be designed to meet these goals. With the advanced materials and fabrication techniques available to prosthetists, individuals using a prosthesis are able to walk farther and with greater energy efficiency than ever before. Generally speaking, individuals who undergo transtibial amputations are likely to return to their previous level of function.2 Those with dysvascular disease or those who have additional comorbidities because of injury or disease need special consideration as they develop their rehabilitation goals and anticipated level of function. The Center for Medicare Services created a hierarchical system to classify the functional potential of those with lower limb amputations. This system, comprising “K-levels,” is summarized in Table 23.1.3 Note that each functional level uses the phrase “has the ability or potential” in the description. This highlights the fact that individuals cannot reach their full potential until their prostheses are provided and rehabilitation has been successful. For certain benefits to be covered under Medicare, the individual must be certified by his or her prosthetist and physician with the appropriate K-level. This is to prevent the prescription of prostheses with costly components that the user will not be able to manage or use effectively. The selection of the proper K-level is greatly

Table 23.1 Classification of the Functional Potential of Patients with Lower-Limb Amputations K-Level

Medicare Functional Classification Level

K0

The patient does not have the ability or potential to ambulate or transfer safely with or without assistance, and a prosthesis does not enhance quality of life or mobility.

K1

The patient has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. This level is typical of the limited and unlimited household ambulator.

K2

The patient has the ability or potential for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs, or uneven surfaces. This level is typical of the limited community ambulator.

K3

K4

The patient has the ability or potential for ambulation with variable cadence. This level is typical of the community ambulator who has the ability to traverse most environmental barriers and may engage in vocational, therapeutic, or exercise activities that demand utilization of a prosthesis beyond simple locomotion. The patient has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high-impact, stress, or energy levels. This level is typical of the demands of the child, active adult, or athlete.

From Centers for Medicare and Medicaid Services. Medicare Region C Durable Medical Equipment Prosthetic Orthotic Supplier (DMEPOS) Manual. Columbia, SC: Palmetto GBA; 2005.

facilitated by the use of a validated, objective measurement instrument such as the Amputee Mobility Predictor.4 These measurement instruments can be used to assess the functional level of a person with an amputation even if they have not yet received a prosthesis.

Early Management of a Prosthesis Goals for the postoperative management of a transtibial amputee include (1) maintaining full ROM of the hip and knee, (2) facilitating rapid healing of the suture line, (3) maintaining or improving cardiovascular and pulmonary conditioning, (4) enhancing static and dynamic balance, and (5) maintaining functional strength in the remaining musculature.5 Table 23.2 breaks the lifelong rehabilitation of the amputee down into nine distinct stages and summarizes the goals of each stage. One common complication of transtibial amputation surgery is a loss of full knee extension. Failure to promote full extension of the tibiofemoral joint can lead to delays in prosthetic fitting while ROM is restored. If the lack of knee extension remains, a permanent joint contracture can alter the prosthetic fitting process and lead to a decreased functional level for the person with an amputation. The clinical team generally encourages rigid dressings that extend well above the knee and hold the knee in full extension. Rigid removable dressings (RRDs) provide more favorable outcomes than elastic bandages when used to control postoperative edema and provide protection to the surgical site.6 RRDs

Table 23.2 Phases of Rehabilitation for Persons with Amputation Phases

Hallmarks

1. Preoperative

Medical and body condition assessment, patient education, surgical-level discussion, functional expectations, phantom limb discussion Residual limb-length determination, myoplastic closure, soft tissue coverage, nerve handling, rigid dressing application, limb reconstruction Residual limb shaping, shrinking, increasing muscle strength, restoring patient’s sense of control Wound healing, pain control, proximal body motion, emotional support, phantom limb discussion Team consensus on prosthetic prescription

2. Amputation surgery and wound dressing 3. Acute postsurgical 4. Preprosthetic 5. Prosthesis prescription and fabrication 6. Prosthesis training 7. Community integration 8. Vocational rehabilitation 9. Follow-up

Prosthetic management and training to increase wearing time and functional use Resumption of family and community roles, regaining emotional equilibrium, developing healthy coping strategies, resuming recreational activities Assessment and training for vocational activities, assessment of further educational needs or job modification Lifelong prosthetic, functional, and medical assessment; emotional support

From Esquenazi A, DiGiacomo RD. Rehabilitation after amputation. J Am Podiatr Med Assoc. 2001;91(1):13–22.

23 • Transtibial Prosthetics

have also been shown to significantly reduce the time between amputation and commencement of prosthetic management.7 In some regions, persons with new amputations are fitted with immediate postoperative prostheses (IPOP) in the operating room or soon after surgery. The IPOP is intended to serve the same purpose as the RRD while also additionally allowing supported weight bearing for early mobility. IPOP sockets are designed to allow some weight-bearing forces direct to the medial tibial flare and patellar tendon because these structures are far from the surgical site and are not likely to be affected by postoperative edema. It is important to note that weight bearing while in an IPOP should be at the level of toe-touch partial weight bearing. Full weight bearing is discouraged, as there is generally not enough area to distribute the full body weight in a manner that the skin will tolerate for extended periods of time. Full weight bearing through an IPOP can damage the healing surgical construct, thus delaying healing and the fitting of a prosthesis. Assistive devices should be used to encourage toe-touch weight bearing while allowing functional use of the remaining muscles. The limb will change rapidly throughout the early rehabilitation process, therefore the prosthetist and therapist must closely monitor the fit and alignment of the IPOP. Adding extra layers of socks to the residual limb will accommodate early changes in limb volume. Eventually this will become counterproductive, and a replacement socket will have to be ordered. IPOPs are fabricated with modular components that allow changes to be made easily. The surgeon may decide that an IPOP is not an option for the individual due to excessive soft tissue damage or delayed wound healing. In these circumstances, an RRD should be utilized.8 One variant of the RRD is a custom-molded plaster socket with a prefabricated plastic collar encapsulating the individual’s limb from the distal end to approximately twothirds of the thigh. There are also other variations, including an adjustable prefabricated plastic socket or a custommolded plastic socket made from a digital scan of the limb.9 Regardless of the style of RRD chosen, the goals are the same. The RRD keeps the knee in full extension to prevent contracture, protects the limb from exterior trauma, and controls swelling through total contact. This removable device is worn over at least one layer of cotton sock and is held in place with Velcro straps (Fig. 23.1). It is also fenestrated to allow airflow and release moisture. The device can be worn 23 hours a day and can be removed easily for dressing changes and bathing. Chapter 20 offers a more detailed discussion of postoperative care.

Prescription of a Prosthesis Such a prescription details all the features of the completed prosthesis and should include socket design, skin-socket interface, suspension strategy, and additional modular components. For transtibial prostheses, the modular components are limited to feet, ankles, shock absorbers, torque absorbers, and dynamic pylons. The socket is the structural component of the prosthesis in which the residual limb is contained. All the forces from the ground during gait are transferred to the limb through the socket. The forces from the limb needed to control the

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Prosthetic sock

Supracondylar cuff Cotton stockinette

Plaster cast

Fig. 23.1 Cross-sectional diagram of a rigid dressing for a transtibial amputation. Cotton stockinette is placed over the residual limb, and padding is placed over vulnerable areas (i.e., suture line, bony prominences). The residual limb is then wrapped with several layers of gauze impregnated with plaster of Paris. Rigid dressings can be used until the suture line closes. They have been shown to reduce postoperative complications and accelerate the rehabilitation process. (From Knee Prosthetics, Prosthetics-Orthotics Program, University of Texas Southwestern Medical Center, TX, 1998).

motion of the prosthesis are transferred to the prosthesis through the socket. Much care and time should be spent on socket design and fitting, as a less than ideal fit can quickly lead to pain, injury, and lack of function. The socket design, interface, and suspension must be considered together, as their functions are often interrelated and interdependent. A soft liner, for example, can function both as an interface and as the suspension for the prosthesis. In the same way, a socket that is designed with a different interface may contraindicate certain suspension options. Forethought regarding how those three design elements intermingle will increase the probability of producing a comfortable and functional prosthesis.

Socket Designs Early transtibial prostheses were fashioned by hollowing out a block of wood and attaching metal single-axis knee joints and a leather thigh corset. The sockets were referred to as “plug-fit” sockets because they were open-ended and the limb fit into the socket like a plug fits in a drain. The attached thigh corsets took advantage of the conical shape of the thigh to transfer weight proximally and transmit mediolateral forces to and from the limb. Although many persons with amputation were able to function with this system, the lack of contact on the distal end of the residual limb often led to painful edema in that area. Such lack of contact can also lead to verrucous hyperplasia, a painful skin condition with a warty appearance.10 Additionally, the joints and corset added bulk and weight to the prosthesis, which restricted knee motion.11

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PATELLAR TENDON–BEARING SOCKET By the end of World War II, the large number of veterans who suffered limb loss during combat inspired prosthetists to experiment with new materials and techniques to improve the comfort and function of prostheses. In 1959, a symposium was held at the University of California Biomechanics Laboratory to promote the development of transtibial socket fitting. The result was the patellar tendon–bearing (PTB) socket design. This design has been used successfully over the past six decades to strategically load the limb in areas that are more tolerant of pressure. The patellar tendon, calf musculature, and medial tibial flare are used for weight loading, while reliefs are made over bony prominences like the tibial crest and head of the fibula. In most cases this eliminated the need for proximal weight bearing.12 The main goal of the PTB socket design was to increase the surface area on the residuum available for weight bearing so as to eliminate the need for the knee joints and thigh corset. The PTB socket was described as “total contact,” meaning that there were supposed to be no voids or air pockets between the limb and the socket. This design allowed weight bearing to occur in any area capable of supporting a load. The term patellar tendon–bearing originates from the use of a patellar “bar” built into the socket at the level of the center of the patellar ligament, midway between the patella and the tibial tubercle (Fig. 23.2). The socket is aligned in approximately 5 degrees of knee flexion, allowing the bar to act as a weight-bearing surface within the socket and enabling 5 degrees of adduction. The proximal trim line of the posterior wall should be located just proximal to the patellar bar to stabilize the limb in the anteroposterior direction and prevent the limb from sliding too far down into the socket. The posterior trim line should be

Fig. 23.2 The patellar tendon bar and medial tibial flare are the major weight-bearing areas of the patellar tendon–bearing socket; this total-contact socket design has been used for more than 60 years in constructing prosthesis enabling a comfortable fit for persons with transtibial amputation. (From Knee Prosthetics, Prosthetics-Orthotics Program, University of Texas Southwestern Medical Center, TX, 1998).

lower on the medial side to accommodate insertion of the medial hamstring tendon during knee flexion. Anteriorly directed compression of the calf musculature maintains the patella tendon firmly against the bar and stabilizes anteroposterior motion of the residual limb within the socket. The other major weight-bearing surface in the PTB socket is the medial flare of the tibia. The proximal end of the tibia broadens out medially and, when stabilized by pressure from the lateral wall of the socket, can effectively accept loading. It is necessary also to create a relief for the fibular head, which is at the same level, to avoid any pressure on that bony structure. Filling the distal end of the socket with a compliant foam material provides slight pressure during full weight bearing, which is necessary to control distal edema. The medial and lateral walls of the PTB socket extend up to the level of the adductor tubercle to provide lever arms for mediolateral stability of the prosthesis. The PTB technique is still used successfully today, and many modern fitting techniques incorporate at least some of the attributes of the original PTB design.

TOTAL SURFACE–BEARING SOCKET The total surface–bearing (TSB) socket serves to further distribute the weight-bearing load over the entire surface of the limb, even in areas that had been traditionally considered to be pressure-intolerant. Strategic compression of soft tissue and relief for bony prominences are the tools used to direct more force into areas of the limb that can tolerate it and less force into areas prone to skin breakdown. The intent in designing a TSB socket is to distribute uniform pressure over the entire surface of the limb.13 It is expected, however, that during a typical step, the pressure in any given location would change from a negative pressure during swing phase to high pressure in stance; if sustained, this would cause tissue damage. Because the forces on the limb change dramatically throughout the gait cycle, this dynamic pattern must be anticipated so that those forces can be used to protect the pressure-intolerant areas. Larger forces mean more tissue compression, requiring greater relief. The density and structure of the tissues comprised by the limb must also be taken into consideration. These properties vary widely between skin, muscle, adipose tissue, and bone. They can even vary within the same tissue type; muscle tissue, for example, behaves one way when it is relaxed and very differently when it is contracting. Once tissues are accommodated, the relative locations of these tissues within the socket must be preserved. This not only provides for optimum positioning of the tissues, but also allows accurate control of the prosthesis. To fully accommodate the dynamic tissue loading that occurs in a prosthetic socket, the prosthetist must consider both the shear and the normal forces on the limb. Shear forces run parallel to the limb surface and are best mitigated through the use a socket interface. Interface materials— such as socks, sheaths, flexible liners, and gel liners—offer a continuum of shear reduction on the skin surface. The best materials to minimize shear are those found in gel liners. Normal forces are those that are applied perpendicular to the surface of the limb. The socket walls should be contoured according to the type of tissue in the area and the anticipated loading patterns. There is no way to reduce

23 • Transtibial Prosthetics

the force on the limb without restricting the individual’s activities; therefore the best way to reduce pressure is to distribute the forces over as broad a surface as possible. The actual forces on the limb are a combination of shear and normal forces that occur together in various proportions. Ambulation is a dynamic event in which the forces on the limb are continually changing. For this reason the prosthetic socket must be designed to function under a variety of loading patterns. The socket must be designed and fitted under physiologic conditions that match those of the intended use. Soft tissue compression will vary with load; the socket contours must reflect the anticipated load so as to prevent excessive loading on bony prominences. Throughout the gait cycle, the forces and moments on the socket and limb change continuously. There is a flexion moment during loading response, a varus moment throughout midstance, an extension moment in terminal stance, and a flexion moment again in preswing (Fig. 23.3). The forces on the limb range from a compressive force 1.2 times body weight in stance to a distractive force slightly higher than the weight of the prosthesis in swing phase.14 A well-fitting prosthesis must provide tolerable pressure distribution in all of these loading conditions. Soft tissue, muscle tissue, and bone contours must each be accounted for in a specific way to achieve a good fit. Soft tissue can tolerate moderate compression, so the prosthetist will precompress that tissue in the socket. Muscles can tolerate mild compression but should be able to contract with each step; therefore less precompression should be applied. The shape of muscle tissue changes when contracted. Flexible materials can be used over muscle bellies to allow for this geometric variability. Finally, bony prominences must be given extra volume within the socket so that when the tissue around them compresses during loading, the pressure will not exceed the tolerable limit.

Loading response

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The load-bearing capabilities of the limb can also be affected by the surgical technique used for the amputation. The Ertl procedure, named after Dr. Janos Ertl Sr., involves the creation of a bone bridge between the distal end of the tibia and fibula, as shown in Fig. 23.4 (see Chapter 19 for more detail). The goal of this procedure is to create a tougher, more force-tolerant limb. One problem this technique aims to solve is nerve impingement. Transtibial amputees are prone to nerve compression between the long bones of the lower leg.15 Forces within the socket push the tibia and fibula together and compress anything in between. If the tibial nerve is trapped between the bones, pain can result. By fusing the bones together at the distal end, the relative motion is minimized, thereby protecting the soft tissue located between them. Many individuals who have had this type of surgical procedure can bear weight directly on the distal end of their limb. This end-bearing capability allows the prosthetist to distribute the person’s weight differently and potentially to provide a prosthesis that does not extend as far proximally. This can increase comfort over standard weight-bearing areas and increase the range of knee flexion available to the individual. However, the increased surgical time and subsequent increase in infection risk are often cited as reasons to forgo the Ertl procedure.16

Interface Materials The material that separates the limb from the socket is referred to as an interface. Interfaces play an important role in lower-limb prosthetics. they can offer shock absorption, mimic soft tissue to provide an extra layer of cushioning for individuals who are bony, and help to mitigate shear forces on the limb. Interfaces influence the hygiene, ease of donning, and maintenance requirements of the prosthesis;

Midstance

Terminal stance

Fig. 23.3 The magnitude and direction of the forces on the socket change throughout stance phase, concentrating pressure in predictable areas. At initial contact and loading, there is an anterior force at the proximal posterior knee and distal anterior residual limb. At midstance, weight-bearing forces create proximal-medial and distal-lateral pressures. At the end of the stance phase, the anterior force moves to the proximal anterior knee and distalposterior residual limb. (From Knee Prosthetics, Prosthetics-Orthotics Program, University of Texas Southwestern Medical Center, TX, 1998).

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Fig. 23.5 Person with amputation wearing a prosthetic sheath. Sheaths are very thin stocking-like garments worn between the skin and prosthetic sock or socket liner. They are used to reduce friction, disperse moisture, and control bacterial growth. (Photo courtesy Todd DeWees, CPO, Shriners Hospital, Portland, OR.)

the socks and socket is relatively low compared with that between the socks and the skin.17 This type of socket is most challenging to fit and is not recommended for mature limbs that have lost much of their soft tissue protection over bony prominences. It is also more difficult to adjust than other socket styles. Fig. 23.4 In the Ertl procedure, a weight-tolerant transtibial residual limb is constructed by joining the distal ends of the tibia and fibula with a bone bridge made with a piece of the fibula. This radiograph shows a healed bone bridge (tibia–fibula synostosis) several months following a transtibial amputation using the Ertl approach. (Reprinted with permission from Dionne CP, Ertl WJ, Day JD. Rehabilitation for those with transtibial osteomyoplastic amputation. J Prosthet Orthot. 2009;21[1]:64–70.)

they are often an integral part of prosthetic suspension. With new materials being developed continuously, there are many interface options for the prosthetist; a discussion of commonly used interface materials is presented here.

HARD SOCKET Early prostheses were made from hard materials like wood, which did not offer much cushioning. Persons with amputation used layers of cotton or wool socks to provide a soft interface between their limbs and the hard sockets. There are several advantages to this system. The socket is relatively thin, so it is easily concealed under clothing; a clean sock can be used each day or changed throughout the day as needed; the number and ply of socks can be adjusted to accommodate fluctuation in limb volume during the day, and the socket itself is very durable. Because there are no compressible surfaces, the fit is reliable; it will not become “packed down” in high-pressure areas. It is nonporous, easy to clean, and relatively maintenance-free. It also does a fair job of eliminating shear, as the coefficient of friction between

SOCKS AND SHEATHS Prosthetic socks can be made from various combinations of cotton, nylon, wool, Lycra, polyester, and spandex. Some manufacturers use silver fibers in their fabrics to enhance the antimicrobial properties of their socks and sheaths (Fig. 23.5). The prosthetic sock provides shock absorption, decreases the shear forces on the limb, wicks away moisture, and is used to accommodate fluctuations in limb volume. To further decrease friction, a nylon sheath is often recommended as the initial layer, with the thicker socks donned over the sheath. The sock also serves as a method of controlling socket fit; as the residual limb matures and shrinks, additional sock plies may be required to restore the fit and comfort of the socket. For convenience, prosthetic socks come in various ply thicknesses. For example, a person can wear one five-ply sock rather than having to don five single-ply socks. This is particularly important since it has been shown that even within the same manufacturer, three one-ply socks are not the same thickness as one three-ply sock.18 It is important to teach the person wearing the prosthesis to use the fewest number of socks to achieve the proper number of plies. New users of a prosthesis are typically provided with an assortment of one-, three-, and five-ply socks from which to select. The socks can be layered one on top of the other to achieve the appropriate number of plies.

SOFT INSERTS Closed cell foam, used because it does not absorb moisture, can be molded over a model of the limb to create a soft insert.

23 • Transtibial Prosthetics

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FLEXIBLE INNER SOCKET If PTB theory is to direct weight bearing into specific areas of the limb and away from others, then the flexible inner socket is the incarnation of that idea. With this system, an inner socket is made over a model of the limb from a flexible material that will stretch upon the application of force. Then a rigid frame is built around the inner socket, corresponding to areas of the residual limb where weight bearing is desirable. The result is a socket that flexes away from forces in areas that are not pressure-tolerant but remains rigid in the force-tolerant areas. Because flexible sockets in rigid frames can eliminate compressive forces in any specific area, this system is useful for persons with particularly bony residual limbs and those with severe localized sensitivity. However, they are not recommended for residual limbs with adherent scarring because pressure differentials created by the frame tend to amplify the shear forces on the limb.

EXPANDABLE WALL SOCKET Fig. 23.6 A foam liner, right, and its socket, left. The foam is compressed as it is pushed into the socket, developing tension as a means of suspension. (Photo courtesy Todd DeWees, CPO, Shriners Hospital, Portland, OR.)

Such an insert lines the entire socket and terminates just proximal to the socket’s trim lines (Fig. 23.6). For increased protection, a distal end pad, which is an extra layer of soft material at the bottom of the insert, can be used to cushion the distal end of the tibia. Soft inserts provide an extra layer of cushioning, which is needed for more mature limbs that lack adequate soft tissue thickness. Soft inserts also give the prosthetist a way of adjusting socket volume and shape for a limb that is prone to change. Such an insert can be worn over a nylon sheath, which is a very thin nylon stocking similar to women’s stockings, or over any number of sock plies. Wearing the insert directly over the skin without a sock can lead to excessive shear and skin breakdown due to the relative motion between the limb and insert. Single durometer inserts provide a uniform compression profile, whereas multidurometer inserts, made from layers of different materials with varied properties, can take advantage of the force-altering characteristics of each layer. For example, a material that has high plastic deformation might offer good shock absorption but would wear out very quickly if used alone. Mating that material with one that has low compression resistance would prevent some of the plastic deformation and extend the useful life of the insert. Soft inserts that can deform during the donning process can be used to accommodate anatomic irregularities that would not be able to slide directly into a rigid socket. For example, an insert for a limb with a bulbous distal end, as in the case of a Syme’s amputation, can be made thicker in the narrow area above the bulge so that the diameter of the finished socket would not impede donning. Another example is the wedge needed for supracondylar suspension; this wedge can be integrated as part of the soft insert to facilitate ease of donning.

When a limb is amputated at or below the ankle, the resulting long residual limb present an interesting challenge to the prosthetist. The proximal trim lines of the prosthesis can be lowered to a more distal position on the limb because there is a long lever arm for prosthetic control during ambulation. However, the distal end of the residual limb is larger in diameter than it is more proximally because of the presence of malleoli. The prosthetist can accommodate for a larger distal size by creating a removable wall in the socket that is replaced after the prosthesis is donned by using a specially designed soft liner or by creating an expandable wall socket. The expandable wall socket is made from an elasticized material that stretches enough for the individual to push his or her limb through in weight bearing and tightens up over the malleoli to provide suspension. This socket is too flexible for the attachment of a foot, so a rigid frame is made over the flexible socket, leaving a small space in which the expansion can occur. This is a self-suspending socket that can be very comfortable for the wearer. It is difficult to fabricate this kind of socket and even more difficult to make adjustments to the fit once it has been fabricated. More information on these designs can be found in Chapter 22. In addition to traditional expandable wall sockets, other technologies have been applied in this area of socket design to create nontraditional sockets. These designs have significant open areas and apply the majority of their support between the muscle bellies, so the amount of soft tissue between the socket and the bone is minimized. This allows space for the muscles of the residual limb to expand during muscle contraction and provides maximum stability to the bone of the residual limb. Examples include the Socket-Less Socket from Martin Bionics and the HI-FI Socket from Biodesigns.

GEL LINER The term gel liner is loosely used in the field to describe a liner that is made from a material that exhibits gel-like properties. There are three basic varieties of these liners: (1) silicone elastomers, which are highly cross-linked at the molecular level; (2) silicone gels that have a relatively low amount of cross-

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linking; and (3) urethanes. The properties of these materials vary and are relevant to the prosthetist and person with amputation because they directly affect the forces transmitted through the materials to the residual limb. Certain properties of interest are coefficient of friction, compressive stiffness, and shear stiffness. Silicone gels have the lowest compressive and shear stiffness values. This makes them useful in reducing compressive loading and limiting shear forces on the limb. Lower shear stiffness would be beneficial for a bony limb but might compromise stability by creating excessive motion on a limb that has more biologic soft tissue. Silicone elastomers present the highest compressive stiffness values, so they are best suited to supporting loading without deformation. Elastomers would be beneficial for use on a limb that has a high proportion of soft tissue. Urethanes show the highest coefficient of friction with skin, a property that is useful for preventing localized skin tension and shear.19 Understanding these properties allows the prosthetist to choose a material that is complementary to the socket design and effectively leverages the force transmission properties of the material against the soft tissue characteristics of the limb. Gel liners are a key component of TSB sockets. They are designed to be worn directly on the skin or over a thin liner referred to as “liner liners.” Liner liners are thin nylon sheaths with silver fibers; they are meant to be worn between the skin and the gel liner to prevent skin irritation caused by the warm and moist environment of the gel. Although great effort is made to eliminate relative motion between the limb and socket, a small amount of motion is unavoidable. Gel liners have a high-friction inner surface where they are in contact with the limb and a low-friction outer surface where they meet the socket. This encourages whatever small amount of motion is present to occur on the outer surface of the liner and minimizes motion at the linerskin interface. The colloidal nature of the gel absorbs the shear that is not dissipated by the liner-socket interface, so that only a small percentage reaches the skin (Fig. 23.7). Incorporation of a locking pin at the distal end of the gel liner allows the liner to be used for suspension as well. This type of liner is referred to as a “locking liner”, as opposed to a “cushion liner”, which has no pin. The pin mates with a locking mechanism built into the socket to suspend the prosthesis. Roll-on gel liners should fit snugly but not tightly. As the liner is stretched, a shear profile is established on the limb. A tighter fit creates higher frictional forces, and if the pressure distribution is not equal, the frictional forces on the skin will be uneven, leading to blisters and skin problems. This can occur with a very bony limb unless the liner is custom-made. Custom-made gel liners are created over a mold of the residual limb. This is indicated for unusually shaped limbs, those with deep invaginations, or those that need specifically located reliefs or cushions. A significant consideration when gel liners are used is their tendency to retain heat against the residual limb, leading to hyperhidrosis. Since there is no way for this excessive perspiration to be removed from the liner without taking it off, there is the potential for a significant impact the user’s function. In one study, 66% of participants reported that hyperhidrosis interfered with daily activities, and 13% reported the level of interference as severe.20 Multiple options are available to users of gel liners that address issues ranging from topical antiperspirants to injections of botulinum toxin (Botox).

Fig. 23.7 An example of a roll-on liner with a distal umbrella for attachment of a suspension mechanism. (Photo courtesy Todd DeWees, CPO, Shriners Hospital, Portland, OR.)

Suspension Another important consideration when a prosthesis is being designed is “suspension,” the method by which the prosthesis is held to the limb. When a prosthesis is suspended perfectly, there is no relative motion between the socket and the limb. When motion occurs because of a faulty or inadequate suspension system, the limb is subjected to an entirely different loading pattern. This motion is referred to as “pistoning,” as it bears some resemblance to the motion of a piston in the cylinder of an internal combustion engine. Pistoning can lead to pain, skin breakdown, and reduced control of the prosthesis. Excessive pistoning can also lead to decreased function for the user, due to fear of the prosthesis coming off. Great care should be taken to minimize motion within the socket. There are several strategies for suspension, which can be used individually as the primary mode of suspension, or more than one technique can be used simultaneously to provide auxiliary suspension. In addition to the methods detailed here, several other methods can be employed. They include such concepts as texturizing the inside of the socket to increase the surface contact area or the use of a unidirectional fabric to allow the residual limb to easily slide into the socket (stance phase). But these increase friction when trying to remove the residual limb (swing phase). These types of supplemental suspensions are not detailed due to the lack of published data to support their efficacy.

WAIST BELT A waist belt connected by an elastic strap to the thigh corset was used to suspend early transtibial sockets. These belts are

23 • Transtibial Prosthetics

Fig. 23.8 Waist belt and an inverted Y-strap suspends the prosthesis through tension in the elastic strap between the belt and Y-strap. The strap is fitted to allow hip and knee flexion during the swing phase. The elastic recoil of the strap during the swing phase enables the swing limb to advance the prosthesis. (From Knee Prosthetics, ProstheticsOrthotics Program, University of Texas Southwestern Medical Center, TX, 1998).

rarely used today and are discussed here primarily as a historical reference. The belt encircles the pelvis between the iliac crests and the greater trochanters. These adjustable belts have buckles on the anterior aspect that mate with an inverted Y-strap attached to the socket, allowing them to be donned separately and then joined together. Because this system crosses the hip and knee joints, flexion and extension of these joints must be accommodated by an elastic component. Further accommodation of knee flexion is accomplished by the inverted Y-strap (Fig. 23.8). The Y-strap is fitted over the patella so that the two arms of the Y move posteriorly during knee flexion to reduce elongation of the elastic strap. The person with amputation can adjust tension in the strap based on individual comfort. Pistoning in the socket is controllable with enough tension in the elastic. Tension in the strap decreases with hip flexion so that the strap has slack while the person is seated. Hip extension produces tension in the strap and aids in limb advancement as it assists hip flexion in preswing.

JOINTS AND CORSET The joints and corset feature (first discussed in the section on “Socket Designs”) provides suspension as well as a weightbearing element if the thigh corset is properly fitted over the femoral condyles. A skillfully molded corset can gain purchase over the smaller circumference of the thigh just proximal to the knee joint. The stiff leather corset is fabricated with either straps or laces that can be tightened as the wearer dons the prosthesis. This permits the limb to pass through the corset and be held securely in position once

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Fig. 23.9 A thigh corset with knee joints is used when the residual limb cannot support the full weight of the patient—for example, it may be useful for someone with a very short residual limb or with significant scarring or fragile skin over traditional weight-bearing surfaces. It can also be used for persons with mechanically unstable knee joints secondary to ligamentous insufficiency. (From Knee Prosthetics, ProstheticsOrthotics Program, University of Texas Southwestern Medical Center, TX, 1998).

the corset is tightened. The knee joints, which are typically made of steel, provide a secure connection to the socket. When the condyles are prominent, this can serve as the primary means of suspension, and a waist belt is not needed. As the prosthetic knee joints are positioned slightly posterior to the anatomic knee joint center, tension in the cuff decreases over the condyles as the knee flexes, thereby enhancing sitting comfort (Fig. 23.9). The joints and corset system can also include a posterior check strap that limits full knee extension. This can be used to eliminate the terminal impact at the end of swing phase, which can be audible, and to prevent excessive wear on the prosthetic knee joints. The thigh cuff allows for full functional range of knee flexion but will cause binding in the popliteal fossa when the knee is flexed beyond approximately 110 degrees. Joints and corset may be the suspension of choice for persons with ligamentous instability of the knee or for those who have a very short residual limb. The joint and corset system can also be used to reduce rotation of the prosthesis in certain activityspecific applications.

CUFF STRAP A cuff strap is a flexible leather cuff that attaches to the medial and lateral walls of the socket at the same point at which orthotic knee joints would be positioned—that is, just posterior and proximal to the anatomic knee center (Fig. 23.10). The cuff has an adjustable strap that

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Fig. 23.10 The cuff strap suspension uses the proximal aspect of the patella as well as the femoral condyles to achieve suspension of the prosthesis on the residual limb. (From Knee Prosthetics, ProstheticsOrthotics Program, University of Texas Southwestern Medical Center, TX, 1998).

completely encircles the thigh just proximal to the patella. After the person dons the socket, the cuff is secured in place so the prosthesis will hang from the cuff during standing and walking. Excessive circumferential tension should not be necessary to maintain the prosthesis in place. The anatomic structures that provide the suspension are the patella and the femoral condyles. To create a strong hold, the medial and lateral walls of the socket must be lower than the standard height. Because this reduces mediolateral stability, cuff strap suspension is not a good choice for short residual limbs. An elastic component may be added to the strap over the patella to increase sitting comfort. This system is simple, quick to fabricate, and provides a secure suspension for the prosthesis while accommodating an unencumbered angle of knee flexion. The cuff does not provide any weight-bearing or mediolateral stability. Cuff strap suspension may also be contraindicated for persons with extra muscle or adipose tissue around the lower thigh.

SUPRACONDYLAR SUSPENSION Suspension can be achieved by incorporating the femoral condyles completely within the rigid transtibial socket. By extending the medial and lateral trim lines of the socket approximately 2 cm proximal to the adductor tubercle, the mediolateral dimension of the top of the socket can be made narrower than the knee joint. This prevents the knee joint from moving upward out of the socket by capturing the femoral condyles. Supracondylar suspension also adds significant mediolateral stability to the prosthesis by increasing the length of the lever arm proximal to knee center and also by increasing the surface contact area, which can be helpful

Fig. 23.11 One option to ease the process of donning a supracondylar or supracondylar/suprapatellar socket is to remove a thick medial wedge when the residual limb is pushed into the socket. This wedge is repositioned once the limb is within the socket. A ridge in the socket along the proximal edge of the wedge holds it in place during ambulation. (From Knee Prosthetics, Prosthetics-Orthotics Program, University of Texas Southwestern Medical Center, TX, 1998).

for short residual limbs. This technique combined with a PTB-style socket is referred to as a PTB-SC. This type of socket can be difficult to don because the width of the proximal opening is smaller than the width of the condyles. This problem can be addressed in two ways: either by including the supracondylar wedge in a soft insert or by using a detachable medial wall. The first method uses a flexible liner that has a wedge built into it proximal to medial condyle. The rigid socket is fabricated over the liner such that the mediolateral dimension of the proximal end of the socket is equal to the widest dimension of the knee. This makes it possible to don the flexible liner first. Then, with slight compression of the liner, the limb and liner together slide into the socket and are locked in place through pressure and friction (Fig. 23.11). The second method uses a steel bar that is formed into the prosthesis. The entire medial wall of the prosthesis, along with the steel bar, can be removed for donning. Once the limb is in the socket, the bar slides back into a channel in the distal portion of the socket and locks into position with a ball detent (Fig. 23.12). It is necessary to have at least a 1-cm difference between the mediolateral dimension of the knee joint and that of the thigh just proximal to the adductor tubercle so as to provide a secure supracondylar suspension. Widening the socket in the region just posterior to the condyles serves to loosen the grip over the condyles while the wearer is seated in 90 degrees of knee flexion. It is worth mentioning that the high medial and lateral walls of this type of socket are apparent, even through long pants when the knee is flexed. Some people might find this unsightly and unacceptable.

23 • Transtibial Prosthetics

Fig. 23.12 Another option for donning supracondylar or supracondylar/suprapatellar sockets is to remove the medial wing of the socket. This allows the wide condyles to pass through the narrow proximal dimension of the socket. The medial wing is repositioned after donning; the metal flange holds the medial wing in place to achieve proximal purchase over the femoral condyles from which the prosthesis is suspended. (From Knee Prosthetics, Prosthetics-Orthotics Program, University of Texas Southwestern Medical Center, TX, 1998).

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Fig. 23.13 The quadriceps bar of the patellar tendon–bearing supracondylar/suprapatellar socket resists knee hyperextension and enhances suspension. It also stiffens the wings to improve purchase over the condyles, further enhancing suspension of the prosthesis on the residual limb. (From Knee Prosthetics, Prosthetics-Orthotics Program, University of Texas Southwestern Medical Center, TX, 1998).

SUPRACONDYLAR/SUPRAPATELLAR By extending the trim line of the anterior aspect of the PTBSC socket up to the level of the medial and lateral walls, the proximal surface of the patella can also be used to assist suspension (Fig. 23.13). The patellar tendon–bearing supracondylar/suprapatellar (PTB-SCSP) socket allows the formation of a quadriceps “bar” above the patella, which provides suspension and resists hyperextension. The continuous trim line at the proximal brim also increases the rigidity of the medial and lateral walls, further enhancing suspension. The advantages and disadvantages of this variation match those of the PTB-SC except that it is even more visible under clothing when the knee is flexed.

SLEEVE One of the most versatile means of suspending a prosthesis is with a suspension sleeve. A suspension sleeve provides suspension through two biomechanical principles: friction and vacuum. The sleeve extends approximately 20 cm proximal and distal to knee center and is fitted over the proximal end of the prosthetic socket (Fig. 23.14). The sleeve should fit snugly but not hinder circulation. Sleeves can be made of a variety of materials depending on the goals of the design. Neoprene and elastic fabric are common materials used for sleeves because they contour nicely to the anatomy and provide a high coefficient of friction with the skin. These sleeves use friction only to suspend the prosthesis because they allow for air to flow through them, in and out of the socket. This is useful for dissipating perspiration and keeping the

Fig. 23.14 A neoprene suspension sleeve, rolled up the leg to contact the skin, can provide a low-profile suspension option. Such sleeves can be used either as primary or secondary suspension. (Photo courtesy Todd DeWees, CPO, Shriners Hospital, Portland, OR.)

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limb cooler, but it also allows undesirable motion to occur between the socket and the limb. Over time, this can lead to pain and skin breakdown. The sleeve can be worn over a sock, which can be good for hygiene; however, this will affect the coefficient of friction between the sleeve and the limb, which could lead to suspension failure. Sleeves permit functional ROM for the knee, but because they bunch up in the popliteal fossa, they can restrict knee flexion beyond approximately 100 degrees.

SUCTION Modern sleeves are referred to as “sealing sleeves” because they are made of nonporous materials that seal the proximal end of the socket against the skin so that no air can flow into or out of the socket. This creates a suction suspension. Oneway air valves are commonly used in conjunction with sealing sleeves to allow air trapped during donning to escape from the socket. Sealing sleeves provide excellent suspension when they are combined with TSB sockets. Once the socket is sealed, very little pistoning can occur, as there are no voids between the limb and the socket. For the sleeve to seal, the sleeve must touch the skin directly for at least the top 5 cm. The skin must be free of deep scars or invaginations in that area, as they would provide a path for air to enter under the sleeve. Because the sealing sleeves rely on an airtight seal to function, they are highly susceptible to failure as a consequence of leaks. Even a small hole in the sleeve can allow air to flow into the socket, defeating the vacuum and impairing suspension. Although sleeves are not very durable, they can be replaced without any special tools or equipment. The soft tissue of the residual limb behaves like an incompressible fluid. For the limb to move within the sealed volume of the socket, the volume of the limb itself would have to change. This can happen only if fluid moves into or out of the limb through the bloodstream, a process that is too slow to be accomplished within the short interval of swing phase. Therefore the cyclic alteration between compression in stance and tension in swing slowly draws fluid into the limb and pushes it back out, assisting normal circulation. Suction suspension may provide a means for improving healthy circulation in the residual limb and controlling limb volume.

LOCKING LINERS The first references to locking liners involved the use of a roll-on silicon liner, referred to as an “Icelandic roll-on suction socket.”21,22 However, the use of the term suction for this type of suspension is incorrect. The liner is primarily held on by friction because it is not possible to maintain a vacuum within a flexible structure. If friction is eliminated through the use of a lubricant, the liner can be pulled off the limb. It is more accurate to describe this type of suspension as a locking mechanism. These roll-on gel liners are compliant enough to contour nicely to the shape of the residual limb and include a threaded hole at the distal end. This hole serves as a point of attachment for the suspension hardware. There are four basic options for the hardware: 1. Early sockets used a ring screwed into the distal end of the liner. When the ring came through a special opening on

Fig. 23.15 Prosthetic gel liner with distal lanyard strap used to pull the limb into the prosthetic socket. The blue puck would be attached inside the distal end of the prosthetic socket. (Photo courtesy Todd DeWees, CPO, Shriners Hospital, Portland, OR.)

the distal end of the socket, the wearer could pass a thin bar through the ring so that it could be retracted back into the socket. This system is still good for individuals who have difficulty doffing their prosthesis, as it allows them to remove the bar and then use both hands to push the socket off. This system requires additional clearance under the limb to accommodate the diameter of the ring and the associated attachment fixture. The bar is also a separate component, so it can easily get lost. The wearer should be instructed to store the bar in the prosthesis and take it out only during the donning process. 2. Difficulties with the ring gave rise to using a strap that is manually fed through a hole in the distal end of the socket and then secured to the outside of the socket (Fig. 23.15). The strap must be of sufficient length to be put through the hole before the limb enters the socket. This eliminates the need to carefully align the sleeve during donning as the limb will be drawn down into the socket by tension in the strap. It also eases the donning force required to get into the socket because the limb elongates and decreases in girth under tension as it is pulled into the socket. As no locking mechanism is mounted on the distal end, no additional clearance is needed, leaving precious space for other components. One variant of this system uses a lanyard and a special lock mechanism to secure the lanyard in the distal end of the socket. The lanyard is permanently attached to the locking mechanism; therefore it must be disconnected from the liner each time the liner is taken off. 3. Most modern sockets use a pin-and-lock mechanism. The pin can range from approximately 3 to 10 cm in length. It works in conjunction with a locking mechanism built into the distal end of the socket, which engages when the individual dons the prosthesis. Some wearers experience frustration with this as it can be difficult to align the pin so that it engages with the locking mechanism. To remove the prosthesis, the wearer must disengage the pin manually while pushing the socket off with the other hand. There are several variants of locking mechanisms. Some produce an audible “click” to indicate that the pin has engaged, but it will lock in only a limited number of positions. Others use a clutch mechanism or a smooth pin that allows for an infinite number

23 • Transtibial Prosthetics

Fig. 23.16 Distal locking system and pin. The pin in threaded into the end of the prosthetic gel liner and the lock body is laminated into the € prosthetic socket. (© Ossur.)

of locking positions. Ideally only one position should be needed—that is, when the limb is positioned correctly in the socket. However, as an the limb volume varies throughout the day, it is not uncommon for there to be an additional click or two as the wearer spends more time bearing weight in the prosthesis (Fig. 23.16). 4. Proximal suspension through the use of a ladder strap and ratchet buckle is a fourth option. Those who find the “milking” sensation of a distal suspension unbearable or wearers who do not have clearance for a distal suspension can use this method. In this system, a ladder strap is attached to the anterolateral side of a cushion liner between the fibular head and the tibial tubercle and just low enough to be contained within the socket. An opening is made in the socket wall just large enough for the ladder strap to pass through. As the ladder strap passes through the socket, it is inserted into a ratchet buckle that has been incorporated into the socket or attached to its side. The ladder strap makes an audible click as it is locked into the buckle to help the user know that the suspension is engaged. Care should be taken not to overtension the strap, as this can damage the cushion liner. One drawback to this method is that there is slightly more motion of the residual limb in the socket as compared with distal suspension.

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suspension. The individual first dons an interface—which can be a sheath, sock, or cushion gel liner—that was designed to go under the prosthesis. Then the wearer dons a thin, flexible, custom-molded socket that has a locking liner rolled over it. Finally, the wearer steps into the rigid frame to engage the locking mechanism. Because the locking liner is under the rigid frame rather than stretched over it, the life of the locking liner is greatly extended. Having the socket under the liner prevents the locking liner from becoming deformed, so that pistoning is virtually eliminated and the distal tissue is protected. To further enhance the suction of this system, an expulsion valve can be incorporated into the flexible socket. This allows any air trapped in the socket during donning to be removed. This oneway valve provides a path for air to move from inside the socket to the outer side of the locking liner. Wearing a sock or a liner with a fabric exterior helps any remaining air to migrate toward the valve and out of the socket.

ELEVATED VACUUM As the advantages of suction suspension are clearly documented in the literature,25,26 there has been considerable interest in using external vacuum pumps to increase the level of suction (decrease the pressure) within the socket. Such a system is referred as providing an elevated vacuum. Pumps can be either electrical (battery-operated) or mechanical. Mechanical pumps use the natural cycle of compression during stance and distraction during swing to pull air from the socket during gait. Electrical pumps have the added benefit of being able to accurately control the level of vacuum within the socket by turning on and off at preset thresholds (Fig. 23.17). Both systems have advantages and disadvantages. Mechanical pumps tend to be lighter in weight, lower in profile, and easier to maintain. Electrical pumps allow more precise control of the negative pressure, and some models allow for situational control of the negative pressure. The downsides are similar except that

Locking liners allow some pistoning to occur.23 The amount of motion can be dramatic when loose tissue is present at the distal end of the residual limb. As the limb is lifted off the ground in swing phase, the weight of the prosthesis pulls on the pin, causing the liner and limb to become longer and contract in girth. This effect is most apparent at the distal end. This milking motion creates unnecessary stress on the distal end of the limb and can lead to pain, edema, and skin breakdown.24 This is especially problematic for limbs with adherent scar tissue, as the liner will attempt to pull the tissue away from the bone. This type of suspension is not ideal for a newly amputated limb, as the distal end will not be fully healed. This problem can be averted if suction rather than the pin is used to hold the liner to the socket wall.

SEMIRIGID LOCKING LINER A semirigid locking liner is used to combine the convenience of a locking liner with the benefits of a full-suction

Fig. 23.17 This figure shows a microprocessor-controlled device that draws air out of the socket to maintain the elevated vacuum needed for effective suspension of the prosthesis on the residual limb. Electronic vacuum pumps are reliable and can accurately maintain specified levels of vacuum. (Courtesy of Hanger Clinic, Austin, TX.)

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electrical pumps must be charged and require greater clearance under the residual limb. An elevated vacuum device maintains limb volume by preventing the fluid loss that occurs during prolonged weight bearing.27 The elevated vacuum environment within the socket leads to decreased motion and therefore to fewer skin problems, improved prosthesis control, better balance, and enhanced comfort.24 Elevated vacuum suspensions have also been shown to improve oxygen perfusion of the amputated limb during gait28 and to have lower peak pressures and lower impact forces than traditional suction sockets.29 During the swing phase of gait, the elevated vacuum suspension has been shown to reduce axial motion of the socket relative to the limb as compared with the passive suction suspension.30 To achieve an elevated vacuum, a sealing sleeve is required to prevent air from entering through the proximal end of the socket. Some wearers report a decrease in the amount of available knee flexion once the air has been evacuated from the socket. This is likely caused by tension in the sealing sleeve as it spans the entire knee joint.

Impression Techniques The first step in creating a well-fitting socket is to capture an accurate impression of the residual limb. This can be done in a variety of ways, ranging from plaster bandages to noncontact optical scanners. Each technique has its own advantages and disadvantages, and there is no one best method for every limb. All methods share the common goal of capturing a model of the limb that accurately represents the location and geometry of each aspect of the limb. Capturing a static impression of the limb is simple and any method will suffice if executed properly. The challenging task is to capture the dynamic nature of the biologic tissue by compressing the soft tissues during the process to simulate the condition of the limb during weight bearing.

HAND CASTING During hand casting, the limb is gently wrapped with either plaster or fiberglass bandage and the prosthetist pushes in key weight-bearing areas while the casting material is setting up. How much compression is needed and which areas to compress is determined based on bony anatomy and the prosthetist’s individual knowledge, skill, and experience. Multistage casting procedures involve molding specific regions of the limb individually and joining them once the individual sections have set up. This allows the prosthetist to position the limb in multiple postures during casting to capture unique features. The insertion of the hamstrings, for example, can be molded during active knee flexion, when they are most prominent. Chapter 6 gives more details about casting.

PRESSURE CASTING Another way to precompress the tissue is to use a pressurizing technique.31 This involves placing the limb into a vacuum or pressure chamber while the plaster is setting up (Fig. 23.18). A vacuum chamber is typically a latex bladder pulled over the wet cast and sealed on the thigh. A vacuum pump attached to the distal end removes all air between the

Fig. 23.18 Pressure casting provides uniform pressure on the residual limb as well as slight distraction, ensuring that the mold and residual € limb match in length. (© Ossur.)

cast and bladder, allowing the atmospheric pressure to compress the limb up to approximately 14 psi. A pressure chamber with a latex bladder attached inside it is another option. The limb, wrapped with wet plaster, is placed in the bladder and air is pumped into the space between the cylinder and the bladder. The pressure in the cylinder can be increased to 30 to 40 psi, providing additional compression. Alternatively, pressure casting can be done with the PCAST method, where pressure is provided by water in a closed cylinder. The full length of the residual limb is wrapped in casting material. The limb is then placed on a flexible bladder inside a metal cylinder. The cylinder is then filled with water, creating a supportive environment in which the prosthetic user can bear weight. He or she then places equal body weight on each limb until the casting has set. This method makes it possible to produce a weigh-tearing mold of the residual limb.32 In all three methods, once the casting material has hardened, the pressure is released and the limb is removed from the chamber. Regardless of the casting method, differential pressure between the limb and the environment serves to apply uniform pressure over the entire surface of the limb. This leads to the most tissue compression in the softest areas and the least amount of tissue compression in the bony areas. The amount of differential pressure required will vary with the individual’s weight, and the prosthetist will use the least amount of pressure required to achieve the optimal fit.

OPTICAL SCANNING Optical scanners can be used to capture the threedimensional external shape of the limb to within 1 mm of accuracy (Fig. 23.19).33 They are quite useful in situations when hand casting is impossible or impractical, as immediately following surgery or with bulbous limbs that cannot be removed from a plaster cast without cutting or distorting the cast. Digital markers and alignment lines can be attached to the virtual model to reference the location of bony landmarks and pressure-sensitive areas. Although it is not possible to compress the skin by hand while scanning because the hand would block the view of

23 • Transtibial Prosthetics

Fig. 23.19 An optical scanner for shape capture. These units allow a mold to be created without having to physically contact the body segment and serve as a method of long-term storage of model shapes. (Photo courtesy Todd DeWees, CPO, Shriners Hospital, Portland, OR.)

the surface, compression of tissues and reliefs for bony landmarks can be accomplished using modification software. Scanners used in applications involving the construction of prostheses typically fall into one of two categories: (1) laser scanners and (2) structured light scanners (white or blue light). Laser scanners use triangulation of the beam reflecting off the surface of an object to determine its position in space. Since this process happens millions of times per second, the software is able to produce a map of the threedimensional surface by connecting these points. Structured light scanners project a light pattern onto the surface of an object and, by measuring the distortion of that pattern, the software can calculate the three dimensionality of the object being scanned. Both systems provide great accuracy and fast scan times, which makes them useful tools in the clinical setting. The use of an optical scanning system to create a digital model of the residual limb, or a computer-aided design (CAD) (Fig. 23.20), also requires a method of transferring that digital model to the real world, referred to as computer-aided manufacturing (CAM). CAD/CAM is a process used extensively in the manufacturing world, but in the Orthotics and Prosthetics world, it is often closely associated with three-dimensional printing (additive manufacturing) and foam carvings of molds (subtractive manufacturing). Although three-dimensional printing of prosthetic devices is done in some limited circumstances, it has not yet become a standard tool employed by the prosthetist. This is expected to change as advances in print materials, print methods, and print speeds are made. Currently three-dimensional printing in transtibial prosthetics is most prevalent in the production of check sockets and custom artistic fairings to provide shape

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Fig. 23.20 Image of a three-dimensional scan of a residual limb. The model is highly accurate to within  1 mm. (Photo courtesy Todd DeWees, CPO, Shriners Hospital, Portland, OR.)

to the prosthesis. More commonly, transtibial models are fabricated using a carver that is computer-guided and carves a foam block into the desired shape. The model produced in this way is then used to produce the prosthetic socket using traditional methods. Prosthetic sockets produced using a CAD/CAM carver have been shown to improve quality-oflife parameters and reduce the wearer’s socket adaptation.34 This system has the additional advantages of reducing fabrication time and maintaining objective data on socket shape and volume over the life of the prosthetic user.

Alignment Alignment refers to the spatial orientation of the prosthetic socket relative to the foot. Alignment will influence the magnitude and direction of the ground reaction force throughout the gait cycle. There are four goals in prosthetic alignment: (1) facilitating heel strike at initial contact, (2) providing adequate single-limb stability during the stance phase, (3) creating smooth forward progression (rollover) during the transition from early to late stance phase, and (4) ensuring adequate swing-phase toe clearance.35 These goals are reached through dynamic alignment of the prosthesis, during which the person walks on a prosthesis that is fitted with an adjustable device that allows for alignment changes in all three planes. Although “normal” gait is not a goal, modern components do allow many persons with transtibial amputations to evade detection of gait abnormalities or deviations by all but the most skillful gait observers. Prosthetic alignment can also be used in conjunction with socket fit to address pressure issues within the socket. Because of this, socket fitting and dynamic alignment must occur simultaneously. Effective fitting and alignment

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requires an iterative process, as changing one aspect can affect many others. The end result is often a compromise. For example, the foot may require excessive dorsiflexion in order for the person to achieve sufficient swing clearance, even though this may contribute to a higher than optimal knee flexion moment during the loading response. The prosthetist must understand the biomechanics of the limb and gait cycle to weigh the factors appropriately and make the best decisions. The modular components that connect the socket, pylon, and foot allow the prosthetist to make angular changes to the alignment. In the sagittal plane, socket flexion or socket extension refers to the tilting of the proximal end of the socket forward or backward in the anteroposterior direction, respectively. In the frontal plane, socket abduction moves the proximal end of the socket medially while socket adduction moves it laterally. Adjustments around the ankle can be described with standard anatomic terminology: inversion, eversion, plantarflexion, and dorsiflexion. Changes to the alignment can refer to the motion of the socket relative to the foot, or vice versa. Dorsiflexing the foot for example, causes socket flexion; while everting the foot leads to the same motion as adducting the socket. The socket can also be shifted medially or laterally in the frontal plane and anteriorly or posteriorly in the sagittal plane. These shifts are referred to as linear changes or slides. These, too, are relative changes. A lateral slide of the socket for example, is equal to a medial slide of the foot. This type of adjustment is useful during static alignment to ensure the foot is directly under the individual’s knee. Linear adjustments can be made by either using a special component that permits this type of slide (Fig. 23.21), or by using a pair of standard pyramid connectors and making equal but opposite angular adjustments.

BENCH ALIGNMENT The first step in the alignment of a transtibial prosthesis is to position the socket in what is known as “bench alignment.” This alignment serves as the starting point for the dynamic alignment process. In a standard bench alignment, the socket is set at 5 degrees of flexion and 5 degrees of adduction while the top of the prosthetic foot is level in both the frontal and sagittal planes and the medial border of the foot is parallel to the line of progression. When viewed in the sagittal plane, a plumb line should fall from anatomic knee center and pass through the foot at a point one-third of the foot length from the back of the heel. In the frontal plane, the line should go from mid-patella through the center of the heel. The reason for the 5 degrees of socket flexion is to elongate quadriceps muscles slightly so that they are better prepared to accept the full weight of the body and to aid in shock absorption during loading response. The 5 degrees of adduction ensures that the foot is sufficiently inset to create the appropriate varus moment during stance. This properly loads the proximomedial and distolateral aspects of the limb that are best able to carry those forces. Standard bench alignment is not used when joint contracture or deformity is present; instead, the actual limb alignment is marked during the casting procedure and that alignment is used as the starting point in the dynamic analysis.

HEIGHT Once the prosthesis has been bench-aligned, the person dons the prosthesis and stands while bearing equal weight on both lower extremities. The first measurement examines the length of the prosthesis. The goal is to achieve relatively equal leg length by comparing the intact and prosthetic limbs. There are two accepted ways to assess the height: statically and dynamically. In a static assessment, the individual is asked to stand with feet shoulder-width apart, knees fully extended, and bearing equal weight on both limbs. The distances from each iliac crest to the floor can be measured and compared. An alternative is to evaluate whether left and right iliac crests appear to be level. The measurement should not be taken in the supine position because the length of the prosthesis changes during weight bearing as a consequence of flexion of the dynamic components and compression of the interface material. In a dynamic assessment, the person is asked to walk and the entire body is observed, especially the head and torso. Many factors will affect the motion of the head and torso, so it is best to focus only on gross asymmetries that can be corrected by changing the length of the prosthesis. When the static and dynamic height measurements are different, a clinical decision is made to determine the optimal length for the prosthesis to provide the best function for the individual. It is not uncommon for the prosthesis to be up to 1 cm shorter than the sound limb under static conditions.

DYNAMIC ALIGNMENT Fig. 23.21 Alignment adaptor attached to foot and diagnostic socket. This adaptor is used in the alignment phase of prosthetic fabrication only. It allows for anteroposterior and mediolateral slide of the prosthetic socket relative to the foot (the foot is shifted 1 cm medially). (Photo courtesy Todd DeWees, CPO, Shriners Hospital, Portland, OR.)

Alignment changes can be made with the standard modular connectors that are used to fasten the components of the prosthesis together. A standard pyramid connector (Fig. 23.22) can be set anywhere within an approximately 20-degree arc of adjustability. This means, for example, that

23 • Transtibial Prosthetics

Fig. 23.22 An example of endoskeletal alignment components set in maximum socket flexion and maximum plantarflexion, creating a posterior shift of the socket relative to the foot. (Photo courtesy Todd DeWees, CPO, Shriners Hospital, Portland, OR.)

the socket can be flexed up to 10 degrees or extended up to 10 degrees from the neutral starting position. This is accomplished by loosening one screw and then tightening the opposite screw equally. Each pyramid permits adjustment in two orthogonal planes. For simplicity, the prosthetist will typically rotate the pyramid so that the adjustable planes are aligned with the frontal and sagittal planes. Transverse plane rotation is almost always infinitely adjustable; the standard connectors can accommodate any foot position. When the dynamic alignment differs greatly from bench alignment, it may be necessary to add a special alignable component to the prosthesis. This component will accommodate a larger window of adjustment and allows for linear changes in addition to angular changes. For example, the foot can be inset relative to the socket simply by sliding the foot medially and retightening the connector. This device is to be used during the dynamic alignment only and then removed during the final fabrication procedure. Small linear adjustments can also be made without the special component by performing equal but opposite angular adjustments on two adjacent pyramid connectors. This method will, however, simultaneously affect the height of the prosthesis. During the dynamic analysis, the prosthetist will ask the individual to walk in a safe environment, typically within the parallel bars, and observe the motion of the prosthesis throughout the gait cycle. Adjustments are made to minimize gait deviations and create a smooth, stable gait pattern. The prosthetist will attempt to create an energy-efficient stride by minimizing the horizontal and vertical displacement of the center of mass. Goals for the optimal alignment are stance stability, swing clearance, equal step length, and

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energy efficiency. Socket fit and suspension play an important role in providing stability, so final adjustments to both aspects are included as part of the dynamic analysis. Although dynamic alignment is typically done on a flat, level surface, many prosthetists will also attempt to simulate other terrains that an individual will encounter in the course of daily life. Ramps, stairs, and uneven surfaces all require slightly different alignments for optimal performance. It is very important to optimize prosthetic alignment as it has been shown to have significant clinical impact on gait kinetics and spatiotemporal parameters, including cadence and mediolateral displacement of the socket.36 Final alignment is often a compromise of function on the varied terrain that an amputee will encounter. As the question of whether the alignment of the prosthesis is “good” is ultimately answered by the function and satisfaction of the person wearing the prosthesis.36 A fairly broad range of alignments can be considered acceptable.37 In an effort to standardize what is ultimately a subjective estimate of proper alignment, the concept of vertical alignment axis and alignment reference center has been proposed. The vertical alignment axis is a vertical line that passes through the geometric center of the socket at the level of the midpatellar tendon. The alignment reference center is the point along the line from the center of the foot through the tip of the shoe, one-third of the way forward from the back of the heel. To align the prosthesis, the individual is asked to bear full weight on the socket while the socket is supported on a padded stand. He or she then determines the socket axis based on the most comfortable weight-bearing position. When the socket is aligned with the socket axis in the most comfortable position and the vertical alignment axis goes directly through the alignment reference center (Fig. 23.23), the prosthesis is generally felt to be well aligned.

ELECTRONIC ALIGNMENT Technology has been developed to help the prosthetist to make the alignment process more objective, thereby making prosthetic alignments more repeatable and predictable. Electronic sensors imbedded in the prosthetic components are capable of transmitting real-time gait data to a nearby computer (Fig. 23.24). The computer processes socket load information during the stance phase of gait, which is superimposed over the patient's baseline data to create a graph (Fig. 23.25).38 Displaying the otherwise invisible forces and moments on the prosthesis cues the prosthetist to focus in on specific variances and consider their possible causes. This can prevent undetected problems with alignment from causing long-term damage to the individual’s limb. For example, an excessive varus moment at the knee can lead to premature medial compartmental osteoarthritis over a long period. This objective data can be captured and kept in the person’s medical record to be referenced if problems arise or changes are necessary in the future.

Additional Features There are many modular components that can be added to a prosthesis between the socket and the foot to enhance certain features and functions. These include shock absorbers, torque absorbers, and dynamic pylons. The downside of such

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Fig. 23.23 The vertical alignment axis and alignment reference center (ARC) of a transtibial prosthesis. Note that the socket axis is set in slight flexion from vertical. The center of the socket should be at the center of the cross section of the socket at the level of the patellar tendon bar. The alignment reference center is one-third the distance from the posterior edge of the shoe worn on the prosthetic foot. PTB, Patellar tendon–bearing. (Reprinted with permission from Lin C, Wu YC, Edwards M. Vertical alignment axis for transtibial prostheses: a simplified alignment method. J Formos Med Assoc. 2000;99[1]:39–44.)

pattern is not attainable with the existing feet alone. Care should be taken to mount these components on the prosthesis as proximally as possible to minimize the inertial effects of the additional weight on the swing phase of gait.

TORQUE ABSORBER

Fig. 23.24 A computerized sensor that can be mounted in-line with other prosthetic components. It can gather kinetic and kinematic gait data as well as socket load in real time. (Reprinted with permission from Orthocare Innovations, Edmonds, WA.)

components is the greater overall weight of the prosthesis and the requirement of sufficient clearance between the socket and foot. When clearance is an issue, the foot choices may be limited. Typically these components are used in cases where excessive shock is expected or when an acceptable gait

When rotational motion in the socket causes discomfort or excessive stress on the skin, a torque absorber can be used to decrease the rotational torque from the ground reaction force. A torque absorber is a component that uses a viscoelastic bumper to allow a limited amount of rotation to occur at the foot without displacing the socket. The amount of rotation is proportional to the torque and can range up to 30 degrees in either direction. This is especially useful in sports applications, such as golf and tennis, which require a wide range of rotation during the activity. Torque absorbers have been shown to increase participation in low- and medium-intensity activities while reducing the interference of associated pain.39 Torque absorbers may also be beneficial for turns encountered in normal daily ambulation, especially for individuals with fragile skin.

SHOCK ABSORBER Although much of the functional shock absorption needed for gait is attainable with controlled knee flexion in loading response, some individuals benefit from the additional vertical excursion afforded by the addition of a shock absorber.40

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Fig. 23.25 This graph shows the anteroposterior and mediolateral socket loads per session by stance phase (0–100%) and is superimposed on the standard deviation range (blue band) of the baseline recording made at the time of first fitting. (Reprinted with permission from Orthocare Innovations, Edmonds, WA. From Europa+ Pamphlet. 2015. Available at: http://ecbiz182.inmotionhosting.com/~orthoc6/wp-content/uploads/2016/01/Europa-IFU.pdf.)

Fig. 23.26 A shock-reducing pylon is mounted directly under the socket to attenuate torque and shock that is transferred from the ground to the limb. It replaces all or part of the pylon, depending on available clearance. (Image provided by Fillauer.)

This component uses a viscoelastic spring to dampen the ground reaction forces by slowing their transmission to the limb. As weight is transferred to the prosthesis, the shock absorber compresses relative to the magnitude of the ground reaction force. This reduces impact by spreading the force out over a longer time interval, leading to a lower overall prosthesis height during early stance. Additionally, both features can be combined into a single unit (Fig. 23.26).

DYNAMIC PYLON Typical prosthetic pylons are rigid and function only as n attachments between the socket and foot to establish the correct overall height. Dynamic pylons allow for energy to be

Fig. 23.27 An example of an energy-storing /energy-return foot with dynamic pylon. This foot would be mounted to the back of the socket. € (© Ossur.)

stored as spring tension as they flex through midstance and into terminal stance. This energy is released in preswing to assist with hip and knee flexion, promote toe clearance, and assist limb advancement. The energy return allows the individual to walk with less energy consumption and increased efficiency, meaning that he or she can walk farther and longer. The angle of flexion in a dynamic pylon is small and is difficult to observe during casual ambulation. The effects are more readily apparent during jogging or running (Fig. 23.27), although even in walking the use of a dynamic pylon has been shown to increase step length and decrease dependency on mobility aids such as crutches.41

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Microprocessor-Controlled Foot/Ankle Systems Microprocessor controlled foot/ankle systems (MPAs) use computer controlled hydraulic cylinders to preposition the foot to accommodate for variations in terrain (Fig. 23.28). This is accomplished through one of two methods. The first is for the ankle to adapt to the slope or variation in terrain during the swing phase of gait while keeping the ankle fixed during stance. The second approach is to adapt to surface changes during the stance phase of gait. Regardless of the approach, all MPA systems have advantages and disadvantages.42 Advantages include better adaptation to slopes and stairs, increased stability on uneven ground, and decreased fall risk. Disadvantages include cost, weight, greater maintenance requirements, and the need for greater clearance under the prosthetic socket. Prosthetic Feet Improvements in prosthetic foot design have led to the availability of foot systems that incorporate one, two, or all three of these features in one device. This has reduced the obstacles of increased weight and the need for extra clearance under the socket. The advancements are attributable to improvements in composite materials, manufacturing processes, and engineering design. An example of such a foot type is a crossover foot in which the design elements of a running-specific foot and those of a daily-use foot are combined. In healthy active prosthesis users, these feet have been shown to reduce oxygen consumption.43 A much more detailed discussion of prosthetic feet can be found in Chapter 21.

Fig. 23.28 A microprocessor-controlled foot-ankle system. This system makes corrections of the ankle position, which is necessary to accommodate for variations in walking surface and provides improved € balance for the user. (© Ossur.)

DIAGNOSTIC SOCKETS Because the fit of the socket is the single most critical factor in providing a functional prosthesis, great care must be taken to make sure that the fit is optimal. One tool used by prosthetists is a thermoplastic socket, usually clear,

Case Example 23.1 A Traumatic Transtibial Amputation PRESCRIPTION OF A PROSTHESIS Let us consider the case of J.W., a 37-year-old male whose left leg was amputated below the knee following a motorcycle accident. He has since recovered from all injuries and is now medically stable. He was recently approved for weight bearing on his left limb as tolerated. He is 5 ft 8 inches tall, weighs 175 lb (79.5 kg), and his residual limb measures approximately 20 cm from knee center to distal end. J.W. has significant amounts of scar tissue on the surface of the residual limb, including a skin graft from his thigh. The skin on the distal end of the limb is adherent to the distal end of the tibia. He was very active prior to his injury and would like to return to that lifestyle as soon as possible. He arrived at the clinic on crutches. QUESTIONS TO CONSIDER ▪ Is J.W. a good candidate for a prosthesis? ▪ What type of interface, suspension, and socket design would be appropriate? ▪ What other components could be recommended? RECOMMENDATIONS The first decision is to determine whether J.W. is a good candidate for a prosthesis. His entry into the clinic on crutches indicates that his balance, upper extremity strength, and contralateral limb are all sufficient condition for gait. The only factor jeopardizing J.W.’s candidacy is the condition of the soft tissue of his residual limb. In the past, poor soft tissue condition could have prevented successful use of a prosthesis, but with the

help of modern techniques and materials, a successful fitting may well be possible. The interface with the skin should be determined next. Two conditions must be considered: the adherent tissue on the distal end and the fragile skin graft. Gel liners are most efficient at eliminating shear forces on the limb. This will be a major factor in preventing skin breakdown of the adherent skin. The skin graft would benefit from a soft durometer gel rather than a silicone elastomer or urethane liner. Selection of the right interface will be critical to J.W.’s outcome. The decision to use an off-the-shelf size or a custom-made liner will depend on the shape of the limb and how well he could be fitted with a standard-size liner. The suspension for J.W. should be the system that will lead to the least amount of pistoning. Elevated vacuum will maintain the limb volume by drawing fluid back into the tissues between weight-bearing cycles. This is important for J.W., as the tissues of his limb will be subjected to a large amount of strain once he reaches his goal of readopting an active lifestyle. FITTING AND ALIGNMENT OF THE PROSTHESIS: VISIT 1 J.W. is seen today for the initial fitting of his first prosthesis. The gel liner is donned directly on the skin and a single-ply sock is worn over the liner. The limb is then placed into the socket and a sealing sleeve is rolled up to mid-thigh to seal off the proximal edge of the socket. J.W. is then asked to stand up between the parallel bars, keeping all his weight on the sound limb. J.W. will

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Case Example 23.1 A Traumatic Transtibial Amputation (Continued) then slowly transfer his weight over to the prosthesis as tolerated. Once he is comfortable bearing his full weight on the prosthesis, he can begin to take his first steps. As he begins to walk and feel more confident, J.W. begins to let go of the bars and walk hands-free. Once he does this, his knee begins to flex rapidly during the loading response and the foot starts slapping the floor.

Today he returns to therapy for a scheduled follow-up appointment. He complains of discomfort at the distal end of his residual limb and loss of stability in the socket. While observing his gait, the prosthetist finds that it appears to be a bit short. Assessment of the residual limb reveals erythema on the distal end and on the distal aspect of the patella.

QUESTIONS TO CONSIDER ▪ Is the alignment of the prosthesis adjusted properly? Is the foot making an appropriate heel strike? Has the heel height of the shoe been properly accommodated? ▪ Is the socket stable on his limb? Are there signs of pistoning? Is there excessive medial shift of the prosthesis during stance? ▪ Are his knee extensors strong enough to eccentrically control knee flexion during full weight bearing?

▪ What changes have occurred since J.W.’s last visit? Has he

RECOMMENDATIONS A plumb bob through the midline of the socket falls between the posterior one third and anterior two thirds of the foot when the shoe is donned, and the top of the foot shell is level with the ground. This indicates that the alignment is appropriate. Muscle strength testing reveals that the quadriceps of the residual limb are 2/5 (two out of five). Due to the lack of strength in the quadriceps muscle group, J.W. is unable to regulate knee flexion during the loading response. A rehabilitation protocol for quadriceps strengthening that includes ambulation with the prosthesis should be implemented. At the same time, the prosthesis can be altered to improve J.W.’s gait pattern as he regains his strength. The foot should be moved anteriorly, relative to the socket. This will decrease the mechanical advantage of ground reaction force to flex the knee by shortening the heel lever. It will simultaneously increase the length of the toe lever, which will provide more stability in midstance. The potential downside is that the knee extension moment in terminal stance will also be increased, so there is potential for the knee to hyperextend. J.W. should be asked to monitor his posterior knee pain and report any as soon as it is recognized. Because his muscle weakness is expected to resolve relatively quickly, alignment of the prosthesis should be monitored on a regular basis so that the foot can gradually be shifted back to the appropriate position and normal gait can be restored. FITTING AND ALIGNMENT OF THE PROSTHESIS: VISIT 2 J.W. has done well with rehabilitation and use of his lowerextremity prosthesis. His limb has healed well and his strength is generally good. He has good balance and endurance for walking with the prosthesis. He has gradually increased his wear time and activity level. He works a 5-hour day in agriculture.

QUESTIONS TO CONSIDER

made changes in the number of sock plies or in his footwear? Has he gained or lost weight? ▪ Is this an alignment- or fit-related issue? When does the pain occur in the gait cycle? Does the pain increase throughout the day? ▪ Is the interface worn out? How old is the interface now? How long should it be expected to last? Are there thin areas in the interface that might indicate excessive pressure and premature wear? RECOMMENDATIONS J.W. reports that his weight and footwear have not changed. He is wearing the same single-ply sock with which he began. His gel liner is still in excellent condition and should be expected to last for about a year of constant wear. Consideration of all the information indicates that the limb has changed since the initial fitting. As his pain is worst at midstance and increases proportionally with the time spent bearing weight, the prosthetist concludes that the limb is too far distal in the socket. J.W. should increase the number of socks he is wearing, one ply at a time, until the limb is seated correctly in the socket. This will also address the length of the prosthesis, which had appeared to be too short. In experimenting with sock plies, J.W. went from initially wearing a single sock to six plies, but he found that this number of socks created a new set of problems. He is feeling excessive pressure on the tibial tubercle and proximal aspect of the fibular head. During loading response, he is unable to regulate his knee flexion because of pain on the anterodistal aspect of the tibia. Despite good suspension, he is also starting to scuff his toe during swing phase. All these symptoms indicate that he is now too far out of the socket. This position decreases control of the tibia and allows the socket to flex and extend beyond the position of the limb, leading to excessive pressure on the ends of the bones. It also positions the bony prominences of the limb in areas that do not have adequate reliefs. Removal of several sock plies is the correct intervention, as this will allow J.W. to seat his limb further into the socket and thus increase comfort and stability. When he wore four-ply socks, his comfort and control were restored.

Case Example 23.2 An Amputation Related to Vascular Disease PROSTHETIC PRESCRIPTION G.R. is a 76-year-old woman with type 2 diabetes and peripheral vascular disease. She sustained an abrasion at the lateral malleolus of the right leg that failed to heal and developed into a stage 4 nonhealing wound. Circulation at the lower leg was markedly impaired. After several months of multiple failed therapies to improve circulation and promote wound healing, the right leg was amputated below the knee. G.R. is 5 ft 4 inches tall and weighs 204 lb (92.5 kg). Prior to the problems with

her leg, she was living independently and caring for her husband, who is significantly disabled. Two months after her surgery, the transtibial amputation wound site was fully healed. Her physician is recommending that she begin bearing weight on the limb as tolerated. She has been using a wheelchair for mobility in the house, but she is able to stand on her left leg with the support of a standard walker. She is concerned that she will not be able to do her chores around the house and go shopping even after she receives her prosthesis. Continued on following page

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Case Example 23.2 An Amputation Related to Vascular Disease (Continued) QUESTIONS TO CONSIDER ▪ What are G.R.’s goals for the prosthesis? Will she be a functional ambulator? Will the prosthesis be used only for standing and transfers? ▪ Will she require assistance with activities of daily living and care for her husband? ▪ What are the main design goals for her prosthesis? What system will allow her to don the prosthesis independently? Which type of prosthesis will require the least maintenance and have most reliable function? RECOMMENDATIONS Evaluating G.R.’s candidacy for a prosthesis will involve assessing her risk-to-benefit ratio as a bipedal ambulator against the negative health effects of prolonged sitting. Her motivation to ambulate is clear in her expressed desire to continue to care for her husband. Her ability to stand on one leg is a fortuitous sign, even if her balance is impaired at this point. Her knee ROM is within normal limits. If her skin integrity is good and her right knee extensors are four of five, she will likely be a good candidate for a prosthesis. Her prosthesis should be easy to put on, as she will not have assistance available. Her limb has ample soft tissue based on her weight and etiology, although her diabetes puts her at risk for fragile skin and delayed healing. The most appropriate interface for her will be one that most effectively reduces shear. A silicone elastomer cushion liner in a TSB socket will work well for her. A sealing sleeve and expulsion valve will utilize suction as a means of suspension, thus minimizing pistoning. This prosthesis should allow her to wear a cotton sock that is easily laundered as she loses limb volume. The trim lines should be set higher proximally to gain as much control as possible for her prosthesis. FITTING AND ALIGNMENT OF THE PROSTHESIS: VISIT 1 G.R. is seen for delivery of her preparatory prosthesis. She is instructed on donning the device and is able to roll on the gel liner and place her limb into the socket with moderate effort. Her limb is seated correctly all the way in the socket. After she rolls the sealing sleeve into position, she stands at her walker and slowly begins to load the prosthesis. She is comfortable in the socket and a small amount of air is heard as it is expelled from the socket through the valve. The sleeve is rolled down so that a corset stay can be inserted between the gel liner and the socket. As no areas of excessive pressure are found, the corset stay is removed and the sleeve is rolled back up. Her first steps are tentative and she is bearing the majority of her weight through her arms during stance on the prosthetic side. After some guidance from her therapist, she begins to bear more weight through the prosthesis. Her strides are asymmetric, with a very large step on the prosthetic side and a truncated step on the sound side. QUESTIONS TO CONSIDER ▪ Why is G.R.’s step length shorter on the sound side? Is the prosthesis aligned properly? Is her range of hip flexion and extension within functional limits? Is she stable in stance? ▪ What are her goals for ambulation? Does she have sufficient stance stability? Does she have adequate clearance in swing? Is her gait pattern energy-efficient? RECOMMENDATIONS The gait pattern G.R. uses is typical of the individual with recent amputation who is uncertain about weight bearing through a

mechanical device. The feeling of instability on the prosthesis causes G.R. to limit stance time on that side, thereby shortening swing phase on the sound side. Alternately, the individual may be accustomed to bearing weight unilaterally on the sound side so that the stance time is increased, allowing the prosthesis to move ahead excessively. Weakness of the quadriceps and gluteus minimus and medius will also impair stance stability. G. R. should be encouraged to take smaller steps with the prosthesis and larger steps with her sound limb. She may need further conditioning of her knee extensors and hip abductors to completely eliminate this asymmetry. Excessive socket flexion can increase prosthetic step length, but it also tends to increase the step length on the sound side as well. Extending the socket makes it more difficult to advance over the foot during stance and will tend to shorten step length on the contralateral side. FITTING AND ALIGNMENT OF THE PROSTHESIS: VISIT 2 G.R. returns for therapy and complains about discomfort in her socket. Inspection of her skin reveals excessive pressure, as evidenced by erythema, on her femoral condyles and fibular head. She has been doing a good job managing her sock plies and is now seated correctly in the socket wearing eight plies. She explains that the tightness she feels does not get worse during weight bearing. QUESTIONS TO CONSIDER ▪ What changes may have taken place since her last visit? As her activity level increases, what is the effect on limb volume? Which areas of the limb are most susceptible to volume loss? ▪ What is the source of the erythema? Is there swelling of the knee? Does the redness appear anywhere else on the limb? Does it appear to be an allergic reaction, such as contact dermatitis? Is her liner clean and in good condition? RECOMMENDATIONS After discussing good hygiene and prosthesis care with G.R., it is clear that she is washing her gel liner daily with a mild soap and then rinsing it thoroughly; she is also washing her limb every day and patting it dry. She is not using any lotions that could create buildup in the liner or cause an allergic reaction within the warm, moist environment of the liner. The fit of the socket is assessed next by probing between the liner and socket with a thin metal corset stay. This is done in the non-weight-bearing state, as that is when she feels the pressure. The corset stay encounters great resistance when it passes over the fibular head and is completely stuck when trying to pass over the femoral condyles. This indicates excessive pressure over those bony structures. Although G.R. is wearing the appropriate number of socks, they are creating extra bulk, which makes the socket too tight in those areas. A referral should be made to her prosthetist so that the socket can be modified. It is likely that pads can be added in strategic areas that are more prone to volume loss, such as the area over the calf muscle and on either side of the tibia. This will take up volume in the socket and require G.R. to reduce the number of sock plies she is wearing. Following that adjustment, she is feeling more comfortable in the socket and her skin is free of irritation.

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which is used during the fitting process and then discarded and often destroyed during the fabrication process. The diagnostic socket or “check socket” is made of a transparent thermoplastic so that the prosthetist can inspect the limb during loading and see the blanching of the skin as the person goes through various activities of weight bearing. The plastic is also very amenable to changes in shape and volume simply by heating a given area and reforming the plastic. Extended fittings, during which the individual takes the diagnostic socket home for a day or more, must be conducted carefully, as some of the materials used for diagnostic sockets are brittle and can fracture under normal loading conditions. Extended fittings can be quite useful, however, the prosthesis will be used under more realistic conditions and some problems will become apparent only after the wearer has spent several hours wearing the prosthesis.

Finishing Techniques After the prosthetist and the wearer are both satisfied with the fit and alignment, the final prosthesis can be fabricated. The exact finishing technique varies based on the components selected, but the main goal is to preserve the alignment and create a lightweight prosthesis with a cosmetically satisfactory appearance. The foot is removed and the remainder of the prosthesis is secured in a vertical alignment jig (Fig. 23.29). The socket is filled with plaster and a pipe, held in place by the alignment jig, and set into the wet plaster. After the plaster hardens, the alignment has been captured and the prosthesis can be removed from the jig. The jig preserves the alignment until the final prosthesis is reassembled. The prosthetist will determine the best method of fabrication to create the lightest-weight prosthesis without sacrificing structural integrity. Extra alignment devices are removed during this process. The final limb is assembled with either endoskeletal or exoskeletal components based on the user’s individual needs.

Fig. 23.29 A prosthetist uses this device to preserve the relative positions of the foot and socket during fabrication. This allows the exact alignment of the diagnostic prosthesis to be transferred to the definitive prosthesis. (Image provided by Fillauer.)

ENDOSKELETAL CONSIDERATIONS As the term endoskeletal implies, the structure of this type of prosthesis is located deep inside the device. The exterior of the prosthesis may consist of passive foam rubber or latex that gives the prosthesis a more anatomic appearance and protects the structural and functional parts hidden underneath (Fig. 23.30). This type of prosthesis has two distinct advantages: adjustability and a realistic appearance. Endoskeletal design allows for the use of modular components that can be adjusted or replaced quickly and easily as needed. If a single component were to fail, repair would involve simple removal and replacement of that component, just as a tire on a car can be changed. These modular components can easily be obtained from the prosthetist, as they are not custom-made. The appearance of the endoskeletal limb can be quite realistic. Virtually any size and shape can be created by shaping soft, lightweight foam over the components. The foam can be coated with a variety of finishes that provide color and texture and may include life-like details such as moles, freckles, pores, and even hair.

Fig. 23.30 A diagram of an endoskeletal prosthesis in which the socket and pylon are concealed within a cosmetic cover. (From Knee Prosthetics, Prosthetics-Orthotics Program, University of Texas Southwestern Medical Center, TX, 1998).

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Premium restorations are nearly indistinguishable from a sound limb.

EXOSKELETAL CONSIDERATIONS When a more durable and easily cleanable prosthesis is desired, an exoskeletal prosthesis can be fabricated. The socket of an exoskeletal prosthesis is attached to the foot through an external composite lamination custom-shaped for the individual (Fig. 23.31). To create this shape, a prosthetic ankle block is first bonded to the socket with rigid foam in the vertical alignment jig. The foam is rigid enough to maintain the alignment between the socket and foot that was preserved in the jig. The foam and ankle block are then shaped by hand to match the contralateral side, only a little bit smaller to accommodate the thickness of the final lamination. The final step is to seal the foam and laminate the exterior. This final composite covering provides the structure of the prosthesis as well as the anatomic shape. Exoskeletal prostheses are often heavier than their endoskeletal counterparts and are always less adjustable. The advantage of the exoskeletal system is durability. The hard surface covering the prosthesis is nonporous, chemically inert, and waterproof, making it easy to clean and less susceptible to damage.

Deviations in Gait Gait deviations can be caused by improper socket fit, by misalignment of the prosthesis, or by weakness or other musculoskeletal pathologic conditions of the individual. They can be quite common in persons with transtibial amputations; one study has shown deviations in nearly 20% of the 60 kinetic, kinematic, and temporospatial parameters of gait.44 Such deviations are known to increase metabolic cost due to excessive displacement of the center of mass.45 Careful evaluation is essential to determine the cause of deviations and what can be done to correct them (Chapter 5 presents a review of the biomechanics of normal gait). Variations in limb volume or shoe type can introduce deviations in a wearer’s gait that had not been noted before. It can be very productive to ask wearers whether they have recently made any changes in their routines. Changes in diet, medications, shrinker wear, or activity level can all affect limb volume. If a shoe with a higher or lower heel is placed on the prosthesis, it will change the socket’s orientation to the ground. Unless there is a component that will accommodate the new heel height, the wearer’s gait will be affected adversely. Common gait deviations are reviewed in the following paragraphs as they occur in the gait cycle in each individual plane.

INITIAL CONTACT Sagittal Initial contact should be made with the heel (Fig. 23.32). If the user makes contact at the midfoot/forefoot first, there may be either excessive plantarflexion of the prosthetic foot or limitation of the person’s knee extension ROM (i.e., knee flexion contracture). Both of these circumstances contribute to a high knee extension moment during loading response that causes the knee to move posteriorly. This motion negatively impacts efficiency and can damage the knee joint over time. Every effort should be made to create a heel strike at initial contact. Interventions include therapeutic

Fig. 23.31 A cross-sectional diagram of an exoskeletal prosthesis that transmits weight-bearing forces through the external lamination. The lamination gets its shape from the rigid foam interior. (From Knee Prosthetics, Prosthetics-Orthotics Program, University of Texas Southwestern Medical Center, TX, 1998).

Fig. 23.32 Ideally, initial contact of the prosthesis with the ground should be at the heel, followed by a controlled flexion of the knee and foot flat. (Diagram courtesy David A. Knapp, CPO, Hanger Prosthetics & Orthotics, North Haven, CT.)

23 • Transtibial Prosthetics

exercises to increase knee ROM and knee extensor strength, prosthetic alignment changes to accommodate knee flexion contractures, and proper height and suspension of the prosthesis. If the prosthesis is too long or does not suspend well, the prosthesis may hit the ground early, shortening swing phase.

Frontal Excessive inversion or eversion of the foot at initial contact indicates misalignment of the prosthesis. The heel of the prosthetic foot should be level when it meets the ground. The lateral border of the heel should contact the surface first; this is related to the transverse plane alignment of the foot to accommodate a normal toe-out angle of 5 to 10 degrees. This lateral heel contact sets up the standard progression of the ground reaction force up the lateral border of the foot and then crossing to the medial aspect of the forefoot during stance phase. Transverse The rotation of the prosthesis is fairly consistent throughout stance phase. The medial border of the foot should be parallel to the line of progression. Transverse plane rotation at initial contact is an indicator that the limb is fitting too loosely in the socket or that the foot is not directly under the limb. External rotation of the prosthesis may be seen with an inset foot, whereas internal rotation could be a result of an outset foot (Fig. 23.33). Loading Response Sagittal. Excessive knee flexion moment during loading response is caused by a foot that is set too far posteriorly, is too dorsiflexed, or has a heel that is too rigid. The transition during loading response should be smooth and controlled. The knee should bend to approximately 20 degrees of flexion as the forefoot meets the ground. This advances the limb and aids in shock absorption. Insufficient knee flexion moment can be caused by a heel that is too soft or a foot that is positioned too far anteriorly. This can cause the knee to hyperextend, leading to pain and inefficiency. Adjustment of the heel lever length, stiffness, and

Loading response

Midstance

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orientation should be made to provide the appropriate degree of knee flexion. When accommodation for the heel stiffness is made, the soling material of the shoe should also be taken into account, because an excessively stiff or soft heel material can exaggerate this tendency.

Frontal Rapid loading of the foot during this phase would produce significant moments at the knee if the foot is not parallel to the ground at initial contact. The plantar surface of the foot should be level during this phase as viewed in the frontal plane. Some modern prosthetic feet have rearfoot inversion and eversion capabilities and can adapt to the surface on weight bearing, making them useful for uneven surfaces. The prosthetist must make sure to observe the motion as the loading occurs. When there is motion while ambulating on a flat surface, the alignment of the foot should be changed to eliminate that motion. Transverse Any rotation of the foot during loading may indicate an excessively loose socket or faulty torsion adapter. Rotary moments can be generated by excessive toe-in or toe-out, and the torsion adapters allow that motion to occur uncontrolled.

MIDSTANCE Sagittal A choppy or segmented midstance is caused by differences in the dynamic characteristics between the prosthetic heel and the prosthetic toe, indicating a lack of stability. The heel and toe lever arms are adjustable by shifting the socket anteriorly to shorten the toe or posteriorly to shorten the heel. The optimal foot position is one where the forward velocity of the knee is consistent between loading response and midstance. The prosthetic foot must accommodate smooth transition of the ground reaction force from the heel to the forefoot during midstance. Over this period, the moment at the knee changes from a flexion moment to an extension moment. A steady increase in dorsiflexion should be observed as the knee moves over the foot.

Terminal stance

Preswing

Fig. 23.33 The progression of the transtibial prosthesis during stance phase. Initial contact is made at the heel, and compression of the prosthetic heel simulates controlled lowering of the foot during loading response. At midstance, weight-bearing forces move anteriorly to the ball of the foot. In terminal stance, the anterior portion of the prosthetic foot simulates toe extension and the heel rises. In preswing, the individual rolls over the toe and moves into knee flexion for effective shortening of the limb for swing limb clearance. (Diagram courtesy David A. Knapp, CPO, Hanger Prosthetics & Orthotics, North Haven, CT.)

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TERMINAL STANCE

Frontal There is a normal and desirable varus moment during midstance. In order to maximize energy efficiency during gait, the body’s center of mass does not shift all the way over the stance foot. The knee should move laterally approximately 1 cm during midstance. Shift of the knee greater than 2 cm indicates an excessive varus moment and will lead to stress on the medial compartment and lateral ligaments of the wearer’s knee. This stress can be reduced by adducting the socket or shifting it medially. If the socket does not move or shifts medially during midstance, the socket is too far inset (or the foot is too far outset), or the socket is excessively adducted. Lateral gapping is a condition in which a large gap occurs during loading between the limb and the lateral wing of the socket. If a gap larger than 2 cm is observed, the socket may be too loose and an additional ply of sock should be added.

Sagittal Drop off is the excessive descent of the center of mass during terminal stance caused by a toe lever that is either too short or too soft. It is often characterized by diminished heel rise. This compromises the energy efficiency of walking. It occurs at a point when the body’s center of mass is already near the bottom of its sinusoidal path. The toe lever of the prosthetic foot must have sufficient stiffness to resist dorsiflexion when the wearer’s entire weight is placed on the ball of the foot. In terms of energy efficiency, this is a critical phase of gait. Proper loading of the forefoot promotes knee stability, maintains altitude (i.e., level pelvis), and stores energy in the ligaments that can be released during swing phase to assist with limb advancement (Fig. 23.34). Early heel-off is an indication that the foot is too plantarflexed or the toe lever is too stiff. The heel should come off the ground at the point when the swing foot has already passed anterior to the stance limb. Forward momentum of the body is impeded by early toe-off and may force the individual into an anterior lean with the trunk to maintain forward progression. The ankle should be set to dorsiflex until the swing limb reaches terminal swing so that the heel remains on the ground until the center of mass has progressed sufficiently forward. This will preserve step length and enhance stability.

Transverse Rotation that occurs during midstance is typically seen between the limb and socket and is almost always attributable to poor socket fit. If motion occurs, the wearer may complain of patellar impingement on either the medial or lateral aspects of the patella. Often, the remedy is to tighten the socket by adding a ply or two of socks. In cases where socks are insufficient to stabilize the rotation, the socket should be adjusted by the prosthetist. Pretibial pads that provide pressure on either side of the tibial crest are an effective solution to stop rotation.

10° Excessive flexion

1/3

1/3

1/3

10° Excessive extension

Fig. 23.34 The socket angle will affect the magnitude and timing of the ground reaction force through the knee during stance phase. Optimal alignment (center) varies with specific foot design but will be approximated by the centerline of the socket falling through the posterior one third and anterior two thirds of the foot. (Diagram courtesy David A. Knapp, CPO, Hanger Prosthetics & Orthotics, North Haven, CT.)

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Frontal The heel should rise off the ground with the knee breaking over the point on the foot between the first and second toes. Any large variance from this position will create instability and consequently shorten step length. The knee should travel in a straight line as it flexes; any lateral motion during this phase will lead to a whip in swing.

Frontal Socket instability during swing is typically caused by either a faulty suspension or a loose-fitting socket. The weight of the socket pulls the prosthesis into varus during swing if the limb is not well seated in the socket. Adding more sock plies and implementing an improved suspension should remedy any swing-phase instability.

Transverse The toe load is highest during this phase of gait; therefore there is potential for rotation of the prosthesis due to suboptimal alignment. External rotation can be caused by a foot that is too far outset or having excessive toe-out. Internal rotation is caused by an excessively inset or internally rotated foot.

Transverse Rotation during swing phase is often caused by a prosthetic “whip.” A medial whip occurs when the heel of the prosthetic foot moves medially in initial swing and then laterally during midswing. A lateral whip follows the opposite pattern. Whips can be caused by misalignment of the knee axis at the onset of swing or by irregular loading of the limb in terminal stance. Alignment of the knee axis in a person using a transtibial prosthesis is determined by the function of the hip and should be addressed by strengthening and ROM exercises. Remedies involve examining the loading of the prosthesis. Medial whips can be caused by a foot that is too far inset or externally rotated. Both medial and lateral whips can be caused by a foot that is too plantarflexed or a toe lever that is too stiff.

PRESWING Sagittal As the body weight transfers rapidly to the contralateral limb, the prosthesis should roll forward over the toe and lift off the ground. Toe-drag may result from a foot that is excessively plantarflexed or from a faulty suspension system. Frontal The knee should not move medially or laterally during preswing. An externally rotated foot can cause a valgus moment that pushes the knee medially as weight is transferred off the prosthesis. A valgus moment can also be caused by an outset foot or an excessively adducted socket. Lateral motion during preswing can be caused by an internally rotated foot, an excessively inset foot, or an excessively abducted socket. Transverse Many of the same factors that lead to instability in the frontal plane can lead to instability in the transverse plane. Appropriate attention to transverse plane alignment throughout stance phase should help to avoid issues in preswing as well.

SWING PHASE Sagittal The transtibial prosthesis swings passively forward during swing phase. If sufficient ground clearance is not obtained, the amount of knee flexion should be noted. In cases where appropriate knee flexion is observed, the suspension of the prosthesis should be evaluated. A faulty suspension or a plantarflexed foot will reduce swing clearance. The amount of pistoning varies with the type of suspension used. Motion exceeding 1 cm should be considered excessive. If knee flexion is observed during swing phase, active and passive motion should be assessed. Weakness or contracture of the knee can limit knee motion, as can a tight suspension sleeve or an aggressive supracondylar wedge. Although suspension and knee flexion are often adversarial, a balance should be attainable that permits enough foot clearance for safe ambulation; otherwise the prosthesis may require shortening.

Troubleshooting A common problem encountered by individuals with recent transtibial amputation is the application of too few or too many sock plies. Sock-ply management is a skill that develops as the individual wears the prosthesis more and is conscientious about examining the limb after doffing the prosthesis. The number of socks will eventually become consistent, but variability is common early in the process of limb maturation. The correct number of socks may vary from day to day or even from hour to hour. There are a few basic cues that those new to the use of a prosthesis must consider to ensure that the limb is in the correct position within the socket. The first cue arises during donning—the limb should slide into the socket with some resistance. This is a subjective determination, and the wearer should be trained to recognize the amount of force needed to fully don the prosthesis with the correct number of socks. Too few socks allows the limb to “bottom out” in the socket, where most of the weight bearing occurs on the distal end, leading to pain, instability, and increased pistoning. Conversely, too many socks prevent the limb from fully entering the socket; leading to loss of control and pressure on bony prominences. Too many plies of socks can also lead to hammocking, which is stress on the distal end soft tissues as they are pulled tight over the distal tibia during weight bearing. For the person who has recently started using a prosthesis, this sensation may feel very much like the bottoming out sensation they feel with too few sock plies. It is important to educate the wearer on differentiating between the two conditions. The second cue indicating the limb is not in the correct position within the socket is increased pistoning, anteroposterior, or mediolateral motion within the socket while walking. This can be caused by an insufficient number of socks. The final cue to incorrect position are signs of erythema found while doffing the prosthesis. Erythema on the distal

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aspect of the fibular head or patella indicates that the limb is too far in the socket and that more socks are needed. If too many socks are being used, the erythema will appear on the tibial tubercle or the proximal aspect of the fibular head because the limb is not far enough into the socket. In this case, there may also be signs of verrucous hyperplasia on the distal end of the limb due to the lack of distal contact. Another common problem that arises is caused by inappropriate shoe wear. Although some prosthetic feet accommodate for the heel height of the shoe, most do not. Wearing a heel that is too high positions the limb, such that there is a relative excessive flexion of the socket and actual excess flexion of the knee joint during stance. A heel that is too low or is used without a shoe tends to hyperextend the knee. Proper footwear is important for safe ambulation. The prosthesis can be checked by evaluating the top surface of the foot shell while the prosthesis is stands on a level surface. If the top of the foot shell tilts posteriorly, the heel is too low (Fig. 23.35). Similar sagittal-plane gait problems can occur by changing between footwear of similar heel height but differing stiffness on soling material. A stiff-soled (leather-soled) shoe will have similar effects to an increased heel height and a softer sole will be similar to bare foot. These changes will be most noticeable in the initial contact and loading response phases of gait. In a well-fitting socket, the skin should appear uniform in color after the prosthesis has been worn. Areas of erythema that fade after 20 minutes are not likely to be problematic. The skin should be soft and supple, especially on the distal end. Firm tissue associated with edema is a sign of poor contact, and an effort should be made to create some contact in the area of the firm tissue. The wearer may not tolerate much pressure, but only a small amount of pressure is needed to push the extra fluid back into circulation.

Heel too low

If erythema is observed over bony prominences and the person’s residual limb is properly seated in the socket, pressure in those areas must be relieved. Prosthetists can adjust the fit of thermoplastic sockets by heating and reshaping the areas needing adjustment. Thermoset sockets, like composites, can be adjusted only by cutting out fenestrations or adding padding to the area around the prominent bone to shift it away from the socket wall. It is important to note that the addition of padding requires the removal of some sock plies to maintain the same volume within the socket. If skin irritation is present, especially over a bony prominence, placing a small mark on the affected areas with lipstick before donning the prosthesis will allow the lipstick to transfer to the socket during ambulation. Once the wearer removes the prosthesis, the lipstick will mark the areas of excessive contact. Alternatively, a thin flexible steel probe (a corset stay works exceptionally well) can be inserted between the socket and the interface to act as a feeler gauge to find areas of high pressure. The wearer should be putting some weight through the socket during this evaluation. To assess distal contact in a finished socket, a ball of soft clay about the size of a pea can be placed into the bottom of the socket prior to donning. After the person dons the prosthesis and walks a few steps, the prosthesis should be removed and the clay examined. The clay should appear compressed. A postcompression clay thickness of 3 to 5 mm is considered ideal. Total contact in the socket can be assessed by lightly powdering the interior surface of the socket with a fine powder like cornstarch and having the individual carefully don the prosthesis and walk a few steps. Any powder that remains on the socket’s surface after walking indicates that those areas are not in contact with the residual limb. The amount of pistoning that is present in a socket depends on the socket design and the type of suspension

Correct heel height

Heel too high

Fig. 23.35 Heel height of the shoes affects the sagittal plane moments throughout stance. A heel that is too low for the prosthetic foot creates excessive extensor moment at the knee in midstance, hampering forward progression. A heel that is too high for the prosthetic foot creates a flexion moment at the knee at midstance, leading to early “drop off” and compromise of stance phase stability. (Diagram courtesy David A. Knapp, CPO, Hanger Prosthetics & Orthotics, North Haven, CT.)

23 • Transtibial Prosthetics

used. If the wearer complains of discomfort while ambulating but is comfortable while standing, pistoning is the likely cause of pain. Pistoning can be assessed by asking the wearer to bear full weight on the socket and then lift the prosthesis off the ground while the examiner palpates the patella. Motion of more than 1 cm should be considered excessive. Faulty suspension and/or loose socket fit are generally responsible for pistoning. Wearing the correct number of sock plies and ensuring that the suspension is functioning well should minimize motion within the socket to pain-free levels. There are several patterns of erythema that indicate poor alignment of the prosthesis. Excessive varus moment on the limb is suspected when signs of pressure are observed on both the distolateral and the proximomedial aspects of the limb. This pattern can be caused by excessive foot inset or too much socket adduction. When the erythema is observed on the distomedial and proximolateral aspects of the limb, an excessive valgus moment is likely. The foot may be too far outset or the socket may be excessively abducted. Anterior distal pressure accompanied by pressure in the posterior proximal aspect of the socket may be a result of an excessively long heel lever arm, excessive dorsiflexion, excessive socket flexion, or a heel that is too firm. This pattern can also be observed when an individual wears a shoe that has a higher heel than the prosthesis can accommodate. Conversely, if the person goes barefoot, the opposite pattern of pressure will be observed—erythema on the posterior distal end and the anteroproximal end. The same pattern can be caused by a toe lever arm that is too long, an overly plantarflexed foot, or an excessively extended socket.

Specialty Prostheses There are novel prosthetic designs that are intended for use in specialized activities such as water sports, running, and bicycling. The biomechanical goals of these prosthetic devices are different from those designed for everyday ambulation. The designs must take into account the unique loading and various environmental exposures. Running feet, for example, lack a heel spring because sprinting takes place on the toes only; a heel would interfere with limb motion and add unnecessary weight. As knee flexion during a sprint may reach beyond 110 degrees, the posterior proximal trim line must be lower. There is significantly more impact force at initial contact; therefore more care should be taken to make sure the person and prosthesis are capable of absorbing the impact slowly in a manner that will prevent damage to the skin and limb. Running also subjects the prosthesis to greater tension in swing phase, so the suspension system will be under increased strain. Runners often use an auxiliary suspension in case their primary suspension fails at high speed. A prosthesis designed for swimming includes more than just the ability to get wet. Attention must be given to the buoyancy of the device. Neutral buoyancy is preferred because a prosthesis that floats may inhibit the individual’s ability to keep his or her head above the water surface, and a prosthesis that sinks could drag the person down with it. Any water that gets inside the prosthesis should have a quick path to get back out once the person finishes swimming. A swimming prosthesis can also be fitted with an adjustable

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ankle that allows the swimmer to lock the ankle in approximately 70 degrees of plantarflexion, which accommodates the use of a swim fin. Waterproof components and materials that do not absorb water are the best choices when one is designing a swimming prosthesis so that the individual can also use the device on the way to and from the swimming area. Any time the prosthesis is used in salt water, it should be thoroughly rinsed with fresh water after swimming, even if it was designed for the marine environment. There are specialized feet for downhill skiing that clip directly into the ski binding, rock-climbing feet that require no shoes, cycling feet that clip directly into the pedals, and many other specialized feet for sports and recreational activities. To save money and time and to avoid having to carry several complete prostheses, active wearers can use a quick disconnect adapter to keep one socket and rapidly switch between different specialty feet. The adapter ensuring the alignment of the prosthesis is optimal for each activity for which the specific foot is intended. It also provides a secure and safe connection so that the individual can feel confident that the prosthesis will not fail. This component does add weight to the system and requires additional clearance under the socket. Most insurance companies will pay for these types of prostheses when the medical necessity is well documented.

Summary Individuals with transtibial amputations have the opportunity to participate in a rehabilitation process that seeks to maximize function and minimize impairments so that they can participate as fully as possible in activities of daily living and instrumental activities of daily living. An interdisciplinary team is available to support medical, nursing, social/ psychosocial, rehabilitation, and prosthetic needs of the individual. The team helps develop a plan of care that addresses the goals of the person, family, and caregivers. Current technology, along with advances in prosthetics for persons with transtibial amputations, offer a wide array of options to the user. These options range from prosthesis use for cosmetic purposes and for home-bound ambulation to community ambulation with variable cadence to intensive athletic involvement. The clinicians dedicated to enhancing the quality of life of persons with transtibial amputation must evaluate many variables when engaging in a postamputation rehabilitation program including the following: (a) the amputee’s overall health, functional status, and mobility skills; (b) the amputee’s motivational level; (c) the componentry and technology of the prosthesis to make sure that the most appropriate and best-fitting prosthesis is produced; and (d) materials and equipment tailored to the individual to optimize the outcome of the rehabilitation process. The Medicare K-level standards speak to the “potential” to achieve a level of ambulation and community engagement. Persons with transtibial amputation should be scheduled for follow-up care to ensure that the prosthetic prescription provided at one point in time meets the needs of the individual later on as changes associated with skill progression and advancement occur. Therapists, prosthetists, and other health care providers should advocate on behalf of persons with amputation for changes in prostheses as the need arises.

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References 1. Gailey R, Nash M, Atchley T, et al. The effects of prosthesis mass on metabolic cost of ambulation in non-vascular trans-tibial amputees. Prosthet Orthot Int. 1997;21(1):9–16. 2. Green VG. Transtibial amputation: Prosthetic use and functional outcome. Foot Ankle Clin. 2001;6(2):315–327. 3. Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services. HCFA Common Procedure Coding System (HCPCS). Springfield (VA): U.S. Department of Commerce. National Technical Information Service. 2001;2001 [Chapter 5.3]. 4. Gailey Robert S, et al. The amputee mobility predictor: an instrument to assess determinants of the lower-limb amputee’s ability to ambulate. Archives of physical medicine and rehabilitation. 2002;83(5):613–627. 5. Esquenazi A, DiGiacomo R. Rehabilitation after amputation. J Am Podiatr Med Assoc. 2001;91(1):13–22. 6. Mueller MJ. Comparison of removable rigid dressings and elastic bandages in preprosthetic management of patients with below-knee amputations. Phys Ther. 1982;62(10):1438–1441. 7. Churilov Irina, Churilov Leonid, Murphy David. Do rigid dressings reduce the time from amputation to prosthetic fitting? A systematic review and meta-analysis. Annals of vascular surgery. 2014;28 (7):1801–1808. 8. Wu Y, Keagy RD, Krick HJ, et al. An innovative removable rigid dressing technique for below-the-knee amputation. J Bone Joint Surg Am. 1979;61(5):724–729. 9. Ladenheim E, Oberti-Smith K, Tablada G. Results of managing transtibial amputations with a prefabricated polyethylene rigid removable dressing. J Prosthet Orthot. 2007;19(1):2–4. 10. Chang Ji Hea, et al. Intractable Verrucous Hyperplasia: A Surgically Corrected Case. PM&R. 2015;7(3):322–325. 11. Witteck F. Some experience with patellar-tendon bearing below-knee prostheses. Artif Limbs. 1962;6:74–85. 12. Radcliffe CA. The Patellar-Tendon-Bearing Below-Knee Prosthesis. Berkeley: University of California Biomechanics Laboratory; 1961. 13. Staats T, Lundt J. The UCLA total surface bearing suction below-knee prosthesis. Clin Prosthet Othot. 1987;118–130. 14. Perry J. Gait Analysis: Normal and Pathological Function. 2 Thorofare. SLACK: NJ; 2010. 15. Pinzur MS, Beck J, Himes R, et al. Distal tibiofibular bone-bridging in transtibial amputation. J Bone Joint Surg Am. 2008;90:2682–2687. 16. Granata JD, Philbin TM. Distal tibiofibular bone bridging in transtibial amputation. Curr Orthop Pract. 2010;21:264–267. 17. Sanders JE, Greve JM, Mitchell SB, et al. Material properties of commonly-used interface materials and their static coefficients of friction with skin and socks. J Rehabil Res Dev. 1998;35:161–176. 18. Sanders Joan E, et al. Amputee socks: how does sock ply relate to sock thickness? Prosthetics and orthotics international. 2012;36(1):77–86. 19. Sanders J, Nicholson B, Zachariah S, et al. Testing of elastomeric liners used in limb prosthetics: classification of 15 products by mechanical performance. J Rehabil Res Dev. 2004;41:175–186. 20. Hansen Colby, et al. Incidence, severity, and impact of hyperhidrosis in people with lowerlimb amputation. Journal of Rehabilitation Research & Development. 2015;52(1). 21. Fillauer C, Pritham C, Fillauer K. Evolution and development of the silicone suction socket (3S) for below-knee prostheses. J Prosthet Orthot. 1989;1:92–103. € The ICEROSS concept: a discussion of a philosophy. The 22. Kristinsson O. Journal of the International Society for Prosthetics and Orthoics J Prosthet Orthot. 1993;17(1):49–55. 23. Ferraro C. Outcomes study of transtibial amputees using elevated vacuum suspension in comparison with pin suspension. J Prosthet Orthot. 2011;23:78–81. 24. Beil T, Street G. Comparison of interface pressures with pin and suction suspension systems. J Rehabil Res Dev. 2004;41(6A):821–828.

25. Roberts RA. Suction socket suspension for below-knee amputees. Arch Phys Med Rehabil. 1986;67(3):196–199. 26. Grevsten S. Ideas on the suspension of the below-knee prosthesis. Prosthet Orthot Int. 1978;2(1):3–7. 27. Board W, Street G, Caspers C. A comparison of trans-tibial amputee suction and vacuum socket conditions. Prosthet Orthot Int. 2001;25:202–209. 28. Rink Cameron, et al. Elevated vacuum suspension preserves residuallimb skin health in people with lower-limb amputation: Randomized clinical trial. Journal of Rehabilitation Research & Development. 2016;53(6). 29. Biel TL, Street G, Covey S. Interface pressures during ambulation using suction and vacuum-assisted prosthetic sockets. J Rehabil Res Dev. 2002;39(6):693–700. 30. Darter Benjamin J, Sinitski Kirill, Wilken Jason M. Axial bone–socket displacement for persons with a traumatic transtibial amputation: The effect of elevated vacuum suspension at progressive bodyweight loads. Prosthetics and orthotics international. 2016;40(5): 552–557. 31. Goh J, Lee P, Chong S. Comparative study between patellartendon-bearing and pressure cast. J Rehabil Res Dev. 2004;41(3B): 491–502. 32. Vee Sin Lee Peter, et al. 10Pressure casting technique for transtibial prosthetic socket fit in developing countries. Journal of Rehabilitation Research & Development. 2014;51(1). 33. Polhemus. Cobra_Scorpion_brochure.pdf. Available at: http://www. polhemus.com/polhemus_editor/assets/New%20FastSCAN% 20Cobra& Scorpion%20brochure.pdf; 2008. Accessed 12.03.11. 34. Karakoc¸ Mehmet, et al. Sockets Manufactured by CAD/CAM Method Have Positive Effects on the Quality of Life of Patients With Transtibial Amputation. American journal of physical medicine & rehabilitation. 2017;96(8):578–581. 35. Smith DG, Fergason JR. Transtibial amputations. Clin Orthop Relat Res. 1999;361:108–115. 36. Lin C, Wu YC, Edwards M. Vertical alignment axis for transtibial prostheses: a simplified alignment method. J Formos Med Assoc. 2000;99 (1):39–44. 37. Jonkergouw Niels, et al. The effect of alignment changes on unilateral transtibial amputee’s gait: a systematic review. PloS One. 2016;11(12). e0167466. 38. Europa+ Pamphlet. 2015. Available at: http://ecbiz182. inmotionhosting.com/~orthoc6/wp-content/uploads/2016/01/ Europa-IFU.pdf. 39. Segal Ava D, Kracht Rose, Klute Glenn K. Does a torsion adapter improve functional mobility, pain, and fatigue in patients with transtibial amputation? Clinical Orthopaedics and Related Research®. 2014;472(10):3085–3092. 40. Gard S, Konz R. The effect of a shock-absorbing pylon on the gait of persons with unilateral transtibial amputation. J Rehabil Res Dev. 2003;40(2):109–124. 41. Lass R, et al. The effect of a flexible pylon system on functional mobility of transtibial amputees. A prospective randomized study. European journal of physical and rehabilitation medicine. 2013;49(6):837–847. 42. Kaluf B, Smith C. “Advantages and Disadvantages of MicroprocessorControlled Prosthetic Ankles” O&P News Aug. 18–20. 43. McDonald Cody L, et al. Energy expenditure in people with transtibial amputation walking with crossover and energy storing prosthetic feet: A randomized within-subject study. Gait & posture. 2018;62: 349–354. 44. Rábago Christopher A, Wilken Jason M. The prevalence of gait deviations in individuals with transtibial amputation. Military medicine. 2016;181(suppl_4):30–37. 45. Weinert-Aplin RA, et al. Medial-lateral centre of mass displacement and base of support are equally good predictors of metabolic cost in amputee walking. Gait & posture. 2017;51:41–46.

24

Transfemoral Prostheses☆ JOAN E. EDELSTEIN and KEVIN K. CHUI

LEARNING OBJECTIVES

On completion of this chapter, the reader will be able to do the following: 1. Describe the functional characteristics, advantages, and limitations of the components of transfemoral prostheses. 2. Compare the design, fit, and function of transfemoral socket designs. 3. Indicate how the alignment of the transfemoral prosthesis influences comfort, stability, and ease of walking with transfemoral prostheses. 4. Relate gait characteristics to prosthetic and anatomic factors.

Components of the Transfemoral Prosthesis The transfemoral prosthesis consists of a foot-ankle assembly, shank, knee unit, socket, and means of suspension.1-3

FOOT-ANKLE ASSEMBLY Most prosthetic feet-ankle assemblies (see Chapter 21) are suitable for a transfemoral prosthesis. The basic solid-ankle, cushion-heel (SACH) foot is adequate for the wearer who will walk at home, but rarely in the community. For the person who is expected to be somewhat more active, the singleaxis or multiple-axis foot is a good alternative because the ankle joint can move from heel contact to foot flat position quickly to maintain prosthetic knee stability during stance phase, especially if the individual has a short amputation limb or weak hip extensors. Active individuals benefit from dynamic response feet, which provide energy storing and release capability to promote rapid advancement of the shank in late stance. Most dynamic response feet are lighter than articulating feet.

Shank The portion of the prosthesis between the foot and the knee unit is the shank. Most transfemoral prostheses have an endoskeletal shank (Fig. 24.1A). It consists of a metal tube that usually has proximal screws for slight adjustments in alignment of the prosthesis. The endoskeletal system enables the prosthetist to interchange or replace modular components rapidly. These considerations are particularly relevant as new wearers become more competent in controlling the knee unit or when the individual has greater functional needs (e.g., involvement in athletic activities). The pylon is ☆

The authors thank Mr. Kei Takamura, MSOP, Resident for his assistance with the pictures. The authors also extend appreciation to Richard Psonak, whose work in prior editions provided the foundation for this chapter.

ordinarily covered with a foam encasement and a smooth cover colored to match the wearer’s skin tone.4,5 The foam cover is carved to mirror the shape of the remaining limb. The foam shell is, in turn, covered by cosmetic stockings or a silicone “skin” tinted to match the wearer’s skin color. Usually, the cover is fitted over the socket, knee unit, and pylon. Some transfemoral covers are split at the knee to minimize wear that would be caused by frequent knee flexion. A few individuals choose ornamental covers made of plastic or other materials; the covers feature fanciful designs and are placed over the shank portion of the prosthesis. Some people, particularly women, like ornamental covers, often made of plastic that has been printed by the three-dimensional process. An endoskeletal shank weighs less than the exoskeletal one. Some people, particularly athletes and those whose occupations involve materials that may stain a cover, prefer to keep the endoskeletal shank bare. A few wearers prefer an exoskeletal (crustacean) shank, especially if their work requires lifting or moving heavy objects, such as furniture. The weight-bearing strength and cosmetic shape of an exoskeletal prosthesis are provided by a laminated shell that incorporates the socket, knee-shin component, and ankle block (see Fig. 24.1B). This system is more durable than the foam-covered endoskeletal shank and requires little maintenance but cannot be easily adjusted. Both exoskeletal and endoskeletal shanks may have a transverse rotation unit installed to allow passive rotation of the shank (Fig. 24.2). The unit has an external button which, when pushed, unlocks the unit, allowing 360 degrees of rotation. The unit automatically locks when the shank is moved back to its normal position. The unit allows the wearer to sit in a crossed-legged position, change shoes without having to remove the prosthesis, and enter and exit automobiles with greater ease. Torque absorbers installed in an endoskeletal or exoskeletal shank respond to the axial rotation that occurs during stance phase, thereby protecting the skin within the socket from excessive shear stress. Torque absorbers are indicated for individuals with fragile, sensitive skin or adherent scars and those involved with sports, such as golfing, or with work 635

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Fig. 24.1 (A) Endoskeletal shank; (B) exoskeletal shank. (A, Shriners Hospital Portland Oregon. B, Pacific University—Physical Therapy Program.)

that requires negotiating uneven ground and forceful rotation. These units add weight to the prosthesis and are susceptible to mechanical failure. A compression spring may also be added to an endoskeletal shank to absorb vertical force, thus facilitating more comfortable walking on rigid surfaces. Often, the

endoskeletal shank has a unit that combines vertical and transverse shock-absorbing mechanisms.

Knee Unit Prosthetic knee units may be classified by axis, stance phase control, and swing phase control mechanisms.

AXIS Knee units permit knee flexion when the wearer sits and, in most instances, when the person walks. The upper part of the unit is connected to the lower part by an axis, either single or polycentric.

Single-Axis Knee Units The single-axis knee has a transverse hinge that allows the shank to swing in flexion and extension. This knee is lightweight and durable. Stability of the knee is achieved by alignment of the parts of the prosthesis with or without additional mechanism.

Fig. 24.2 Transverse rotation unit installed between the socket and the knee unit. (# Ottobock.)

Polycentric Knee Units The polycentric knee has two or more pairs of bars connecting the upper and lower portions of the unit. The bars pivot at both ends thus creating a moving center of rotation (Fig. 24.3). As the wearer bends the knee, the bars cross proximally and posteriorly, thereby changing the center or rotation and thus promoting knee stability during stance phase. The polycentric knee unit’s inherent stance phase stability makes it especially appropriate for individuals

24 • Transfemoral Prostheses

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Fig. 24.3 Polycentric knee unit. (A) Flexed. (B) Extended. (A and B, Shriners Hospital Portland Oregon.)

who have short amputation limbs or weak hip extensors. However, polycentric knees are less durable than single axis units.

STANCE CONTROL Manual Locking Knee Units A single-axis knee may have a distal pin lock (Fig. 24.4). The pin automatically locks with an audible click when the knee is fully extended. The wearer stands without worrying about inadvertent knee flexion, but walks with a stiff knee. The prosthesis is often slightly shorter than the sound side limb to facilitate foot clearance during swing of the prosthesis. The person unlocks the knee by pulling a cord on the outside of the socket; the cord is attached to the lock mechanism. A manual lock is indicated for those with weak hip extensors or whose balance, endurance, or cooperation are problematic. It is also useful for people whose occupations require prolonged standing.

Fig. 24.4 Manual locking knee. (# Ottobock.)

Braking Mechanisms A knee unit with a braking mechanism is stabilized during early stance phase (Fig. 24.5) but permits knee flexion in late stance and swing phase. In one version a wedge is forced into a curved groove, thereby preventing unwanted knee flexion, particularly if initial contact is made when the knee is not completely extended, as when walking on uneven ground. During late stance and swing phase, the weight-activated brake is disengaged. This unit is indicated for individuals who have recently undergone amputation or who have poor balance. Braking units add weight, mechanical complexity, and cost to the prosthesis. Some knee units incorporate both a lock and a brake.

SWING PHASE CONTROL Extension Aid An extension aid can be a strip of elastic webbing attached to the front of the socket and proximal shank. Flexing the

Fig. 24.5 Stance control knee. (# Ottobock.)

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knee in late stance stretches the webbing; during swing phase the webbing recoils, exerting an extension force on the shank, kicking it forward so the wearer can strike the floor with an extended knee. Webbing located inside the knee unit has a similar effect in late swing; in addition, an internal extension aid maintains the knee flexed when the person sits.

HYDRAULIC KNEE UNITS Hydraulic knee units regulate the swing of the shank according to the walker’s speed. The unit has an oil-filled cylinder attached to the knee axis, whether single-axis or polycentric. A piston from the axis to the cylinder interior descends during early swing; this action forces oil to flow through narrow channels to provide frictional resistance. The faster the knee swings, the greater the resistance. Variable resistance permits a swing phase that simulates normal gait. The amount of resistance can be adjusted by the prosthetist who widens or narrows the channels through which the oil flows. The more narrow a channel, the greater the resistance. Variable resistance is useful for active individuals and those with mobility impairment. However, hydraulic units are heavier and more expensive than other units. Some hydraulic knee units also have stance control provided by a braking mechanism that markedly increases resistance to knee motion at early stance when the knee unit is subjected to a flexion moment of force (Fig. 24.6). This feature allows the individual to walk with greater confidence over uneven surfaces and use a step-over-step pattern when negotiating hills and descending stairs. Some units have a mechanism that enables the wearer to lock the knee against flexion. This feature is useful when the person sits and prepares to stand on an unsteady surface. While sitting, the individual lifts a lever at the rear of the knee. During the standing maneuver, the knee extends but cannot flex. The person walks away on a knee locked in extension until the individual voluntarily moves the rear lever.

PNEUMATIC KNEE UNITS Pneumatic knee units have an air-filled cylinder into which a piston descends during early swing and ascends during late swing. Because air is also a fluid, the amount of resistance is directly proportional to the speed of motion; the faster the person walks, the greater the resistance thereby reducing the asymmetry between anatomic and prosthetic leg motion. Pneumatic knees usually weigh less and are less expensive than hydraulic ones; however, they provide less precise cadence control because air is less dense and less viscous than oil.

MICROPROCESSOR KNEE UNITS Microprocessor knee units have electronic sensors that monitor the action of hydraulic knee units during swing and ground force during stance. Sensors measure angles, moments of force, and pressures at 50 or more times per second. Adjustments can be made with a laptop or handheld computer. Software algorithms determine the phase of gait, automatically adjusting knee functions to approximate normal function. Most outcome measures taken with adults using microprocessor units were favorable, enabling people to move more naturally.6-16 Most of these mechanisms provide a stumble recovery feature that limits unintentional bending of the knee that could occur on uneven terrain. With electronic units, wearers experienced fewer falls.17,18 Units have been successfully fitted to adults wearing bilateral transfemoral prostheses.19 Microprocessor knee units are powered by rechargeable lithium-ion batteries, which usually can be fully charged in 2 hours and last for approximately 24 hours. Microprocessor knee units are more expensive than other knee units and may not be robust enough for obese patients or those whose activities involve imposing heavy loads on the prosthesis or those who wear the prosthesis in hazardous environments, such as water, coal mines, or commercial bakeries.

SOCKET As with all prostheses, the socket is the most important component because the wearer inserts the amputation limb into the socket. Sockets must be comfortable and permit the wearer to move the hip during walking and sitting.

MATERIALS

Fig. 24.6 Hydraulic knee unit. (Endolite a Blatchford Company.)

Most transfemoral sockets are made from plastic. Thermosetting resin creates a rigid socket that is durable, easy to clean, and usually less expensive to produce. However, it is more difficult to adjust the contours to achieve a comfortable fit for individuals with minimal soft tissue or sensitive amputation limbs. Flexible sockets are vacuum formed from flexible thermoplastics. The socket is encased in a rigid frame, which provides support during weight bearing. The socket accommodates to changes in muscle contour as the wearer moves and can be easily modified by heat. They are more comfortable, especially in sitting, because the wearer contacts the chair with a pliable interface. Flexible sockets are somewhat less durable and more expensive to fabricate than rigid ones.

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SHAPE

ISCHIAL CONTAINMENT

Quadrilateral This shape has four walls fashioned to contain the thigh (Fig. 24.7A). A flat posterior shelf is the primary weightbearing surface for the ischial tuberosity and adjacent gluteal muscles. The anterior wall creates a posteriorly directed force to stabilize the ischial tuberosity on its seat; the wall is approximately 2 inches higher than the posterior wall to minimize unit pressure. The anterior wall has a convexity (buildup), the Scarpa bulge, which increases the area contacting the tender femoral triangle. The medial wall has a concavity (relief) for the adductor longus tendon and is approximately level with the posterior brim. The lateral wall is approximately as high as the anterior wall; it has a relief for the greater trochanter. The anterior-posterior dimension is more narrow than the medial-lateral dimension.

The ischial containment socket (see Fig. 24.7B) covers the ischial tuberosity. The socket is thus wider anteroposteriorly than mediolaterally to resist lateral shifting of the socket during weight bearing and to maintain the femur in as much adduction as possible. The relatively wide anteroposterior dimension is intended to provide more room to accommodate muscle contraction. The ischial containment socket has relatively high medial and posterior walls and a lower anterior wall than the quadrilateral socket. The lateral wall is approximately the same height on both the ischial containment and quadrilateral designs. A variation of the ischial containment socket is the Marlo Anatomical Socket (see Fig. 24.7C). Its lower posterior trim lines allow the user to sit directly on the buttock instead of on the posterior socket.20

Fig. 24.7 Posterior views of quadrilateral socket (A) with the ischial tuberosity on the posterior brim; ischial containment socket (B) with ischial tuberosity inside the socket; Marlo Anatomical Socket (C) with the ischial tuberosity within the socket; and subischial socket (D) with the socket trim line considerably below the ischium.

A

B

C

D

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Unlike the quadrilateral and ischial containment designs, the subischial socket terminates several inches below the pelvis (see Fig. 24.7D). Preliminary evidence suggests that wearers are more comfortable and have greater hip mobility and stability while wearing this socket.21-24 The transverse contours of the sockets also differ (Fig. 24.8).

Suspension Systems Some provision for suspending the transfemoral prosthesis is necessary during the swing phase of walking and when the wearer is climbing ladders, stairs, and ramps. As compared with a transtibial prosthesis, the heavier transfemoral prosthesis creates a greater challenge for suspension.25

SUCTION Suction suspension requires snug proximal socket fit and an air-expulsion valve that allows air to exit but prevents air from entering the socket. Donning may be accomplished by drawing tubular cotton stockinet (or an elastic bandage) over the thigh to the inguinal ligament, then passing the distal end of the stockinet through the valve hole. Usually, the patient stands and pulls down on the stockinet while flexing and extending the opposite hip and knee until the entire stockinet is withdrawn. This process requires considerable agility and balance. The valve is then installed in the socket. A second option is to apply a lubricant to the thigh to enable sliding the limb into the socket that already has the valve installed. After the thigh is inside the socket, the valve is pressed to release any trapped air. Intimate fit required for suction suspension enhances prosthetic control and proprioception.26,27 Suction suspension is inappropriate for patients with a recent amputation whose limb volume will continue to reduce or for those with fluctuating edema or unstable weight. High shear force associated with donning may preclude its use for patients with fragile or sensitive skin, painful trigger points, significant scarring, adhesions, or upper limb weakness.

A

C

Elevated Vacuum (Subatmospheric) Suspension A variation of suction suspension is elevated vacuum (subatmospheric) suspension, which also uses a difference in air pressure to suspend the socket on the amputation limb.26-29 Suction suspension allows air to exit through the valve when the amputation limb moves in swing phase, whereas elevated vacuum suspension uses a pump to create a constant pressure differentiation. Consequently, suspension is more secure and the socket can have a lower trim line. A person with a long transfemoral amputation limb may be fitted with a socket that exerts greater suction distally as compared with other socket designs. The proximal border is 2 to 4 inches lower with other designs, thus increasing comfort and range of hip motion. Elevated negative pressure around the distal two-thirds of the amputation limb eliminates compressing the proximal limb. A roll-on liner contains soft tissues and a vacuum pump creates negative pressure to remove air from the sealed environment between socket and liner. Vacuum holds the liner firmly to the walls of the socket and controls volume fluctuations. Pistoning between the limb, liner, and socket is virtually eliminated, affording wearers greater proprioception and a sense that the prosthesis feels lighter. Elevated vacuum improves blood circulation and may help to heal wounds.

LINERS Suspension with liners significantly reduces friction on the amputation limb. Donning is simple and can be accomplished while seated. However, liners become worn or torn and must be replaced several times a year depending on the wearer’s activity level. Liners may increase skin temperature and perspiration. A few people develop dermatitis. Liners must be cleaned daily to prevent accumulation of perspiration and bacteria.

B

D

Fig. 24.8 Cross-section views of transfemoral sockets. The quadrilateral socket has a narrow anteroposterior dimension (A); ischial containment socket (B) and Marlo Anatomical Socket (C) have narrow mediolateral dimensions. The subischial socket (D) has a more oval shape.

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ROLL-ON LINERS Roll-on liners are made from urethane and other elastomers. Worn against the skin, roll-on liners are donned by being turned inside-out, then rolled over the amputation limb. The roll-on liner creates negative pressure and is somewhat adhesive. The liner can be used for suspension with a shuttle lock, lanyard, or air expulsion valve or as part of an elevated vacuum socket. Although liner use facilitates donning, sitting, walking, and comfort, problems with durability remain.

Cushion Liner With Air Expulsion Valve A resilient liner is put on the amputation limb, which is then pushed into the socket, creating negative pressure environment by expelling air through an expulsion valve (Fig. 24.9A). A vacuum pump may be installed in the socket to create negative pressure to enhance suspension. Shuttle Locking Liner The liner has an external cap. In the center of the cap a serrated pin protrudes approximately 1½ inches (Fig. 24.9B). The pin engages a shuttle lock inside the bottom of the socket, when the wearer stands and pushes the amputation limb down into the socket. To remove the prosthesis, one disengages the serrated pin by depressing a release button on the medial aspect of the socket exterior.

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Lanyard The wearer dons a liner on the bottom of which is a lanyard (strap or cord). The lanyard is routed through a hole in the distal socket. The person then guides the lanyard (see Fig. 24.9C) up the lateral exterior of the socket to secure it with hook and loop tape or a ratcheted strap (see Fig. 24.9D).

TOTAL ELASTIC SUSPENSION BELT The total elastic suspension (TES) belt is made of an elastic neoprene. The distal sleeve of the TES belt fits snugly around the proximal half of the socket. TES encircles the waist and attaches in front with hook and loop tape (Fig. 24.10). The TES belt is easy to don, comfortable to wear, and an excellent auxiliary suspension system. It is often chosen for the person who has had recent surgery whose amputation limb has not yet matured to stable size, for older patients unable to use suction or liners, and for those with tender skin or adhesions. It is also secondary suspension for athletes. The TES system has limited durability, especially for active people, and tends to retain heat.

SILESIAN BELT A Silesian belt is usually made from Dacron webbing or leather (Fig. 24.11). One end is attached to the lateral aspect of the socket. The belt encircles the lower trunk and passes

Fig. 24.9 (A) Air expulsion valve system. After the liner is donned, the amputation limb is pushed into the socket, expelling air through the valve, creating negative pressure. A vacuum pump attached to socket creates negative pressure between the socket and roll-on liner. (B) The shuttle lock system uses a pin that engages into a receptacle in the bottom of the socket (C). The lanyard system incorporates a strap or cord in the liner that is routed through a slot or hole in the distal socket and used to pull the amputation limb into the socket. (D) Lanyard suspension with lateral rotational control. (A–C, Shriners Hospital Portland Oregon. D, Image courtesy of KISS Technologies LLC.)

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Fig. 24.10 Total elastic suspension belt. (Image by Amputee Supplies Inc via https://amputeestore.com.)

Fig. 24.12 Pelvic belt with hip joint.

maximum hip motion. This system suspends the prosthesis and helps to control rotation and medial-lateral stability of the amputation limb. The pelvic belt is bulky and heavy and may be uncomfortable when the wearer sits.

Fig. 24.11 Silesian belt suspension.

through a loop or buckle on the anterior socket where it is secured. The Silesian belt augments other modes of suspension. It resists the tendency of the prosthesis to rotate internally during the donning process.

PELVIC BELT The pelvic belt (Fig. 24.12) is made of leather and attached to the prosthesis by means of a metal or solid nylon singleaxis hip joint. The joint center should be positioned just superior and anterior to the greater trochanter to permit

Osseous Integration Osseous integration involves attaching a metal pin surgically implanted in the femur to a metal fixture surmounting the knee unit, thereby eliminating the need for a socket. Implantation is performed after the amputation limb has healed from the initial amputation surgery. Prosthetic duration of use, mobility, and gait efficiency improve with this procedure.27,30-32 Mild infection at the skin penetration site can be readily managed,33 with implant-associated osteomyelitis necessitating removal of the femoral pin being relatively uncommon.34 Patients with shorter amputation limbs experience more force on the thigh duration a fall.35 Those with osseous integration required fewer visits for prosthetic service than adults with socket-suspended prostheses.36

TRANSFEMORAL ALIGNMENT Prosthetic alignment refers to the spatial relationship of each part of the device to the others. The purpose of alignment is to increase the wearer’s comfort and ability to control the prosthesis.37-39

SAGITTAL ALIGNMENT The most important goal in transfemoral prosthetics is to obtain knee stability during stance phase. A prosthetic knee

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Case Example 24.1 Grandmother Who Wants to Dance at Her Granddaughter’s Wedding T. F. is a 68-year-old grandmother who wants to attend her granddaughter’s wedding. She visits her prosthetist, asking for assistance with her 6-year-old transfemoral prosthesis. T. F. underwent elective amputation 6 years ago after she developed osteomyelitis and nonunion of a comminuted fracture of her left femur after being hit by a car. Although she was initially deconditioned, her rehabilitation was successful, and she returned home to live independently after a 2-month stay in a subacute rehabilitation setting. T. F.’s amputation limb is relatively short: 4½ inches from the perineum to the distal end. Her prosthesis has a pelvic belt, rigid quadrilateral socket, polycentric knee, endoskeletal shank, and single-axis foot. She walks in the community with a straight cane. She complains that her prosthesis rubs her thigh, is heavy and noisy, and pinches when she sits. Her immediate goal is that she be able to “blend into the wedding ceremony” with her prosthesis not a distraction. She hopes to dance with her son and her new grandson-in-law at the wedding reception.

Her prosthetist consults with her physician and suggests a new flexible ischial containment socket in a rigid frame, retaining the original foot and knee unit. The prosthetist recommends a roll-on liner with a shuttle locking device to replace the pelvic belt to improve suspension and decrease pistoning. The new socket and suspension system will give T. F. better control of her prosthesis, allowing her to participate in all wedding activities more easily. QUESTIONS TO CONSIDER

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Why was a pelvic belt used in T. F.’s initial prosthesis? Why did the team not recommend a TES belt, Silesian belt, or suction suspension? Why did the team decide to replace T. F.’s rigid socket with a flexible one? Why did the team retain the polycentric knee unit? What other knee units would be appropriate for her? Why did the team retain the single axis foot? What other feet would be appropriate?

Case Example 24.2 Young Man Injured in a Motorcycle Accident C. J. is a 23-year-old electrician who lost control of his motorcycle on an icy roadway 10 days ago, sustaining moderate head injury, traumatic amputation of the left lower limb, and comminuted fracture of the right femur. On admission, he was taken to the operating room for debridement and closure of his amputated limb and open reduction/internal fixation of the fractured femur. Initially responsive to pain and voice, C. J. now fluctuates between level 4 (confused and agitated) and 6 (confused and appropriate) on the Rancho Los Amigos Cognitive Scale. C. J. is extremely agitated and combative while in bed but calms somewhat when seated in a bedside chair. He demands to be allowed to get up to walk but cannot comprehend the need to limit weight bearing on the fractured side and does not seem to understand that he has an amputation. The rehabilitation team wonders if his cognitive function will improve if he can be upright. After much consideration, the team decides that C. J.’s amputation limb is healed sufficiently for early fitting with an ischial containment socket suspended by suction and a TES belt, with a locking knee and solid-ankle, cushion-heel (SACH) foot. The team hopes that careful early mobilization into upright posture will reduce his combativeness without compromising healing. When on a tilt table (with a 3-inch lift under the left foot to maintain the non–weight-bearing status of the fractured right femur), C. J.’s cognition and behavior improved rapidly. Within several days, he could begin to ambulate in the three-point

that is unstable could lead to a fall. Alternately, a knee that is difficult to flex interferes with swing phase clearance and increases the likelihood of tripping. Variables influencing knee stability are: 1. Alignment of the socket, knee, and ankle 2. Mechanical stability of the knee unit 3. Muscular control of knee action Optimum alignment allows the wearer to control prosthetic movement. If the knee axis is positioned slightly

pattern, non–weight bearing on the right side, using a walker for short distances with moderate assistance. Over the next 3 weeks, he became independent with crutches and continued to use the locking knee while his fracture heals enough to safely tolerate full weight bearing safely. The team anticipates that his prosthetic prescription will be significantly modified as he recovers from his head injury and can learn to use a more advanced prosthesis. QUESTIONS TO CONSIDER

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Why was an ischial containment socket selected for C. J.’s initial prosthesis? Considering his current cognition and non–weight-bearing status, why did the team select a locking knee unit? Why did the team recommend a SACH foot for the initial prosthesis? (See Chapter 21 for detailed information about prosthetic feet.) Would an extension aid, torque absorber, and/or transverse rotational unit be appropriate at this point for C. J.? What are the implications for safety, energy cost, and appearance of gait when using a locked knee and a SACH foot? As C. J. regains cognitive function and the fracture heals, what options should the rehabilitation team consider for his next prosthesis?

posterior to a vertical line from the greater trochanter to the ankle, the weight line passes anteriorly, the resulting extensor moment provides alignment stability; thus minimal hip extensor power is required. However, stable alignment increases the hip flexor effort required to initiate knee flexion in late stance phase. If the knee is positioned at or slightly in front of the vertical line, the weight line passes behind the knee, and stance phase is less stable and greater muscular contraction is needed; however, this alignment enhances the ability to flex the knee to initiate swing phase (Fig. 24.13).

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Fig. 24.13 (A) Maximum alignment stability when the weight line (W) passes anteriorly to the knee axis. (B) Minimum alignment stability when the weight line passes through the center of the knee axis. (C) No alignment stability when the weight line passes behind the knee axis. Stability must be achieved by mechanism within the knee unit.

An individual’s ability to control the prosthetic knee is determined by the strength of hip extensors and by the length of the amputation limb. An inverse relationship exists between length of amputation limb and amount of muscular force necessary to control the prosthetic knee. Voluntary control is compromised by a hip flexion contracture and weakness of hip extensors. Aligning the socket in slight flexion elongates hip extensors, thereby enhancing their contractile ability. Socket flexion also reduces the wearer’s tendency to substitute for hip extensor weakness with excessive pelvic lordosis. Knee control is also influenced by the mechanical properties of the prosthetic knee. A manually locking knee offers complete stability. Mechanical stability can be provided by (1) hydraulic swing and stance units and (2) weight-activated stance control knee units. Stability is compromised when the wearer descends ramps. Stability increases when the prosthetic foot is placed relatively anteriorly and by a low shoe heel.

FRONTAL ALIGNMENT The socket is adducted to maximize the effect of the adductors, thereby reducing lateral trunk bending. The femur, without its distal attachment at the knee, is susceptible to marked lateral displacement within the socket during stance phase. Lateral shift results in lateral bending of the trunk to maintain balance (Fig. 24.14). Pelvic stability is compromised by shortness of the amputation limb and abduction contracture. The prosthetic foot is placed as

Fig. 24.14 (A) In the intact leg, when weight is borne on the stance limb, gravity causes the pelvis to dip to the swing side. Contraction of the gluteus medius on the stance side prevents excessive dip. (B) Amputation removes the distal attachment of the femur to the knee; consequently, the femur tends to move laterally within the socket during weight bearing. Adduction of the lateral socket wall helps to counteract lateral femoral displacement.

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Fig. 24.15 Height of the prosthesis should approximate that of the sound limb. (A) Compare the heights of the iliac crests. (B) Checking the pelvis using a leveling device. (A and B, Shriners Hospital Portland Oregon.)

medial as possible to permit a relatively narrow walking base that also reduces fatiguing trunk sideward motion.40

EVALUATION OF THE PROSTHESIS Whatever its design, the socket must fit comfortably when the patient stands, walks, and sits, without undue pressure from its margins. The patient dons the prosthesis, stands, then walks for several minutes. When the prosthesis is

removed, the clinician examines the skin of the trunk and amputation limb, noting any evidence of excessive pressure that would indicate the need to modify the contours of the socket. The height of the prosthesis is evaluated when the wearer stands with weight equally distributed on both feet. The pelvis should be level (Fig. 24.15). The initial prosthesis may be ¼ inch shorter than the intact side to enhance toe clearance in swing phase.

Case Example 24.3 Why Should Changing Shoes Be an Issue? P. O. is 21-year-old accountant and former marathon runner who sustained amputation just above the knee as the result of a motor vehicle accident. He was fitted with a transfemoral prosthesis. After a few days of inpatient rehabilitation, P. O. could ambulate with a straight cane in a fairly symmetric step-through pattern. He often attempts to ambulate without the cane. Whenever he does, his physical therapist cautions him against varying from the therapy program until his amputation limb is completely healed and tolerates full weight bearing on the prosthesis. P.O. can tolerate 3 h in his prosthesis and is anxious to begin full-time wear. P. O. discharged himself from the hospital against physician’s orders. Two days after leaving the hospital, he wore his favorite pair of cowboy boots with 2-inch heels to party with friends. While negotiating the first step out of his house, his prosthetic knee buckled and he fell down the rest of the steps, fracturing the femur of his residual limb and cracking the frame of his socket. He is readmitted to the hospital for open reduction internal fixation and eventually learns to ambulate with a swing-through pattern using bilateral axillary crutches. He is discharged from the hospital after 1 week but is not able to return to prosthetic use for the next 3 months. He returns to physical therapy on an outpatient basis for prosthetic training once again. This time, he is more cautious and attentive to the instruction and advice of his rehabilitation team. His story now serves as a warning about “what not to do when you go home” to everyone who attends the prosthetic clinic that assisted him. QUESTIONS TO CONSIDER

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Describe the functional relationships among (a) mechanical stability of P.O.’s weight-activated stance control knee, (b)

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its alignment and position with respect to the trochanterknee-ankle line, and (c) the length of his residual limb. How might the alignment of his knee unit be adjusted as his limb heals and is better able to tolerate forces generated during normal walking? What are the advantages of moving the axis of rotation of the knee unit forward? Under what conditions would the prosthetist move the axis of rotation of the knee until it is posterior? What would you recommend for P. O. as he begins his outpatient rehabilitation after his fractured femur heals? Why would the rehabilitation team be concerned about the time P. O. spends in his prosthesis only 2 weeks after the amputation? What would be an appropriate wearing schedule for someone like P. O. who has been had an early prosthetic fitting? In what ways might the team’s recommendation about in-prosthesis time be different as P. O. begins his second period of rehabilitation? Why did P. O.’s weight-activated stance control knee become unstable when he changed into his cowboy boots? What forces were acting at the knee at the time that it buckled? Is there anything he could have done to counteract the instability associated with higher heels? What would have happened if he had instead put on a pair of sandals with no heels at all? What types of functional problems might he have encountered during gait? How might he minimize the effect of changing to shoes with lower heels and preserve his functional abilities? What is the lesson from P. O.’s situation that should be conveyed to individuals new to prosthetic use?

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BASE OF SUPPORT The distance between heel centers during comfortable walking is 2 to 4 inches. The prosthetic foot and shoe should be flat on the ground with relatively equal weight bearing on medial and lateral borders. This can be assessed by slipping a piece of paper under both sides of the forefoot and rearfoot—the distances should be fairly equal. The individual must also be able to shift weight comfortably between the intact and prosthetic limbs. Adequacy of the suspension system is evaluated by asking the patient to elevate the pelvis on the amputated side to lift the prosthetic foot off the ground. The amputation limb should remain securely within the socket.

TRANSFEMORAL GAIT Normal gait results from symmetric relationships of the head, trunk, and upper and lower limbs. A transfemoral prosthesis markedly alters these relationships. Asymmetry imposed by amputation increases the demand for postural and balance adaptations. The more asymmetric the pattern, the greater the energy cost of walking. Individuals with musculoskeletal and neuromuscular impairment, common among those with diabetes or advanced age, experience altered gait with significant increase in falls.41-44

SIDE VIEW Viewing the patient from the side of the prosthesis enables determining the adequacy of hip, knee, and ankle motion. The wearer should extend the hip at heel contact to stabilize the prosthetic knee. The knee should extend smoothly, with little hesitation. Heel contact is the most unstable point in prosthetic gait. Stability increases when the foot-flat position is reached. Prosthetic and intact limb step lengths should be equal in distance and cadence. The individual should initiate swing phase smoothly. Step length and swing arc are influenced by knee flexion during late stance phase.

As the patient moves from midstance into early swing, controlled, gradual knee flexion should occur for toe clearance during swing phase. Adults wearing the C-Leg knee unit that has electronic control walked with increased step length and velocity.45

REAR VIEW Viewing the patient from behind enables judging the adequacy of suspension, width of the walking base, and trunk movement during prosthetic stance. The prosthesis should remain securely on the body throughout the gait cycle. Slipping or rotation of the prosthesis should be minimal. The walking base and path of the swinging legs should be approximately 2 to 4 inches between the heel centers. A wide base increases energy expenditure and is less attractive. The pelvis should remain relatively horizontal during the prosthetic stance phase, with a maximum drop of 5 degrees on the intact swing side. Patients with a short amputation limb or weak hip abductors will probably exhibit a pelvic drop to the side of the intact limb during stance on the prosthesis. Lateral trunk bending ensures toe clearance, but this maneuver is fatiguing. Ideally the foot and knee move forward in the same plane. If the prosthesis has been donned improperly, evidence of a medial or lateral whip may be seen with the foot circumscribing with an inward or outward arc during swing phase. Asymmetric movement is common among those who walk with a transfemoral prosthesis because the individual lacks sensation from the prosthetic foot and knee. The socket may not stabilize the femur sufficiently, and the knee unit does not move in exactly the same way as the anatomic knee. Consequently, the walker achieves lower plantar pressure and ground reaction force.46,47 Trunk muscle force and spinal loads are also lower among people walking with a transfemoral prosthesis,48 although the walker uses more muscle activity.49

Case Example 24.4 Problem Solving When the Prosthesis Suddenly Does Not Fit T. M. is a 60-year-old businessman who, 3 years ago, sustained transfemoral amputation as the result of diabetes. He is complaining about his prosthesis. He had been comfortably fitted 9 weeks earlier. Today he reports that his socket is too small, preventing him from fitting fully into it. He fears that the tightness will cause skin breakdown, a frightening prospect for a person with diabetes. T. M. is wearing a transfemoral prosthesis with a stance control knee, dynamic response foot, and he is using a locking roll-on-liner for suspension. T. M. wears his prosthesis at least 10 h a day. When T. M. enters the clinic, he is obviously experiencing discomfort and is not shifting his weight equally over the prosthesis during the stance phase of gait. He has returned to using a pair of axillary crutches to reduce his discomfort. When he removes the prosthesis, proximal redness and tenderness over the medial thigh is apparent. On T. M.’s previous visit he wore a single three-ply sock over a 3-mm roll-on liner. Today he is donning a five- and a three-ply

sock over the liner. When asked why he has increased the sock ply, T. M. reports that since he had progressed from a liner-only fit to wearing an additional three-ply sock in 3 weeks, he thought that by 9 weeks he should be wearing eight to nine ply of sock. The prosthetist and therapist explain the indications for increasing sock ply. T. M. returned to using a three-ply sock over the liner and regained the comfort he experienced before his arbitrary addition of socks. He is relieved to be able to ambulate without crutches. QUESTIONS TO CONSIDER

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What is the typical strategy for managing volume control and limb shrinkage in the first months following amputation? What factors influence the maturation of limb volume? When might a new user expect that the amputation limb will reach stable volume? What are the indicators that an additional sock is necessary? What must the new prosthetic wearer understand to adjust Continued on following page

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Case Example 24.4 Problem Solving When the Prosthesis Suddenly Does Not Fit (Continued)

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sock ply appropriately? How can the clinician help a new prosthetic wearer master the art of changing sock ply to adjust prosthetic fit? How would T. M.’s complaints about fitting be different if he were wearing too few prosthetic socks? How many sock ply must a new user be wearing before it is time for the prosthetist to adjust the socket or fabricate a

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new one? What other indicators might there be that it is time for a change in socket or suspension? How might improper socket fit (whether too loose or too tight) affect the wearer’s stability in stance and mobility during swing phase?

CHANGING SHOE HEEL HEIGHT

INADEQUATE SUSPENSION

All prosthetic feet are designed to be worn with shoes of a particular heel height (Fig. 24.16). Matching the heel rise of the prosthetic foot to the shoes most often worn by the patient is essential. A heel wedge placed inside the shoe can be used to accommodate shoes that have a lower heel than that for which the foot was designed. Changing to shoes with significantly lower heels results in excessive knee stability in stance. Conversely, a change to shoes with much higher heels compromises alignment stability of the knee and places much greater demand on muscular control of knee unit.

Inadequately tightened or badly worn suspension straps, belts, or closures should be suspected when the wearer experiences pistoning (vertical motion) of the amputation limb within the socket. The prosthesis drops when it is unweighted during swing, resulting in a relatively longer swing limb and challenging toe clearance. In addition, the socket may rotate on the amputation limb, leading to gait deviations. New users should assess the adequacy of suspension systematically each time they don the prosthesis. All must periodically inspect belts, straps, and closures for signs of fraying, stretching, or significant wear.

OVERUSE

WORN OR LOOSENED COMPONENTS

Whether learning to use a prosthesis, most patients benefit from a gradual break-in period. This strategy allows the skin, soft tissue, and musculature to become accustomed to forces acting on the amputation limb. Overuse can lead to muscle soreness, skin irritation, and, if excessive, skin breakdown. New users should increase the wear time in their prosthesis gradually, carefully inspecting the skin each time the prosthesis is removed; they should wear a compression garment when not in the prosthesis.

As for any device used daily, the prosthesis should be inspected periodically for signs of excessive wear or loosening of components. Periodic checkups with the prosthetist should be scheduled, especially if the wearer engages in physically demanding work or leisure activities.

IMPROPER DONNING When a prosthesis is not properly oriented on the amputation limb, it cannot operate efficiently. The wearer may experience discomfort within the socket or may exhibit gait deviations. Emphasis on developing a systematic method of donning is essential.

A

B

PATIENT INNOVATION Prosthetic wearers who do not understand the alignment and design specifics of their prostheses may attempt to modify them. If a patient who had been progressing well in gait training and compliant with compression strategies suddenly has difficulty with socket fit, patient innovation should be suspected. Padding may have been added or removed from inside the socket. If knee stability has suddenly changed, the wearer may have attempted to adjust knee unit function. Concerns about alignment should be

C

D

Fig. 24.16 Shoes with differing heel heights affect knee stability for individuals who are using a transfemoral prosthesis. (A) Most prosthetic feet are designed for a standard {3/4}-inch heel. (B) Decreasing heel height creates an extension moment at the knee, leading to an excessively stable knee. (C) Increasing heel height creates a flexion moment, leading to instability of the prosthetic knee. (D) Special prosthetic feet are made for shoes with high heels.

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directed to the prosthetist whose knowledge, equipment, and experience can make any necessary adjustments.

TRANSFEMORAL PROSTHETIC GAIT Balance Walking depends on confident balance. Consequently, rehabilitation of the individual who has been fitted with a transfemoral prosthesis includes exercise designed to enable the patient to achieve stable balance. Level, type, and etiology of amputation influence balance,56-58 as does the stiffness of the ankle unit.59 The Berg Balance Scale is a suitable assessment of balance for adults wearing prostheses.59-61 Assessing Ability to Walk Because people walking with a prosthesis consume more energy and are more vulnerable to stress on the vascular system, assessing the patient’s walking potential is vital. The 6-minute walk test is a practical, valid assessment.62-64

ENERGY EXPENDITURE An individual with a transfemoral amputation faces considerable energy expenditure when ambulating with a prosthesis (Box 24.1).50-55 The energy cost of gait increases significantly as the length of the residual limb decreases. The individual ambulating on a transfemoral prosthesis walks more slowly to avoid an increase in energy consumption per minute and is less efficient in terms of energy expended over distance (per meter). This increase in energy cost is manifested as a higher rate of oxygen consumption, elevated heart rate, and notable reduction in comfortable (self-selected) walking speed. Because of high energy cost, older individuals with highlevel transfemoral amputations may be limited in their ability to become functional community ambulators. Those with vascular disease who wear a prosthesis often walk slowly, on flat terrain, with the assistance of a walker or cane. Elderly adults with bilateral transfemoral amputations rarely become community ambulators, instead choosing a wheelchair for mobility. The goal of a well-designed and accurately fitted transfemoral prosthesis is an energy-efficient gait in as natural a pattern as possible. Gait quality improves as the individual becomes more experienced with the prosthesis. If gait problems persist, especially if the risk of falls or skin irritation is present, the source of the problem should be identified, and attempts made to correct it. A person wearing an ill fitted or improperly aligned prosthesis will compensate by altering the gait pattern.

EARLY STANCE COMPENSATIONS Lateral Trunk Bending The observer stands on the prosthetic side, facing the walker, and notes bending toward the prosthetic side when the prosthesis is in stance phase. Lateral trunk bending (Fig. 24.17) is a common compensation for failure to stabilize the femur in the socket. If the lateral prosthetic wall does not stabilize the femur in adduction, the femur abducts, causing pelvic drop on the swinging side. Some wearers lean toward the stance (prosthetic) side to ensure toe clearance. Lateral trunk bending also avoids uncomfortable pressure in the perineum, especially if the medial socket wall is excessively high or sharp. The patient with a fleshy adductor roll is likely to be pinched by the socket. Lateral trunk bending can also occur if too few prosthetic socks are worn so that the amputation limb is positioned too deeply in the prosthesis. A socket aligned in abduction or a prosthetic foot excessively outset from the midline position both widen the base of support; consequently, the only way to shift weight onto the prosthesis is by leaning laterally. Trunk bending is more apparent in the individual with a short amputation limb. Walking with a cane, preferably on the prosthetic side, reduces lateral trunk bending. Abducted Gait The observer stands behind the walker, facing the individual. The walking base is abnormally wide. The patient exhibits excessive side-to-side sway to accomplish weight transfer from one limb to the other. The prosthesis may be too long. The socket may be aligned in insufficient

Box 24.1 Prosthetic Features That Affect Energy Expenditure

▪ ▪ ▪ ▪

Weight of the prosthesis Socket fit Alignment of the prosthesis Functional characteristics of the prosthetic components

Fig. 24.17 Lateral trunk bending over the prosthesis is typically the result of discomfort in the perineum. (Shriners Hospital Portland Oregon.)

24 • Transfemoral Prostheses

adduction or may cause discomfort in the groin or laterodistal end of the amputation limb. Weak hip abductors fail to stabilize the femur during stance phase on the prosthesis. The person with poor balance may abduct the prosthesis to widen the walking base, even though this maneuver results in excessive mediolateral trunk motion.

KNEE INSTABILITY The observer stands on the prosthetic side, facing the walker. At initial contact, the prosthetic knee should be fully extended to position the prosthetic foot appropriately for smooth loading as body weight is transferred onto the prosthesis. As loading occurs, the prosthetic foot rolls smoothly into a foot-flat position. Problems with either of these functions increase the risk of instability and shorten the swing time and step length of the contralateral limb. If the prosthetic knee cannot maintain the necessary extension as the heel strikes the ground and the prosthesis is loaded, several possible prosthetic and patient-related factors should be considered (Fig. 24.18). The most common patient-related problems that lead to knee instability at initial contact include significant hip flexion contracture or weakness of hip extensor muscles, which compromise the patient’s ability to stabilize the prosthetic knee by using active hip extension. If strength and range of motion are adequate, four different prosthetic factors might lead to knee instability:

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1. The knee axis may be aligned too far anterior to the weight line, promoting a flexion moment. 2. The socket may not have been set in the optimal preflexed position that places the hip extensor muscles at a biomechanical advantage for stabilizing the knee. 3. The prosthetic foot may have been aligned in excessive dorsiflexion. 4. The plantar flexion bumper or SACH heel may be too stiff. 5. The shoe heel may be too high.

Foot Slap The observer stands on the prosthetic side, facing the walker. The speed that the prosthetic forefoot descends to the floor at heel contact is determined by the stiffness of the heel or plantar flexion bumper and by how forcefully the individual loads the heel. The heel cushion or plantar flexion bumper may be too soft for the user’s weight and activity level. Alternatively, someone who fears instability in early stance may drive the heel into the ground to ensure complete knee extension. For those using a locking knee, reaching a foot-flat position quickly is essential for smooth transition throughout stance phase. External Rotation of the Prosthetic Foot The observer stands behind the walker, facing the individual. If the wearer exhibits external rotation of the prosthetic heel in early stance as weight is transferred onto the prosthesis, this action can lead to skin irritation and instability. The most common causes are an excessively firm heel cushion or plantar flexion bumper and inappropriate toe-out alignment of the prosthetic foot. When girth of the amputation limb is decreasing, the socket may become loose, compromising the wearer’s control of the prosthesis. In the presence of weak hip muscles, the wearer may be unable to control the prosthesis during transition from swing to stance phase. Someone who fears knee instability in early stance may extend the prosthetic knee too vigorously at heel contact to ensure full knee extension. The shoe may be too tight for the prosthetic foot.

MIDSTANCE TO LATE STANCE COMPENSATIONS Swing Phase Compensations The wearer must initiate swing with enough hip flexion momentum to achieve the prosthetic knee flexion necessary for toe clearance and, in late swing, extend the knee in extension in preparation for the next heel contact.

Fig. 24.18 An unstable prosthetic knee during stance phase often results in a quick, short step taken by the sound limb. The problem may be caused by hip extensor weakness, hip flexion contracture, or anterior displacement of the prosthetic knee. (Shriners Hospital Portland Oregon.)

Excessive Knee Flexion (High Heel Rise) The observer stands on the prosthetic side, facing the walker. With excessive knee flexion/high heel rise (Fig. 24.19), the prosthetic foot rises higher than does the contralateral foot during its swing phase. High heel rise may delay extension of the prosthetic knee during late swing phase. This compensation occurs if friction on the knee unit is inadequate or the knee extension aid is loose. Lateral and Medial Whips The observer stands behind the walker, facing the individual. A whip occurs when forward progression of the distal

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Vaulting The observer stands behind the walker, facing the individual. A wearer who forcefully plantar flexes the ankle on the intact side ensures clearance for the prosthesis through its swing (Fig. 24.21). Causes of vaulting include insufficient suspension, loose socket, excessive friction in the knee unit, and a foot set in excessive plantar flexion effectively lengthening the prosthesis and thereby compromising toe clearance. A prosthesis that is too long may compel the patient to vault. Individuals who are frail will exhibit other means of clearing the floor during swing phase rather than vaulting. Circumduction The observer stands behind the walker, facing the individual. The patient with weak musculature who has difficulty clearing the prosthesis during swing phase may circumduct the prosthesis (Fig. 24.22). The foot moves in a semicircular pattern. The pattern is also adopted by prosthetic wearers who fear stubbing their toe during swing or who are reluctant to use knee flexion because of anticipated instability in the subsequent early stance period. Circumduction also can be the result of a foot set in excessive plantar flexion, which makes the prosthesis functionally longer. Hip Hiking The observer stands behind the walker, facing the individual. Rather than circumduct to clear the prosthetic toe during swing phase, the patient may elevate the pelvis on the prosthetic side. Fig. 24.19 Excessive knee flexion/heel rise in early swing delays the extension of the knee, which is necessary to prepare for the next initial contact. (Shriners Hospital Portland Oregon.)

parts of the prosthesis follows a semicircular path. A lateral whip (Fig. 24.20A) describes the lateral arc made by the prosthetic heel. The knee unit may be aligned in excessive internal rotation, or the socket may have been internally rotated during donning. With a medial whip (see Fig. 24.20B), the prosthetic heel moves medially. The heels of the swing and stance limbs may narrowly miss contact at midstance and midswing. Although this occurs when the prosthetic knee is aligned in too much external rotation, it also results when the prosthesis is donned in too much external rotation or the Silesian belt pulls the socket into excessive external rotation. Medial whips may also be the consequence of poor socket fit, especially by those with flabby thigh tissue.

Terminal Impact The observer stands on the prosthetic side, facing the walker. Terminal impact occurs during late swing. The shank moves forward so quickly that one can hear an audible impact at the knee unit. This gait compensation occurs when the friction at the knee unit is insufficient with or without an excessively taut extension aid. Wearers fearful of knee instability in early stance may flex the hip on the amputated side forcefully in early swing to increase momentum for knee extension, then forcefully extend the hip in late swing to snap the knee into full extension in preparation for the next early stance.

OTHER ISSUES Ideally, an individual ambulating with a transfemoral prosthesis walks with a narrow base with minimal sway. Symmetry in stride length, cadence, and arm swing characterize an optimal gait pattern, with minimal energy cost. In addition to walking on level surfaces, patients with sufficient muscular and cardiopulmonary function should be trained to negotiate stairs.65,66 Prostheses equipped with microprocessor knee units facilitate ascent and descent.67-70 Negotiating ramps is another advanced skill for people wearing transfemoral prostheses. Standing on a slope is facilitated by a prosthesis with a microprocessor-controlled prosthetic foot.71 The microprocessor-controlled knee unit also aids ramp ascent and descent.72-76

Summary Advances in technology and rehabilitation have greatly benefited individuals wearing transfemoral prostheses. Treatment by the prosthetic clinic team, namely physician, prosthetist, and physical therapist, should enable the patient to obtain the best possible function. The team should develop a prosthetic prescription based on relating the characteristics of the foot-ankle assemblies, shanks, knee units, socket designs, and suspension options to the needs of a given patient. Alignment of the various components is intended to maximize comfort and enable walking with the prosthesis in the most efficient manner.

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Fig. 24.20 (A) A lateral whip describes the shank and foot swinging in a lateral arc. (B) A medial whip describes the opposite movement. (A and B, Shriners Hospital Portland Oregon.)

Fig. 24.21 Vaulting describes exaggerated plantar flexion of the intact ankle, which provides clearance for the prosthesis during swing phase. (Shriners Hospital Portland Oregon.)

Fig. 24.22 With circumduction, the prosthesis swings in a wide lateral arc to facilitate toe clearance in swing. (Shriners Hospital Portland Oregon.)

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21. Fatone S, Caldwell R. Northwestern University flexible subischial vacuum socket for persons with transfemoral amputation—Part 1: Description of technique. Prosthet Orthot Int. 2017;41:237–245. 22. Fatone S, Caldwell R. Northwestern University flexible subischial vacuum socket for persons with transfemoral amputation—Part 2: Description and preliminary evaluation. Prosthet Orthot Int. 2017;41 (3):246–250. 23. Kahle JT, Highsmith MJ. Transfemoral interfaces with vacuum assisted suspension comparison of gait, balance, and subjective analysis: ischial containment versus brimless. Gait Posture. 2014;40:315–320. 24. Kahle JT, Highsmith MJ. Transfemoral sockets with vacuum-assisted suspension comparison of hip kinematics, socket position, contact pressure, and preference: ischial containment versus brimless. J Rehabil Res Dev. 2013;50:1241–1252. 25. Gholizadeh H, Abu Osman NA, Eshraghi A, Ali S. Transfemoral prosthesis suspension systems: a systematic review of the literature. Am J Phys Med Rehabil. 2014;93:809–823. 26. Gholizadeh H, Lemaire ED, Eshraghi A. The evidene-base for elevated vacuum in lower limb prosthetics: literature review and professional feedback. Clin Biomech (Bristol, Avon). 2016;37:108–116. 27. Al Muderis M, Lu W, Li JJ. Osseointegrated prosthetic limb for the treatment of lower limb amputatioons: experience and outcomes. Unfallchirurg. 2017;120:306–311. 28. Gholizadeh H, Abu Oman NA, Eshraghi, Ali S, Yahyavi ES. Satisfaction and problems experienced with transfemoral suspension systems: a comparison between common suction socket and seal-in liner. Arch Phys Med Rehabil 2013; 94:1584-1589. 29. Rink C, Wernke MM, Powell HM, Gynawali S, Schroeder RM, et al. Elevated vacuum suspension preserves residual limb skin health in people with lower limb amputation: randomized clinical trial. J Rehabil Res Dev. 2016;53:1121–1132. 30. Branemark R, Berlin O, Hagberg K, Bergh P, Gunerberg B, Rydevik B. A novel osseointegrated percutaneous prosthetic system for the treatment of patients with transfemoral amputation: a prospective study of 51 patients. Bone Joint J. 2014;96-B:106–113. 31. Hagberg K, Hansson E, Branemark R. Outcome of percutaneous osseointegrated prostheses for patients with unilateral transfemoral amputation at two-year follow-up. Arch Phys Med Rehabil. 2014;95: 2120–2127. 32. Van de Meent H, Hopman MT, Frolke JP. Walking ability and quality of life in subjects with transfemoral amputation: a comparison of osseointegration with socket prostheses. Arch Phys Med Rehabil. 2013;94: 2174–2178. 33. Al Muderis M, Khemka A, Lord SJ, Van de Meent H, Frolke JP. Safety of osseointegrated implants for transfemoral amputees: a two-center prospective cohort study. J Bone Joint Urg Am. 2016;98:900–909. 34. Tillander J, Hagberg K, Berlin O, Hagberg L, Branemark R. Osteomyelitis risk in patients with transfemoral amputations treated with osseointegration prostheses. Clin Orthop Relat Res. 2017;475: 3100–3108. 35. Schwarze M, Hurschler C, Seehaus F, Correa T, Welke B. Influence of transfemoral amputation length on resulting loads at the osseointegrated prosthesis fixation during walking and falling. Clin Biomech (Bristol, Avon). 2014;29:272–276. 36. Haggstrom EE, Hansson E, Hagberg K. Comparison of prosthetic costs and service between osseointegrated and conventional suspended transfemoral prostheses. Prosthet Orthot Int. 2013;37:152–160. 37. Gottschalk F, Kourosh S, Stills M. The biomechanics of transfemoral amputation. Prosthet Orthot Int. 1994;18:12–17. 38. Zahedi MS, Spence WD, Solomonidis SE, Paul JP. Alignment of lowerlimb prostheses. J Rehabil Res Dev. 1986;23:2–19. 39. Kobayashi T, Orendurff MS, Boone DA. Effect of alignment changes on socket reaction moments during gait in transfemoral and knee disarticulation prostheses: case series. J Biomech. 2013;46:2539–2545. 40. Fatone S, Dillon M, Stine R, Tillges R. Coronal plane socket stability during gait in persons with transfemoral amputation: pilot study. J Rehabil Res Dev. 2014;51:1217–1228. 41. Perry J, Burnfield JM. Gait Analysis: Normal and Pathological Function. 2nd ed. Thorofare, NJ: Slack; 2010. 42. Esquenazi A. Gait analysis in lower-limb amputation and prosthetic rehabilitation. Phys Med Rehabil Clin N Am. 2014;25:153–167. 43. Malchow C, Fiedler G. Effect of observation on lower limb prosthesis gait biomechanics: preliminary results. Prosthet Orthot Int. 2016;40: 739–743.

24 • Transfemoral Prostheses 44. Barr JB, Wutzke CJ, Threlkeld AJ. Longitudinal gait analysis of a person with a transfemoral amputation using three different prosthetic knee/ foot pairs. Physiother Theory Pract. 2012;28:407–411. 45. Devan H, Carman A, Hendrick P, Hale L, Ribeiro DC. Spinal, pelvic, and hip movement asymmetries in people with lower-limbk aamputation: systematic review. J Rehabil Res Dev. 2015;52:1–19. 46. Castro MP, Soares D, Mendes E, Machado L. Plantar pressures and ground reaction forces during walking of individuals with unilateral transfemoral amputation. PM R. 2014;6:698–707. 47. Pruziner AL, Werner KM, Copple TJ, Hendershot BD, Wolf EJ. Does intact limb loadin differ in servicemembers with traumatic lower limb loss? Clin Orthop Relat Res. 2014;472:3068–3075. 48. Shojaei I, Hendershot BD Wolf EJ, Bazrgari B. Persons with unilateral transfemoral amputation experience larger spinal loads during levelground walking compared to able-bodied individuals. Clin Biomech (Bristol, Avon). 2016;32:157–163. 49. Wentink EC, Prinsen EC, Rietman J, Veltink PH. Comparison of muscle activity ptterns of transfemoral amputees and control subjects during walking. J Neuroeng Rehabil. 2013;10:87. 50. Bell JC, Wolf EJ, Schnall BL, Tis JE, Potter BK. Transfemoral amputations: Is there an effect of residual limb length and orientation on energy expenditure? Clin Orthop Relat Res. 2014;472(10):3055–3061. 51. Wezenberg D, van der Woude LH, Faber WX, de Haan A, Houdijk H. Relation between aerobic capacity and walking ability in older adults with a lower-limb amputation. Arch Phys Med Rehabil. 2013;94: 1714–1720. 52. Jarvis HL, Bennett AN, Twiste M, Phillip RD, Etherington J, Baker R. Temporal spatial and metabolic measures of walking in highly functional individuals with lower limb amputations. Arch Phys Med Rehabil. 2017;98:1389–1399. 53. Starholm IM, Mirtaheri P, Kapetanovic N, Versto T, Skyttemyr G, et al. Energy expenditure of transfemoral amputees during floor and treadmill walking with different speed. Prosthet Orthot Int. 2016;40: 336–342. 54. Giovaag T, Starholm IM, Mirtaheri P, Hegge FW, Skjetne K. Assessment of aerobic capacity and walking economy of unilateral transfemoral amputees. Prosthet Orthot Int. 2014;38:140–147. 55. Wezenberg D, de Haan A, Faber WX, Slootman HJ, van der Woude LH, Houdijk H. Peak oxygen consumption in older adults with a lower limb amputation. Arch Phys Med Rehabil. 2012;93:1924–1929. 56. Kamali M, Karimi MT, Eshraghi A, Omar H. Influential factors in stability of lower-limb amputees. Am J Phys Med Rehabil. 2013;92: 1110–1118. 57. Ku PX, Abu Osman NA, Wan Abas WA. Balance control in lower extremity amputees during quiet standing: a systematic review. Gait Posture. 2014;39:672–682. 58. Nederland MJ, Van Asseldonk EH, van der Kooij H, Rietman HS. Dynamic Balance Control (DBC) in lower leg amputee subjects: contribution of the regulatory activity of the prosthesis side. Clin Biomech (Bristol, Avon). 2012;27:40–45. 59. Wong CK, Chen CC, Welsh J. Preliminary assessment of balance with the Berg Balance Scale in adults who have a leg amputation and dwell in the community: Rasch rating scale analysis. Phys Ther. 2013;93:1520–1529. 60. Wong CK. Interrater reliability of the Berg Balance Scale when used by clinicians of various experience levels to assess people with lower limb amputations. Phys Ther. 2014;94:371–378.

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61. Major MJ, Fatone S, Roth EJ. Validity and reliability of the Berg Balance Scale for community-dwelling persons with lower-limb amputation. Arch Phys Med Rehabil. 2013;94:2194–2202. 62. Erjavec T, Vidmar G, Burger H. Exercise testing as a screening meaure for ability to walk with a prosthesis after transfemoral amputation due to peripheral vascular disease. Disabil Rehabil. 2014;36:1148–1155. 63. Kahle JT, Highsmith MJ, Schaepper H, Johannesson A, Orendurff MS, Kaufman K. Predicting walking ability following lower limb amputation: an updated systematic literature review. Technol Innov. 2016;18: 125–137. 64. Sansam K, O’Connor RJ, Neumann V, Bhakta B. Can simple clinical tests predict walking ability after prosthetic rehabilitation? J Rehabiil Med. 2012;44. 968974. 65. Young AJ, Simon AM, Hargrove LJ. A training method for locomotion mode prediction using powered lower limb prosthesis. IEEE Trans Neural Syst Rehabil Eng. 2014;22:671–677. 66. Hobara H, Kobayashi Y, Tominaga S, Nakamura T, Yamasaki N, Ogata T. Factors affecting stair-ascent patterns in unilateral transfemoral amputees. Prosthet Orthot Int. 2013;37:222–228. 67. Inoue K, Hobara H, Wada T. Effects of inertial properties of transfemoral prosthesis on leg swing motion during stair ascent. Conf Proc IEEE Eng Med Biol Soc. 2013;2013:1591–1594. 68. Bellmann M, Schmalz T, Ludwigs E, Blumentritt S. Stair ascent with an innovative microprocessor-controlled exoprosthetic knee joint. Biomed Tech (Berl). 2012;57:435–444. 69. Aldridge Whitehead JM, Wolf EJ, Scoville CR, Wilken JM. Does a microprocessor-controlled prosthetic knee affect stair ascent strategies in persons with transfemoral amputation? Clin Orthop Relat Res. 2014;472:3093–3101. 70. Lawson B, Varol HA, Huff A, Erdemir E, Goldfarb M. Control of stair ascent and descent with a powered transfemoral prosthesis. IEEE Trans Neural Syst Rehabil Eng. 2013;21:466–473. 71. rnst M, Altenburg B, Bellmann M, Schmalz T. Standing on slopes – how current microprocessor-controlled prosthetic feet support tanstibial and transfemoral amputees in an everyday task. J Neuroeng Rehabil. 2017;14:117. 72. Burnfield JM, Eberly VJ, Gronely J, Perry J, et al. Impact of stance phase microprocessor-controlled knee prosthesis on ramp negotiation and community walking function in K2 level transfemoral amputees. Prosthet Orthot Int. 2012;36:95–104. 73. Wolf EJ, Everding VQ, Linberg AL, Schnall BL, Czerniecki JM, Gambel JM. Assessment of transfemoral amputees using C-Leg and Power Knee for ascending and descending inclines and step. J Rehabil Res Dev. 2012;49:831–842. 74. Lura DJ, Wernke MM, Carey SL, Kahle JT, Miro RM, Highsmith MJ. Differences in knee flexion between the Genium and C-Leg microprocessor knees while walking on level ground and ramps. Clin Biomech (Bristol, Avon). 2015;30:175–181. 75. Ledoux ED, Lawson BE, Shultz AH, Bartlett HL, Goldfarb M. Metabolics of stair ascent with a powered transfemoral prosthesis. Conf Proc IEEE Eng Med Biol Soc. 2015;2015:5307–5310. 76. Highsmith MJ, Klenow TD, Kahle JT, Wernke MM, Carey SL, et al. Effects of the Genium microprocessor knee system on knee moment symmetry during hill walking. Technol Innov. 2016;18:151–157.

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Prosthetic Options for Persons With High-Level and Bilateral Amputation☆ MILAGROS JORGE, J. DOUGLAS CALL and TYLER MANEE

LEARNING OBJECTIVES

On completion of this chapter, the reader will be able to do the following: 1. Discuss the incidence and prevalence of high-level and bilateral lower limb amputations. 2. Describe the etiology of high-level and bilateral lower limb amputations. 3. Identify the two primary biomechanical limitations of hip disarticulation and higher-level prostheses. 4. Estimate the relative energy cost of ambulation with high-level or bilateral lower limb loss. 5. Describe the prosthetic and rehabilitation needs of persons with high-level and bilateral lower limb amputations.

High-level transfemoral and bilateral amputations of the lower extremity are the result of trauma or disease pathology such as peripheral vascular disease due to health conditions such as diabetes. The 21st century began as a time of war in many places around the globe. The United States and other members of the North Atlantic Treaty Organization have engaged in war and military conflicts. Traumatic amputations associated with war due to the use of land mines, improvised explosive devices (IEDs), and combat fire have resulted in the increased incidence and prevalence of high-level and bilateral lower limb amputations.1 Peripheral vascular disease—either primary or diabetes-related—is the leading cause of bilateral amputations in the United States.2,3 Such a significant limb loss presents a substantial challenge to the patient, the prosthetist, and other rehabilitation professionals. Successful fitting of a prosthesis is often time-consuming and difficult; however, for many individuals with high-level or bilateral lower extremity amputations, prostheses can enhance functional independence and mobility. This chapter summarizes key concepts for the prescription and fabrication of prostheses in individuals with high-level transfemoral and bilateral lower extremity amputations as well as their rehabilitation as based on clinical factors, research evidence, and expected outcomes.

High-Level Lower Limb Loss The first part of this chapter focuses on options for patients with a unilateral high-level lower limb loss, which is an amputation at or above the hip joint. Hip disarticulation ☆

The authors extend appreciation to John W. Michael, whose work in prior editions provided the foundation for this chapter.

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and transpelvic and translumbar losses have been estimated to comprise fewer than 2% of all amputations in the United States.4 As a result, only those clinicians associated with specialty centers, such as major trauma hospitals, have the opportunity to see significant numbers of such cases. Most prosthetists, therapists, and physicians see only a handful of patients with such high-level loss in a practice lifetime. One result of treating each high-level patient as one of a kind is that many different approaches can be found in the literature.

ETIOLOGY Hip disarticulation is a relatively rare amputation. The incidence is reported at 0.5% to 3.0%.4,5 There are three distinct causes of hip disarticulation: vascular disease, trauma, and malignancy. Vascular impairment, whether or not associated with diabetes mellitus, is the most common cause of lower limb loss in the industrialized world. Dysvascular symptoms are generally most pronounced in the distal limb, leading to nonhealing ulceration, infection, gangrene, and ablation. The trunk and upper thigh are usually spared even in the presence of severe peripheral vascular disease. Vascular disease sometimes, although rarely, leads to high-level amputation.6,7 The assumptions about healing, cardiovascular limitations, and tolerance of activity derived from experience with dysvascular amputations do not apply to patients with high-level amputations. Most of the latter are relatively healthy and have reasonable cardiopulmonary reserves, excellent cognition, and a strong desire to attempt the use of a prosthesis. The more common cause for hip disarticulation or highlevel lower limb amputations today is a traumatic injury, resulting in lifesaving emergency medical and surgical

25 • Prosthetic Options for Persons With High-Level and Bilateral Amputation

intervention. In civilian life within the industrialized countries, motor vehicle accidents are the most common cause of lower extremity amputations. The use of land mines in developing nations throughout the 20th century has also contributed to high-level limb loss. Although the international community has banned the practice of placing land mines, many still exist and continue to inflict trauma that may result in high-level amputations. Military conflicts in Iraq and Afghanistan and the use of IEDs has created numerous wounded warriors who survive the trauma and are transported to military hospitals for medical care and rehabilitation.8 Military hospitals are aggressively addressing the rehabilitation needs of military amputees. The Intrepid Center for Fallen Heroes Fund constructed the Center for the Intrepid at Brooke Army Medical Center in San Antonio, Texas. This is a state-of-the-art rehabilitation facility that can, in some cases, enable soldiers with limb loss to continue their military careers. The center’s rehabilitation programs work to maximize the functional abilities of men and women whether they plan to return to active duty or go back to civilian life. Because of the prolonged U.S. involvement in the Iraq and Afghanistan wars, there are now a greater number of individuals with hip disarticulations.9 Many high-level amputations are performed because of tumors of the femur, such as osteosarcoma. Fortunately the frequency of tumor-related high-level amputation is decreasing with advances in limb salvage procedures and more effective chemotherapy and radiation therapy.10-13 Patients who require amputation because of tumor can be divided into two groups: those with benign or fully contained tumors who require no further oncologic intervention and those undergoing chemotherapy and radiation after amputation. Persons with benign or fully contained tumors are typically in excellent physical condition after their amputations, eager to return to their former lives as much as possible, and ready for early fitting of a prosthesis. The benefits of early fitting are well established and are both physical and psychologic.10 Early mobilization and single-limb gait training on the contralateral limb with an appropriate assistive device is recommended to reduce the risk of deconditioning, which occurs even after a few days of hospitalization.14,15 The rehabilitation and management of patients requiring chemotherapy or radiation therapy may have to be adapted or delayed depending on the patient’s physical condition, energy level, tolerance of activity, and stage of healing. Most patients with high-level amputations should be offered the opportunity for be fitted with a prosthesis and for rehabilitation. A multidisciplinary rehabilitation team experienced in the management of persons with amputations is essential to assure the most desirable outcomes.14,15 Physical therapists working with individuals with high-level amputations are encouraged to initiate immediate postoperative fitting, which facilitates mobility training as soon as possible.16

BIOMECHANICS Although, historically, loss of the entire lower limb assumed the use of locked joints in the prosthesis, ample clinical evidence indicates that locked prosthetic joints are seldom

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necessary. Since the 1950s, free-motion hip, knee, and ankle joints for hip disarticulation and transpelvic prostheses have become the norm. The Canadian design hip disarticulation prosthesis was introduced by Colin McLaurin,17 and its biomechanics were clarified by Radcliffe in 1957.18 These same biomechanical principles also apply to the functional design of prostheses for patients with higher-level amputation. In essence, the high-level prosthesis is stabilized by the ground reaction force (GRF), which occurs during walking.19 For example, when standing quietly in the prosthesis, the person’s weight-bearing line falls posterior to the hip joint, anterior to the knee joint, and anterior to the ankle joint. The resultant hip and knee extension moments are resisted by mechanical hyperextension stops of the prosthetic hip and knee joints, and the dorsiflexion moment is resisted by the stiffness of the prosthetic foot (Fig. 25.1). This same principle permits the patient with paraplegia using bilateral Scott-Craig knee-ankle-foot orthoses to stand without external support.20 (See Case Example 25.1 and Case Example 25.2.) Ambulation with a high-level prosthesis also relies on the GRF (Fig. 25.2). When an experienced prosthetic wearer walks with an optimally aligned hip disarticulation or transpelvic prosthesis, the dynamic gait is surprisingly smooth and consistent. Patients with hip disarticulation or transpelvic amputations who have sufficient balance and strength

Fig. 25.1 Static balance with a high-level lower limb prosthesis is achieved when the ground reaction force passes posterior to the hip joint and anterior to the knee and ankle joints. The resulting extensor moments at the hip and knee and dorsiflexion moment at the ankle make the prosthesis stable. Mechanical stops in the prosthetic joints prevent further movement and the patient is able to stand without exertion. (Courtesy Otto Bock Orthopedic Industry, Inc., Minneapolis, MN.)

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Case Example 25.1 A Patient With Traumatic Hip Disarticulation J.S. is a 20-year-old man with a traumatic hip disarticulation amputation caused by a motorcycle accident 2 weeks earlier. His residual limb is healed but complicated by multiple skin grafts and insensate areas in the abdominal region from the amount of trauma. He is eager to return to college as quickly as possible to avoid having to repeat this semester’s courses but must walk several blocks to various buildings on the small, hilly campus. He has a lean, athletic build and demonstrates excellent balance and strength when ambulating on his remaining limb with bilateral forearm crutches. QUESTIONS TO CONSIDER • What additional information might be gathered to help determine J.S.’s potential to use a hip disarticulation prosthesis? How does his medical history and reason for amputation affect his rehabilitation prognosis? • How should J.S.’s readiness to be fitted with a prosthesis be determined? What tests and measurements should be used? • What major concerns or challenges will J.S., his prosthetist, and his rehabilitation team face in fitting his hip disarticulation prosthesis? • What options for socket and suspension will the team likely consider for J.S., given his functional needs and prognosis? • What factors will influence the choice of knee unit for J.S.’s prosthesis? What type of knee should be recommended? Why? • What factors will influence the choice of a prosthetic foot for J.S.’s prosthesis? What type of foot should be recommended? Why?

• How should J.S.’s rehabilitation goals be prioritized as he begins his prosthesis training? How should his rehabilitation progress? How should the efficacy of intervention be assessed to determine how well these goals have been met? • How should the International Classification of Function Core Set for persons following amputation be applied to this patient? RECOMMENDATIONS On the basis of findings during the evaluation and discussion with J.S. about his current functional needs and ultimate goals for the use of a prosthesis, the team recommends an initial endoskeletal prosthesis with a foam-lined thermoplastic socket that includes additional gel padding in the region of the tender grafted skin, a microprocessor-controlled stance and swingcontrol hydraulic knee, dynamic-response foot, and torque absorber. The clinical team considered first providing a less complex knee but decided against that option because it would require training to use a less responsive prosthesis followed by retraining with the microprocessor knee more appropriate for his projected functional abilities, thereby increasing the duration of his rehabilitation. Intensive in-patient therapy should be focused on ambulation first within the parallel bars and then with his forearm crutches to facilitate J.S.’s return to campus. He will continue with outpatient therapy until his gait has matured and will likely learn to ambulate with no balance aids. When his socket no longer fits because of normal postoperative atrophy, he will receive a new custom socket and protective covering for the prosthesis but will continue to use the same functional components originally provided for as long as they remain functionally appropriate for his needs.

Case Example 25.2 A Patient With Bilateral Lower Extremity Amputations Caused by Chronic Dysvascular/Neuropathic Disease R.W. is a 72-year-old woman who recently underwent an elective right transtibial amputation because of infection associated with diabetic neuropathy. Her residual limb is well healed and not unduly edematous, and she is eager to return to the condominium she shares with her daughter. Five years previously, R.W. underwent left transfemoral amputation after failed femoral-popliteal bypass surgery; she had been a successful full-time prosthesis wearer until she was hospitalized for her second amputation. QUESTIONS TO CONSIDER • What additional information might be gathered to help determine R.W.’s potential to use prostheses for her new right transtibial and existing left transfemoral residual limbs? How will her medical history and reason for amputation affect her rehabilitation prognosis? • How should R.W.’s readiness to be fitted with a transtibial prosthesis be determined? What tests and measurements should be used to make this determination? • What major concerns or challenges will R.W., her prosthetist, and her rehabilitation team face in fitting the new transtibial prosthesis? • Given her functional needs and prognosis, what options for socket and suspension will the team likely consider for R.W.’s new transtibial and transfemoral prostheses?

• What factors will influence the choice of knee units for R.W.’s transfemoral prosthesis? What type of knee should be recommended? Why? • What factors will influence the choice of prosthetic feet for R.W.’s transtibial and transfemoral prostheses? What type of foot should be recommended for each prosthesis? Why? • How should rehabilitation goals be prioritized as R.W. begins her training? • How should rehabilitation be assessed? • Should R.W.’s wearing schedules for her new transtibial limb be similar to or different from her that for her transfemoral limb? Why or why not? • How should the efficacy of intervention be assessed to determine how well the goals have been met? • How should the International Classification of Function Core Set for persons following amputation be applied to this patient? RECOMMENDATIONS Although her age and comorbidities make the use of two artificial limbs challenging, R.W. is a good candidate for bilateral fitting because of her motivation and proven success with a prior prosthesis. Her existing transfemoral prosthesis is well worn and no longer fitting optimally, so the rehabilitation team recommended that two new prostheses be prescribed. The transtibial prosthesis will provide primary balance and propulsion and enable R.W. to rise from a seated position,

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Case Example 25.2 A Patient With Bilateral Lower Extremity Amputations Caused by Chronic Dysvascular/Neuropathic Disease(Continued) applying significant forces to her residual limb. Her initial transtibial prosthesis will include a roll-on locking liner for suspension and a soft insert to protect the residual limb and provide added mediolateral stability at the knee through its supracondylar contours. She will use lightweight, solid-ankle dynamic response prosthetic feet on both artificial limbs because she prefers these components and has found them both stable and functional with her unilateral prosthesis. R.W.’s new transfemoral prosthesis will be similar to what she has successfully worn, with a roll-on locking liner for suspension and a flexible ischial containment socket within a rigid frame for weight bearing and rotational stability. The roll-on suspension permits donning from a seated position, which is particularly advantageous for people with bilateral amputations. Initially R.W. will wear an auxiliary elastic suspension belt for added security and rotational control. R.W.’s unilateral prosthesis incorporated a single-axis knee with pneumatic swing control, but she will require a more mechanically stable design for bilateral stability. Because of

Fig. 25.2 The ground reaction force at initial contact. From loading response through midstance (A) and terminal stance (B) and just prior to preswing (C) of the gait cycle for patients using a unilateral high-level prosthesis. Once properly aligned, the prosthesis will move in a consistent, predictable fashion and permit slow but steady ambulation. The patient uses trunk motion to initiate and control prosthetic movements. (From Van der Waarde T, Michael JW. Hip disarticulation and transpelvic management: prosthetic considerations. In: Bowker JH, Michael JW, eds. Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles. 2nd ed. St. Louis: Mosby-Year Book; 1992:539– 552.)

A

can learn to walk without any external aids, although the use of a cane is common. The basic functions of the GRF during ambulation with one type of high-level prosthesis can be summarized as follows: At initial contact, as the prosthetic heel touches the ground, the GRF passes posterior to the ankle axis, the heel cushion compresses, and the foot is lowered to the ground. At the same time an extension moment is created at the prosthetic knee as the GRF passes anterior to the knee joint axis (see Fig. 25.2A). By midstance, alignment stability is maximal as the GRF passes posterior to the prosthetic hip joint axis

cardiopulmonary restrictions and the loss of her second leg, the clinical team believes that she will not vary her walking pace as widely henceforth, so the weight of a pneumatic swing-control unit is no longer necessary. R.W. will receive a stable polycentric knee in her new prosthesis and undergo gait training for several weeks. Although she is eager to have her endoskeletal prostheses finished with protective covers that make them appear more lifelike, this fabrication step will be deferred until after she has completed gait training and mastered the use of bilateral artificial limbs. R.W.’s prosthetist will see her periodically to reevaluate the alignment of both prostheses as her gait pattern matures, making small changes in alignment in response to her changing needs and balance. Once her gait pattern has stabilized, the final fabrication will be completed. For traversing long distances, R.W. will also be prescribed a wheelchair with a posteriorly offset axle. Training in wheelchair transfers and mobility will also be an important part of her rehabilitation.

B

C

and anterior to the prosthetic knee joint axis, just as it does during quiet standing (see Fig. 25.2B). As forward progression continues into preswing, the GRF moves posterior to the knee joint axis, allowing the knee to bend passively and facilitate swing-phase foot clearance while weight is being shifted onto the opposite limb (see Fig. 25.2C). Two major biomechanical deficits are inherent with hip disarticulation and transpelvic prostheses. First, the prosthetic limb is always fully extended at midswing because of the loss of active hip flexion. As a result, the length of the prosthesis is typically shortened slightly compared with

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the length of the remaining limb to assist in toe clearance during the swing phase of gait. The consequence of this strategy, however, is a second biomechanical deficit— limb-length discrepancy.21

COMPONENT SELECTION The earliest designers of prosthesis for hip disarticulation insisted on locking all prosthetic joints. Later, proponents of free-axis joints advocated the use of only basic components, such as a single-axis knee and ankle. In recent years, a strong consensus has emerged that, to meet the patient’s functional needs and goals fully, components for patients with hip disarticulation and transpelvic amputations should be selected for the same reasons and with the same criteria as for those with transfemoral and transtibial amputation.22-24 The assessment of components such as a passive microprocessor-controlled knee versus an active powered microprocessor-controlled knee for level walking is evaluated for each individual.25

Choosing a Prosthetic Foot All prosthetic feet have been successfully used for high-level amputations. Nonarticulating designs are often chosen because of their dependability, durability, and low maintenance; these designs rarely require servicing as a result of wear and tear. Single-axis feet (which allow the patient to quickly attain a stable foot-flat position) are used when enhanced knee stability is a concern. Multiaxial and dynamic response designs are usually reserved for higheractivity individuals who appreciate the added mobility of such components. Microprocessor-controlled hydraulic and externally powered prosthetic foot/ankle systems such as the Biom, Elan, Triton, and Proprio are additional options to assist in gait but are generally cost-prohibitive or avoided due to their additional weight.26 Choosing a Prosthetic Knee Unit The prosthetist selects a particular knee unit on the basis of the patient’s functional needs. Because of the biomechanical stability of these prostheses, locked-knee designs are rarely necessary. They have two additional drawbacks: they must be unlocked before sitting and they may increase the risk of injury in the event of a fall. When stability is a primary concern, stance control or polycentric knees may be most appropriate. When properly aligned, single-axis knees also work well. The prosthetist might choose a pneumatic or hydraulic knee unit to provide fluid swing-phase control for patients who are active and want the ability to change cadence.27,28 Most recently, quite encouraging clinical results have been reported with a microprocessor-controlled hydraulic stanceand swing-control knee, allowing active individuals to descend stairs foot over foot with a hip disarticulation prosthesis for the first time.29,30 As with prosthetic foot/ankle systems, powered knee systems such as the Ossur Power Knee are available to provide the user with not only stance stability and free swing but also propulsion. This can drastically reduce energy expenditure during ambulation.26 Choosing a Prosthetic Hip Joint The majority of patients with hip disarticulation benefit from a free-motion hip joint, although locking joints are still

sometimes chosen for those with limited ambulation capabilities. Great effort has been made to provide some measure of active hip flexion motion in these prostheses because that would reduce or eliminate the key biomechanical deficits previously noted. In prior decades, modification of the hip joint by adding a coil-spring mechanism that induced hip flexion when the prosthesis was unweighted was tried with some success, but maintenance and breakage of the spring precluded widespread acceptance. More recently, a flexible carbon fiber thigh strut that functions as a leaf spring has been used clinically with good success. Initial reports suggest that this approach increases cadence and that the improved swing clearance achieved by better prosthetic hip and knee flexion eliminates the need to shorten the prosthesis.31 The use of vertical shock-absorbing shin elements and knees with stance flexion features is also being explored, with encouraging clinical acceptance. More advanced options, such as the Ottobock Helix system, also exist, providing dynamic stability and triplanar motion control, making it easier to extend the leg and clear the toe during gait.32,33

Torque Absorbers With the loss of three major biologic joints of the lower limb, a corresponding loss of the body’s ability to compensate for the rotary motions inherent in gait occurs. For this reason, many prosthetists strongly recommend that a torqueabsorbing device be included in these high-level prostheses. Torque absorbers typically improve both stride length and comfort by absorbing rotational forces that would otherwise be transmitted to the socket as skin shear. Incorporation of a lockable turntable above the prosthetic knee is also suggested to facilitate common daily activities such as dressing and entering a vehicle (Fig. 25.3).

ENERGY CONSUMPTION The major unresolved drawback to prosthetic use in those with high-level amputations is the tremendous increase in effort required to control a prosthetic limb with passive joints. Walking with a hip disarticulation or transpelvic prosthesis is much like controlling a flail biologic leg. The weight of the prosthesis is a contributing factor to the energy needed to be ambulatory. The concentration and energy required to ambulate makes short-distance ambulation much more practical than distance walking for all but the most vigorous adult wearers. Researchers investigating energy consumption during prosthetic walking and the relationship to physical fitness have reported that older persons with hip disarticulation who have good physical fitness were able to use the prosthesis successfully in community settings.34 Most rehabilitation professionals believe that any patient with an amputation who is physically and mentally capable of using a prosthetic device should, if interested, be fitted with an initial prosthesis. This recommendation applies particularly to those with high-level amputations who may feel “cheated” and become depressed if their clinical teams do not allow them to try using a prosthesis. Although patients may opt not to use the prosthesis for some activities, having the device available as a tool is worthwhile. This gives the user the ability to employ it situationally as he or she

25 • Prosthetic Options for Persons With High-Level and Bilateral Amputation

A

B

C

D

Fig. 25.3 A lockable turntable (A) positioned in the prosthesis above the prosthetic knee (B) makes dressing, entering a vehicle, and similar daily tasks much easier for individuals with high-level amputation (C and D). A torsion adapter absorbs the torque forces generated during gait and decreases the stress on both the patient’s skin and the prosthetic components. Such ancillary components should always be considered for patients with high-level amputations. (Courtesy Otto Bock Orthopedic Industry, Inc., Minneapolis, MN.)

may. These situations can include standing for long periods while they are using their hands for manual tasks or social situations where they wish to appear symmetric or without crutches. Younger patients with hip disarticulation surgery due to trauma are capable to intensive rehabilitation training and proficient users of prosthetic devices.35

SOCKET DESIGN A variety of socket designs have been described in the clinical literature. The most critical factors for their successful use are careful fitting and secure suspension regardless of which socket design is selected. For patients with hip disarticulation, encapsulation of the ascending pubic ramus may add stability, although not every patient is able to tolerate a proximal trim line in the perineum. Suspension is achieved by carefully contouring the socket just proximal to the iliac crests whenever possible. The socket should provide stability from front to back, side to side, and top to bottom. The interior of the hip disarticulation socket is fabricated from either flexible silicone rubber (Fig. 25.4A) or thermoplastic material (see Fig. 25.4B). The socket contour prevents a pistoning action within the socket. The socket is aligned with the knee and foot components (see Fig. 25.4C). When the patient is obese or has no ileum, shoulder straps

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may be necessary to minimize swing-phase pistoning of the prosthesis. Custom silicone designs and the Martin Bionics Bikini Socket™ (available at martinbionics.com) (Fig. 25.5) are newer options that show considerable promise. The transpelvic socket must fully enclose the gluteal fold and perineal tissues and completely contain the soft tissues on the amputated side. Full enclosure provides comfortable weight bearing on the residual tissues despite the absence of a hemipelvis. Failure to contain the transpelvic residuum adequately results in obvious protrusion where the trim lines are insufficient. Prosthetists modify the positive plaster model of the transpelvic residuum to incorporate a diagonally directed compressive force in the socket design in order to support and contain transpelvic tissues and eliminate the risk of perineal shear and tissue breakdown. For patients with translumbar amputations, weight bearing is achieved with a combination of soft tissue compression and thoracic rib support. Despite the loss of more than half of the body mass in this amputation, weightbearing tolerance is better than might be expected. Designs that allow the patient to vary the compression by adjustable straps are often useful. Patients with translumbar amputations require a socket for effective seating and wheeled mobility. Many patients with translumbar amputations successfully progress to ambulation for short distances with a prosthesis and may choose to wear prosthetic limbs to enhance their cosmetic appearance and self-image. Long-term follow-up demonstrates positive outcomes; return to work or school is usually a realistic goal. For most patients, polycentric knees provide sufficient stability for the household ambulation typical of this population, making locking joints unnecessary. The development of hip-knee-ankle systems such as the Helix 3D system from Ottobock (which incorporates a microprocessor knee and ankle systems to dynamically react to the patient’s gait and thus improve efficiency and safety) have dramatically improved the quality of gait obtainable by persons with high-level amputation. However, there cost may be prohibitive; they are generally reserved for those with veterans or worker’s compensation insurance coverage.32

REHABILITATION OUTCOMES AFTER HIGH-LEVEL AMPUTATION Despite the obvious challenges that face patients with highlevel amputations, a substantial percentage are able to manage a prosthetic device with appropriate training and longterm follow-up. Although the rate of prosthesis use varies, the trend is toward increasing functional use of a prosthesis.36,37 The use of a multidisciplinary team approach and fitting by an experienced prosthetist are believed to enhance the likelihood of success and to improve functional outcomes. In the rehabilitation of persons with lower extremity amputations, a primary functional goal is ambulation with a prosthetic device. Because these devices are very expensive and lower extremity amputations often occur in the elderly, insurance gatekeepers are faced with the task of determining who would best benefit from prosthetic equipment and how to best utilize the available resources. There is a need to assess amputees regarding the potential for use versus nonuse of the prosthetic equipment ordered.38

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A

Fig. 25.4 (A) The interior of a hip disarticulation socket fabricated from flexible silicone rubber. Note the contouring of the proximal brim to encase the crest of the ileum. (B) Hip disarticulation thermoplastic socket. (C) Hip disarticulation prosthesis with components: socket, hip joint, upper pylon, rotator, knee joint, lower pylon, and foot. (A, From Michael JW. Component selection criteria: lower limb disarticulations. Clin Prosthet Orthot. 1988;12(3):99–108. B, From Kelly BM, Spires MC, Restrepo JA. Orthotic and prosthetic prescriptions for today and tomorrow. Phys Med Rehabil Clin N Am. 2007;18(4):785–858, Copyright ª 2007 Elsevier Inc. C, Courtesy of Otto Bock Health Care, www.ottobockus.com.)

Fig. 25.5 The Martin Bionics Bikini Socket™ (martinbionics.com) has been on the market since about 2005, and has become the standard of care on an international basis for hip disarticulation and hemipelvectomy level users, with thousands of amputees around the world using it. Its an incredible technology. At ⅓ the size and ⅓ the weight of a conventional socket, it offers exceptional stability, control and comfort, and overcomes many of the issues surrounding antiquated conventional hip level sockets. (www.martinbionics.com).

In the United States in 1995, Medicare established K levels or Medicare Functional Classification Levels as a structured approach to quantifying need and potential benefit of prosthetic devices for patients after lower limb amputation. Today the Medicate K Levels are widely used to determine the predictability of persons with amputations to be effective users of prosthetic equipment (Table 25.1).39 Detailed information on the rehabilitation of persons with amputations is covered in Chapter 26. For persons who have undergone hemipelvectomy, hip disarticulation, or multiple amputations, the rehabilitation process varies based on the precipitating events that led to the limb loss—for example, in the instance of limb loss due to IEDs, burn care may be the priority.13 The outcomes vary based on health-related circumstances, the patient’s age, and his or her motivating factors. Using the International Classification of Function model, persons with high-level amputations should be assessed and supported in achieving the highest functional levels possible.40

25 • Prosthetic Options for Persons With High-Level and Bilateral Amputation

Table 25.1 Medicare Functional Classification Levels Level 0

Does not have the ability or potential to ambulate or transfer safely with or without assistance; a prosthesis does not enhance quality of life or mobility

Level 1

Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence; typical of limited and unlimited household ambulators

Level 2

Has the ability or potential for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs, or uneven surfaces; typical of the limited community ambulator

Level 3

Has the ability or potential for ambulation with variable cadence; typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands utilization of a prosthesis beyond simple locomotion

Level 4

Has the ability or potential for ambulation that exceeds basic ambulation skills, exhibiting high-impact, stress, or energy levels; typical of the demands of the child, active adult, or athlete

From https://www.amputee-coalition.org/resources/your-k-level/.

Bilateral Lower Limb Loss The loss of both lower limbs complicates the rehabilitation process, especially if both limbs are lost simultaneously. In North America, simultaneous bilateral loss is infrequent; such cases are typically the result of traumatic transportation or industrial accidents or electrocution. In the developing world, simultaneous limb loss is more frequent; in areas of armed conflict and postwar zones, roadside bombs, and land mines are major causes.41,42 Fortunately most patients with traumatic amputations are healthy and strong and generally have a good prognosis for the successful use of prostheses. In the United States the major cause of bilateral lower extremity limb loss is dysvascular disease. The National Health Interview Survey (NHIS) is the principal source of information on the health of Americans and is one of the major data collection programs of the National Center for Health Statistics, which is part of the Centers for Disease Control and Prevention (CDC). The 1996 NHIS includes the most current data base with the most comprehensive data on amputation and persons living with limb loss.43 The CDC reports the number of hospital discharges for nontraumatic lower extremity amputation; the number of cases of diabetes (listed as a discharge diagnosis) increased from 45,000 in 1991 to 86,000 in 1996, when they peaked; they then decreased to 66,000 in 2006. From 1988 to 2006, the number of diabetes discharges again increased by 20%.4 When vascular disease affects both limbs, as is often the case, patients with single dysvascular amputations face a significant risk of eventual bilateral limb loss. After the amputation of a single lower limb, the chance that the contralateral limb will also be lost over the following 2 to 3 years has been reported to be as high as 50%.44 Clinical follow-up suggests that successful use of a unilateral prosthesis increases the likelihood of success with bilateral artificial limbs. For this reason early fitting after initial amputation is strongly advocated, even when amputation of the opposite limb seems imminent.

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The rehabilitation of persons with bilateral lower extremity limb loss is similar to the rehabilitation of persons with unilateral amputation.45 One major difference is that using two artificial limbs is physically more difficult; thus the pace of advancement is slower and treatment must be individualized according to the patient’s strength, balance, and ability. Breaking down complex skills into small incremental tasks that can be more readily mastered is generally useful. Without the benefit of a sound limb, patients with bilateral loss can be expected to walk slowly and cautiously, often with a relatively wide-based gait that maximizes their sense of balance. Bilateral transfemoral amputees face even greater energy demands and lower rates of full-time prosthetic use for functional ambulation.14 The use of balance aids such as canes is common but not universal in the gait training and mobility rehabilitation process for persons with bilateral amputations. Environmental barriers such as ramps, hills, irregular surfaces, and curbs or stairs present special challenges that must be identified and overcome. The ability to sit, rise from a chair, fall in a controlled manner, and recover from a fall are all important tasks to be mastered. Transfer with and without artificial limbs is also an important skill to foster independence. Persons with bilateral lower limb amputations require a wheelchair for mobility for independent toileting in the night and for times when the prosthetic legs need repair. The rehabilitation of persons with bilateral lower limb amputations occurs in various phases, including a preoperative phase if time permits, an immediate postoperative phase, and an acute rehabilitation phase. The rehabilitation process is patient-centered and should be individualized for each one, taking into account his or her physical condition, biomechanical loss, and need for a prosthesis. The reason for the amputation influences the pace and level of rehabilitation. An otherwise healthy individual who sustained traumatic limb loss may be able to advance rapidly unless there is skin trauma on the residual limb. Early fitting is a critical factor in attaining a long-term successful outcome.46

ENERGY COST The effort required to use a unilateral prosthesis increases in direct proportion to the level of amputation: the longer the residual limb, the lower the energy cost of walking with a prosthesis.47 Saving as much functional limb length as possible is therefore an axiom in amputation surgery. Although preservation of the anatomic knee joint is important for patients with unilateral amputations, it is a critical consideration in cases of bilateral limb loss. When at least one biologic knee joint remains, the chances for practical ambulation increase significantly. In general patients with dysvascular amputations have lower energy reserves and expend more effort in walking than do those with traumatic amputations.38 Long-term use of bilateral transfemoral prostheses is uncommon but not impossible for elderly patients with dysvascular amputations. In contrast, a significant number of those with traumatic bilateral transfemoral amputations successfully use prostheses long term.48 Patients with bilateral transtibial amputations tend to do well with prostheses regardless of the reason for the amputation. Interestingly, bilateral transtibial prostheses require less effort than a unilateral transfemoral prosthesis; this finding emphasizes the importance of retaining biologic knee function whenever possible.

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Section III • Prostheses in Rehabilitation

COMPONENT SELECTION The selection of components for patients with bilateral lower limb amputations is made by the same guidelines as for unilateral limb loss. There are no unique or distinct components specifically designed or intended for use in bilateral prostheses. The prosthetist should consider both prostheses together rather than simply generate a “right-side” and a “left-side” prescription recommendation. Prosthetists generally recommend that the same ankle-foot device be used on both sides so that gait mechanics will be consistent, but this is not an absolute necessity. Some patients ambulate best with different prosthetic feet depending on the level of their amputations, the length and condition of their residual limbs, the nature of their preferred activities, and other individual characteristics. The range of physical differences between two patients with bilateral lower limb loss makes each patient and each prosthetic fitting a unique challenge. During the dynamic alignment procedure, a brief clinical trial with the recommended components is often helpful in confirming suitability for a specific individual before the prescription details are finalized. This trial is particularly helpful for experienced ambulators, who commonly develop strong preferences for specific components after walking with them for many years.

Bilateral Transtibial Amputations In North America, a solid-ankle cushion-heel prosthetic foot is often chosen for patients with bilateral transtibial amputation because such feet offer predictable standing balance. Most patients with bilateral amputation are concerned about falling backward. The prosthetist often chooses to use a slightly stiffer heel resistance to minimize the risk of backward falls. When concern about forward falls also exists, the prosthetist may also choose to use a slightly stiffer keel to offer additional resistance to falling forward. Patients classified as limited ambulators, those with poor postural responses, and those who walk with a very slow cadence often find this approach useful. Active patients walk well with elastic-keel and dynamicresponse feet or with multiaxial designs as long as they have sufficient strength and postural responses to manage these flexible components. Theoretically single-axis feet are designed to generate an abrupt hyperextension moment at midstance, which loads the cruciate ligaments of the residual limb. In practice there is little evidence that this loading is harmful; some patients with bilateral transtibial amputations prefer single-axis feet, choosing them over solid-ankle or dynamic-response designs. Patient preference is an important consideration in prosthetic prescription; preference is even more critical for patients with bilateral amputation who literally have no “good foot” to stand on other than the feet on the prosthetic devices. If a patient expresses definite dissatisfaction with a particular foot during the fitting process, an alternative component should be tried before proceeding further. The consideration of ancillary components, such as torque absorbers or shock-absorbing pylons, is important for all patients with bilateral amputations. Because such patients must bear all their body weight on prosthetic devices all the time, components that increase comfort or

protect the skin are particularly appropriate. Lessening the weight of the prostheses, particularly at the ankle-foot area, is also important, because lighter-weight prostheses are easier to control and they are more likely to be accepted. Whenever possible, heavier components should be placed as close to the socket as possible.

Bilateral Transfemoral Amputation Postural responses are compromised in patients with bilateral transfemoral amputations because of the loss of both anatomic ankles and knees. For this reason, a primary goal of prosthetic prescription is stability in the stance phase of gait. One of the most effective prosthetic components for stance-phase stability during level walking is a polycentric knee unit. For those patients who have the potential to walk at varying speeds, the addition of fluid swing-phase control is recommended. Hydraulic stance- and swing-control units are also quite successful for this population. In recent years, microprocessor-controlled hydraulic knees offering both stance- and swing-phase control have been well received clinically, and many experts believe that this technology offers more reliable stability and better mobility under real-world conditions than strictly mechanical knee mechanisms. The risk of injury in a fall is greater if locking or stance-control knees are used in both prostheses. For patients with significant stability issues, such a knee may be used on one side. Because single-axis knees are stabilized by muscle control and postural responses at the hip, older adults with dysvascular amputations often find bilateral single-axis knees difficult to use safely. Bilateral single-axis knees may be appropriate for small children because their short stature reduces the balance required to manage adult-size components. Ankle-foot components that emphasize stability and standing balances are typical for the group with bilateral limb loss. Solid-ankle designs predominate. Articulating designs are used less often; only individuals with very long transfemoral residual limbs and good muscle strength are typically able to control the added mobility provided by articulating ankle components. Many patients with bilateral transfemoral amputations use crutches or canes to assist with balance and postural control. Single-axis or multiaxial feet become easier to control if the patient leans forward slightly, shifting the center of gravity forward, so that the weight line falls anterior to the ankle axis at all times, thus eliminating the risk of falling backward. Ancillary components, such as torque absorbers, often make walking easier and more comfortable for patients with bilateral transfemoral amputations. There is some evidence that including components that permit controlled transverse rotation improves the gait kinematics of patients who wear two lower limb prostheses. Locking rotation devices make many activities of daily living easier to accomplish. Because the weight of such ancillary components must be considered, the perception of the artificial limb feeling heavy is minimized if the devices are positioned as far proximally within the prosthesis as possible. Transfemoral and Transtibial Amputation For patients with one transfemoral and one transtibial amputation, the preservation of one biologic knee makes

25 • Prosthetic Options for Persons With High-Level and Bilateral Amputation

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prosthetic use much easier and successful ambulation more likely. For most patients, the transtibial side is the propulsive and balance limb and the transfemoral side supplements these functions. On the basis of these functional differences, the prosthetist may choose to use different prosthetic feet. When the transfemoral amputation is relatively short, for example, a single-axis foot and stance control knee might be recommended for the transfemoral prosthesis whereas a dynamic response foot might be used in the transtibial prosthesis.

SOCKET DESIGNS AND SUSPENSION The person with bilateral lower limb loss is constantly bearing full weight on artificial limbs while walking or standing. All options to increase skin protection and comfort should be actively considered, and suspension must be as secure as possible. A soft insert and flexible sockets may be used to enhance comfort during wear and reduce the likelihood that shear forces will be problematic for the skin. Suction and/or elevated vacuum suspension—with silicone sleeves or inserts as necessary—minimize pistoning during swing and should be considered for the majority of patients with bilateral amputation. Cotton or wool prosthetic socks are often used as an interface between the residual limbs and the sockets when suction suspension is not feasible. In that event, supracondylar wedge or cuff suspensions are typically used in transtibial prostheses; Silesian belts are often used in transfemoral designs. Because most patients with bilateral amputations use a pair of prostheses, suspension belts are usually integrated into a single assembly. Because thigh corsets with metal side joints, hip joints, pelvic bands, and waist belts can be cumbersome for donning and doffing, they are typically avoided unless absolutely necessary. Ischial containment sockets are as effective for patients with bilateral amputation at the transfemoral level (of one or both limbs) as they are for patients with a single transfemoral amputation. Patients who have previously worn a quadrilateral transfemoral socket and those who are limited ambulators may be satisfied with a traditional quadrilateral design. Total contact of the residual limb in the socket is important for both ischial containment and quadrilateral socket skin integrity. The loss of both feet and both knees makes the use of bilateral transfemoral prostheses quite challenging. For many adults with acquired limb losses, an initial fitting with sockets attached to special rocker platforms may be advocated to facilitate initial gait training. These “stubbies” lower the wearer’s center of gravity considerably and therefore require less energy and balance than full-length prosthetic limbs, giving the patient the best chance for successful ambulation (Fig. 25.6). Once the patient is able to balance effectively on the stubbies, the prostheses can be converted to use artificial feet with solid pylons, which are gradually lengthened to increase the height of the prostheses. If the patient is able to manage full-length prostheses, prosthetic knees are incorporated and a definitive prosthesis with full components is provided. Not all patients with bilateral transfemoral amputation choose to pursue ambulation with prostheses. Some are unable to build the necessary muscle strength or postural

Fig. 25.6 A pair of shortened prostheses, sometimes called stubbies, for early gait training in patients with bilateral traumatic transfemoral amputations. In these prostheses, patients can develop postural control without having to worry about the stability of prosthetic knee units. (From Devinuwara K, Dworak-Kula A, O’Connor RJ. Rehabilitation and prosthetics post-amputation. Orthop Trauma. 2018;32(4):234– 240. Copyright ª 2018. Elsevier.)

control for a safe gait. Others find the energy cost of ambulation with prostheses excessive. In these cases, patients choose wheelchair mobility as a much less strenuous means of mobility and willingly adopt wheelchair use for the independence it provides. Many patients with bilateral transfemoral amputations find a wheelchair most practical for long-distance mobility and use their prosthetic limbs for walking short to moderate distances at home and work. Some patients accept the stubbies for long-term use, particularly if these devices allow them to remain independent in the home setting. Others choose to use their stubbies at home because they take less effort, but they wear full prostheses in public.

Summary Individuals with high-level or bilateral lower limb amputations are rare in the developed world. In North America, they are believed to represent fewer than 5% of all persons with amputations. Given these statistics, most prosthetists and therapists have limited opportunity to work with patients with such significant levels of limb loss. Although successful prosthetic training and rehabilitation for these patients are challenging, a large body of clinical information about managing such cases is available in the literature. This chapter highlights the key principles involved in rehabilitation of the person with high-level or bilateral lower limb amputations. Surgical technique during the amputation largely determines the potential for long-term ambulation. Gentle handling of soft tissues and careful preservation of all functional joints and bone lengths are essential. Anchoring functioning muscles to bone (myodesis) at their normal resting length is strongly encouraged whenever possible.

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The socket design and suspension methods chosen for patients with high-level or bilateral amputations should incorporate strategies to protect the skin and maximize patient comfort, especially for individuals with bilateral amputations. Components reflect each individual’s need for stability and responsiveness at the ankle-foot, knee, or hip joint level. Ancillary components to make the prosthesis more comfortable and easier to manage are advocated. Although patients with bilateral transfemoral amputation caused by vascular disease often have difficulty mastering dual prosthetic devices, long-term use of functional prostheses is a realistic goal for patients with traumatic or tumor-related amputation who are otherwise healthy. With appropriate fitting and rehabilitation, many patients with hip disarticulation and transpelvic amputations continue to use their prostheses definitively. Even patients with translumbar amputation are able to return to productive education or work activities with an appropriate prosthesis for sitting or limited ambulation. Despite the obvious physical and psychological challenges faced by patients with high-level or bilateral lower limb amputations, prosthetic rehabilitation must always be considered and is often successful, especially when offered by an experienced multidisciplinary team in a supportive setting. Although the sequelae from amputations of this magnitude present significant challenges, advances in surgical technique, prosthetic design and components, and rehabilitation contribute to successful outcomes for patients with highlevel and bilateral amputations.

References 1. Hermes LM. Military lower extremity amputee rehabilitation. Phys Med Rehabil Clin N Am. 2002;13(1):45–65. 2. Li Y, Burros NR, Gregg EW, Albright A, Geiss LS. Declining Rates of Hospitalization for Nontraumatic Lower-Extremity Amputation in the Diabetic Population Aged 40 Years or Older: U.S. 1988-2008. Diabetes Care. 2012 Feb;35(2):273–277. 3. Monteiro-Soares M, Martins-Mendes D, Vaz-Carneiro A, DinisRibeiro M. Lower-limb amputation following foot ulcers in patients with diabetes: classification systems, external validation and comparative analysis. Diabetes Metab Res Rev. Jul 2015;31(5):515–529. 4. Zeigler-Graham K, Mackenzie EJ, Ephraim PL, et al. Estimating the prevalence of limb loss in US 2005–2050. Arch Phys Med Rehabil. 2008;89(2):422–429. 5. Dillinger TR, Pezzin LE, Mackenzie EJ. Limb amputation and limb deficiency; epidemiology and recent trends in US. South Med J. 2002;95 (8):875–883. 6. Group TG. Epidemiology of lower extremity amputation in centers in Europe, North America, and East Asia. The global lower extremity amputation group. Br J Surg. 2000;87(3):328–337. 7. Narres M, Kvitkina T, Claessen H, Droste S, Schuster B, Morbach S, et al. Incidence of lower extremity amputations in the diabetic compared with the non-diabetic population: A systematic review. PLoSONE. 2017;12(8). https://doi.org/10.1371/journal.pone.0182081. 8. DeBruyne Nese F. American War and Military Operations Casualties: Lists and Statistics. https://fas.org/sgp/crs/natsec/RL32492.pdf; April 2017. Accessed 8 January 2018. 9. Schnall BL, Baum BS, Andrews AM. Gait characteristics of a soldier with a traumatic hip disarticulation. Phys Ther. 2008;88(12): 1568–1577. 10. Ferrapie AL, Brunel P, Besse W, et al. Lower limb proximal amputation for a tumor: retrospective study of 12 patients. Prosthet Orthot Int. 2003;27(3):179–185. 11. Katrak P, O’Connor B, Woodgate I. Rehabilitation after total femur replacement: a report of 2 cases. Arch Phys Med Rehabil. 2003;84(7): 1080–1084.

12. Belthur MV, Grimer RJ, Suneja R, et al. Extensible endoprosthesis for bone tumors of the proximal femur in children. J Pediatr Orthop. 2003;32(2):230–235. 13. Healey AJ, Tai N. Traumatic amputation—a contemporary approach. Trauma. 2009;11:177–187. 14. Davidson JH, Jones LE, Cornet J, et al. Management of the multiple limb amputee. Disabil Rehabil. 2002;24(13):688–699. 15. Madsen UR, Hommel A, Berthelsen CB, Bååth C. Systematic review describing the effect of early mobilisation after dysvascular major lower limb amputations. Journal of Clinical Nursing. 2017;26(21):3286–3297. 16. Hordacre B, Birks V, Quinn S, Barr C, Patritt BL, Crotty M. Physiotherapy Rehabilitation for Individuals with Lower Limb Amputation: A 15-Year Clinical Series; June 2012: 70–80. [wileyonlinelibrary.com]. https:// doi.org/10.1002/pri.1529. 17. McLaurin CA. The evolution of the Canadian-type hip disarticulation prosthesis. Artif Limbs. 1957;4:22–28. 18. Radcliffe CW. Biomechanics of the Canadian-type hip disarticulation prosthesis. Artif Limbs. 1957;4:29–38. 19. Stark G. Overview of the hip disarticulation prosthesis. JPO J Pract Orthod. 2001;13(2):50–53. 20. Lehmann JR, Wareen CG, Craig-Scott Hertling D. orthosis: a biomechanical and functional evaluation. Arch Phys Med Rehabil. 1976; 57(9):438–442. 21. Van der Waarde T, Michael JW. Hip disarticulation and tran¬spelvic management: prosthetic considerations. In: Bowker JH, Michael JW, eds. Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles. 2nd ed St. Louis: Mosby-Year Book; 1992:539–552. reprinted 2002. 22. Michael JW. Component selection criteria: lower limb disarticulations. Clin Prosthet Orthot. 1988;12(3):99–108. 23. Michael JW. Prosthetic knee mechanisms. Phys Med Rehabil State Art Rev. 1994;8(1):147–164. 24. Ludwigs E, Dipl-Ing AK, W€ ustefeld D. Evaluation of the Benefits of a New Prosthetic Hip Joint System in Activities of Daily Function in Patients after Hip Disarticulation or Hemipelvectomy. Journal of Prosthetics & Orthotics (JPO). 2013;25(3):118–125. 25. Creylman V, Knippels I, Janssen P, Biesbrouck E, Lechler K, Peeraer L. Assessment of transfemoral amputees using a passive microprocessorcontrolled knee versus an active powered microprocessor-controlled knee for level walking. BioMed Eng OnLine. 2016;15(Suppl 3):142. 26. Windrich M, Grimmer M, Christ O, Rinderknecht S, Beckerle P. Active lower limb prosthetics: a systematic review of design issues and solutions. BioMed Eng OnLine. 2016;15(Suppl 3):140. 27. Klute GK, Berge JS, Biggs W, Pongnumkul S, Popovic Z, Curless B. Vacuum-assisted socket suspension compared with pin suspension for lower extremity amputees: effect on fit, activity, and limb volume. Arch Phys Med Rehabil. 2011;92(10):1570–1575. 28. Michael JW. Prosthetic knee mechanisms. Phys Med Rehabil State Art Rev. 1994;8(1):147–164. 29. Stinus H. Biomechanics and evaluation of the microprocessor controlled C-leg exoprosthesis knee joint. Z Orthop Ihre Grenzgeb. 2000;138(3):728–782. 30. Seelena HMA, Hemmena B, Schmeetsa AJ, Amentb AJHA, Eversb SMAA. Costs and consequences of a prosthesis with an electronically stance and swing phase controlled knee joint. Technology and Disability. 2009;21:25–34. 31. Kralovec M, Houdek M, Andrews K, Shives T, Rose P, Sim F. Prosthetic Rehabilitation After Hip Disarticulation or Hemipelvectomy. American Journal of Physical Medicine & Rehabilitation. 2015;94(12):1035–1040. 32. l2013 Ludwigs E, Kannenberg A, W€ ustefeld D. Evaluation of the Benefits of a New Prosthetic Hip Joint System in Activities of Daily Function in Patients after Hip Disarticulation or Hemipelvectomy. Journal of Prosthetics & Orthotics (JPO). 2013;25(3):118–125. 33. Nelson LM, Carbone N. Functional Outcome Measurements of a Veteran With a Hip Disarticulation Using a Helix 3D Hip Joint: A Case Report. Journal of Prosthetics & Orthotics (JPO). 2011;23(1):21–26. 34. Chin T, Kuruda R, Akisue T, Iguch T, Kurosaka M. Energy consumption during prosthetic walking and physical fitness in older hip disarticulation amputees. JRRD. 2012;49(8):1255–1260. 35. Schnall BL, Baum BS, Andrews AM. Gait Characteristics of a Soldier With a Traumatic Hip Disarticulation. Phys Ther. 2008;88(12): 1568–1577. 36. Hordacre B, Birks V, Quinn S, Barr C, Patritti BL, Crotty M. Physiotherapy Rehabilitation for Individuals with Lower Limb Amputation: A 15Year Clinical Series. Physiother Res Int. 2013;18:70–80.

25 • Prosthetic Options for Persons With High-Level and Bilateral Amputation 37. Melcer T, Pyo J, Walker J. et al. Rehabilitation and multiple limb amputations: A clinical report of patients injured in combat. JRRD. 2016;53(6):1045–1060. 38. Roffman CE, Buchanan J, Allison GT. Locomotor Performance During Rehabilitation of People With Lower Limb Amputation and Prosthetic Nonuse 12 Months After Discharge. Phys Ther. 2016;96(7): 985–994. 39. K-Levels. https://www.ottobockus.com/therapy/resources-forprosthetics/what-are-k-levels.html. Accessed 31 May 2018. 40. Deathe AB, Wolfe D, Devlin M, Hebert J, Miller W, Pallaveshi L. Selection of outcome measures in lower extremity amputation rehabilitation: ICF activities. Disability & Rehabilitation. 2009;31 (18):1455–1473. 41. Korver AJH. Amputees in a hospital of the International Committee of the Red Cross. Injury. 1993;24(9):607–609. 42. Shahriar SH, Masumi M, Edjtehadi F, et al. Cardiovascular risk factors among males with war-related bilateral lower limb amputation. Mil Med. 2009;174(10):1108–1112. 43. Adams P, Hendershot G, Marano M. Centers for Disease Control and Prevention/National Center for Health Statistics. In: Current estimates

44. 45. 46.

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from the National Health Interview Survey, 1996. Vital Health Stat 10; 1999:1–203. 200. Amputee Coalition. https://www.amputee-coalition.org/limb-lossresource-center/resources-filtered/resources-by-topic/limb-lossstatistics/limb-loss-statistics/. Marzoug EA, Landham TL, Dance C, Bamj AN. Better practical evaluation for lower limb amputees. Disabil Rehabil. 2003;25(18): 1071–1074. Webster JB, Hakimi KN, Williams RM, Turner AP, Novell DC, Czemieck JM. Prosthetic fitting, use, and satisfaction following lower-limb amputation: A prospective study. JRRD. 2012;49(10) 1493–15. Traballesi M, Porcacchia P, Averna T, Brunelli S. Energy cost of walking measurements in subjects with lower limb amputations: a comparison study between floor and treadmill test. Gait Posture. 2008;27(1):70–75. Su P-F, Gard SA, Lipschutz RD, Kuiken TA. Gait characteristics of persons with bilateral transtibial amputations. JRRD. 2007;44(4): 491–502.

26

Early Rehabilitation in Lower Extremity Dysvascular Amputation☆ JULIE D. RIES and KELLY J. NEGLEY

LEARNING OBJECTIVES

On completion of this chapter, the reader will be able to do the following: 1. Organize each component of a comprehensive physical therapy examination for the individual with transtibial or transfemoral amputation and synthesize this information. 2. Establish diagnosis, prognosis, and treatment plan of care for rehabilitation. 3. Implement a well-defined and focused treatment plan that addresses the needs of the individual with transtibial or transfemoral amputation as related to participation restrictions, activity limitations, and impairments. 4. Prioritize issues about which transtibial or transfemoral amputees and their caregivers must be educated and execute a reasonable education plan. 5. Identify appropriate outcome measures for use with transtibial or transfemoral amputees. 6. Provide a justification for the clinical decision making associated with each phase of the comprehensive physical therapy rehabilitation of dysvascular amputees.

Persons who have undergone transtibial or transfemoral amputations may approach rehabilitation with a sense of expectancy, excitement, and, often, apprehension. They may be relieved to have healed and curious about the prostheses that they are about to receive. They may be anxious to commence their rehabilitation and may have realistic or notso-realistic expectations. To facilitate optimal rehabilitation outcomes, the physical therapist must consider the amputee’s goals, physical abilities, and mobility needs along with his or her previous functional level. This chapter explores the key components of successful rehabilitation for dysvascular transtibial or transfemoral amputees. It presents the components of a thorough examination and discusses the evaluation process resulting in a diagnosis and prognosis.1 The chapter also provides a range of interventions for persons with new transtibial or transfemoral amputations, from early physical therapy (PT) treatment ideas that focus on preparing the limb for the use of a prosthesis and building tolerance to prosthesis wear to more functionally oriented activities aimed at ensuring safety and efficiency in gait as well as the development of functional mobility skills. As the amputee masters these skills, interventions progress to more complex, higher-level bipedal activities. With many individuals, vocational, leisure, and even sporting activities can be addressed to facilitate the return to a productive and enjoyable life. This chapter focuses primarily on strategies for initial and intermediate-level rehabilitation, including a short discussion of more advanced training. Anticipated functional ☆

The authors extend appreciation to Victor Vaughan, whose work in prior editions provided the foundation for this chapter.

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outcomes for prosthesis users who have undergone a transtibial or transfemoral amputation are addressed. Evidence-based practice requires the integration of best research evidence, clinical expertise, and the patient’s values.2 Although more research is needed to inform rehabilitation decisions for lower extremity dysvascular amputees,3 evidence does support that those who participate in more intensive postamputation rehabilitation—especially in collaborative interdisciplinary care—benefit from these programs.4–7 Changes in reimbursement for the provision of health care services have necessitated a transition in how postamputation rehab ilitation care is provided in the United States.8 Preeducation and early training for prosthesis wear, which historically was performed in the inpatient rehabilitation environment, is now more often provided in home-care or outpatient clinics, with stringent limits to the number of PT visits. It is imperative that therapists working with this population have an excellent understanding of the “big picture” progression of care, the need for appropriately intensive training, and a mechanism for follow-up over time. The goal of this chapter is to provide a foundation for evidence-based practice in the management of dysvascular transtibial or transfemoral amputees regardless of the practice setting.

Components of the Physical Therapy Examination Effective PT management for amputees begins with a thorough and comprehensive initial examination. In the PT examination, the physical therapist must obtain the patient’s history,

26 • Early Rehabilitation in Lower Extremity Dysvascular Amputation

conduct a systems review, administer tests, and take measures to obtain baseline data. Ideally, the data collected will represent all levels of the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF) model,9 including impairments, activity limitations, and especially participation restrictions (e.g., What would the individual like to be able to do that he or she cannot do currently?), with attention to contextual factors (environmental and personal modifiers). The PT examination may occur before amputation, immediately following amputation, at the time the prosthesis is fitted, or after the individual has already obtained his or her prosthesis; it may also occur in any practice setting.

PATIENT’S HISTORY The patient’s history comprises the health-related, personal, and social data that give context to the individual’s current situation and reveals the individual’s desires and expectations. The person’s perspective of his or her illness, functional limitations, and disability has a powerful influence on the rehabilitation process and the person’s adaptation to limb loss.10 In fact, components of a positive outlook— such as optimism and hopefulness—are associated with constructive coping, adjustment to amputation, and better rehabilitation outcome.11,12 A number of important areas must be explored while the patient’s history is being taken. Although all areas provide important information, several are integral to the establishment of the diagnosis and treatment plan. The person’s

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general health status may affect his or her overall health perceptions, physical functions, psychologic functions, role, and social functions. Discussion of the current condition/chief complaint gives the therapist a sense of the individual’s concerns, previous interventions, and course of events. It is important to understand the individual’s goals and aspirations and to gauge whether they appear to be over- or under-ambitious. The therapist can then address these issues, with education and interaction with peer mentors as possible interventions. The interview process provides valuable insights about the person’s communication ability, emotional status, cognitive abilities, preferred coping strategies, insight into the rehabilitation process, and usual learning style as well as the availability of emotional and instrumental support systems (assistance with activities of daily living [ADLs]). Information about the person’s preamputation and/or preprosthetic level of activity and mobility is helpful in establishing a realistic prognosis. Amputees who are functionally ambulatory prior to and/or immediately following amputation surgery are more likely to recover at least a modest degree of ambulation ability with a prosthesis; specifically, the ability to stand on one leg and higher levels of fitness are associated with prosthetic success.13,14 Focused and probing interview questions are often helpful in obtaining clear and accurate information. Although many individuals are excellent historians, others may have an incomplete understanding or imprecise memory of what has happened. It is always advisable to confirm information when possible. Table 26.1 represents relevant components of the client’s history.

Table 26.1 Important Patient–Client History Components of Physical Therapy Examination Component

Issues to Consider

Social history

Cultural beliefs and behaviors Family and caregiver resources Social interactions, activities, and support systems Amenability to peer/mentor support

Employment/work/leisure

Current and/or prior work Current community/leisure activities and goals related to community/leisure activities Family/work roles

Living environment/equipment

Assistive devices and adaptive equipment Home environment (e.g., stairs? railings? shower vs. tub?) Projected discharge destination if inpatient

General health status

General health perception Physical and psychologic function

Social health habits

Health risks (e.g., smoking, alcohol, or drug abuse) Level of physical fitness and exercise habits

Family history

Relevant family medical history and health risks

Medical/surgical history

Prior hospitalizations, surgeries Preexisting medical and other health-related conditions

Chief complaint/current condition

Concerns that led the amputee or caregiver to seek physical therapy services Current medical or therapeutic interventions Mechanism of injury/disease including date of onset and course of events Amputee/caregiver/family expectations and goals Amputee/family/caregiver’s perceptions of the amputee’s emotional response to the current situation Previous therapeutic interventions for this problem

Activity level

Amputee’s current and prior level of function in mobility, self-care, activities of daily living, and home management Current and previous functional demands in work and community/leisure activities

Medications

Medications for current condition (prescription and over-the-counter) Medications for other coexisting conditions (prescription and over-the-counter)

Review of available records

Laboratory and diagnostic tests

Format and terminology adopted from The Guide to Physical Therapist Practice.1

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The interview is a means to gather important information that is later used to guide treatment interventions and begin the process of education about amputation, treatment, and prosthesis training. Many individuals with amputations do not have a clear understanding of what to expect during rehabilitation or how their disease process might progress. Amputation is not selective to a specific age group, cultural background, educational experience, or socioeconomic level. Every individual benefits from being well educated about his or her condition and treatment. For many, the events that brought them to rehabilitation may be a blur of disjointed experiences and medical jargon or a laundry list of conditions that seem unrelated or independent. The physical therapist can help them to place their history and experience into a meaningful context, which, in turn, assists them in forming realistic expectations and may decrease the likelihood of complications or a second amputation.

SYSTEMS REVIEW The systems review is a gross, limited review of the anatomic and physiologic status of the amputee’s cognitive, cardiopulmonary, musculoskeletal, vascular, integumentary, neuromuscular, endocrine, gastrointestinal, and urogenital systems. This screening process aids in focusing and prioritizing the tests and measures portion of the examination. For instance, a gross screen of range of motion (ROM) and strength of all uninvolved extremities may reveal them to be within normal limits, eliminating the need for further assessment. An integumentary screen may reveal an intact and healing surgical site but also a stage II sacral pressure

ulcer requiring further assessment and inclusion in the plan of care. The systems review helps to focus the rest of the examination in the most constructive and productive way.

TESTS AND MEASURES Tests and measures are deliberately prioritized to elicit the most relevant objective data for a given individual. Components of functional status will always be a top priority (this may include tests and measures associated with balance, gait, and mobility). Some categories of tests and measures may be revealed as unwarranted if the systems review “clears” the system (e.g., integumentary, musculoskeletal, and cognitive screenings may effectively eliminate the need for immediate further testing in these areas). Combining collected data with findings from the history and systems review, the physical therapist establishes a working diagnostic hypothesis related to the movement system dysfunction that the individual is experiencing. The physical therapist chooses, from an array of possible tests and measures, those that will best confirm or deny the developing diagnostic hypothesis. Data collected funnel the therapist’s thought process to prioritize problems and formulate the most appropriate plan of care. It is important to note that some assessments, such as strength testing or joint play motions, might require modification of technique because limb loss necessitates a change in the lever available for applying therapeutic forces. Table 26.2 provides categories of tests and measures appropriate for the lower extremity amputee. Decisions about specific areas included in the assessment are driven by many factors, including clinical setting, time since amputation, and whether or not the individual has received

Table 26.2 Data Gathered in the Initial Physical Therapy Examination Functional mobility

Strategies used and need for assistance with bed mobility (rolling, scooting, supine to/from sit) and transfers (transfer method and surfaces with and without prosthesis) Wheelchair mobility if appropriate: method of propulsion, need for assistance

Anthropometric characteristics and postural screen

Comment on body composition and dimensions, including height and weight (body mass index not valid given amputation); observe any issues with edema and presumed cause (e.g., congestive heart failure, renal dysfunction) Postural screen in sitting and standing: focus on pelvic and spine position Body mechanics during functional tasks

Motor function of trunk and extremities

Strength screening and specific tests where indicated Screening of hand function and dexterity (relevant to prosthetic donning/doffing) Observation of muscle power and endurance Observations on motor control: timing, coordination, and agility

Balance

Sitting balance assessment without prosthesis (accommodation to loss of body part, change in center of mass and base of support); with prosthesis this might include ability to maintain static sitting and withstand displacement forces; ability to dynamically reach and shift trunk in varying directions Assessment of standing balance without prosthesis (important predictor of prosthetic success) and with prosthesis might include timed ability to maintain static standing without upper extremity (UE) support, ability to withstand displacement forces, ability to dynamically reach and shift center of mass in varying directions

Ambulation status and gait deviations

Ambulation without prosthesis (i.e., need for assistance, type of assistive device, distance, terrain) Ambulation with prosthesis (i.e., need for assistance, type of assistive device, distance, terrain) Prosthetic gait deviations from observational gait analysis Functionally ambulatory clients will require assessment of higher level ambulatory skills (e.g., stops/starts, turns, altered terrain, stairs, ramps)

Residual limb inspection

Size (length, girth), shape (cylindrical, conical, bulbous), redundant tissue (“dog ears” or adductor roll), edema (characteristics of edema); current efforts at shrinking/shaping Integument status: incision line (indications of healing versus concern/infection); scar (general appearance, tissue mobility versus adhesions), overall color and integrity of skin Tolerance to prosthetic wear: observations on prosthesis removal

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Table 26.2 Data Gathered in the Initial Physical Therapy Examination (Continued) Remaining limb inspection

Circulation: assessment of color, temperature, trophic changes, pulses, responsiveness to position changes Integument: overall status and integrity of skin, presence of ulcers, lesions, calluses; status of nails Neurologic: peripheral nerve integrity (motor and sensory testing), reflex integrity Evidence of neuropathy via motor, sensory, and/or autonomic signs Under the care of a podiatrist? If not, is this a referral that is warranted? Appropriate footwear?

Prosthesis assessment

Ability to don/doff: based on client report, observation Socket fit: based on client perceptions of comfort, observation, and palpation of residual limb landmarks in socket Prosthetic alignment: based on observation in static standing and during gait If client does not yet have a prosthesis, therapist should be considering optimal components to meet the client’s needs

Aerobic capacity/endurance

Descriptor of any activity undertaken by client that could be considered an endurance activity and how it is tolerated Data may include (1) rate of perceived exertion during functional activities; (2) vitals with activity as compared to rest, including recovery vitals; (3) signs or symptoms of cardiovascular and/or pulmonary system pathology (e.g., angina, dyspnea) in response to increased oxygen demand during increased activity Exercise testing not likely a component of exam, but, during functional activities, does the amputee’s aerobic capacity seem to be a limiting factor?

Mental functions

Cognitive screen Observations related to individual’s ability to comprehend instructions, attend to task, solve problems, show good safety awareness and judgment Preferred learning strategies Motivation

Pain

Location and description of pain experience with intensity ratings Screen for surgical pain, residual limb pain, phantom pain, remaining limb pain, back pain, longstanding chronic pain, pain associated with comorbidities (e.g., arthritis) Current regimen for management of pain and its effectiveness

Range of motion (ROM) and joint integrity and mobility

ROM limitations with functional implications (these will reveal themselves in mobility and gait assessment) Especially important to assess: hip extension, adduction, internal rotation (both lower extremities [LEs]); knee extension (both LEs as able); ankle dorsiflexion (remaining LE); bilateral UE overhead function Are limitations due to muscle length/flexibility and/or soft tissue extensibility? Observed joint play/ accessory motions at joints with limitations Any signs of joint pathology or ligamentous integrity issues noted?

Assistive/adaptive devices and equipment

Is current equipment serving the needs of the client? Is other equipment warranted? Occupational therapy colleagues may advise clients as related to self-care and activities of daily living equipment

Attention to specific client needs

Home-care environment: if therapist has the benefit of seeing client in his or her living environment, it is prudent to assess the ability to enter/exit the home and manage relevant environmental obstacles Specific client goals: if a client comes to physical therapy with unambiguous goals related to home, community, work, or leisure activities, the therapist should assess the client’s skills relevant to achieving these goals and include them in the plan of care

a prosthesis. An inpatient assessment on postoperative day 2 will include different priorities than those associated with a home-care assessment for an individual who is 1 month postamputation and ready to be fitted for a prosthesis. And here again the priorities will differ from those associated with the outpatient clinic visit of an individual who has recently received a prosthesis and is ready to learn how to use it.

The Evaluation Process The process of evaluation requires the physical therapist to interpret and integrate the information obtained from the history, systems review, and tests and measures to identify the primary areas of participation restriction, activity limitation, and impairment. The physical therapist uses professional judgment to predict the likely functional outcome and time required for effective preprosthetic and/or prosthetic rehabilitation. The evaluation must include a summary of the individual’s major problems and the presumed underlying causes. Problems are prioritized, with

those that have the most significant functional implications receiving top priority. This is done within the personal and environmental context of the individual, as the same problem may affect different people in different ways. For instance, poor sensation of the residual limb in an individual who is cognitively intact may be easily resolved with education about compensating for the sensory deficit with visual inspection, effectively reducing the risk of compromising skin integrity. Another person with the same sensory deficit who also has cognitive impairment may present a higher risk of skin problems and require a more extensive educational intervention focused on residual limb care with the assistance of others who can help monitor skin integrity. Physical therapists must also be skilled in determining the functional implications of specific problems. For instance, a slight knee flexion contracture can be accommodated for in transtibial socket alignment, whereas a significant knee flexion contracture prohibits fitting with a conventional prosthesis. Prosthesis prescription and PT intervention may be different for two individuals with similar amputations but different degrees of contracture.

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Establishing a Physical Therapy Diagnosis and Prognosis The establishment of the PT diagnosis for a lower extremity amputee is related to the movement system and must be put into a functional context; for instance, a documented PT diagnosis might be: “difficulty in walking” or “abnormality of gait and mobility.” The physical therapist uses data from the history and test findings in the context of knowledge of previous amputee outcomes to predict each person’s rehabilitation potential and probable functional outcome. Based on the individual’s prognosis, measurable short-term and long-term goals are defined to guide intervention planning. These goals are used to inform outcomes assessment as rehabilitation progresses. An important component of the prognosis is determining the likely time frame for achievement of the optimal outcome. A young, active, healthy person with a traumatic transtibial amputation void of postoperative complications is likely to progress through rehabilitation quickly, achieving a high level of function in a short time, perhaps a few weeks. A medically frail and deconditioned individual who has a transfemoral amputation as a result of vascular compromise or a nonhealing neuropathic ulcer will have a longer rehabilitation course, often many months, likely resulting in a less ambitious final functional outcome. Research findings indicate several prognostic indicators of functional use of a prosthesis following rehabilitation. All of the following have been found to negatively affect functional use despite rehabilitation efforts: advanced age,13–15 the presence of comorbidities,13–15 level of amputation (transfemoral vs. transtibial),13,14 cognitive and/or memory impairment,13,14,16 and lower levels of functioning prior to amputation rehab ilitation as indicated by fitness, mobility, ADLs, and/or functional tests.13–15 This information is not intended to suggest the exclusion of individuals with any of these predictors from rehabilitation efforts; in fact, there is some evidence of training success in those 80 years of age and older17,18; but therapists must be realistic in assessing the challenges facing each individual user of a prosthesis. An efficient and useful predictor of functional prosthesis use is the level of preamputation mobility. Persons with amputation who were ambulatory before surgery and/or after amputation prior to receiving a prosthesis are much more likely to be able to use a prosthesis for ambulation.13,14,19,20 Consideration of all of these factors should be reflected in the plan of care, along with specific goals and the anticipated rate at which those goals will be met.

PLAN OF CARE The PT plan of care includes information about the frequency, duration, location, and specific PT interventions and is directly related to the goals delineated by the evaluation/prognostic process. Little is known about dose-response relationships in PT generally and in amputation rehabilitation specifically,21 although underdosing in rehabilitation is a consistent issue. The prioritized problem list provides a foundation for functional short- and long-term goals that direct rehabilitation activities. If independent donning and doffing of a prosthesis is the primary short-term goal, the associated treatment plan

must include education strategies, opportunities to practice this skill, and remediation or adaptation of any movement components that, if missing, would compromise the individual’s ability to perform this necessary task (e.g., the person may need to improve grip strength or intrinsic hand strength to manipulate prosthetic suspension). The plan includes information about equipment to be ordered, referrals to be made, and the ultimate PT discharge plan. A person’s perception of lack of compassion on the part of the health care providers or conflicting information related to care will affect the individual’s experience negatively22; therefore the plan of care should be established sensitively and in collaboration with the individual, including good bidirectional communication related to goals and expectations.23

Preprosthetic Interventions Successful use of a prosthesis involves a variety of prerequisites, including functional ROM of the hip and (if applicable) knee; functional strength of muscles at the hip and (if applicable) knee; adequate motor control and balance; sufficient aerobic capacity and endurance; effective edema control, skin and soft tissue management of the maturing residual limb; and sensory integrity of the residual limb. It is crucial to address these areas early in the rehabilitation process. Inability to achieve a certain status or level of performance in one area does not prohibit a good prosthetic outcome; however, difficulties in multiple areas have an impact on prosthetic candidacy and use. Each of these areas should be carefully evaluated and appropriate interventions undertaken to achieve at least minimal requirements for functional prosthetic use if not an optimal level of performance. Even when older adults with dysvascular amputations are deemed not to be candidates for the use of a prosthesis, they should be given the opportunity to benefit from rehabilitation interventions.17,24

RANGE OF MOTION Early and aggressive achievement of functional ROM of the involved lower extremity is of paramount importance. Assessment and treatment of ROM of the intact limb is also important, as loss of ROM of either limb has an impact on the quality and energy efficiency of functional mobility and gait. The flexor withdrawal pattern of hip flexion, abduction, external rotation, and knee flexion is a position associated with lower extremity pain and is often a position of choice for the residual limb after surgery. Elevation of the extremity on pillows serves to reinforce this undesirable posture and puts these individuals at risk for contracture formation (especially hip and knee flexor contractures), which can have a negative impact on the ultimate use of a prosthesis.14,25 Maintaining or increasing available ROM at the hip for persons with a transfemoral residual limb and at the hip and knee of the transtibial residual limb continues to be a primary treatment goal as the person moves from preprosthetic into prosthetic rehabilitation. The prevention of loss of ROM is much easier than efforts to regain lost motion. Prone positioning is an excellent strategy to combat contracture formation of the hip flexors and should be prescribed (30–60 minutes daily in bouts of 10–15 minutes) as

26 • Early Rehabilitation in Lower Extremity Dysvascular Amputation

early as possible for all individuals who are able to tolerate this position. Those with significant contractures may not be able to tolerate prone initially; a pillow or wedge under the abdomen may minimize discomfort while still achieving a stretch. Low-load long-duration stretch is safe and can lead to significant elastic and plastic changes in soft tissues.26 Sidelying hip extension or the Thomas test position are options for those unable to achieve a prone position. Amputees should understand the difference between hip joint extension and the substitution of increased anterior pelvic tilt or lumbar lordosis. Full-functional hip active range of motion into flexion, extension, and adduction is critical to achieving efficient ambulation and functional mobility with a prosthesis. Typical gait on level surfaces requires the hip to move from 30 degrees of flexion to 10 degrees of extension and requires adduction slightly beyond neutral.27 More extreme ranges of hip flexion are required for transitioning from sit to stand and reaching forward from a seated position; hip abduction range is required for sidestepping in a functional context. Although alignment of the transfemoral socket will decrease the need for the typical amount of hip extension required during walking or abduction during side-stepping (due to the slight flexion/posterior tilt and adduction/lateral tilt of the transfemoral socket), it is advisable to work toward functional ROM in all planes of motion and to balance strength and ROM around the hip joint. To avoid knee flexion contracture in a transtibial amputee, a postoperative rigid dressing or knee extension splint or board (e.g., transfer board extending from under a seating cushion) can be an effective technique early in the process to position the knee when it is resting in an extended position while the amputee is seated. Full knee extension ROM is required in typical ambulation on level surfaces27 and for exploiting passive stability at the knee joint in static standing; however, prosthetic alignment of the typical transtibial socket (slight flexion/anterior tilt) eliminates the need for full knee extension during gait. Nonetheless, maintaining

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or regaining full knee extension in individuals with recent transtibial amputations should be encouraged with the use of strategic positioning, a knee-extension splint, and/ or frequent active quadriceps exercises (“quad set”). If the person is using a splint or positioning board, he or she must also be taught to check the integrity of the residual limb’s skin regularly so as to minimize the risk of pressure-related skin damage, which would delay use of the prosthesis. For individuals with transtibial amputations, achieving knee flexion ROM is sometimes overlooked early in rehabilitation. Typical gait on level surfaces generally requires approximately 60 degrees of knee flexion,27 and more than 90 degrees is required for efficient step-over-step stair ambulation, rising from a seated position, and high-level mobility activities such as kneeling or rising from the floor. Table 26.3 summarizes potential prosthesis problems associated with loss of functional ROM. Physical therapists may utilize active and passive stretching, joint mobilization, manual therapy techniques, and other modalities to facilitate ROM recovery. ROM is emphasized in individual education and home positioning and exercise routines. All exercises started during the preprosthetic phase are generally appropriate to continue as prescribed or to be progressed as tolerated during the prosthesis training phase. Once full functional ROM is achieved, the person should be educated to maintain this level.

STRENGTH There is abundant evidence of a significant strength difference between the muscles of the amputated limb compared with those of the sound limb in transtibial and transfemoral amputees as well as evidence that the sound limb shows strength deficits compared with the limbs of age-matched peers without amputations.28–33 Although direct relationships between strength impairment and activity limitations cannot be assumed, there is some evidence to support the

Table 26.3 Consequences for Prosthetic Use Due to Limitations in Range of Motion Range-of-Motion Limitation

Potential Functional Limitation

Implication

# Hip extension

Inability to achieve upright posture in stance and inability to take advantage of extensor moment at hip; hip and low back extensors firing continually to maintain upright Resultant anterior pelvic tilt Compensatory knee flexion in transtibial amputees Body cannot progress beyond prosthetic leg during gait

Fatigue of hip and low back extensors Chronic low back pain Instability during stance phase of gait Decreased step and stride length of contralateral limb in gait

# Hip adduction

Abducted stance in gait (wide base of support) or lateral lean in stance phase

Increased lateral excursion of center of mass or abductor lurch/lateral lean on ipsilateral side during stance, decreasing gait efficiency

# Internal rotation

Toe-out stance and gait Pelvic progression over stance limb in gait may be limited (contralateral pelvis rotates anteriorly from fulcrum of weight bearing hip; if limited internal rotation, this will impede pelvic rotation on fixed femur)

Knee joint pain and/or pathology of knee joint because of lack of anterior/posterior orientation in transtibial amputee using prosthesis Decreased step and stride length of contralateral limb in gait

# Knee extension in transtibial prosthetic user

Limb functionally shorter Inability to take advantage of extensor moment at knee; knee extensors firing continually to maintain knee stability

Gait deviations associated with leg-length discrepancy Quadriceps fatigue, decreased midstance stability in gait

# Knee flexion in transtibial prosthetic user

Inability to place foot flat on the floor when sitting Inability to climb or descend stairs step over step

Inability to weight bear through prosthesis during sit-tostand transfers Limited to step-to-step method, which may be less efficient and slower

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impact of weakness on gait and mobility. Hip extensor strength in the lower extremity amputee is the most critical contributor to knee stability in the sagittal plane during gait34 and a useful component to predict functional outcome (e.g., performance on the 6-minute walk test).35 Hip abductor strength in lower extremity amputees is correlated with improved weight bearing on the prosthetic limb in quiet stance and stability in the frontal plane during gait.32,36 Accurate baseline strength assessment on both the involved and intact lower extremity during the preprosthetic phase will serve to guide therapeutic exercise interventions. Assessing hip and, in transtibial amputees, knee strength of the residual limb may be challenging, as the standard lever arm for providing resistance has been altered by the amputation. Isokinetic instrumentation or a handheld dynamometers may be used to more objectively evaluate muscle strength, although the psychometric properties of these tests are still under scrutiny.37,38 Functional strength of the hip and knee during closed-chain (reverse action) activities both concentrically and eccentrically is very important, as this reflects muscle activity during normal gait and functional activities. Although strengthening programs should address all muscles of the residual and sound limbs, prioritizing exercises that address hip extensor and abductor strength on the amputated side—and knee extensors for those with transtibial amputations—are appropriate, as these muscle groups will be pivotal for stance stability during prosthetic gait.29,31–34 Preamputation weakness of proximal muscles is often subtle with little to no observable abnormality in preamputation gait patterns; however, these impairments of strength (and likely muscle endurance) may be magnified in prosthetic gait. Periods of disuse prior to and following amputation typically produce further weakness and disuse atrophy in the involved limb. With proximal muscle weakness and the loss of distal musculature replaced by the weight of a prosthesis, problems with gait are likely. Hip and pelvic control in single-limb stance is inherently important to stability and to the effective forward progression of the body over the prosthesis. The strength requirements for ambulation with a prosthesis are similar but

not identical to those of normal gait. Both the involved and intact lower extremities display increased muscle activity during their respective stance phases. Biomechanical review studies of prosthetic gain provide evidence of increased and prolonged activity of the hip abductors and extensors on the amputated side and, if present, the knee extensors.39–41 Studies also confirm increased ground reaction forces and demand on the intact limb, presumably as a result of the absence of the normal foot and ankle mechanism on the prosthetic side. This results in increased hip abductor, hip extensor, and, if present, knee extensor muscle activity and power generation of the intact limb.39,40 A comprehensive strengthening program targeting the lower extremity muscle groups should be initiated early and progressed appropriately. Utilization of closed- (e.g., residual limb on bolster or gymnastic ball, or individual in kneeling position if tolerated) and open-chain exercise techniques, with both concentric and eccentric muscle contractions, is appropriate and effective. Progressive resistance protocols are often used to improve strength and muscle endurance. Resistance may be applied manually (e.g., proprioceptive neuromuscular facilitation [PNF] techniques are desirable, as they strengthen multiple joints and planes simultaneously) or with equipment (e.g., cuff weights, elastic bands, or pulley weights). Resistance is generally not applied at or near the suture line until the surgical wound is well healed. Using body weight is an effective way to introduce resistance training (e.g., bridging or planks with modifications as needed). Basic physiologic principles of strengthening (e.g., overload principle, specificity of training) are employed in the design of an appropriate resistance program, and exercises should specifically target muscles identified as weak in the examination and muscles that are functionally required in gait, transfer, and mobility activities. Strengthening within the context of functional activities is ideal. Correct exercise technique is important to achieving the desired strength gains, and the physical therapist’s expertise in movement analysis is important in helping individuals to understand how to perform their exercises properly and how to self-critique performance. Table 26.4 highlights some exercises that may be helpful

Table 26.4 Examples of Therapeutic Exercises for Strengthening Used in Preprosthetic Training Muscle Group

Exercises

Hip extensors

Bridging with residual limb over ball, bolster, foam wedge, or padded stool; start bilateral and progress to unilateral with focus on pelvic stability Prone leg lifts with weights or elastic band Manual resistance in prone, side lying, or even sitting (to strengthen early in range) Supported standing (parallel bars) hip extension with manual resistance, pulley weights, or elastic band PNF resistive techniques in supine, side lying, or standing

Hip abductors

Side lying bridges (amputated side down) with small deflated ball, small foam block, small bolster or wedge under knee (TTA) or distal femur (TFA) of residual limb; hip abduction into small bolster elevates pelvis and body weight Hip abduction in side lying (amputated side up) with weights, elastic band, or manual resistance Supported standing hip abduction with pulley weights or elastic band PNF resistive techniques in supine, side lying, or standing

Hip adductors

Side lying bridges (amputated side up) straddling small stool with padding/pillow under knee (TTA) or distal femur (TFA) of residual limb with intact lower extremity (LE) through legs of stool; hip adduction into padding on stool elevates pelvis and body weight Hip adduction in side lying (amputated side down with intact limb resting anteriorly flexed on pillow or wedge) with weights, elastic band, or manual resistance Supported standing hip adduction with pulley weights or elastic band PNF resistive techniques in supine, side lying, or standing

26 • Early Rehabilitation in Lower Extremity Dysvascular Amputation

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Table 26.4 Examples of Therapeutic Exercises for Strengthening Used in Preprosthetic Training (Continued) Muscle Group

Exercises

Hip flexors

Supine hip flexion (with knee extension for TTA) with manual resistance or weights Supported standing hip flexion with pulleys or elastic bands PNF resistive techniques in supine, side lying, or standing

Hip ER/IR

Seated or supine hip ER and IR with manual resistance or elastic bands PNF resistive techniques in supine, side lying, or standing

Knee extensors (TTA)

Seated long-arc quad with manual resistance or weights Supine short-arc quad over bolster or wedge with manual resistance or weights PNF resistive techniques in supine, side lying, or standing

Knee flexors (TTA)

Seated knee flexion with manual resistance or elastic bands Prone knee flexion with manual resistance, elastic band, or weights PNF resistive techniques in supine, side lying, or standing

ER, External rotation; IR, internal rotation; PNF, proprioceptive neuromuscular facilitation; TFA, transfemoral amputation; TTA, transtibial amputation.

in strengthening the residual limb of a transtibial or transfemoral amputee. Amputees often go through protracted periods of inactivity before and after amputation and present with a generalized loss of strength. A comprehensive strengthening program addresses not solely the residual limb but also the uninvolved limb, trunk, and upper extremities, as the full-body strength demands will be increased during preprosthetic and prosthetic training. Strengthening of the abdominals, paraspinals, and other trunk muscles is important, as a stable core is essential for mobility training, transfers, and gait. Hand strength and dexterity may be a prerequisite to independent prosthetic donning and should be addressed as needed. As an individual’s strength improves, exercises become more functionally oriented as well as more intense. Closed-chain exercises can take on greater emphasis as individuals transition to prosthetic training from the preprosthetic phase, and strengthening may occur in the context of upright functional activities. The optimal strengthening protocol will depend on the characteristics of the individual amputee, including his or her general health and mobility and current strength levels and goals.

BALANCE AND POSTURAL CONTROL Effective postural control during functional tasks has two fundamental components: (1) controlling the body’s position in space for purposes of stability (maintaining center of mass over base of support) and (2) orientating the trunk and limbs in space (appropriate relationship between body segments and between body and environment).42 The normal balance mechanism relies on visual, vestibular, and somatosensory input. Visual and vestibular information add awareness of position in space with respect to objects in the environment and to gravity, and somatosensory input provides information about the positions of the joints of the lower extremity and the pressures through those joints. Balance mechanisms function both proactively and reactively. With loss of the distal limb to amputation, somatosensory and proprioceptive input can no longer provide direct information about the position of the limb and its interaction with

support surfaces. Balance deficits are well documented in amputees,28,43,44 as is diminished balance confidence.45,46 Balance, as assessed with a variety of different measures, is associated with prosthetic ambulation outcome.13,14,28,35 Static stance in prosthetic users is epitomized by the uneven distribution of weight (favoring the intact side) and increased postural sway.44,47 This information is useful for formulating plans for balance interventions. Risk factors for falls in individuals with dysvascular amputations are consistent with those for the general older adult population (i.e., lower extremity weakness, increased age, multiple comorbidities, and/or polypharmacy)48; however, an additional finding, somewhat paradoxic, is the protective nature of lower balance confidence and poorer performance on balance tests against falling.45,49 This probably reflects the self-limiting mobility of those who lack confidence in their balance, yet it serves as an excellent reminder that overconfidence in balance performance can be dangerous. The incidence of falls among amputees is higher than that in age-matched peers without amputation, and risk factors for falls seem to vary across different phases of recovery (acute care vs. rehabilitation vs. community dwelling).43,48 Notably such falls often occur in the context of transitional movements such as transfers to and from a wheelchair,50 thus highlighting the importance of education regarding safe transfer strategies. Before discussing standing balance training, it is important to mention that some individuals will have difficulty adjusting to changes in sitting balance and bed mobility following lower extremity amputation. The loss of the weight of the amputated lower extremity diminishes the stabilizing potential of the lower body for supine-to-sit transitional movements; this is abundantly evident in individuals with bilateral lower extremity amputations who struggle to achieve sitting from a side-lying or supine position. Such individuals must rely more on upper extremities and trunk musculature for position changes. In sitting, lack of a second foot on the floor and, in the case of transfemoral amputation, loss of the surface area of the thigh on the seating surface alter the base of support, and loss of the mass of the lower extremity elevates the body’s center of gravity, making sitting more precarious. Most individuals adjust

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fairly quickly, developing competence and confidence in static sitting; but the inability to shift weight onto the missing foot can challenge dynamic sitting, especially with reaching tasks requiring movement anterior and ipsilateral to the amputated side. For this reason, seated reaching ability is evaluated during the initial examination and is addressed in treatment as necessary. Once an individual is training with a prosthesis and again has 2 feet on the floor, dynamic sitting balance often need not be a focus of treatment. In the preprosthetic phase, standing balance assessment and training might include single-limb standing in the parallel bars or at a support surface with decreasing reliance on upper extremity support. Ability to stand on the sound limb without upper extremity support has been associated with better prosthetic gait outcomes in individuals with unilateral lower extremity amputations,13,14 making this an important skill to assess and train as early as possible. In transtibial amputees, if the individual can tolerate a kneeling position over the healed surgical site (early efforts at this may include straddling a bolster with knees on mat and progressing to high kneeling), this is an excellent way to decrease the degrees of freedom for early upright balance training. In those with transfemoral amputation, if they can tolerate some pressure to the healed distal end, the individual may kneel with the intact limb on the mat and the residual limb resting on a foam block or wedge. A progression might be to stand with the sound limb on the floor and rest the residual limb (transtibial or transfemoral) on an elevated surface (e.g., mat, gymnastic ball, or foam block), providing balance support but minimal weight bearing. Preprosthetic gait training with an appropriate assistive device (AD) is another useful and functional approach to upright balance training. Because sensory and proprioceptive input from the distal segment is absent after amputation, individuals must learn to compensate for this lack of important postural information. Given underlying vascular pathology and comorbidity of diabetic neuropathy in amputees, the somatosensory mechanisms that inform balance cannot be presumed to be intact on the remaining limb. In addition to the loss of sensory input (due to loss of limb and compromised sensory status of remaining limb), the loss of muscles of the amputated foot and ankle will compromise preprogrammed postural responses. Balance reactions are considered to result from the combination of preprogrammed synergistic muscle activity as well as a continuous adaptive feedback system gleaning information from lower extremity joints.42 The ankle, hip, and change in support/stepping strategies are used to ensure that the center of mass stays within the base of support in response to anteroposterior perturbations and these postural strategies are evident during functional activities. The ankle strategy requires intact ROM and strength of the ankle. After amputation, this strategy is no longer available to the involved limb and the person may not be able to resolve the balance perturbation using intact limb response only; thus he or she may have to rely on a hip strategy (movement of the trunk over the base of support) or a change in support strategy (stepping or hopping to move the base of support under the center of mass).

Therapeutic balance challenges during preprosthetic rehabilitation provide opportunities to address environmental demands during various functional tasks in anticipatory (feedforward) and reactive (feedback) modes. For example, successfully catching and throwing a ball or batting a balloon requires the person to anticipate postural demands in an effort to throw and react to postural challenges in an effort to catch. This task can be progressed through a series of postures (e.g., seated, straddling bolster on mat, kneeling on mat with amputated side on foam block, standing in parallel bars with amputated side on foam block, standing in parallel bars in unilateral stance, decreasing reliance on upper extremity support in bars). Reaching activities in standing help individuals develop skill and confidence in their anticipatory postural responses and, should the reach distance be excessive, their reactive postural responses as well. Therapists must consider the person’s ultimate likely functional requirements and design a variety of balance tasks to help the person achieve levels of functioning commensurate with his or her potential. To facilitate improved balance and success in the self-identification of limits of stability, individuals must experience loss of balance in the context of training. This can be achieved safely with excellent guarding technique and can be facilitated by the use of harness systems (e.g., Zero G, Biodex, LiteGait) if available. Independent donning of the prosthesis may require a certain level of balance proficiency. Once the amputee has been fitted with a prosthesis, the therapist can revisit the same balance activities performed preprosthetically and the focus of balance training becomes the equal distribution of weight between the intact and prosthetic sides. In the context of integration of sensory information within the balance systems, individuals may learn to substitute for lost somatosensation and deduce the position of the prosthetic foot and contact with the support surface by the angle of the hip or, in the case of the person with a transtibial amputation, the knee, and pressures felt within the prosthetic socket.

CARDIOVASCULAR ENDURANCE A thorough assessment of an amputee’s cardiovascular status followed by appropriate aerobic/endurance training is an integral part of preprosthetic and prosthetic management. The energy requirement for prosthetic gait is higher than that of individuals who ambulate on two intact lower limbs. The aerobic capacity of dysvascular amputees has been demonstrated to be lower than that of age-matched peers without amputation.51–53 Some key physiologic considerations for prosthetic gait as evidenced in literature reviews52,53 include the following: • The energy cost of walking is greater in individuals with amputations than those without. • Higher level amputations are associated with higher energy costs of gait than lower level amputations. • Persons with dysvascular amputations demonstrate greater energy cost of gait than those with traumatic amputations.

26 • Early Rehabilitation in Lower Extremity Dysvascular Amputation

• Customary or self-selected gait speed decreases with higher levels of amputation. • The average rate of oxygen consumption during selfselected gait speed may not be significantly greater than normal, especially for transtibial prosthetic users, as individuals decrease their self-selected speed to mitigate rising oxygen consumption. • It is generally more efficient for an individual with a prosthesis to ambulate with the prosthesis (with or without an AD) than it is to ambulate without the prosthesis using an AD. An exception to this may be the person with a dysvascular transfemoral amputation, where energy expenditure may be similar with and without a prosthesis if the individual is highly dependent on the AD. Energy expenditure for over-ground walking in people with unilateral dysvascular amputations is increased by up to 36% for transtibial and up to 65% for transfemoral amputations.53–57 Many individuals are deconditioned upon entering the rehabilitation course and, given that fitness correlates with the successful use of a prosthesis,13,14 aerobic training is an essential component of the preprosthetic and early prosthetic rehabilitation phases. It is well documented that peak oxygen consumption (VO2max) in individuals with dysvascular amputations is significantly less than in healthy age-matched peers without amputation.51,52,58 The VO2max is decreased, but the energy cost of gait is increased, thus simply walking can consume a much larger percentage of VO2max52,59 and cause individuals to be functioning closer to their aerobic threshold. With this in mind, there is some evidence that the ability to train at 50% of VO2max may be associated with a “successful” prosthetic outcome (operationally defined as the ability to walk 100 m with or without an AD) in older adults with high-level amputations (transfemoral and hip disarticulation).60,61 Preprosthetic aerobic conditioning may be in the form of wheelchair propulsion, single-limb ambulation with an appropriate AD, bilateral upper and/or unilateral lower extremity ergometry, circuit training, or swimming. Amputees often continue these activities as they enter the prosthetic phase of rehabilitation. As the condition of the residual limb and wearing tolerance permit, ambulation with the prosthesis can be used as a cardiovascular endurance activity. Individuals who are taught to monitor their own pulse, respiratory rate, and/or rate of perceived exertion are able to participate more confidently and independently in aerobic training. Training programs are individually prescribed by the therapist based on the person’s past medical history and current cardiovascular, pulmonary, and musculoskeletal status utilizing standardized guidelines for older adults as a goal (see American College of Sports Medicine Guidelines for Exercise Testing and Prescription).62 For maximal impact, the therapist must introduce the appropriate level of challenge within the context of an activity that is agreeable and motivating to the amputee. For individuals with few cardiovascular restrictions, once they are tolerating prosthetic wearing, brisk walking and/or the use of exercise equipment (e.g., treadmill, stationary bicycle, NuStep, stair climber, elliptical machine, circuit training) constitute excellent endurance training activities for the appropriate person. An amputation need

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not prevent individuals from participating in health and wellness exercise programs during and following their rehabilitation.

EDEMA CONTROL OF THE RESIDUAL LIMB The reduction of postsurgical edema is critical in the early postoperative rehabilitation phase. Use of standard or removable rigid postoperative dressings (e.g., cast or prefabricated polyethylene dressing) after transtibial amputation appear to be superior to soft dressings (including Ace wrapping) in controlling the volume of the residual limb63,64 and are associated with a shorter time from amputation to initial fitting of the prosthesis.65,66 Removable rigid dressings seem to be the optimal choice for postoperative dressings because they offer the same benefits as standard rigid dressings (edema control, limb shaping, and protection) but also offer the opportunity to inspect the surgical site and monitor wound healing; however, this type of postoperative care is not routinely used in the United States, perhaps because of the debate among payers regarding who is responsible for reimbursement (hospital vs. insurance). When the more common soft dressings are used, Ace wrapping for compression is applied over the transtibial residual limb dressing. Ace wraps should be applied in oblique angles (not circumferentially, so as to avoid a tourniquet effect), with a gradual increase in pressure from distal to proximal, and always extending above the knee (as the transtibial prosthetic socket engulfs the medial and lateral aspects of the knee). Amputees and their family members should be instructed in wrapping technique, as the Ace wrap typically has to be reapplied several times a day. The transfemoral residual limb does not lend itself to rigid postoperative dressings and is more challenging to Ace wrap, as it requires anchoring over the pelvis, and it may be difficult for an amputee to elevate the pelvis for wrapping. Nevertheless, techniques for postsurgical compression wrapping should be a part of the treatment plan. After the staples or sutures have been removed, use of a commercial pressure garment (“shrinker”) is suggested for persons with either transtibial or transfemoral amputations. Residual limb edema plays a big role in determining when initial prosthesis fitting will take place—if the prosthesis is fitted too early and the residual limb is still substantially shrinking, this will affect the intimacy of prosthetic socket fit, making training more difficult and increasing the risk of complications caused by a poorly fitting socket. Prerequisites for initial prosthesis fitting include sutures removed, surgical wound healed or healing, and edema controlled, with distal measurements less than or equal to proximal measurements. The importance of continued shrinking efforts, even after prosthesis training has begun, should be emphasized. Individuals must usually continue to wear a shrinker when they are not wearing their prosthesis, at least during early training efforts, to reduce the likelihood of insidious edema when the prosthesis is not being worn. If amputees allow the edema to return to the limb, the socket may no longer fit and aggressive efforts to reduce the limb volume will have to precede any further prosthesis training. Individuals

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prone to fluctuations in fluid volume (e.g., those with kidney dysfunction or congestive heart failure [CHF]) will likely have to use a shrinker indefinitely. For others, whose residual limb ultimately reaches a stable size and shape, a shrinker may not be necessary once the prosthesis is consistently being used. The decision to discontinue the use of a shrinker permanently is based on two factors: (1) consistency in the number of sock layers worn during the day and (2) the ability to don the prosthesis without decreasing the usual number of sock layers after a night’s sleep without the shrinker. Significant changes in body weight can also dramatically affect socket fit. All amputees should be educated regarding the importance of contacting the prosthetist and/or therapist if their weight changes significantly over time.

SOFT TISSUE MOBILITY OF THE RESIDUAL LIMB Soft tissue and bony adhesions that limit tissue mobility around the incision scar and the surrounding area may have an impact on tolerance, comfort, and use of the prosthesis. Surgical amputation can include muscle-to-muscle (myoplasty), muscle-to-fascia (myofascial), and/or muscleto-bone (myodesis) surgical fixations to stabilize the remaining muscle.67 Scarring or adhesions can occur in any or all of these tissues. The normal stresses and shearing forces of cyclic loading and unloading during gait require that soft tissue throughout the residual limb be mobile. If the soft tissue is not able to move independently of the scar tissue or skeletal structures, the resulting stress can lead to tissue breakdown and/or discomfort. Soft tissue mobilization techniques early in the rehabilitation process can help to establish appropriate tissue mobility in the residual limb. Once the surgical incision has been closed securely, soft tissue massage can be an effective tool for maintaining tissue mobility. Deep friction massage may be helpful in managing scar tissue that is restrictively adhered. Individuals can be instructed in the use of this modality with specific guidelines for proper technique. Appropriate deep friction massage targets movements between skin, subcutaneous soft tissue and fascia, and muscle layers. Improper deep friction massage technique is ineffective in managing scar tissue and potentially harmful for the person with fragile skin and soft tissue, as friction generated between the fingers and skin results in irritation, blistering, or breakdown and can delay the use of a prosthesis until adequate healing has occurred.

SENSORY STATUS OF THE RESIDUAL AND REMAINING LIMBS Residual limb and sound limb sensibility is formally assessed during the initial PT examination. Standard sensation testing guidelines may be used to assess all sensory modalities (pain, temperature, light touch, deep pressure, proprioception, vibration). Semmes-Weinstein monofilament testing may be used to assess for protective sensation of the sound limb. Several commonly occurring postamputation sensory phenomena can have implications for functional outcome in persons with amputations. These include hyposensitivity, hypersensitivity, phantom sensations, and phantom limb pain.

Hyposensitivity Hyposensitivity is most often encountered among those with a history of diabetes, neuropathy, traumatic nerve damage, or vascular disease. Limited research suggests that deep pressure remains intact but superficial pain sensibility is impaired in transtibial residual limbs.68 Amputees who have impaired sensation are at high risk for skin breakdown because they may not recognize discomfort associated with skin irritation resulting from repetitive stresses and pressures. Inclusion of education about the preventative need for visual inspection for signs and symptoms of soft tissue lesions and supervised practice of this task can reduce the risk of skin breakdown. Adaptive equipment, such as mirrors, or the assistance of caregivers may be necessary for people with concurrent limitations in cognition, flexibility, and/or visual impairment. Hypersensitivity Early in rehabilitation, it is not uncommon to encounter a generalized hypersensitivity of the residual limb. This hypersensitivity is thought to be a consequence of nerve damage from amputation surgery itself.69 Hypersensitivity can be effectively managed by bombarding the residual limb with tactile stimuli using a variety of textures and pressures. Strategies for reducing hypersensitivity include gently tapping with the fingers, massaging with lotion, touching with a soft fabric (e.g., flannel or towel), rolling a small ball over the residual limb, and implementing a specific wearing schedule for shrinkers and removable rigid dressings. Intensity of intervention is based on the individual’s tolerance to the sensory stimulation. The techniques can be progressed in intensity, type of modality used, and duration of stimulus (e.g., touching the limb with a rougher fabric and increasing wearing time for the shrinker). Amputees are strongly encouraged to use these techniques independently as part of their home program. Over time these techniques should help to reduce the hypersensitivity, with the ultimate goal of tolerance to normal sensory input without discomfort. Physiologically, overloading the nervous system with sensory stimuli is thought to encourage habituation via downregulation of neural receptors. Localized hypersensitivity may be an indication that a troublesome neuroma has developed at the distal end of a surgically severed peripheral nerve. A neuroma is suspected when localized tapping sends a shock sensation up the leg (the Tinel sign).70 If conservative clinical treatment is unsuccessful in reducing hypersensitivity and pain caused by a neuroma, injection of a local anesthetic directly into the region or surgical removal may be necessary. Targeted muscle reinnervation is a surgical technique that can be both preventative and corrective for cases of acute and chronic postamputation neuroma pain and hypersensitivity.69,71 Although this technique was initially developed to facilitate intrinsic control of upper extremity prostheses, it appears that it also has the added benefit of reducing neuroma formation and decreasing postamputation pain in lower limb amputees.69,71,72 The procedure involves transferring the cut ends of peripheral nerves to targeted motor units of the remaining limb (e.g., tibial nerve to a motor branch of the semitendinosis),71 creating specific electromyographic signals detectable by a myoelectric prosthesis.

26 • Early Rehabilitation in Lower Extremity Dysvascular Amputation

Targeted nerve reinnervation is another similar technique that also demonstrates success at reducing neuroma formation at the time of amputation. It may be more appropriate for those individuals who are ineligible or uninterested in using myoelectric prostheses because the procedure is less concerned with the rearrangement of the muscle-nerve units following amputation and generally allows for more distal nerve transfers.73 Although slightly different in approach, both procedures may minimize neuroma formation by reducing the aberrant sprouting of the severed nerves.69,72,73

Phantom Limb Sensations Phantom limb sensations are quite common after amputation.70,74–76 Many individuals report experiencing feelings of itching, tingling, numbness, or sensations of heat and cold in the toes or foot of the limb that has been amputated. Although the sensation can include the entire missing extremity, proximal sensation often fades, leaving only distal perceptions, a phenomenon known as “telescoping,” presumably related to the large area of somatosensory cortex dedicated to the distal extremity.70,77,78 Phantom limb sensation is a relatively harmless condition that tends to resolve in 2 to 3 years without treatment.70,78 It has potential functional implications, as it may be useful in providing a semblance of proprioceptive feedback from the prosthesis. Be alerted, however, as to the importance of educating individuals of the potential danger of phantom limb sensations: nighttime falls are not uncommon when, half asleep, an individual attempts to stand and walk to the bathroom, expecting the phantom foot to make contact with the floor. Phantom Limb Pain Phantom limb pain occurs in 50% to 80% of all persons with amputation and has wide variability in presentation.75,76,78 The incidence of phantom limb pain has been demonstrated to be greater with upper extremity as compared with lower extremity amputations78–80 and with proximal as compared with distal amputations78; both have been shown to decrease over time.76,78,79 When phantom pain occurs, it is most often described as a cramping, squeezing, aching, or burning sensation in the part of the limb that has been amputated. The spectrum of complaints may vary from occasional mild pain to continuous severe pain. The absence of observable abnormalities in the residual limb is common. Although the etiology of phantom pain is not definitively understood, changes in the peripheral nervous system, the spinal cord, and reorganization at the level of the cerebral cortex may all be involved in the perception of phantom limb pain.76,78,81–83 It is uncertain whether phantom pain is associated with preamputation limb pain, and the relationship with source of amputation (vascular versus traumatic) is also unclear.74,79,84 Whatever the etiology and predisposing factors, phantom limb pain is challenging to manage and disabling if the pain is severe. At present there are no evidence-based practice recommendations for the management of phantom limb pain. Mirror therapy has been used in the management of phantom limb pain85; it involves strategically placing the sound limb in front of an angled mirror to create the illusion that the amputated limb is intact; the individual watches the reflection in the mirror as he or she performs exercises of the sound limb and imagining the movement of the phantom limb. The

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individual receives visual feedback (in the mirror) confirming the “movement” of the phantom limb (the residual limb is concealed behind the mirror). This pairing of thinking about moving the phantom limb and seeing it move is aimed to help resolve the mismatch of information that exists in phantom limb pain (i.e., feeling pain in an extremity that does not exist is a conflict between the sensory experience and the visual experience). Graded motor imagery85,86 has also been used in treating phantom limb pain. Intervention components include a series of left/right limb orientation tasks directed toward limb laterality (distinguishing the phantom from the intact limb), explicit motor imagery tasks (imagining moving the amputated limb through a series of exercises), and mirrored visual feedback tasks. Although the mechanism by which these strategies minimize pain remains unknown, it is thought that both mirror therapy and graded motor imagery influence neural networks and cortical reorganization to combat the maladaptive neural plasticity caused by phantom limb pain. Other strategies used to address phantom limb pain include medications (antidepressants, anticonvulsants, and analgesics), neural blockade, transcutaneous electrical nerve stimulation, heat and cold modalities, acupuncture, biofeedback, firm pressure applied to the residual limb (e.g., massage, compression or prosthetic socket), exercises of the phantom limb, psychologic treatment, and education.75–78,87,88

Residual Limb Pain Residual limb pain is another potential limiting factor in lower extremity amputees. Common early after surgery, this pain usually subsides over time.70,76,78 Ongoing complaints of residual limb pain should prompt careful inspection of the residual limb, as the therapist may pick up on signs of infection or small cutaneous or subcutaneous problems that could manifest as pain. This careful inspection and follow through is especially important in individuals with diabetes and vascular disease, as data suggest that those who have an initial distal amputation at any level are at a substantial risk of revision of amputation to a higher level (Table 26.5);89 they have higher mortality90 and increased risk of readmission to the hospital.91 The therapist should also be mindful that residual limb pain is often confused with prosthesis-related pain, and in some cases a simple fix (e.g., adjustment of prosthesis or number of socks) can provide relief.70

CARE OF THE SOUND LIMB Ongoing assessment of the intact lower extremity should be the responsibility of the amputee with support from the physical therapist and, if necessary, caregiver. Individuals with diabetes, peripheral neuropathy, or peripheral vascular disease who have lost one leg as a result of the disease process have a significant chance of losing the other leg, given the symmetric distribution of disease processes and the increased functional demand on the remaining limb after amputation. The added burden to the remaining limb extends beyond the preprosthetic period. Once ambulatory with a prosthesis, individuals will preferentially initiate level surface walking with the prosthetic limb, placing a larger burden on the sound limb for stability and propulsion.92 As an ambulatory individual makes adjustments to increase walking speed and distance and navigate uneven surfaces, demands continue to increase on the sound limb.93–95

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1 Year

3 Years

5 Years

perform daily foot inspection independently because of disease or visual impairment or decreased agility, individuals must be able to direct a caregiver in inspecting the foot. Even if individuals are physically incapable of performing certain tasks for their own health and safety, they are ultimately responsible for their own care. Developing or improving on a person’s skill at directing assistance is a useful and realistic PT treatment goal.

Overall rate of a second amputation surgery

26.7%

48.3%

60.7%

CANDIDACY FOR A PROSTHESIS AND PRESCRIPTION

Ipsilateral minora

22.8%

39.6%

52.3%

Ipsilateral major

4.7%

11.8%

13.3%

Table 26.5 Published Data on Reamputation of the Ipsilateral Limb or Amputation of the Contralateral Limb by Level of Initial Amputation Izumi (2006)164—Retrospective review of 277 participants with major and minor amputations with diabetes over a 10-year period

Contralateral minora

3.5%

18.8%

29.5%

Contralateral major

11.6%

44.1%

53.3%

Overall rate of a second amputation surgery

N/A

32.5%

N/A

Ipsilateral minor

10.5%

N/A

14.2%

Ipsilateral major

7.1%

N/A

8.4%

Contralateral minor

3.2%

N/A

8.4%

Contralateral major

5.7%

N/A

11.5%

Glaser (2014)89—Retrospective review of 1715 participants with major and minor amputations from nonhealing wounds with or without peripheral artery disease or ischemic rest pain over a 12-year period

96

Shah (2013) —Review of 391 participants with major amputations and vascular disease over a 5-year period Ipsilateral

N/A

N/A

14%

Contralateral

N/A

N/A

13.8%

Contralateral amputation-free survival rate

60%

49%

33%

a

Data reported as “minor” amputation was at the level of the toe.

Contralateral limb amputation is a very real threat in those with diabetes and renal and/or vascular compromise,89,96 although advances in revascularization technology may explain the recent trend toward decreased rates of reamputation (see Table 26.5). Special consideration should be given to those with chronic renal insufficiency and end-stage renal disease, as current literature suggests that this population has the highest risk of contralateral limb loss.89,96 To minimize the risk of loss of the remaining limb, close monitoring of limb condition (especially for subtle or insidious trophic, sensory, or motor changes) and optimal foot care is essential. Ongoing, systematic and frequent assessment of pulses, edema, temperature, and skin is suggested. Education about the importance of a daily routine of cleansing, drying, and closely inspecting the foot (including the plantar surface and between the toes) is crucial. Podiatric care of nails, corns, and plantar calluses, appropriately fitting footwear or accommodative foot orthoses, and avoidance of barefoot walking are three additional imperatives for the longevity of the remaining foot. If unable to

The members of the interdisciplinary team involved in the care and rehabilitation of an amputee may include the surgeon, a physiatrist, a prosthetist, a physical therapist, an occupational therapist, a social worker, a rehabilitation nurse, and a vocational rehabilitation counselor. Many hospitals and rehabilitation centers have established prosthesis clinics that bring together the appropriate professionals to address the needs and problems of users. Deciding on an individual’s candidacy for a prosthesis the first major clinical step to be taken. Although the literature has identified predictors of the outcome of prosthesis use,13–15 the team considers the individual’s needs, motivation, and functional capacity in determining candidacy. Factors most often considered in whether to fit an individual with a prosthesis include the following: 1. Medical history: Disabling medical conditions may prohibit successful prosthetic use. Although the specific influence of multiple comorbidities on an amputee’s candidacy for a prosthesis and its later use remain unknown, several studies relate an increased number of comorbidities with poorer prosthetic outcome.13 Advanced cardiac or pulmonary disease that significantly impairs functional status before amputation has an impact on a person’s prosthetic candidacy. A history of cerebrovascular accident with hemiplegia of the side opposite the amputation may limit functional use of a prosthesis, although some evidence suggests that the degree of motor impairment is more predictive of outcome than the side of involvement.14 Cognitive functioning may be associated with prosthetic outcomes, suggesting the value of a cognitive screen as a component of prosthetic candidacy assessment. In 2017, Frengopoulos et al. demonstrated that lower scores on the Montreal Cognitive Assessment were associated with poorer prosthetic performance and outcomes.97 2. Premorbid and present level of function: An individual who required substantial assistance for functional mobility before amputation may have limited prosthetic training goals. Preamputation ambulation ability is predictive of walking ability with a prosthesis,14 although it is important to consider how far back to measure walking ability; a series of toe or forefoot amputations may precede transtibial or transfemoral amputation, and individuals may have had limited walking mobility for months prior to the final surgery. Individuals who are independent with functional activities, ADLs, and ambulation with an AD after amputation will do well with a prosthesis. 3. Body build: Morbid obesity may pose significant challenges to fitting a prosthesis. Amputees should not, however, be

26 • Early Rehabilitation in Lower Extremity Dysvascular Amputation

excluded from fitting and training on the basis of their weight alone, as an updated systematic review by Kahle et al. suggests that when controlled for comorbidities, age and sex, body mass index is not a significant predictor of walking ability.13 There is some evidence that underweight individuals may perform more poorly than people of normal weight and obese individuals,98,99 although this is an admittedly confounded variable. 4. ROM: Significant hip and knee flexion contractures are best addressed prior to prosthetic fitting if an individual is to achieve efficiency and functional independence with a prosthesis, as contractures have been shown to have a negative impact on functional outcome.13,25,100 5. Support at home: People who are likely to require assistance must depend on family members, significant others, or formal caregivers to help with one or more tasks. The potential to be a limited household ambulator with a prosthesis may be important in reducing the burden on caregivers and may allow a person to remain at home with a caregiver as opposed to living in an institution. Because there are no definitive criteria for determining who is and is not a strong candidate, careful consideration of the individuals’ characteristics and situation is imperative. Some authors believe that even individuals who show limited or moderate potential for success based on existing criteria should be fitted with a prosthesis and afforded the opportunity to try.17 Should an individual be deemed a reasonable candidate, these same considerations and others are used in determining the specific prescription for that individual. The Medicare Functional Classification Level consists of five categories (K levels 0–4) and is used to determine which prosthesis components are appropriate based on the amputee’s level of function and rehabilitation potential.101 Although all components of the prosthesis must be justified for payment by Medicare, only knees and feet are bound by Medicare K levels (e.g., a K-1 amputee can have the same suspension system as another with a K-3 level). It is imperative that amputees be assigned the appropriate functional level, as assignment into a lower K level may hinder optimal mobility. For instance, classification as K-1 will result in a SACH foot, whereas a K-2 amputee is eligible for a multi-axis foot and a K-3 for a dynamic response foot; amputees rated K-2 or K-3 will have greater ease in walking over uneven surfaces compared with those classified as K-1.101 Use of higher K-level componentry transfemoral amputees who were initially assigned into lower K levels (i.e., upgrade to use of microprocessor knees) appears to reduce falls risk and improve mobility, reminding therapists to suspend biases that higher-tech equipment should be reserved only for younger individuals.102–104 The process of K-level determination is not consistent across clinicians, prosthetists, and physicians, and the providers who determine the K levels are also not consistent. A survey of 213 U.S. prosthetists by Borrhenpol et al. in 2016 found that 47.3% of prosthetists assign K levels alone, 42.9% of prosthetists collaborate with other health care providers (e.g., physical therapists), and 7.3% reported that K levels were assigned by the amputees’ physicians.101 In the same study, it was also concluded that a standard method for K-level determination does not exist; some

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prosthetists and clinicians reported using performancebased measures such as the Amputee Mobility Predictor (AMP), Berg Balance Scale [BBS], or the 2-minute walk test; others used self-report measures such as the Orthotics and Prosthetics Users Survey (OPUS) or Activities Specific Balance Confidence (ABC) Scale.101 Some literature suggests that the AMP may be the ideal outcome measure to determine K levels, especially in differentiating between K levels 3 and 4.105 However, the wide range of scores across multiple K levels makes it difficult to use the AMP to determine one specific level.106 It should be noted that if an individual’s functional ability increases over time, the rating can be raised. K Level 0: This does not imply the ability or potential to ambulate or transfer safely with or without assistance, and such a prosthesis does not enhance the individual’s quality of life or mobility. K Level 1: This enables the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at a fixed cadence; it is a household ambulator. K Level 2: A prosthesis at this level enables the ability or potential for ambulation with and to traverse low-level environmental barriers such as curbs, stairs, and uneven surfaces; it is a limited community ambulator. K Level 3: Such a prosthesis can facilitate the ability or potential for ambulation with variable cadence; it is an advanced community ambulator, enabling the amputee to traverse most environmental barriers. It may also enable vocational, therapeutic, or exercise activity that demands utilization of the prosthesis beyond simple locomotion. K Level 4: This type of prosthesis implies an ability or potential for ambulation that exceeds basic ambulation skills, exhibiting high-impact, stress, or energy levels; it is useful to active children, young adults, and older adults engaged in recreational activities and sports. It is important for physical therapists to understand the role they play in determining the K level. Because therapists spend a great deal of time working with people one on one, they often have a clearer idea of the individual’s goals or needs than do other members of the team. The therapist may gain insight or information that is important in the decision-making process. If he or she is familiar with the components of prostheses and the K levels under which those components are covered, the therapist may begin to form an opinion about the best prosthetic prescription for a given amputee during the early rehabilitation phase. Reassessment on a regular basis during the initial stages of rehabilitation and sharing the current and projected mobility status with the interdisciplinary team is the ideal model for the determination of K levels and prosthetic prescriptions. The physical therapist must have a basic understanding of prosthetic components and design to be able to contribute to the prescription process. In the dynamic biomedical industry, it is challenging to stay current with developments in prosthetic design and technology, and prosthetic options can seem overwhelming! Excellent working relationships with local prosthetists can be of great benefit, and therapists should be critical consumers of the professional literature related to componentry with special attention to research sponsors (who are often the prosthetic companies). A therapist with

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a thorough understanding of the different characteristics of prosthetic feet can help to work with the prosthetist in identifying the type of foot that is most suitable and economical to meet a specific person’s functional needs. Therapists must also be familiar with the special needs of certain clinical populations so that they can assist in determining the optimal prescription to meet those needs. People with diabetes who are at great risk for additional skin breakdown and poor healing may benefit from a socket with a soft insert or from a silicone sleeve designed to reduce friction during use. Frail or deconditioned individuals may reach higher levels of function if lightweight components are chosen and stability in prosthetic prescription is emphasized. Decisions to change socket design or suspension for long-term prosthesis users must be carefully considered. A person who has worn a particular type of prosthesis for a long time may have difficulty acclimating to a new type of device. If a person has no complaints about a prosthesis other than “it’s worn out,” it is advisable to use similar components for a replacement prosthesis. If a person is expressing interest in new goals or activities (e.g., a prosthesis user who has never run and would like to try jogging), prescription changes may be warranted.

Early Training for Use of a Prosthesis Initial fitting occurs when the surgical incision is healed (or is healing without complications) and girth measurements at the distal residual limb are equal to or less than proximal girth measurements. The time from surgery to initial fitting in uncomplicated dysvascular amputees generally ranges from 6 to 12 weeks. Individuals with uncomplicated traumatic amputations may be fitted as early as 2 to 3 weeks, and individuals with dysvascular amputations complicated

A

B

by delayed wound healing or medical issues may have to wait several months prior to being fitted for initial prosthesis. Although a prolonged wait time may be frustrating, it can be used in priming the amputee for training with appropriate flexibility, resistance, endurance, and balance. Several important components of early rehabilitation can be effectively addressed in group classes and/or through printed materials. These components include care of the sound limb, donning and doffing the prosthesis, establishing a wearing schedule, managing and preventing skin breakdown, positioning with the prosthesis, and care of equipment.

DONNING AND DOFFING THE PROSTHESIS Donning the prosthesis will become second nature for an amputee—just another component of getting dressed each day—but early in rehabilitation it must be deliberately taught through a series of specific steps that will be dictated by the prosthesis’s components. The most common suspension system for a transtibial prosthetic device is a roll-on silicone liner with a pin-lock suspension system. Donning of this type of prosthesis is represented in Fig. 26.1. This procedure requires the individual to attend to the orientation of the distal pin when rolling the liner onto the residual limb so as to anticipate appropriate need for socks for optimal fit, to orient the pin into the ring-lock mechanism in a seated position, and to stand and bear weight for the final engagement of the suspension mechanism. On weight bearing, the pin will depress into the ring, which is confirmed by a predetermined number of audible clicks to indicate appropriate fit (too many or too few clicks point to a need to reassess alignment and prosthetic socks). Other types of suction/vacuum suspension systems (e.g., a roll-on seal-in ring for transtibial or transfemoral prostheses or double wall vacuum system or classic valve system for transfemoral prostheses) have

C

Fig. 26.1 This person with a recent transtibial amputation demonstrates the correct sequence for donning her prosthesis. (A) First, she applies the silicon liner, attending to the orientation of the pin. (B) Once the liner has been positioned, prosthetic socks are added, one at a time, and carefully adjusted for a smooth fit until the desired number of layers is reached. (C) The final step is to insert the residual limb with socks and liner into the prosthesis. The prosthesis is donned in the seated position, gradually increasing weight bearing to achieve the desired total contact fit.

26 • Early Rehabilitation in Lower Extremity Dysvascular Amputation

distinctive requirements for optimal donning technique and usually require cleaning of the residual limb and/or application of a lubricant prior to donning. Balance and hand strength and dexterity may be prerequisites to independent donning; they are therefore addressed in the preprosthetic phase. The chapters on prosthetic components elucidate further the donning requirements for specific types of prostheses, and therapists can rely on their prosthetist colleagues to answer questions about specific donning needs related to any device with which they are not familiar. Whereas donning technique is specific to socket and suspension type, there are some universal themes in donning that should be taught to all users. For instance, individuals are taught to dress the prosthesis first (i.e., for ease of dressing, put the prosthesis through a pant leg and place a shoe on the prosthetic foot prior to donning the limb). Additionally, all users must learn to pay close attention to the orientation of the socket in the horizontal plane. The contours of the socket are precisely designed to accommodate the residual limb’s anatomy. In a person with a sensate residual limb, this may be constructive in assuring proper alignment, as the socket will not “feel right” unless it is oriented correctly. In the person with impaired sensation in the residual limb, vision and palpation of the residual limb structures may be used to assure proper alignment. Often individuals use the prosthetic foot as a reference for horizontal plane alignment; static prosthetic alignment often places the foot in slight outtoeing in standing, and the individual can use this visual cue as affirmation of proper prosthetic alignment. Early instruction and assessment of donning and fit of the transfemoral socket often requires the therapist to palpate the ischial tuberosity and potentially other structures (e.g., pubic rami, adductor tendons) for optimal positioning within the socket. This requires clear and professional communication and education to clarify the purpose and process of a palpation that would otherwise be considered a serious invasion of personal space.

Prosthetic Fit: Socket Design and Sock Use A close fit between the residual limb and the socket is necessary for successful training. The optimal prosthetic fit is quite snug, like that of a custom-made glove on the hand. The total-contact socket is designed to distribute weight bearing over a maximal surface area, assist in venous blood return, provide sensory feedback through the residual limb, and enable an efficient transfer of muscle function to the prosthetic device. Although the socket is prepared over a positive model of the amputee’s limb, either through casting or computer technology, the dynamic nature of the residual limb may require socket modifications in the early days of training. Frequent and careful inspection of the residual limb and feedback from the user will serve to assess socket fit and tolerance to wear. Socket comfort is extremely important to amputees regardless of etiology.107–109 New users must be educated on the principles of fit and weight bearing and on what to expect with their first attempts at standing while wearing a prosthesis. Because of the nature of the full-contact socket and the distribution of weight bearing throughout, the prosthesis may feel “tight,” “squeezing,” or “strange.” All are normal and expected initial responses to prosthesis wear. Total contact within the socket is very important, and skin problems can occur when total contact is not achieved.

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Amputees should understand where weight-bearing pressures are best tolerated on the limb and where pressure sensitivity is likely to occur. Although they may initially expect to bear weight through the distal end of the limb, they must understand that sockets are designed to distribute weightbearing forces across several areas. For the transtibial socket, these areas include the patellar tendon, anteromedial and anterolateral surfaces of the residual limb, medial tibial flare, and distal posterior aspect of the residual limb. For the ischial-ramal containment transfemoral socket, they include the posterior aspect of the residual limb, with the pubic ramus (medially), ischial tuberosity (posteriorly), and greater trochanter (laterally) contained in the prosthetic socket. The ischial-ramal containment socket also distributes pressure through the lateral femur to increase the efficiency of the hip abductors in weight bearing. The quadrilateral socket, not often prescribed but still in use with long-time users, utilizes pressure anteriorly on the Scarpa triangle, forcing the ischial tuberosity to rest on a posterior shelf of the socket. Prosthetic socks are used to modify the fit between the socket and the shrinking residual limb. Proper use of prosthetic socks enhances residual limb weight bearing in pressure-tolerant areas, decreases the likelihood of skin breakdown in pressure-intolerant areas, and increases comfort within the socket. Wool or cotton prosthetic socks are available in three different layers (thicknesses): one (thinnest), three, and five (thickest). Amputees who use a rigid or flexible socket may first apply a thin sheath directly over the skin (under the socks) to minimize friction and wick moisture away from the skin. Socks are then applied before the limb is placed in the socket. If a sheath is not used, socks are applied directly on the residual limb. When silicone suction suspension or a friction-reducing liner that requires skin contact is used, socks are applied after the sleeve or liner has been placed on the clean residual limb. For liners with a pin-in-ring locking mechanism, a small hole in the bottom of each sock will allow for engagement of the pin within its receptacle. Socks are combined to create a snug fit that uses the fewest socks to achieve the appropriate sock thickness (e.g., one 3-layer sock is preferable to three 1-layer socks). Users should be encouraged to establish a careful routine of donning the appropriate number of socks, one layer at a time, smoothed free of wrinkles, with seams facing down and away from the residual limb. For some users, including those prone to fluctuations in fluid volume (e.g., those with kidney dysfunction or CHF), a few minutes in a dependent position without a shrinker or Ace wrap in place can substantially increase the size of the residual limb. For this reason, they must wear their compression device until the moment when they are ready to don their prostheses. Amputees should be informed that initiation of weightbearing activities in the prosthetic socket significantly decreases limb edema and accelerates maturation of the residual limb as a result of the total contact and the pumping of muscle contractions during weight-bearing and movement. Shrinkage of the residual limb in early training is accommodated by the addition of layers of socks to maintain a snug residual limb-prosthesis interface. Fluctuations in limb volume associated with edema in the first weeks and months after amputation often mean that the appropriate number of sock layers must vary from day to day and often within a given day. Given fluctuations in the size of the

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residual limb during early training and the need for a precise socket fit, new users of prostheses must carry extra socks with them whenever they are going to be out for more than 2 to 3 hours. Because of the potential for rapid fluctuations in limb size, choosing and monitoring the correct number of socks may be challenging for those new to the use of a prosthesis. Therapists and prosthetists work with new users to assist in the development of problem-solving skills and strategies to determine the appropriate number of socks to use. Most individuals become adept at judging the adequacy of sock layers when given the opportunity to practice and solve problems early in their rehabilitation. When too few socks are used, the residual limb can descend too far down within the socket and the distribution of weight throughout the residual limb may be affected. Sometimes the amputee will hear more than the usual number of clicks when donning a pin-in-ring suspension device. Another indication may be sensations of pain in the distal residual limb and/or pistoning during ambulation; this can occur when the prosthesis slips downward when unweighted and upward on weight bearing. If pistoning is suspected, close observation of the anterior or posterior trim line of the socket or border of the liner during an unweighted hip-hiking motion of the prosthetic side may reveal that slippage is occurring; in such a case, additional sock layers are indicated. When the transtibial prosthesis and socks are taken off to inspect the skin, reactive hyperemia (redness) is seen at the proximal patellar tendon and the inferior border of the patella as well as at the distal anterior residual limb. Redness may also be present on the fibular head, which has contacted the socket below its intended relief area. These are all signs that the residual limb is sinking too deep into the socket and that additional sock layers should be added. Too few socks in a transfemoral socket may lead to increased weight bearing and hyperemia on the distal residual limb and complaints of pressure in the groin as the socket rides up higher than intended. Although pistoning is usually an indication of too few layers of socks, paradoxically it can also be seen in a person wearing too many layers because the residual limb is never fully situated in the socket and therefore never gains good purchase, causing the socket to move up when weight bearing and down when unweighted. Indications that too many layers of socks have been donned may be complaints that the prosthesis is difficult to don, fits too tightly, or feels slightly longer during gait. In the transtibial amputee, if inspection of the skin after ambulation reveals reactive hyperemia on the distal patellar tendon, tibial tubercle, and/or head of fibula, these landmarks may be contacting the socket above their intended reliefs (i.e., too many socks prohibits the residual limb from being well positioned in the socket). In the ischial containment transfemoral socket, too many socks will prohibit the residual limb from gaining good purchase within the socket and the amputee will not feel “locked” into the socket. In long-term users who are still using a quadrilateral socket design, the ischial tuberosity will be elevated off the posterior shelf. These are indications that one or more layers of socks should be removed to enhance socket fit. Prosthetic socks can also be used creatively to solve problems with socket fit. If, for example, the girth of the amputee’s distal residual limb has decreased more quickly than its proximal girth, creating a pendulum effect within the socket

during ambulation, one of the prosthetic socks can be cut to cover just the lower half of the residual limb. When layered between two full-sized socks, the shorter sock helps to fill the extra space within the socket, ensuring total contact between the limb and socket. Typically, when the precision of fit within the socket is compromised by 15 or more layers of sock, switching to a new prosthetic socket is indicated. How soon the initial socket will have to be replaced varies depending on the pattern of shrinkage of the residual limb. For some, the first replacement socket may be necessary in 2 to 3 months, whereas others may use their initial socket for 6 months or more. The socket may be replaced additional times as the residual limb continues to shrink during the first postoperative year. An individual is considered to be ready for the definitive prosthetic socket when the size of the residual limb is stable for an 8- to 12-week period, as indicated by girth measurements and by a consistent number of sock layers for prosthetic fit; this generally takes anywhere from 6 to 18 months after surgery. With each new socket, close monitoring of the residual limb throughout the adjustment period is necessary.

ALIGNMENT OF THE PROSTHESIS This is evaluated in quiet standing (statically) and during gait activities (dynamically). Static alignment refers to the relationships between the socket, prosthetic knee joint (if applicable), pylon, prosthetic ankle/foot, and floor; the length of the prosthesis; and the overall fit of the socket on the residual limb. Because the assessment of static alignment is the first standing activity in which an amputee engages, it is prudent to carry this out in the parallel bars or with substantial support if parallel bars are not readily available. Information gleaned from this assessment can provide clues regarding pressure distribution on the tissues of the residual limb within the socket. Problems with alignment affect not only pressures within the socket but also the biomechanics of gait and the translation of forces from the prosthetic foot up the kinematic chain. The assessment of dynamic alignment includes all components of static alignment but in the context of movement and also the assessment of suspension and symmetry of gait. Both static and dynamic alignment must be evaluated from anterior, posterior, and lateral (prosthetic and sound side) views. Table 26.6 provides a basic rationale for standard transtibial and transfemoral static alignment, which is important for therapists to understand given the close association of prosthetic alignment with the biomechanics of gait. For a thorough review of prosthetic alignment, see the chapters on the relevant components.

WEARING SCHEDULE FOR THE PROSTHESIS It is vital that new users of a prosthesis understand the importance of the gradual progression of wearing time and are compliant with their personalized wearing schedule. Constant reassessment of socket fit and comfort and diligent assessment of the skin of the residual limb after bouts of wear are necessary during the entire training phase. Amputees and/or their care providers should be well educated on residual limb inspection. Rapid and significant changes in residual limb shape and size are common in early

26 • Early Rehabilitation in Lower Extremity Dysvascular Amputation

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Table 26.6 Static Alignment of Prosthesis and Rationale Alignment

Rationale for Alignment

POSTERIOR VIEW Prosthesis height (symmetric leg length)

Prevents gait deviations associated with leg-length discrepancy Provides optimal weight bearing through the socket to prevent pain and skin issues Prevents sound limb orthopedic deformity associated with leg-length discrepancy

Plumb line: midsocket to slightly lateral to midheel

In the transtibial prosthesis, creates slight varus moment during stance, as in normal gait In the transtibial socket, directs compressive forces to pressure-tolerant areas at medial proximal (medial tibial flare, medial femoral condyle) and lateral distal (fibular shaft) residual limb and minimizes compressive forces on nontolerant areas at lateral proximal (fibular head) and medial distal residual limb In the transfemoral socket, directs forces onto the residual lateral femoral shaft

Slight adduction of transfemoral socket

Adduction of the transfemoral socket serves to improve length tension relationship and efficiency of the hip abductors in maintaining a level pelvis during unilateral stance

LATERAL VIEW Transtibial socket in 5–10 degrees of flexion (anterior tilt of socket, encouraging slight knee flexion) when in a midstance position

Distributes weight-bearing forces to anterior pressure-tolerant aspect of transtibial residual limb Limits vertical displacement of center of mass at midstance to decrease energy cost of gait Allows for controlled knee flexion in loading response and late stance, as in normal gait Prevents abnormal hyperextension of the knee in midstance

Transfemoral socket in 5 degrees of flexion (posterior tilt of socket, encouraging hip flexion) with the knee in full extension at the midstance position

Serves to improve length tension relationship and efficiency of the hip extensors during stance phase of gait Distributes weight bearing forces to posterior pressure-tolerant aspect of transfemoral residual limb

Plumb line: midsocket to anterior edge of heel

In transtibial alignment, allows for knee flexion from mid- to terminal stance In transtibial alignment, prevents hyperextension of the knee in stance

Assessment of trochanter-knee-ankle line

In transfemoral alignment, provides assessment of the location of the center of rotation of the knee joint in the transfemoral prosthesis relative to hip and ankle, which dictates the stability of prosthetic knee extension during stance and the ease of prosthetic knee flexion in preparation for swing

prosthetic training due to weight bearing, compression within the socket, and the muscle pumping action that occurs with walking. As a result, socket fit may become less intimate, which can lead to skin issues. The duration of early wearing time is usually conservative, especially for individuals with a history of skin integrity problems. Initial weightbearing activities are closely supervised, lasting no longer than 5 to 10 minutes in between skin inspections. Inspection of the residual limb after the first few minutes of weight bearing should reveal redness of the skin in predictable loadbearing regions. Because both the transtibial and transfemoral sockets are designed to be in total contact with the residual limb, the entire limb may develop a mild reactive hyperemia (redness) that is apparent when the socket is first removed. Once an individual is spending 30 to 60 minutes in the prosthesis without problems, total time in the prosthesis is gradually increased, often in increments of 15 to 30 minutes as tolerated. The therapist works with the amputee to determine how much of the wearing time he or she should spend up and walking. People with no history of skin integrity

problems (e.g., traumatic amputation or revision of congenital limb anomaly) often progress quickly with wearing activities, whereas those with sensory impairment or peripheral vascular disease may have to progress more cautiously. An individualized written schedule should be provided to guide prosthetic wearing of the prosthesis and prevent misunderstandings about the time permitted for its use and the suggested amount of upright weight-bearing activity per bout of wear.

POSITIONING People will often need instruction about positioning of the lower extremity in the prosthesis when seated. The trim lines of the transtibial socket are designed for optimal pressure distribution during upright weight-bearing activities. The high posterior wall of the socket is necessary to provide counterpressure to the anterior weight-bearing surface in stance but can place undue pressure on the hamstring tendons in sitting. The patellar tendon indentation in the prosthesis is designed to take weight in standing but can place

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pressure on the anterior aspect of the tibial tuberosity if the prosthesis slips down when the person is seated. Similarly, the transfemoral socket can shift or lose suction in sitting, which can result in undue pressure if the person remains sitting for a long time. It is optimal that, when seated, the individual’s prosthetic foot rest flat on the floor or foot plate of the wheelchair so that the residual limb remains in total contact with the socket. This helps avoid the risk of undue pressure and decreases the chance of gapping between the prosthesis and the residual limb, which may allow edema to develop. Additionally, although some individuals may be anxious to carry out exercise programs with the prosthesis in place, they must understand that using the prosthesis for activities other than walking (e.g., weighted long-arc quad riceps exercise, recumbent cycling ergometer use) changes the magnitude and direction of forces on the residual limb and may increase the possibility of skin breakdown.

PREVENTION AND MANAGEMENT OF SKIN PROBLEMS IN THE RESIDUAL LIMB Because prolonged wound healing and the development of skin irritation can delay training and significantly affect daily functioning,110,111 the prevention and management of skin problems are important components of treatment. The prevalence of skin problems on the residual limb in prosthesis users has been reported to be between 36% and 63%.112–114 Especially vulnerable to skin issues are very active users and those with impaired hand function.114,115 Thermal discomfort and sweating within the socket is a complaint shared by up to 53% of prosthesis users.111,116 Pressure, friction, and shearing forces are the primary causes of skin breakdown related to prosthetic wear. If, during weight bearing, external pressure exceeds capillary refill pressure (25–32 mm Hg) for an extended time, the delivery of oxygen and nutrients and the removal of waste products from active tissues are interrupted. If relief of pressure is provided, this local ischemia is followed by a reactive vasodilation or hyperemia. This is the mechanism that produces the redness over weight-bearing areas that is observed in new users of prostheses. A blanchable area of redness over weight-bearing areas, which returns to normal skin coloration within 10 minutes, is to be expected in early training and indicates normal reactive hyperemia.117 If redness persists or the skin does not blanch on firm palpation, tissue damage has likely occurred and the risk of skin breakdown will increase significantly. It is important that therapists and amputees recognize the implications of redness over pressure-tolerant versus pressure-sensitive areas of the residual limb. If a pressuretolerant area shows evidence of excessive pressure, socket fit and alignment may be appropriate but the amount of weight bearing or duration of wearing may have to be decreased. If pressure-sensitive areas are showing signs of too much pressure, it is more likely that socket fit or alignment must be adjusted. When excessive redness is observed, successful problem solving dictates changing a single variable at a time and assessing the effect of this one change on the problem. If multiple changes are made at the same time (e.g., wearing time, alignment, and socket fit are all altered), it will be unclear which change solved the problem

if indeed the problem is solved. If the problem is not solved, there will be no way of knowing if the interventions may have been more successful independent of one another. An individual’s risk for skin breakdown on the residual limb is determined by physiologic and mechanical factors. The vascular, sensory, and musculoskeletal conditions of the residual limb are the physiologic determinants, whereas socket fit, prosthetic alignment, amount of weight bearing, and duration of weight bearing are the mechanical determinants. Each of these risk factors may have clinical implications. A conservative prosthetic wearing schedule and frequent residual limb inspection may be indicated for those with skin breakdown caused by any of the physiologic risk factors. If poor scar and soft tissue mobility of the residual limb leads to tissue breakdown, deep friction massage over the involved area (after healing) and/or application of a friction-minimizing sheath within the socket may be appropriate interventions. Improper socket fit or alignment can result in increased weight bearing on pressure-sensitive areas of the residual limb and may result in skin breakdown. If poor fit is suspected, problem solving requires a thorough reevaluation of donning technique, the number of socks being used, and reassessment of total contact within the socket. If these areas are sufficient, potential problems with prosthetic alignment are investigated. It is important to note that increasing duration of prosthetic wearing too quickly in a well-aligned and appropriately fitting prosthesis can result in skin breakdown in pressure-tolerant areas of the residual limb. An individual who has been successfully ambulating with partial weight bearing using axillary crutches may develop skin breakdown on progression to cane use as a result of increased weight bearing. The presence of skin breakdown is not a direct contraindication to further use of the prosthetic device. In fact, the physiologic (and psychologic) benefits of keeping an older adult with a dysvascular amputation mobile and ambulatory versus the drawbacks of immobility that may result from discontinuing use of the prosthesis must be considered in deciding how best to manage skin issues. A recent systematic review by Highsmith et al. revealed that comorbidities that may delay the healing of residual limb ulcers— such as chronic smoking, volume fluctuations, infection, or a history of ulceration—may lead to a decision to discontinue use of a prosthesis for the duration of wound healing; however, in a compliant amputee without these characteristics, modified use of the prosthesis is a viable strategy.110 The first priority should be to identify the cause of breakdown and eliminate it by systematically making appropriate changes. Close observation and ongoing assessment and treatment of any lesions using appropriate nonadherent dressings inside the socket will allow use of the prosthesis to continue, although it may be on a modified schedule. Certainly if during training a lesion becomes progressively worse despite clinical management, a hiatus may be indicated. In the example presented previously, a return to bilateral crutch use and diminished prosthetic wearing time may be indicated until the lesion has healed. After healing, ambulation time might be divided between bilateral and unilateral crutch use to build tolerance for increased weight bearing. Full-time unilateral crutch use may then be attempted as a prelude to transitioning again to cane use.

26 • Early Rehabilitation in Lower Extremity Dysvascular Amputation

As the amputee begins to ambulate over different terrains, the magnitude and direction of weight-bearing pressures within the socket may change, presenting additional mechanical risk factors for skin breakdown. Descending stairs using a step-to-step pattern protects the residual limb by leading with the prosthetic leg; when advancing to a reciprocal step-over-step technique, the residual limb experiences a different pattern of pressure distribution. As step height increases, so does the total excursion through ROM necessary to descend the stairs using a step-over-step strategy. Ambulation on uneven terrain, such as grass or gravel, produces different pressures within the socket than walking on a predictable, level surface. When the potential causes of skin breakdown are being evaluated, it is important to consider the characteristics of the environments and the task demands of the activities in which the individual has been engaging. Changing task technique by adapting the movement strategy or the environment or adding an AD can provide just enough protection for the residual limb to prevent skin irritation and breakdown. If localized increased pressure is determined to be the cause of tissue breakdown, pressure relief is the goal and socket modification by the prosthetist may be necessary. Certain methods of pressure relief are inappropriate and should be avoided. The use of “donut” padding around an area of breakdown or potential breakdown is counterproductive for three reasons. A donut pad (1) increases pressure to the area surrounding the lesion when the limb is placed in the socket, (2) increases the ischemic effect of weight bearing, and (3) potentially leads to edema or extrusion of the vulnerable tissue through the “hole” of the donut. Dressings should be used sparingly inside a prosthetic socket as the socket fit is designed to be snug, and any padded dressing increases pressure over the affected area, which is counterproductive to the goal of wound healing. There are multiple options for thin, self-adherent, nontextured dressings (e.g., Tegaderm, Second-Skin) that can be used within the prosthesis’s socket to effectively provide another “tissue” layer to an area that is threatening to break down or is in the process of healing.

CARE OF PROSTHETIC EQUIPMENT Amputees will likely receive explicit instructions about the proper care and maintenance of their prosthetic equipment from the prosthetist but may need reinforcement of these concepts during rehabilitation. The prosthetic’s socket and liner should be wiped daily with a damp cloth. Prosthetic socks should be washed daily and laid flat to dry (wool socks shrink when dried in an electric clothes dryer). When not being worn, most prosthetic devices (with the exception of those with hydraulic mechanisms) should be stored in a flat position to minimize the risk of damage should they fall over (hard sockets are particularly vulnerable to traumatic cracks).

Prosthetic Gait Training Functional ambulation involves moving the body through space effectively and efficiently while meeting environmental and task demands. In the prosthesis user, this has many

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prerequisites, including (1) achieving the necessary baseline of flexibility, strength, and endurance; (2) building tolerance to prosthesis wear and weight bearing through the residual limb; (3) controlling dynamic weight shifting through the prosthetic foot in all planes of movement; and (4) reintegrating postural control and balance despite the missing sensory/proprioceptive input, muscle activity, and ROM from the amputated limb. The skilled physical therapist will shepherd the amputee through the training process, helping him or her to build proficiency and confidence along the way. An individual’s fears and concerns influence determination and motivation and are powerful determinants of community ambulation.46,118 A person who is otherwise functionally capable of safe ambulation may choose not to venture outside home because he or she lacks confidence or is fearful of being identified as disabled or different. In contrast, a person whose clinical picture is less promising for functional prosthetic use but who is determined to return to a busy and productive life “on two feet” may very well do so; thus therapists must not underestimate the power of motivation!

INITIAL TRAINING For the new user of a prosthesis, the initiation of gait training typically begins with ambulation on level surfaces with few environmental demands. The parallel bars are an excellent starting point, offering a stable, secure, protected environment with minimal challenges. If bars are unavailable, a countertop or table, raised mat or plinth, chair backs, or ADs can all be appropriate alternatives. Individuals are encouraged to use a relaxed, open-handed grip when they train in the bars, as the tendency to pull and rely heavily on the secure bars is a difficult habit to “untrain” when transitioning to a less protected environment (Fig. 26.2). When an individual receives the prosthesis and is eager to take the first steps, it is useful to limit cues and simply allow the individual to walk. Ambulation in the parallel bars helps the therapist to identify gait deviations early in training before maladaptive habits become problematic. Based on this preliminary gait assessment, individual problem areas can be addressed with gait training and exercise activities. Early therapeutic activities will progress from initially supporting and later challenging the individual’s postural stability. Progressing from weight bearing and gait activities with significant bilateral upper extremity support to minimal or no support is a common early goal in the rehabilitation process of both transtibial and transfemoral amputees. During all activities with the new user of a prosthesis, the therapist must remain cognizant of the need for frequent skin checks for signs of pressure intolerance and skin irritation. A typical progression of early prosthetic training activities might include the following: 1. Static weight bearing with decreasing dependence on upper extremity support (e.g., progressing from bilateral open-handed upper extremity support to contralateral open-handed upper extremity support to ipsilateral open-handed upper extremity support to no upper extremity support). 2. Standing reaching activities that require the person to reach to a variety of heights and directions within a functional context. These activities are progressed by

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Section III • Prostheses in Rehabilitation

B

C

Fig. 26.2 Weight bearing, weight shifting, and balance activities in early prosthetic training. (A) A new prosthetic user practices loading weight onto the prosthesis by performing a trunk rotation and reaching activities in the parallel bars. Note full weight bearing through the prosthesis, demonstrating good prosthetic alignment and erect trunk and head posture, with a gentle open-handed grip on the parallel bars. (B) Rotation to the sound limb facilitates weight shifting on and off the prosthesis and can challenge balance and postural control. (C) Stepping up a low step can increase weight bearing through the prosthesis in the early stages of rehabilitation.

decreasing upper extremity support, increasingly challenging reaching limits in all directions, and varying foot position. Therapists should carefully observe and critique weight shifting and weight bearing during reaching tasks. Reaching excursion in the direction of the prosthetic limb should be significantly greater with the prosthesis than it is without. If reaching distances are similar, this is likely an indication that the individual is not truly using the prosthesis to broaden his or her base of support; this is required to promote a larger shift of center of mass in reaching. These early reaching activities are prerequisites to later more progressed functional goals such as reaching to high shelves, lifting something of substantial weight, and picking objects up from the floor. 3. Simple dynamic weight-shifting activities, consisting of loading and offloading body weight through the prosthesis in multiple directions (anterior/posterior, medial/lateral, and diagonal patterns) as is required in gait and functional activities. These tasks are progressed by decreasing upper extremity support and/or varying foot positions (parallel stance, step stance, tandem stance). It may be helpful to cue the individual to think about the weight going through the “ball” or “heel” or the medial or lateral surface of the prosthetic foot as he or she shifts weight in different directions. This heightened awareness of what is happening distally may help to correlate sensations within the prosthesis’s socket with former somatosensory experiences of the foot. Another strategy during weight-shifting activities is to have the individual focus proximally on pelvic position. The focus on the pelvis is important for several reasons: (a) There is clear evidence of asymmetries in pelvic stability and control during gait in amputees.119 (b) The pelvis is key to stability in upright posture, so the individual is cued in to

this important locus of control. (c) By focusing on the pelvis, the individual is being directed to control a part of the body that is intact and “whole.” Although he or she may never have focused on pelvic awareness prior to rehabilitation, this takes the focus off the prosthesis and the “new” challenges that the amputee is facing. (d) Awareness of pelvic position in early weight-shifting activities may make later gait demands, such as emphasizing pelvic protraction or rotation, easier for the individual to grasp. In controlling the pelvis during weight-shifting activities, the amputee might envision the pelvis as a tabletop with a tall vase centrally located on the table, so if the pelvis tips in any direction, the vase will fall and break; or they may imagine a ball on that table and—regardless of the direction of the weight shift— they must not let the ball roll off of the table. These cues are intended to encourage anterior, posterior, and lateral translational movements of the pelvis without substantial anterior, posterior, or lateral tilting of the pelvis. 4. Repeated stepping activities (e.g., breaking down the gait cycle into its component parts, varied stepping patterns in different directions) with decreasing upper extremity support. The focus here is in loading and offloading the prosthetic limb with good proximal/pelvic control. Repetitive loading of the prosthesis is an appropriate task, even without full translation of weight over the foot, as it requires repetitive and appropriate positioning of the prosthetic limb (as required for the initial contact phase of gait) and initiation of the transfer of weight (as required for the transition from initial contact into loading response). The progression to full weight bearing and the single-limb support phase of gait is an intuitive next step, as is the integration of loading and offloading the prosthesis within the full gait cycle. Although the use of weight bearing and stepping strategies outside of the

26 • Early Rehabilitation in Lower Extremity Dysvascular Amputation

functional context of walking may seem contrary to fundamental tenets of motor learning (i.e., encouraging action-directed/whole task performance), practicing the component parts and integrating them into functional gait and mobility skills is a reasonable and acceptable motor learning principle.42 Regardless of the focus of the intervention (weight bearing, balance, postural control, or coordination and sequencing), the activity can and should be integrated into the gait cycle or the functional task within the same treatment session. 5. Stepping with the uninvolved limb onto an elevated surface (begin with a low surface and progressing to height and/or beginning with a stable surface, such as stepstool or thick book, and progressing to a less stable surface, such as an air disc or small ball) forces increased weight bearing through the prosthetic limb with progressively decreasing upper extremity support. The focus is on slow and controlled motions of the sound limb without substantial proximal instability on the weightbearing prosthetic limb. Activities might include stable standing on the prosthetic limb while performing toe tapping with the sound limb on a stool or manipulating of a ball on the floor (rolling the ball forward and back under the foot) (see Fig. 26.2). 6. Gait training to minimize gait deviations within or progressing out of the parallel bars. Early in gait training, individuals may benefit from an exaggerated effort to dig the prosthetic heel into the floor at initial contact so as to use the resulting pressure at the posterior residual limb as an indicator of contact with the floor and, in the case of transfemoral amputation, to assure prosthetic knee extension. The individual may learn to interpret this sensory experience within the socket as the secure position for proceeding with loading response and progressing into midstance. Many prosthetic knees rely on the translation of weight bearing over the prosthetic

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forefoot in terminal stance and preswing to generate the knee flexion required to forward the limb in swing phase and this may require focused practice. These loading and offloading techniques can be practiced in pregait stepping drills or repetitively in early gait training. 7. Sit-to-stand and stand-to-sit activities, to enhance the ease and independence of transitional movements. Transtibial amputees are encouraged to integrate partial weight bearing through the prosthesis, whereas it is much more difficult for transfemoral amputees to bear weight during transitional movements with a prosthesis. Beginning training to/from high surfaces with arm rests and progressing to lower surfaces without arm rests and varying training to include different types of support surfaces will enhance the individual’s ability to generalize the sit-to-stand skill to a variety of settings. Some individuals may have difficulty aligning themselves symmetrically over their feet in static stance when initially training with the prosthesis. They may appear hesitant to weight the prosthetic limb and their perceived line of gravity may strongly favor the sound limb with the prosthetic-side hip appearing abducted and the sound hip adducted. Ironically, individuals who have been especially active and functional during the preprosthetic phase, ambulating with crutches or a walker, may find weight bearing through a prosthesis difficult. During the preprosthetic phase, the sound limb often gravitates to a more central location under the individual so that their center of gravity is directly over their single-foot base of support. These individuals must work to reorient their lower extremity positioning and line of gravity to center themselves over their “new” 2-footed base of support. Fig. 26.3 represents this concept. Individuals who are hesitant to bear weight through the prosthesis due to fear or weakness or habitual pattern may be tempted to use the prosthesis as an “assistive device” for

Fig. 26.3 Line of gravity with and without the prosthesis. (A) During the preprosthetic phase, the line of gravity shifts to directly over the sound limb. (B) Individuals must work to reorient their lower extremity positioning and line of gravity to fall midline when wearing their prostheses.

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ambulation rather than as a true replacement limb. These individuals maintain the prosthetic limb in an abducted posture and struggle to decrease reliance on upper extremities and the sound lower extremity during standing and ambulation activities. It is important for both therapist and new prosthesis wearer to recognize that improved weight bearing allows for decreased mechanical stresses on the sound limb, which inevitably has vascular compromise. Clinical strategies that are used to encourage optimal alignment and weight shifting over the prosthesis may include stepping on a bathroom scale to provide objective data regarding weight bearing through the prosthesis, use of a mirror for visual feedback to self-assess alignment, and biofeedback in the form of video games such as the Wii fit.120 Progressing prosthetic training requires increasing challenges to postural control and balance. A typical and detrimental mistake often made in rehabilitation is implementing a treatment plan that is beneath the capabilities of the amputee. Therapists are reminded that physically and functionally challenging the person training with a prosthesis is vital to reaching his or her full potential. New prosthesis users who constantly seek upper extremity support and/or have the therapist guarding and intervening with even the slightest loss of balance will never establish and understand their own limits of stability and will not develop the ability to monitor and maintain their own balance with confidence. Ultimately, dynamic therapeutic activities without (or with limited) upper extremity support and activities that require both anticipatory and reactive balance strategies (e.g., playing catch, kicking a ball with a partner) can be used to prepare the prosthesis user for more open, unpredictable real-world environments (Fig. 26.4). Coordination, sequencing, and timing of gait may be facilitated by auditory or visual cues. Use of a metronome or musical beat to time steps or a floor ladder or spaced targets to drive step length can be integrated into gait training. The focus on pelvic awareness and control (as introduced in the context of weight shifting, discussed earlier) can be further emphasized in training with the integration of PNF techniques in standing and during pregait and gait activities.121 Facilitating muscle activation via joint approximation, using rhythmic stabilization (i.e., having the individual hold pelvic position against resistance in varying directions) to strengthen and improve pelvic control, and providing mindful and deliberate verbal, tactile, and/or manual cues to facilitate control and movement of the pelvis are all PNF strategies. The therapist’s hand placed on the anterolateral aspect of the involved pelvis to cue movement into the hand can facilitate anterior progression of the pelvis over the prosthetic foot (Fig. 26.5). Although techniques focusing on pelvic control are relevant for transfemoral amputees—as the position, movement, and control of the pelvis and hip will dictate knee stability and mobility— transtibial amputees will also benefit from improved pelvic control. These manual techniques are relevant for facilitating both the stance and swing phases of gait. In unilateral stance on the prosthetic limb, the amputee must be able to stabilize and control the trunk and pelvis over the prosthesis. This requires adequate reverse-action function and strength in hip abductors (to counteract the gravitational adduction torque in the frontal plane at the

hip) and extensors (to maintain the hip and trunk in an upright and extended position in the sagittal plane). Forward progression with weight bearing on the prosthetic limb is a challenge that requires a focus on pelvic control. There is often a tendency for the prosthetic limb to rotate or “drift” posteriorly during the stance phase (sometimes referred to as a “retracted” position of the pelvis), accompanied by hip flexion/anterior trunk lean; the swing-side pelvis should be rotating forward at this time, but the stance-side pelvis should not actively rotate posteriorly. This posterior pelvic rotation and hip flexion makes smooth transition over the prosthetic limb impossible as it disrupts the normal forward translation of body weight over the prosthetic foot. The therapist can facilitate forward pelvic progression during stance using principles of PNF with deliberate application of hand position and input to muscles (e.g. resistance, quick stretch). Swing phase likewise requires training to facilitate the correct motion. An effective swing will allow for correct step length and facilitates a smooth transition into stance. Symmetric step lengths are conducive to a fluid and energy efficient gait pattern. There are two specific cues that may help transfemoral amputees to achieve a good swing of the prosthetic limb. First, the person must be encouraged to step forward with a normal step on the uninvolved side; amputees are often hesitant to do this. When they have an asymmetric gait pattern, it is often because the prosthetic step is very large (because they are comfortable taking weight through the sound limb) and the sound limb step is very small (because they are not comfortable taking weight through the prosthesis). A full-size step with the sound limb step leaves the prosthetic-side hip extended and pelvis posteriorly rotated (relative to the active anterior rotation of the swinging sound limb). Because of the design of many prostheses, anterior pelvic rotation in the transverse plane at preswing will facilitate “knee break.” This effectively shortens the limb to allow clearance during swing phase. Transfemoral amputees should be cued to rotate the pelvis forward while flexing the hip, which will swing the prosthetic limb forward, extending the knee for initial contact. Early gait training with a transfemoral prosthesis might involve practice and perhaps facilitation of this forward pelvic translation to help the person get the feeling of the knee break and initial swing. The same types of PNF techniques that are used to facilitate stability of the pelvis during weight bearing can be used to facilitate active movement of the pelvis for optimal swing. Forceful hip flexion in the absence of pelvic rotation to advance the prosthesis prohibits normal step length. Likewise vaulting, hip hiking, and circumduction are not efficient methods of forwarding the prosthesis during swing phase. These are common gait deviations that should be mitigated as quickly as possible. Gait training with a harness (with or without bodyweight support) either over ground or on a treadmill has become a popular treatment strategy in many PT clinics, perhaps because it offers a safe environment to challenge and progress walking ability and increase walking confidence. Finding a consensus in the literature on optimal gait training methods to advance distance, speed, and other time/space parameters is challenging owing to the heterogeneity of the research literature as it relates to subject population (traumatic vs. dysvascular), training techniques,

26 • Early Rehabilitation in Lower Extremity Dysvascular Amputation

689

C Fig. 26.4 Progression of weight shifting and balance activities in prosthetic training. (A) Trunk rotation outside of the parallel bars, using all planes of movement and decreasing reliance on upper extremities. (B) Stepping up to a higher surface outside of the parallel bars to increase the challenge and translate into community mobility. (C) Throwing and catching activities encompass balance (feedforward and feedback), coordination, postural control, and weight bearing through the prosthesis.

and varying levels of amputation.122 The effects of harnessed treadmill training with and without body weight support have not yet been examined in new users of prostheses. A preliminary study of “seasoned” community users found no significant difference between body weight support and conventional treadmill training in improving endurance and falls risk as measured by the 6-minute walk test and the Timed Up and Go.123 Self-selected comfortable

gait speed on the treadmill has been demonstrated to be significantly slower than over-ground walking at the same energy cost, which suggests a higher energy cost in walking on the treadmill than over ground.124 A small case series suggests that movement strategies may also be altered in walking on a treadmill versus over ground,125 although some authors attribute this to the constraints of the treadmill.126 Therapists who have harness systems and/or

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Section III • Prostheses in Rehabilitation

Fig. 26.5 Facilitation of forward pelvic motion for efficient prosthetic gait. (A) The therapist can use manual techniques to cue pelvic position. (B) The therapist can use proprioceptive neuromuscular facilitation at the pelvis and appropriate resistance, asking the patient to move the pelvis upward and forward as he or she steps with either limb.

treadmills available should use their critical reasoning skills to determine the individualized potential benefit of these modalities as a component of gait training activities. The use of mental imagery of successful motor mastery of prosthetic training activities may be an appropriate adjunct to PT,127 although recent research efforts to demonstrate its effectiveness are not without methodologic flaws.128 Virtual reality and video gaming have become more common in the rehabilitation of older adults129 and lower limb amputees but are not yet well studied. A small Canadian survey study demonstrated therapists’ positive perceptions about the use of commercial gaming (e.g., Nintendo Wii Fit) in improving weight shifting and walking abilities in amputees undergoing rehabilitation.120 Therapists could consider gaming as a potentially fun and motivating treatment modality within their treatment tool kit. There is limited evidence that treadmill walking in a virtually depicted environment via a Computer Assisted Rehabilitation Environment (CAREN) system may translate to over-ground walking,126,130 but this limited research involves young participants with traumatic amputation, and this technology is not readily available.

ASSISTIVE DEVICES ADs can provide help with balance only (i.e., single-point cane or quad cane) or with weight bearing and balance (i.e., standard walker, rolling walker, axillary crutches, or Lofstrand crutches). The goals of AD use are to provide only the amount of support that is necessary to protect the healing residual limb and to reduce the risk of falling without hampering the individual’s willingness or ability to load the prosthesis. It may be prudent to spend time on prosthetic weight-bearing and weight-shifting activities in the protected environment of the parallel bars or at a stable surface to allow the person to progress directly to an AD that aids in balance only. Optimally, the prosthetic limb can tolerate 100%

weight bearing, so that upper extremity weight bearing through an AD is unnecessary. Individuals who demonstrate good weight bearing, strength, and balance may progress directly from the parallel bars to the use of a single-point cane or no AD at all. Quad canes should be prescribed with caution, as they are frequently misused as weight-bearing devices and the wide base can create a tripping hazard. For those who are unable to achieve early full weight bearing through the prosthesis and require a weight-bearing AD, the devices of choice are crutches or rolling walkers. Crutches allow individuals to progress to a two-point gait using a stepthrough gait pattern. Individuals may begin with bilateral support and progress to unilateral support with crutches as prosthetic weight bearing improves. Rolling walkers are preferred over standard walkers, which impede a reciprocal gait pattern, limiting forward progression to a “step-to” rather than “step-through” movement strategy. This limitation, imposed by the walker’s cross bar, hampers smooth forward progression of the center of mass over the base of support and precludes effective terminal stance and preswing. A wheeled walker can minimize interruptions to the gait cycle if it is advanced between each step or if the person is instructed to push the walker continually while walking (like a grocery cart). Standard walkers are used only when individuals are long-term users and are resistant to transitioning to a new device or are threatened by the potential instability of the wheels. Individuals may require different levels of ADs in different environments. For instance, a transtibial amputee may reach functional independence with a prosthesis and no AD in the home but utilize a straight cane while walking in the community, where there are more challenging environmental conditions. The use of ADs by transtibial and transfemoral amputees may be influenced by age, strength, balance, confidence, and the manner in which a long history of vascular disease has affected their physical activity and mobility up to the amputation.

26 • Early Rehabilitation in Lower Extremity Dysvascular Amputation

PROSTHETIC GAIT An understanding of the biomechanics of normal gait is crucial for physical therapists, as it provides the standard by which prosthetic gait is measured.131 An important objective of prosthetic fit, alignment, and PT intervention is to achieve a gait that is safe, comfortable, energy-efficient, and cosmetically agreeable to the amputee. Although some may demonstrate a near-normal symmetric gait pattern that is free of significant deviations without the use of ADs, this may not be a realistic goal for all dysvascular amputees. In fact, review studies support a definite asymmetry in gait in both traumatic and dysvascular amputees.39,40,92,119 This is attributable to adaptation following the loss of muscle activity of the amputated limb. Although therapists often strive for symmetry in gait activities, perhaps a truly symmetric gait pattern is an unlikely achievement. It is also well documented that the gait speed of amputees is slower than that in age-matched peers without amputation.28,52,132 Biomechanically there are several well-documented changes in comparing prosthetic gait to gait of able-bodied individuals. In transtibial amputees, the lack of plantarflexors is thought to be the most influential component driving gait changes39,40,133,134; this is compensated for by increased activity and power of the muscles around the hip of the prosthetic limb, most notably the hip extensors. In transfemoral amputees, the strength, endurance, and power demands on the musculature of the hip are higher still, as the hip must also compensate for the missing knee. Prosthetic devices are often marketed as improving efficiency, biomechanics, and quality of prosthetic gait. Systematic reviews do not provide statistically convincing evidence of these benefits when microprocessor- and non-microprocessor–controlled knees are compared (e.g., pneumatic, hydraulic, and mechanical)135 or dynamic response/energy-storing feet are compared with articulating feet (e.g., single-axis, multiple-axis). However, there is some evidence of improved gait efficiency with energy-storing feet as compared with SACH feet in transtibial amputees.136 There is also some limited evidence of componentry positively affecting balance in dysvascular older adult amputees (e.g., microprocessor knee, vacuum-assisted socket).137,138 Despite the lack of evidence supporting objective benefit of more advanced prosthetic componentry, individuals often perceive benefits related to efficiency and confidence in their gait.135 Power or robotic knees and feet and the introduction of bionics to prosthetic components are not yet well studied, so their benefits and drawbacks are yet to be identified. A broader discussion of prosthetic componentry is beyond the scope of this chapter, but the therapist should work closely with the prosthetist in identifying the best prosthetic prescription for amputees based on their ambulation and functional goals. As movement experts, physical therapists perform observational gait analysis to determine gait deviations and their causes. Commonly observed prosthetic gait deviations have many different potential contributors. Deviations may be a product of intrinsic factors (pertaining to the individual using the prosthesis) or extrinsic factors (pertaining to the prosthesis and/or environmental factors). The observed problem may be a primary gait deviation, caused directly by an intrinsic or extrinsic factor, or a compensatory/secondary deviation, a result of the individual’s attempt to avoid a primary deviation.

691

During initial gait training, prosthetic alignment issues may not be immediately evident. Hesitancy to fully load the prosthesis and upper extremity weight bearing through the parallel bars or AD will affect the resulting gait pattern. As the individual becomes more willing to bear weight through the residual limb, a “truer” gait pattern will emerge and the function of the prosthesis will become more critical. The therapist, along with the prosthetist, must be attentive to the need to correct prosthesis alignment as the individual improves in weight bearing and as impairments improve (i.e., changes in strength, ROM, or balance might warrant changes in the alignment of the prosthesis). When occupied in solving problems, the clinician must think about why certain gait deviations might occur and whether they are primary or compensatory. Answers to these questions allow the therapist to focus treatment on the most salient issues. For example, a transfemoral amputee new to the use of a prosthesis is observed to ambulate with a forward-leaning trunk throughout the stance phase of gait. This may be a primary gait deviation resulting from a hip flexion contracture that limits the individual’s ability to achieve upright posture, or it could be the direct result of weak hip extensors. This may also be a compensatory strategy of the person who is fearful of knee instability during stance. By using a forward-leaning trunk, the individual modifies the ground reaction force vector during stance phase to stay significantly anterior to the knee joint, thus improving stability at the knee by creating an extensor moment at that joint. If this is deemed to be the issue, the therapist must determine if it is related to an intrinsic (e.g., weakness, lack of confidence) or extrinsic issue (e.g., prosthetic alignment). In another example, consider a transtibial amputee who shows knee instability during loading response and throughout midstance, as evidenced by lack of knee extension or excessive knee flexion. If the instability is occurring on level surfaces, environmental causes of the problem can be ruled out (walking down a slope will cause this problem). If evaluation of the static alignment of the prosthesis reveals appropriate alignment of the foot and pylon but the socket is set in excessive knee flexion, this could contribute to the problem. Thorough evaluation of the problem requires assessment of potential intrinsic causes as well. If examination reveals full, strong, active ROM at the knee and no complaints of pain, the therapist must look to the joints proximal to the problem. Assessment of the hip may reveal a hip flexion contracture that leads the person to maintain knee flexion as a compensatory strategy to maintain upright posture. When these two (excessive socket flexion and hip flexion contracture) distinct potential causes of the problem are identified, the therapist can then prioritize and address each cause. Initiation of a stretching intervention to address the ROM limitation can be started immediately but will take time before it has an impact on the problem. Extrinsic causes can be modified immediately: if quality of gait improves and deviations are eliminated after realignment (typically the responsibility of the prosthetist), this suggests that alignment was the factor underlying the gait deviation. If a socket realignment does not have a significant impact, magnifies the observed gait problem, or leads to a new gait deviation, the underlying cause is likely to be an intrinsic issue needing PT intervention. Table 26.7 describes some of the more common prosthetic gait deviations and their most likely potential causes.

Gait Deviation

692

Table 26.7 Prosthetic Gait Deviations Phase of Gait

Categorya

Possible Causes

Lateral trunk lean toward prosthetic side

Anterior trunk lean

Insufficient weight bearing through prosthesis

Inadequate prosthetic foot clearanceb

Loading response through terminal stance

Loading response through terminal stance

Loading response through terminal stance

Throughout swing phases

Intrinsic

Lacking hip abductor strength and/or timing on prosthetic side (compensate with lateral lean to avoid Trendelenburg) Abductor contracture on prosthetic side Hip joint pain on prosthetic side Very short transfemoral residual limb (poor purchase in socket, poor leverage)

Prosthetic (extrinsic)

Prosthesis too short Foot too outset Transfemoral socket medial wall trim line too high Transfemoral socket places femur in abduction Transfemoral socket lateral wall fails to provide adequate femoral support/stabilization

Environmental (extrinsic)

Uneven terrain

Intrinsic

Hip flexion contracture Lacking knee extensor strength and/or timing in individual with transtibial amputation (compensate with forward lean to create extensor moment at knee) Fear of instability of physiologic or prosthetic knee Insufficient hip extensor strength or lumbar extensor strength making maintenance of an upright trunk difficult

Prosthetic (extrinsic)

Transtibial socket set too posterior (forcing knee hyperextension) Transtibial socket lacks anterior tilt Transfemoral prosthetic knee positioned too anterior (TKA line not providing stability)

Environmental (extrinsic)

Walking up incline

Intrinsic

Residual limb pain or hypersensitivity Excessive upper-extremity weight bearing on assistive device Instability of the physiologic or prosthetic knee joint Decreased muscle strength of residual limb Fear of falling/lack of confidence in prosthesis

Prosthetic (extrinsic)

Prosthesis is too long Poor socket fit

Environmental (extrinsic)

Walking uphill Walking on rugged terrain

Intrinsic

Poor hip stabilization on sound limb (pelvic drop on prosthetic side during swing) Lacking active anterior pelvic rotation (strength and/or timing issue) to initiate prosthetic swing Lacking hip flexion (strength and/or timing issue) to initiate prosthetic swing Lacking knee flexion (strength and/or timing issue) to contribute to prosthetic swing in transtibial amputation

Prosthetic (extrinsic)

Prosthesis too long Transfemoral prosthetic knee too “stiff” Prosthetic foot/ankle too plantarflexed

Environmental (extrinsic)

Uneven terrain with unexpected elevations

Section III • Prostheses in Rehabilitation

GAIT DEVIATIONS COMMON TO TRANSTIBIAL AND TRANSFEMORAL AMPUTEES USING PROSTHESES

Pistoning (downward translation of prosthesis on residual limb when unloaded)

Throughout swing phases

Intrinsic

Error in sock application (too few or too many layers)

Prosthetic (extrinsic)

Inadequate suspension Poor socket fit

Environmental (extrinsic)

Muddy or flooded environment can create pull on prosthesis

GAIT DEVIATIONS COMMON TO TRANSTIBIAL AMPUTEES USING PROSTHESES Excessive knee flexion/knee instability

Excessive knee extension (no shock absorption)/hyperextension

Excessive genu varus moment at knee

Initial contact or loading response to midstance

Midstance

Midstance

Intrinsic

Knee or hip flexion contracture Lacking knee or hip extensor strength and/or timing Anterior distal residual limb pain

Prosthetic (extrinsic)

Excessive dorsiflexion of the prosthetic foot Excessive transtibial socket flexion (anterior tilt) Transtibial socket positioned anterior to prosthetic foot Excessive heel cushion stiffness (SACH foot) Prosthesis too long

Environmental (extrinsic)

Walking down inclines

Intrinsic

Lacking knee extensor strength and/or timing (hyperextend knee as compensation) Cruciate ligament insufficiency Lacking hip extensor strength and/or timing Posterior distal residual limb pain

Prosthetic (extrinsic)

Excessive plantarflexion of prosthetic foot Lacking appropriate socket flexion (posterior tilt of socket) Excessively soft heel cushion (SACH foot) Socket positioned posterior to prosthetic foot Prosthesis too short

Environmental (extrinsic)

Ascending inclines/walking uphill

Intrinsic

Medial collateral ligament insufficiency Coxa vara at hip Medial distal residual limb pain

Prosthetic (extrinsic)

Excessive outset of prosthetic foot Tilt of transtibial socket in frontal plane

Environmental (extrinsic)

Walking on uneven surfaces

Intrinsic

Lateral collateral ligament insufficiency Coxa valga at hip Lateral distal residual limb pain

Prosthetic (extrinsic)

Excessive inset of prosthetic foot Tilt of transtibial socket in the frontal plane

Environmental (extrinsic)

Walking on uneven surfaces

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Continued on following page

26 • Early Rehabilitation in Lower Extremity Dysvascular Amputation

Genu valgus moment at knee

Initial contact or loading response to midstance

Phase of Gait

Categorya

Possible Causes

Early heel rise/early knee flexion or “drop off”

Midstance to preswing

Intrinsic

Hip and/or knee flexion contracture Weakness of hip extensor muscles Anterior/distal residual limb pain

Prosthetic (extrinsic)

Excessive dorsiflexion of prosthetic foot Socket positioned anterior to prosthetic foot Too much socket flexion (anterior tilt) The opposite prosthetic problems (plantarflexed foot, socket positioned posteriorly, not enough socket flexion) can all cause this same gait deviation if the person is working to “overcome” being forced into hyperextended knee position by the prosthesis

Environmental (extrinsic)

Walking down inclines or hills

Intrinsic

Knee hyperextension as compensation for instability or weakness earlier in stance makes transition to knee flexion difficult Decreased anterior weight shift (weight through heel of prosthesis) Posterior/distal residual limb pain

Prosthetic (extrinsic)

Excessive plantarflexion of prosthetic foot Socket positioned posterior to prosthetic foot Insufficient socket flexion Excessively long keel of prosthetic foot

Environmental (extrinsic)

Walking up inclines/hills

Delayed heel rise/delayed knee flexion

Terminal stance to preswing

GAIT DEVIATIONS COMMON TO TRANSFEMORAL AMPUTEES USING PROSTHESES Excessive anterior pelvic tilt/lumbar lordosis

Abducted gait

Delayed prosthetic knee flexion

Initial contact through preswing

Initial contact through preswing

Terminal stance to preswing

Intrinsic

Hip flexion contracture Weak hip extensors and/or abdominals Effort to shift center of gravity anteriorly for stability at prosthetic knee

Prosthetic (extrinsic)

Insufficient flexion (posterior tilt) of socket TKA line does not provide adequate knee stability

Environmental (extrinsic)

Walking up inclines/uphill

Intrinsic

Hip abduction contracture Adductor tissue roll/redundant tissue Impaired balance (compensatory widened base of support) Distal femur pain

Prosthetic (extrinsic)

Prosthesis too long Socket alignment places femur in abduction Medial socket wall too high

Environmental (extrinsic)

Uneven terrain

Intrinsic

Lacking active anterior pelvic rotation (strength and/or timing issue) to offload prosthesis Lacking hip flexion (strength and/or timing) to initiate swing of prosthesis

Prosthetic (extrinsic)

TKA line providing excessive knee stability Excessive plantar flexion of prosthetic foot or excessively soft heel cushion (SACH foot)

Environmental (extrinsic)

Walking up inclines

Section III • Prostheses in Rehabilitation

Gait Deviation

694

Table 26.7 Prosthetic Gait Deviations (Continued)

Medial heel whip

Lateral heel whip

Terminal swing impact (prosthetic knee extension thrust)

Preswing to early swing

Intrinsic

Loose residual limb tissue that rotates freely around femur Improperly donned socket in internally rotated position

Prosthetic (extrinsic)

Prosthetic knee oriented in external/lateral direction Prosthetic foot oriented laterally Prosthetic foot toe break oriented laterally

Environmental (extrinsic)

Rugged terrain

Intrinsic

Loose residual limb tissue that rotates freely around femur Improperly donned socket in externally rotated position

Prosthetic (extrinsic)

Prosthetic knee oriented in internal/medial direction Prosthetic foot oriented medially Prosthetic foot toe break oriented medially

Environmental (extrinsic)

Rugged terrain

Intrinsic

Excessive anterior pelvic rotation and/or hip flexion to assure knee extension in swing

Prosthetic (extrinsic)

Insufficient knee stiffness, excessive extension aid

Environmental (extrinsic)

Environment demands rapid movement

Intrinsic problems are due to personal factors. Extrinsic problems are associated with prosthetic issues (alignment or fit) or environmental issues (best understood by analyzing the specific condition or activity in which they are observed). b Possible compensations for inadequate prosthetic swing-phase clearance include a lateral lean of the trunk toward the sound limb, vaulting on the sound limb, hip hiking or circumduction of the prosthetic limb, and, in the case of transtibial amputation, a steppage gait. SACH, Solid ankle cushioned heel; TKA, trochanter-knee-ankle.

26 • Early Rehabilitation in Lower Extremity Dysvascular Amputation

a

Preswing to early swing

695

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Section III • Prostheses in Rehabilitation

Notably, chronic low back pain is a common complaint among both transtibial and transfemoral amputees using prostheses, with studies reporting a prevalence of back pain between 52% (study population with roughly half traumatic and half disease-related amputations)139 and 61% (subgroup of study including only dysvascular amputations).140 Back pain may be associated with lumbopelvic asymmetries in the movement strategies of the individual with amputation.141,142 Chronic back pain has been linked to strength and endurance deficits of low back extensors in individuals with amputation;143 A recent study demonstrated pain-relieving benefits of a strengthening program that improved strength and endurance of lumbar extensors and strength of abdominal muscles in long-term prosthetic users (amputation etiology was trauma, although mean subject age was 64 years).144 Therapists should be prepared to utilize manual therapy techniques and exercise interventions as appropriate to address complaints of back pain.

GAIT TRAINING ON ALTERNATE SURFACES To adapt to and meet environmental demands, the individual using a prosthesis must be able to adjust his or her step length and cadence while ambulating in response to environmental conditions or circumstances. The PT program might begin with practice opportunities until the person is able to achieve a normal cadence. It might then progress to activities that demand an increased or decreased cadence, stops and starts, and transitional gait movements, such as sidestepping, turning, walking backward, and obstacle avoidance. These skills can initially be practiced in the clinic with minimal environmental demands. They can be progressed to situations in which the environment presents a challenge, such as crossing a street in a timely manner, getting on and off an elevator or escalator, walking through a crowded corridor in a busy store, or walking to a seat in the middle of an auditorium. Successful community ambulation also requires management of many different ground surfaces, including steps, curbs, ramps, and varied terrain. In providing therapeutic practice opportunities for a person who is new to the use of a prosthesis, the therapist considers the following important extrinsic variables: 1. Level of physical assistance required for safe performance 2. The specific demands of the environment, such as depth or height of steps and curbs or degree of slope of a ramp 3. The need for an AD or railing 4. The optimal technique for performing the task safely 5. The ability to superimpose an additional activity while walking or moving in the environment (dual and multitasking) An initial goal might be to decrease the level of assistance (physical assist or AD) on these alternative surfaces. This can be accomplished by simplifying one or more of the variables of the task, such as decreasing the depth of the step/ curb, allowing the use of sturdy rail versus crutch or cane, and/or allowing the sound limb to “lead” or dominate the task. As skill improves, the task demands are increased. Early skills in stair climbing are generally developed in a step-to gait pattern with the sound limb leading in ascent and the prosthetic limb leading in descent. Advanced gait

training activities may instead require the person with amputation to use the sound limb first in descent, placing the weight bearing eccentric control demand on the prosthetic limb, or require ascent with the prosthetic limb leading. These step-over-step stair ascent/descent strategies are possible for transtibial and transfemoral amputees who have the appropriate knee componentry (e.g., microprocessor knees allow for descent, power knees allow for ascent/ descent). Step-over-step stair descent requires placement of the prosthetic forefoot off of the step to allow for the forward progression of the prosthetic shank, mimicking the ankle dorsiflexion required in lowering the body weight to the next step. The management of slopes, inclines, and ramps is challenging for both transtibial and transfemoral amputees. In both situations, the loss of sensory information in the prosthetic limb (and possibly the sound limb) limits the ability to know where the foot is in space and the relative stiffness of the ankle (depending on type of prosthesis) does not allow for the fully functional dorsiflexion or plantarflexion that is required for adaptability to the slope of the surface.145 In the person with a transfemoral prosthesis, the loss of the knee joint and accompanying quadriceps control compounds the challenge. Most people with transfemoral prostheses navigate inclines, declines, ramps, and slopes using one of two methods (or some combination of the two). They will either shorten the step length of the involved limb to help compensate for the lack of quadriceps contraction and ankle mobility and continue with an asymmetrical step-to-step pattern or they will turn partially sideways and employ a sidestepping pattern leading with the uninvolved limb going up and prosthetic limb going down. By reorienting the axis of rotation for knee motion in this manner, there is less risk of the slope directly affecting knee position or stability. The method used is generally determined by personal preference and the grade of the slope. As in stair descent, if the person has a microprocessor-controlled knee, angled surfaces are more easily managed by the computer control of the knee, especially in descending. New technology has focused on the design of an “intelligent” ankle prosthesis that allows for real-time adaptability when walking over uneven surfaces and also provides some plantarflexion power during push-off.145,146 Literature also suggests that these types of ankles allow transtibial amputees to have increased gait speed and toe clearance when walking over uneven surfaces as compared with those using nonpowered prosthetic ankles145 and to some extent help improve dynamic balance in stance when walking down a slope.147 Research to date has not involved older dysvascular amputees; only adults with traumatic amputations. Curtze demonstrated that when transtibial amputees using prostheses were faced with the challenge of rough terrain versus smooth surfaces, arm swing speed increased (presumably to assist with balance) and gait speed decreased slightly, but other gait parameters were not significantly altered.148 Vrieling and colleagues concluded that specific training for prosthetic gait initiation, termination, obstacle crossing, and incline and decline management should be a purposeful component of the rehabilitation regime, as movement strategies of these functional tasks are different

26 • Early Rehabilitation in Lower Extremity Dysvascular Amputation

than those of able-bodied individuals,93,149–151 and addressing these tasks in rehabilitation has the potential to impact safety and confidence. Superimposing functional activities on gait during therapeutic treatment prepares individuals for the daily “real world” challenges that they are sure to encounter. The variety of functional tasks practiced by the individual should be driven by the goals specific to that person. Safe ambulation while carrying objects of varying weights and sizes is an important functional skill and an appropriate PT activity. The individual’s specific goal may be to carry a full laundry basket down the hall or a cup of hot coffee from the kitchen to the living room. As individuals become functional users of prostheses, household tasks and leisure or work activities may guide their therapeutic needs. Safe ambulation while using other skills, such as texting, is another very likely goal. The physical therapist should anticipate the home and community mobility needs of the amputee and provide a repertoire of practice opportunities, appropriately increasing the environmental challenges as tolerated. Ideally, when crossing the street, one can ascend the curb without disrupting gait cadence, even if this means leading with the prosthetic foot; this may be a realistic goal for some but not others. The unpredictable surface of uneven terrain encountered in walking across a lawn can challenge postural responses significantly; this requires varying practice strategies depending upon AD use. Backward stepping is required to open a refrigerator door and sidestepping is a skill needed in environments such as theaters. These skills can be practiced out of context and then put into the appropriate functional framework. A supervised community outing is an excellent strategy for addressing and achieving some of these advanced ambulation goals.

697

High-level activities, such as jogging and athletic endeavors, are not routine goals of individuals with dysvascular amputation; however therapists should not discount participation in advanced activities for appropriate prosthetic users. Some individuals with amputation may wish to resume certain sport or leisure activities that they participated in prior to their amputation, and this may be a motivating factor in rehabilitation. With technologic advances in prosthetics and increased exposure of high-level athletes in venues like the Paralympics, there is greater visibility and awareness of the potential for active living with a prosthesis. Therapists should be willing to work with individuals with amputations to return to sport or to take up a new sport. Gardening, bowling, even indoor rock climbing may be specific activities that can be integrated into therapy goals. Table 26.8 describes some more advanced rehabilitation activities that can help to prepare individuals to take part in their chosen activity.

FUNCTIONAL ACTIVITIES A comprehensive rehabilitation program includes a variety of other functional activities, such as transfer training from a variety of surfaces, reaching and picking up objects from different levels and surfaces, kneeling, management of falls, and rising from the floor. Motor learning theory supports that prescriptive instruction on different functional tasks such as these may not be the most effective way to assist individuals in developing these skills; rather, encouraging individuals to solve their own motor problems and figure out how to best perform a given functional task allows them to “own” the task and to better generalize to other related tasks.42 The skilled therapist will design an environment for success when introducing new skills and should have

Table 26.8 Advanced Exercises and Activities for Lower Extremity Amputees Standing balance activities

Standingactivities oncompliant surface(foam, Bosuball) ormobilesurface(rockerboard,Biomechanical Ankle Platform System [BAPS] board); can progress to superimpose tasks while standing (ball catch/ throw) Catching and throwing balls of different shapes, sizes, and weights and throwing variable distances; can progress with altered base of support (staggered stance, tandem stance) Prosthetic single-limb stance, with stool stepping with sound limb, progress to stepping on less stable surface (foam, Bosu ball); can progress to superimpose tasks while standing (ball catch/throw) Elastic bandUE and/orLE strengtheningactivities whilestandingwithout UE support (i.e., bandaffixedto wallordoorandindividualworksagainstresistanceindiagonalorstraightplanepatterns);thisrequires balance and stability of the core and LEs when performing UE exercise and stability of the opposite LE and core when performing LE exercises

Dynamic balance activities with progressively superimposed speed and agility requirements

Dynamic ambulatory tasks: functional multidirectional walking; starts, stops, and turns in rapid progression; obstacle avoidance (over, around); figure-eight walking; head turns while walking; progressively more narrow base of support with goal of line/beam walking Altered terrain walking: a string of yoga mats laid out over towels on floor at unpredictable intervals makes a nice indoor rugged terrain; outdoor walking on grass, sand, or gravel. Other environmental challenges: steps, curbs, ramps, elevators, escalators Picking up objects of different weights and sizes from floor: carrying objects while walking Dual-tasking: superimposed motor task on gait (ball catch/throw), superimposed cognitive task on gait (serial subtractions, naming items in a category) Floor transfers: reasonable to train with all individuals (not reserved for only high-level training), but can work toward less reliance on external support and getting onto and off of floor in timely and safe manner Progressing to task-specific goals: fast-walking; sport/leisure-specific goals (gardening, bowling)

Cardiovascular activities

Swimming, cycling, treadmill walking, stepper

LE, Lower extremity; UE, upper extremity.

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suggestions and ideas to offer, if needed, to the amputee who is attempting new tasks. Additionally, the therapist should creatively progress the demands of the task as appropriate, always challenging the individual as they work toward realistic and functional goals. Specific functional tasks should also be designed to address unique goals as they relate to ADLs, job-related activities, or recreational activities. Occupational therapists have excellent knowledge of adaptive devices and skill in environmental adaptation and may also screen for return to driving, thus working with these team members is of great benefit. For many amputees there is a strong desire or need to return to work and leisure activities. A review of international studies on return to work after lower extremity amputation identified the return to work rate at 66% for persons with lower extremity amputation (inclusive of changes in job responsibilities and transition to part-time work), but this was for all amputation etiologies, and many studies represented young adults with traumatic amputations.152 Factors found to be associated with success in returning people to work after lower extremity amputation include younger age at the time of amputation, lower level of amputation, higher education level, good prosthetic comfort, and higher gross annual income.152,153 Certainly no amputee who is motivated to return to work should be discouraged on account of having failed to meet these criteria. Functional tasks that simulate job activities would be appropriate to incorporate into the plan of care. A small study of return to leisure activity in older adults demonstrated that after surgery, lower extremity amputees decreased their participation in leisure activities, but their satisfaction with the activities remained high.154 In progressing functional, vocational, and leisure activities, therapists should design interventions that are specific to the individual’s needs and desires, are task-oriented, and provide opportunities for creative problem solving. Whether the individual is working toward a very focused goal (e.g., of walking his daughter down the aisle at her wedding without an AD) or a goal that requires a variety of skills (e.g., returning to gardening, which entails walking over rugged terrain, kneeling, rising, and carrying objects), the physical therapist must use his or her expertise in movement analysis, motor learning, and skill acquisition to facilitate the amputee’s success.

OUTCOME ASSESSMENT Measuring the effectiveness of PT interventions on the function and quality of life of an amputee is an important component of the plan of care for both prognosis and reimbursement.155 The overriding goal of rehabilitation is to return the amputee to the highest functional level attainable with the best possible outcome and to do so within the number of visits allotted by the insurance company (unless the person can self-pay). The documentation of change over time is also important to determine functional K levels to assist with prosthetic prescription and eligibility. The ICF framework reminds us that it is important to assess performance at different levels of the ICF paradigm: the bodyfunction level (impairments), the activities level (activity limitations), and the participation level (participation restrictions). Currently there are no definitive guidelines

as to what outcome measures should be used with individuals undergoing rehabilitation15,156,157; however, careful documentation of performance in each domain of the ICF can be useful. Additionally, some outcome measures may be more or less appropriate depending on whether or not the individual has obtained his or her prosthesis. Impairment level changes that may be measured might include increases in ROM or strength. Changes in activity limitations might include improvements in transfer ability (less assistance or improvement in varied surfaces), ambulation (less assistance, change in AD, or increased distance and/ or speed), or ADLs (less assistance or improved endurance). Participation restriction level changes might include improved satisfaction with ability to carry out specific life roles in the family or with respect to social/work/leisure activities. Some of the outcome measures that have been used in amputation rehabilitation are amputation-specific (e.g., Amputation Mobility Predictor with and without prosthesis [AMP and AMPnoPRO], Houghton Scale, or the Prosthetic Evaluation Questionnaire [PEQ]); others are broader rehabilitation outcome measures that have been used with this population (e.g., BBS, ABC Scale, Functional Independence Measure [FIM]). Standardized walking tests that have been used in amputation rehabilitation research include 2-minute walk test, 6-minute walk test, Timed Up and Go, and 10-minute walk test. Reid et al. recently demonstrated that the 2-minute walk test predicts the 6minute walk test in lower extremity amputees and therefore may be used to save the time and energy of those evaluated.158 Although normative values for these outcome measures in amputees have not been well established, norms are available for the older adult, and these can be useful in monitoring change over time and assessing performance relative to age-matched peers without amputation. Gait speed has been routinely linked to function and overall health status in the older adult; therefore it is important to assess baseline gait speed and monitor change over time.159 Self-selected gait speed is slower in dysvascular versus traumatic amputees and slower in transfemoral versus transtibial amputees.160,161 Recent normative data on gait speed in the dysvascular amputees are scarce; however, a 2016 study by Wong et al. presented gait speed data from 180 users of prostheses (about half of whom were dysvascular amputees) as calculated from the 2-minute walk test.162 Independent community ambulators walked at 1.06  0.32 m/s (range: >0.8– 1.2 m/s); limited community ambulators/household ambulators walked at 0.59  0.29 m/s (range: 0.5–0.8 m/s); and limited household ambulators walked at 0.41  0.29 m/s (range < 0.5 m/s). These benchmarks may be useful in considering the functional implications of gait speed findings. Minimal detectable change (MDC) scores are becoming an increasingly popular way to demonstrate change in performance in PT. MDC provides the amount of change required to represent “true” change in performance, more than the expected performance variability and measurement error. A systematic review in 2014 by Hawkins et al. ranked many of the available outcome measures that may be useful in monitoring the progress of lower-limb

26 • Early Rehabilitation in Lower Extremity Dysvascular Amputation

699

Table 26.9 Outcome Measures for Lower Extremity Amputees Test-Retest Reliability Intraclass Correlation Coefficient (95% Confidence Interval)

Standard Error of Measurement (SEM)

Minimal Detectable Change (Calculated at 90% Confidence Interval)

Amputee Mobility Predictor (AMP)165

.88 (.79–.93)

1.5 U

3.4 U

Houghton Scale166

.96 (.92–.97)

N/A

N/A

Orthotics and Prosthetics Users Survey (OPUS)167

.96 (.89–.98)

N/A

12.1 Ua

Prosthetic Evaluation Questionnaire–Mobility Subscale (PEQ-MS)168

.92 (.90–.94)

.24 U

.55 U

Locomotor Capabilities Index (LCI)169,170

.91 (.79–.96)

.98 Ub

2.72 Ub

Prosthetic Limb Users Survey of Mobility (PLUS-M)168

.97 (.95–.98)c

1.93 U

4.50 U

2-min walk test165

.83 (.71–.90)

14.8 m

34.3 m

165

6-min walk test

.97 (.95–.99)

19.4 m

45.0 m

Timed Up and Go165

.88 (.80–.94)

1.6 s

3.6 s

Outcome Measure AMPUTATION-SPECIFIC

GENERAL

171

Berg Balance Scale

Activities specific Balance Confidence (ABC) Scale168

d

.945

N/A

.95 (.93–.96)

.21 U

N/A e

.49 Ue

a

Authors focused on smallest detectable difference as compared against the Lower Extremity Functional Scale (LEFS). Data for the LCI-5 (newer version of original LCI) and MDC(95). c Data for the 12-item version of test. d Authors focused on intra- and interrater reliability. e Data for five-point ordinal scale version of test. MDC, Minimal detectable change. b

amputees.156 Table 26.9 displays the test-retest reliability and MDC scores (if available) of those outcome measures that were ranked high for both validity and/or reliability for the lower-limb amputee population.

Summary The rehabilitation of lower-limb amputees is both challenging and rewarding. Early in the rehabilitation process, functional mobility, ROM, strengthening, and aerobic conditioning are prioritized as the residual limb is prepared for the fitting of a prosthesis. On receipt of the prosthesis, a gradual wearing schedule in the context of a comprehensive rehabilitation program6,163—including weight-bearing activities, gait training, resistive training in gait, balance training, and functional task training—is introduced and strategically progressed. Emphasis is on gait safety, comfort, quality, and efficiency (with or without an AD) and on safe and independent functional mobility with the prosthesis. Training progresses to include varied functional activities under many environmental conditions. Physical therapists may work with these individuals in acute care, inpatient rehabilitation, or long-term care, home care, or another outpatient environment. The diversity of amputees requires the therapist to carefully consider individual circumstances to guide the education and practice strategies of the rehabilitation program.

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26 • Early Rehabilitation in Lower Extremity Dysvascular Amputation 150. Vrieling AH, van Keeken HG, Schoppen T, et al. Gait termination in lower limb amputees. Gait Posture. 2008;27(1):82–90. 151. Vrieling AH, van Keeken HG, Schoppen T, et al. Gait initiation in lower limb amputees. Gait Posture. 2008;27(3):423–430. 152. Burger H, Marincek C. Return to work after lower limb amputation. Disabil Rehabil. 2007;29(17):1323–1329. 153. Schoppen T, Boonstra A, Groothoff JW, van Sonderen E, G€oeken LN, Eisma WH. Factors related to successful job reintegration of people with a lower limb amputation. Arch Phys Med Rehabil. 2001;82(10): 1425–1431. 154. Couture M, Caron C, Desrosiers J. Leisure activities following a lower limb amputation. Disabil Rehabil. 2010;32(1):57–64. 155. Xu J, Kohler F, Dickson H. Systematic review of concepts measured in individuals with lower limb amputation using the International Classification of Functioning, Disability and Health as a reference. Prosthet Orthot Int. 2011;35(3):262–268. 156. Hawkins AT, Henry AJ, Crandell DM, Nguyen LL. A systematic review of functional and quality of life assessment after major lower extremity amputation. Ann Vasc Surg. 2014;28(3):763–780. 157. Norvell DC, Williams RM, Turner AP, Czerniecki JM. The development and validation of a novel outcome measure to quantify mobility in the dysvascular lower extremity amputee: the amputee single item mobility measure. Clin Rehabil. 2016;30(9):878–889. 158. Reid L, Thomson P, Besemann M, Dudek N. Going places: Does the two-minute walk test predict the six-minute walk test in lower extremity amputees? J Rehabil Med. 2015;47(3):256–261. 159. Middleton A, Fritz SL, Lusardi M. Walking Speed: The Functional Vital Sign. J Aging Phys Act. 2015;23(2):314–322. 160. Su P-F, Gard SA, Lipschutz RD, Kuiken TA. Differences in gait characteristics between persons with bilateral transtibial amputations, due to peripheral vascular disease and trauma, and able-bodied ambulators. Arch Phys Med Rehabil. 2008;89(7):1386–1394. 161. Hagberg K, H€ aggstr€om E, Brånemark R. Physiological cost index (PCI) and walking performance in individuals with transfemoral prostheses compared to healthy controls. Disabil Rehabil. 2007;29(8):643–649.

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27

Advanced Rehabilitation for People With Microprocessor Knee Prostheses CHRISTOPHER K. WONG and JOAN E. EDELSTEIN

LEARNING OBJECTIVES

On completion of this chapter, the reader will be able to do the following: 1. Provide a chronology for the development of prosthetics research leading to the microprocessor knee (MPK) prosthesis. 2. Compare knee control function for a variety of MPK prostheses. 3. Explain functional ambulation skills and activities of daily living that are challenging for users of transfemoral prosthesis or higher that do not have MPK. 4. Describe the Medicare K-level requirements when considering MPK prostheses for patients. 5. Explain the similarities and differences of MPK prostheses. 6. Describe how an MPK unit can benefit the user during gait, stair climbing and ramp negotiation, transfers, and stumbling. 7. Discuss prosthetic and training solutions for common gait deviations from which MPK prostheses can significantly benefit. 8. Evaluate a variety of physical therapy interventions that can be applied when rehabilitating individuals with transfemoral amputation who use MPK prosthesis. 9. Describe the evidence to support use of MPK prostheses.

Historical Development Since Ambroise Par
e’s sixteenth-century articulated transfemoral prosthesis,1 surgeons, patients, and engineers have attempted to imitate the function of the human leg. In the United States, scientific prosthetics development began in 1945 with the establishment of the Prosthetic Appliance Service of the Veterans Administration and the research and development program of the National Academy of Science.2 Early versions of sophisticated knee units include the 1942 Filippi hydraulic stance control unit3 and the hydraulic swing and stance control knee unit patented by engineer Hans Mauch and radiologist Ulrich Henschke in 1949.4 The Veterans Administration approved the first hydraulic swing-phase control mechanism in 1962; the component linked a hydraulic knee unit to a single-axis ankle.5 Research beginning in the 1970s led to the 1993 introduction by Blatchford (Basingstoke, England) of the first commercially available microprocessor-controlled prosthetic knee: the Endolite Intelligent Prosthesis. The Intelligent Prosthesis required a wired connection to program the variable swing phase control. The Adaptive Prosthesis followed in 1998, allowing wireless programming and featuring an onboard processor that controlled adjustment of the hybrid pneumatic/hydraulic microprocessor knee (MPK); Endolite’s sixth-generation MPK is the Orion (Fig. 27.1).6 Since introduction of the Intelligent Prosthesis, 704

at least six other companies have joined the marketplace in offering MPK prostheses. Otto Bock (Duderstadt, Germany) initiated the hydraulic C-Leg MPK in 1997.2,7-10 Other manufacturers presented comparable units. Ossur (Reykjavik, Iceland) launched the Rheo Knee in 2006 and the Power Knee in 2009.11 In the United States, Freedom Innovations (Irvine, California) introduced the Pli
e MPK unit.12 The Nabtesco Corporation of Japan also offers MPK units through the Swedish distributor, Centri AB.13 The purpose of this chapter is to (1) discuss the unique features of MPKs that are increasingly available and (2) provide prosthetic and training solutions for persons with common gait deviations that can be reduced by using an MPK.

Overview of Non-Microprocessor Knee Prostheses After amputation that includes the knee joint, people face significantly more difficulty in mobility tasks than those whose knees remain intact. Without the knee and the muscles that control it, the prosthesis user must control knee flexion in new ways to avoid falling. The simplest way to remain stable is to use a mechanically locked knee unit. Some older first-time prosthesis users prefer the security of a locked knee to one that is unlocked.14 If the knee is not locked, knee stability can be maintained simply through

27 • Advanced Rehabilitation for People With Microprocessor Knee Prostheses

705

Fig. 27.1 Orion: a pneumatic microprocessor knee unit with stance and swing-phase control. (Courtesy of Blatchford, blatchford.co.uk.)

alignment of the joint axes combined with significant residual limb gluteal muscle power. However, many prosthesis users who wish to walk in the community with additional stability benefit from more sophisticated nonMPK units. Weight-activated friction-brake knees are non-MPK units that control knee flexion upon initial loading and through most of stance phase. Weight bearing on the prosthesis activates strong braking resistance to knee flexion even when the knee is slightly bent. If the knee is flexed more than 20 degrees, no flexion resistance is provided, making stair descent or stumble recovery difficult. Hydraulic non-MPK units provide sufficient resistance to weight-bearing knee flexion beyond 20 degrees to allow step-over-step descent of stairs or curbs (Fig. 27.2).15 Hydraulic or pneumatic knees also provide variable levels of resistance to knee flexion during swing phase to minimize asymmetry between sound and prosthetic knee flexion at different gait speeds. The two different resistance modes in hydraulic knees make these units ideal for those who are able to move at different speeds and traverse a variety of surfaces such as encountered in the community. However, these knees require specific motions during gait to provide the mechanical cue, such as a firm knee hyperextension force of at least 0.1 second in terminal stance phase,11 to switch between the two different levels of resistance required for weightbearing stance phase and non–weight-bearing swing phase. If a sufficient cue is not achieved at the end of swing phase, the appropriate resistance to support the weight-bearing limb will not be applied and a fall may occur. Alternatively, if the cue is not achieved at the end of stance phase, the leg may remain stiff in swing phase, leading to an awkward gait pattern. As a result, the user must be careful to move with adequate hip action to prevent stumbles. Users of non-MPK prostheses must use compensatory techniques for other activities. For instance, to go from sit to stand, the wearer generally places more weight on the sound limb and depends on that leg, and arms as needed, to raise themselves to standing. When sitting, unweighting the prosthetic leg is required in order for the knee to bend easily. Such basic activities place extra stress on the sound

Fig. 27.2 Prosthetic and sound foot placement for stair descent. (Courtesy Otto Bock Health Care, www.ottobockus.com.)

limb, which can contribute to the frequent reporting of low back and sound limb pain among prosthesis users.16 Another example is descending slopes, a difficult activity for users of transfemoral prostheses. A step length matching that of the sound limb often results in a prosthetic knee angle that exceeds the approximately 20-degree safety range of a hydraulic stance phase control or a weightactivated knee unit. Thus most prosthesis users learn to take very short steps. Finally, ascending stairs step-over-step is very difficult for any transfemoral prosthesis user, generally requiring use of a bannister if the step is of standard height.

Introduction to Microprocessor Knee Prostheses Unlike non-MPK prostheses that use alignment, locked knees, or weight-activated friction brakes, and hydraulic or pneumatic mechanisms, MPK prostheses incorporate an onboard microprocessor to compute data from various electronic sensors and provide real-time adjustments during the user’s activities. The computer’s processor enables rapid adjustments in knee resistance during both swing and stance phase control, usually with pneumatic or hydraulic components. The speed of microprocessors allows data sampling from sensors in the MPKs at speeds of faster than 50 times per second17 to provide more responsiveness to individual movements than can be offered by non-MPK pneumatic and hydraulic knee prostheses. Based on input from various combinations of joint position and motion sensors,

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Section III • Prostheses in Rehabilitation

pressure sensors, and gyroscopes, proprietary software algorithms determine the phase of gait or function of the leg to provide real-time adjustment of resistance within the MPK unit to facilitate the optimal walking pattern. The prosthetist performs the initial MPK calibration for the wearer’s typical use patterns with software specific to the MPK manufacturer. Calibration requires that the wearer walk at slow, normal, and fast speeds for about 12 meters (40 feet). Then the wearer negotiates stairs and ramps so that the appropriate knee resistance levels can be set. At times, additional adjustments may be necessary as the user bears more weight on the prosthesis and participates in more activities. MPKs offer a variety of swing and stance phase control functions, including resisted swing phase knee extension and knee flexion, resisted stance phase knee flexion, powered stance phase knee extension, locked or unlocked (free) knee motions, and various combinations for specific functional applications. MPKs offer stance phase knee resistance within a 0- to 35-degree range (Table 27.1).6 As with the non-MPK units that have both swing and stance phase control functions, the MPK must switch between different functions. MPK units receive data from various sensors, such as force and angle sensors, accelerometers, and gyroscopes, that indicate the portion of stance phase, especially initial loading. Some MPKs, like the CLeg and the Rheo Knee, allow controlled knee flexion upon initial loading to reduce vertical shock impact and normalize gait. Angle and velocity of the knee indicate the oncoming of terminal swing. An MPK like the Genium has a gyroscope, which senses the direction of movement and determines when the user lifts the leg to ascend stairs or to step over an obstacle (Fig. 27.3). In general, manufacturers suggest that MPKs with stance phase control be prescribed for Medicare K2 to K3 level users (Table 27.2) whereas MPKs with both stance and swing phase control be prescribed for K3 to K4 level users who will utilize different walking speeds.11,17 However, most available MPKs are designed for low- to moderate-impact activities.11,17 Processor and actuator speeds are typically insufficient for high-speed activities and, as with all electronic devices, MPKs are vulnerable to overheating. While a few new entries into the market such as the Otto Bock X3 have been designed to support high-speed and impact activities, most prosthesis users at the K4 level who engage in high-impact activities, such as running or jumping, are more suited to hydraulic non-MPK designs.11

Fig. 27.3 Genium microprocessor knee with gyroscope, accelerometer, and angle sensors responds to movement in all directions. (Courtesy Otto Bock Health Care, www.ottobockus.com.)

In addition to different combinations of swing and stance phase control, the commercially available MPKs have other options. For instance, the Plie 3.0 knee utilizes a pneumatic mechanism that the user pumps regularly to adjust resistance levels (Fig. 27.4).12 The pneumatic Hybrid is available with both single and multiaxis knee joints that allow up to 160 degrees.13 MPKs, however, generally provide knee flexion range from 120 to 140 degrees, which exceeds that of most non-MPKs. MPKs generally dampen knee extension to minimize terminal knee extension impact as well as to adjust the arc of shank swing to the speed of walking, but not early swing phase knee flexion. The C-Leg and Genium have dampened swing phase knee flexion to approximate the 60 degrees normal in level walking.17,18 The Power Knee offers powered robotic assistance in sit-to-stand and stair ascent functions (Fig. 27.5).11 All MPKs have some common characteristics. Although individual MPK technical specifications vary, all are

Table 27.1 Microprocessor Knee Prostheses Offer a Variety of Knee Control Functions MANUFACTURER Gait Phase Controlled

Endolite

Swing only

Smart IP

Freedom Innovations

Fillauer Europe

Stair ascent (powered assist)

Ossur

Intelligent Hybrid

Stance only Swing and stance

Otto Bock Compact

Orion 3, Smart Adapt

Plie 3.0

Intelligent Single Axis

C-Leg, X3, Genium

Rheo Knee, Power Knee Power Knee

27 • Advanced Rehabilitation for People With Microprocessor Knee Prostheses

707

Table 27.2 Medicare Functional Levels for People With Unilateral Transtibial and Transfemoral Amputation Functional Abilities With Prosthesis

Level

Typical User Profile

K1

Household ambulator

Has ability or potential to transfer and ambulate on level surfaces at slow speeds with fixed cadence. Time and distance severely limited.

K2

Limited community ambulator

Has ability or potential to ambulate and traverse common environmental barriers such as curbs, stairs, or uneven surfaces. Time and distance often limited.

K3

Community ambulator

Has ability or potential to ambulate at faster speeds with variable cadence and traverse most environmental barriers. Can undertake vocational, therapeutic, or exercise activity that demands use beyond ambulation. Time and distance still somewhat limited.

K4

Active user (child, active adult, athlete)

Has the ability or potential for prosthetic use that exceeds ambulation, including high impact, torsion, or energy levels common to sport. Time and distance essentially unlimited.

Fig. 27.4 Plie 3.0: a water-resistant pneumatic microprocessor knee unit. (Courtesy Freedom Innovations LLC, www.freedominnovations.com.)

powered by batteries that must be charged 4 to 14 hours for use limited in general to 1 to 5 days. The Power Knee, the only MPK to provide robotic assistance to movement, maintains its charge for only 12 hours.11 Depending on use intensity, the Smart Adaptive MPK can maintain charge for up to 14 days.6 The battery and hydraulic mechanisms do not function in all environments and are limited to

€ Fig. 27.5 Power Knee provides assisted knee extension. (© Ossur.)

operating temperatures ranging from 10 to 60°C (14 to 140°F) for the C-Leg,17 sufficient for most people’s requirements. As with other electronic devices, such as laptop computers, MPKs are also vulnerable to sand, debris, and water—especially salt water. The Plie knee can withstand occasional submersion in shallow water, while the Ottobock X3 can operate underwater and is even salt-water resistant (see Fig. 27.4). Electronic signals such as repeated beeps or vibrations warn the user of impending shutdown due to computer or hydraulic overload or other malfunction, as well as changes in mode of function. The wearer must learn the meaning of the different signals to assure proper use. Upon shutdown, MPK will default to various states. Most default to swing phase control, which allows knee bending in swing phase but can also permit collapse in stance phase. The C-Leg and Power Knee default to stance phase resistance, which causes the knee to lock and protects against falls if the microprocessor receives abnormal input that can occur during a stumble or step onto an obstacle or uneven surface. A stance phase resistance default setting, however, requires circumduction, hip hiking, or vaulting in swing phase until normal MPK function is restored. The battery and other electronic components add weight, causing MPKs to be heavier than hydraulic non-MPK units. Weights for MPK units range from 1145 g (2.5 lbs) to 2700 g (6 lbs) for the more complicated Power Knee, compared with the hydraulic non-MPK units such as the SR9517 that weighs 360 g (12.6 oz) or the Mauch Knee that weighs 1140 g (2.5 lbs).11 Although the Mauch Knee Plus can accommodate high-impact use by users weighing up to 166 kg (366 lbs),11 MPKs are generally designed for low- to moderate-impact use by individuals who weigh less than 125 kg (275.6 lbs). The Genium can support people up to 150 kg (330.7 lbs).17 Typical MPK units cost US$16,000 to 18,000 with total cost of the prosthesis as much as US$50,000 in 2004.19 Costs for a prosthesis outfit with an MPK now can exceed US$120,000 for the Ottobock X3.20 Standard warranties run 2 to 3 years with some

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companies offering extended 5- to 6-year warranties.17 Cost to provide the prosthesis can be 2 to 3 times the cost of a non-MPK unit. Among 40-year-old adults seeking to negotiate stairs and enhance safety, the benefits of transitioning to an MPK yielded gains in multiple quality-adjusted life years at just over €3000.21 Patient and family expenses, such as housekeeping and decreased work productivity for non-MPK users, more than exceeded the per-unit MPK cost and associated interventions such that the overall cost to MPK users was roughly half of non-MPK users in a twogroup Dutch cost-analysis study.22 Any MPK can be integrated with many other prosthetic components. Endoskeletal construction is typically employed to save weight and provide space for componentry. Each company recommends integrating its MPK with an energy-storing foot selected from its catalog. The difference between feet may not make a substantial difference23 and can be individually determined based on the judgment of the prosthetist, patient, physician, and therapist. When integrating an MPK into a hip disarticulation prosthesis, some shank, feet, or hip joint units may provide functional benefits. Particularly useful are shank devices that provide transverse plane rotation, such as the Delta Twist, which can dampen rotation and can be combined with most MPKs. The Ceterus foot,11 for instance, may also help provide transverse plane rotation accentuated by the longer step lengths that sometimes result when using an MPK.24 The Helix3D hip joint provides transverse plane rotation unlike other prosthetic hip joints.

Microprocessor Knee Prostheses Control Mechanisms The MPK works by sensors transmitting input to the microprocessor, which converts the data so that the appropriate output can be provided. In some cases, artificial intelligence allows the MPK to adapt to the user’s movements in different activities. Two types of mechanisms provide input to the MPK namely, computational and interactive.25 Computational control mechanisms use sensors to detect movement and forces and send this information to a computer that processes the information and adjusts the resistance provided by the knee mechanism to accommodate for variations determined by the data. For instance, 70% body weight borne through the weight-bearing foot will be interpreted as occurring during stance phase leading to full resistance to knee flexion. This intrinsic mechanism is so-called because the sensory information and decisionmaking process is intrinsic to the knee unit sensors and microprocessor, which prompts an automatic reaction. It is the most common form of input mechanism. Interactive control mechanisms, more common to upperlimb myoelectric prostheses, integrate the user’s conscious initiation. Pattern recognition or electromyographic signal sensors detect the movement initiation. Upper-limb prosthetic function is distinctly different from lower-limb function. Arm movement is modulated primarily by the cognitively variable central nervous system to perform complex acts like grasping a variety of foods. In the lower limb, most everyday function involves walking, which is

modulated by the spinal cord and central pattern generators without many fine motor variations. While the prosthesis user would not want to think about each of the average 6000 steps taken each day,26 the future may bring interactive control of the prosthesis through myoelectric input. Preliminary experiments with people with lower-limb amputations using myoelectric technology in a virtual environment demonstrate that electrodes imbedded in muscles of the residual lower limb can be used to facilitate specific movements, as is typically done in myoelectric upper-limb prostheses. However, the time to complete simple tasks like extending and relaxing the knee in sitting exceeded 1.5 seconds.27 Perhaps myoelectrically driven intrinsic control mechanisms may eventually assist slow and deliberate non-weight-bearing tasks for people with leg amputation. Currently, the Proprio foot, outfitted with an accelerometer, joint sensor, and motorized actuator, can plantarflex and dorsiflex the foot in non-weight-bearing positions upon receiving the correct cues (by heel tap or wireless remote control) enabling the user to sit or don trousers more easily (Fig. 27.6). Other functions for the transfemoral prosthesis user, such as rotating the leg to place it on the knee to don shoes and socks, would be the kind of action such an interactive control system may perform in the future.11 Once the sensor data has been input and the microprocessor has determined what function is occurring, the MPK can provide two types of knee movement output: resistance or powered assistance. Most commonly, MPKs resist movement, which can be thought of as an eccentric force such as knee function in gait that resists knee flexion in early stance or resisting knee extension in terminal swing phase. By providing the appropriate amount of resistance through the required range of motion, the MPK can assist the wearer to walk at varied speeds and descend stairs and ramps with less difficulty. Powered MPKs can also assist movement, comparable to a concentric force. Such a force can be helpful in ascending stairs and rising from a chair, especially for those with

€ Fig. 27.6 Proprio foot. (© Ossur.)

27 • Advanced Rehabilitation for People With Microprocessor Knee Prostheses

bilateral limb loss or a weak intact limb. While powered assistance provides the potential for the most complete replication of normal leg function, this potential is limited by actuator technology and electromechanical speed. For instance, the human knee moves over 300 degrees/s in walking28 and can increase to over 600 degrees/s in running.29 It would be difficult for actuators that have activation times only as fast as 10 ms12 to create such high velocities, without overheating when maximum speeds are maintained. User adaptation and acceptance of a powered MPK improves over time30 and has led to improvements in functional walking tests. However, active control can restrict mobility for middle-age and older adults,31 perhaps due to the complexity even though most adjustable parameters are not required for common functions.32 Artificial intelligence is used in MPKs to varying degrees. Standard setup includes initial programmed learning while the wearer walks with the MPK at various speeds and negotiates ramps and stairs. Setup programming prepares the prosthesis for normal function but may not provide sufficient information for the knee to respond appropriately during unexpected events, such as stepping into a divot. Though technically possible, most MPKs do not use real-time accommodation, as it is unnecessary for ordinary use. For instance, even unexpected situations such as stumbles cause predictable inputs that are anticipated by default settings.

Common Mobility Problems and Potential Solutions Despite sophisticated technology, prosthesis users face a variety of problems in moving around the community. Some problems can be significantly improved by MPK use, although users who are transitioning from non-MPK prostheses may have developed habits that must be unlearned. To illustrate how an MPK unit can benefit the user, common problems in gait, stair and ramp negotiation, transfers, and stumbling will be presented. People with lower-limb loss using an MPK demonstrate improved gait symmetry.33,34 Few studies have focused on physical therapy training to improve prosthetic walking function, but various approaches including functional training, balance training, and exercises for specific muscle groups have shown promise.35 Despite rigorous training and dedicated practice, some gait deviations persist.15,36 The most common deviations from which MPK users can significantly benefit are discussed here with prosthetic and training solutions.

STANCE PHASE Loading response: A common stance phase deviation is decreased prosthetic knee flexion during loading response. Decreased knee flexion develops because amputation of the knee robs the lower limb of the eccentric function of the quadriceps, which typically absorbs impact shock as the knee flexes approximately 15 degrees during initial loading.37 Knee buckling in loading response is a primary concern in early prosthetic training. The experienced non-MPK user may prevent collapse and potential falls by keeping the

709

knee extended in loading response. Decreased prosthetic knee flexion, however, diminishes shock attenuation and transmits stress up the kinetic chain to the hip, pelvis, and spine.38 Weight-activated friction brakes stabilize the knee when in the safe 0- to 20-degree knee flexion range. Hydraulic units provide graded resistance to knee flexion within the 0- to 20-degree range for descent of stairs, but will buckle readily beyond this range. Although this range of support is usually adequate for level walking, more range is required when descending a ramp, stepping on uneven surfaces, or when missteps occur. Lacking graded eccentric knee flexion control upon initial loading, the user learns to walk with a habitually extended knee. Prosthetic solutions: Some MPKs, like the C-Leg and Rheo Knee, allow knee flexion upon loading to provide the normal shock-absorbing function of the anatomic knee upon heel strike. For experienced prosthesis users who have learned to walk with the prosthetic knee extended upon initial contact, this function may seem strange. Indeed, the transfemoral amputation limb generates substantial hip extension power in the initial loading phase of gait particularly on the amputated side to push the thigh posterior and maintain the knee extended as well as to power the body forward over the stance limb.39 The new MPK user transitioning from a non-MPK unit must unlearn old habits and let the knee bend upon initial contact to benefit from the MPK’s capacity for greater shock absorption. The prosthetist can adjust the level of resistance as the user adapts. Training solutions: Whether learning to walk with a prosthesis for the first time or transitioning to an MPK that allows dampened knee flexion upon initial contact, prosthetic training should develop both movement ability and trust in the leg. Although strengthening the gluteus maximus is always beneficial to increase eccentric motor control that can support knee flexion control, the major factor is developing the trust in the MPK to allow knee flexion. Initially standing in parallel bars to provide security, the MPK user can step forward onto the prosthesis, perceiving the resistance to knee flexion as weight progresses from the heel to the toe. Repeatedly leaning on the prosthetic foot to rock from heel to toe as the knee bends gives the MPK user awareness of the strength of knee resistance and helps foster trust in the leg (Fig. 27.7). Training can progress to practice stepping performed with knee flexion upon heel contact as the body advances over the prosthetic foot, causing knee extension, similar to an able-bodied gait. This can be practiced in the parallel bars and later advanced to walking with initial knee flexion upon heel contact, guarded by the physical therapist, who can ensure that the knee unit will progress into extension as in normal gait. Training proceeds to ramp descent, best begun using a railing with therapist assistance. Developing the confidence to descend ramps while the MPK flexes through initial loading can seem like a leap of faith at first. Making the transition from walking with a hyperextended prosthetic knee to allowing the knee unit to flex during loading response can be difficult. Nevertheless, as little as 10 weeks has been needed to acclimate to the MPK.40 Asymmetric step length: Various physical impairments make asymmetric step length a common deviation for prosthesis users. The sound-limb step is typically shorter than that of the prosthesis. Amputated side hip extensor

710

Section III • Prostheses in Rehabilitation

Fig. 27.7 Rocking onto toes to feel the microprocessor knee flexion resistance.

weakness, uncertain balance, and limited hip extension range of motion, further restricted by the 10-degree hip flexion built into the transfemoral socket bench alignment all cause a briefer sound-limb swing time and shorter step length. Decreased hip rotation and concomitant lessened contralateral pelvic rotation also contribute to shorter prosthetic steps. Increasing hip extension range of motion and hip strength improves balance and facilitates longer prosthesis stance time. Practice walking with shorter soundlimb step lengths can also reduce asymmetry.24 Gluteus maximus strength is critical during initial loading to generate the hip extension force in early stance that lifts the center of gravity from lowest to highest point and converts stance limb torque from internal to external rotation. Extensor strength is the strongest predictor of prosthetic walking speed.41 In the absence of quadriceps and with the inevitable atrophy of the hamstrings,42 hip extension and abduction display the greatest strength loss after amputation.43 Atrophy of gluteal fast twitch fibers explains the slower gluteal contraction latency periods observed in amputated limbs.44 Greater demand and slower contractions on the weakened amputated side hip extensors decrease the user’s ability to quickly raise the center of gravity from the lowest point in dual limb stance to the highest point by midstance,41 particularly if long prosthetic steps are emphasized early in the rehabilitation process when gluteal strength is weakest. As a result, prosthetic stance time is significantly briefer than on the sound side, leading to shorter sound-limb swing phase duration and step lengths.45,46 Hip abductor weakness reduces the ability to maintain the body in prosthetic limb stance. This leads to a similar scenario in the frontal plane that also contributes to shorter sound-limb steps.47 Insufficient gluteus medius strength also diminishes the confidence to maintain single-limb stance long enough to complete the normal lateral weight shift. The prosthesis user compensates by placing the sound foot

farther from the midline, widening the base of support. The wide base shortens the gluteus medius length-tension relationship, further impairing hip abduction strength while simultaneously requiring a larger lateral weight shift. Hip abductor weakness also plays a role in step length asymmetry, with weakness correlating with slower gait, shorter steps on both sides, and decreased weight bearing on the prosthesis.47 Those with shorter amputation limbs have more abductor weakness, demonstrated in midstance by faster and/or greater pelvic drop.48,49 In both situations, longer and/or wider steps are a disadvantage to the gluteal muscles. In terminal stance, decreased prosthetic side hip extension range of motion restricts the body’s advance over the prosthetic foot causing the sound limb to take a shorter step forward. Lack of sufficient hip extension due to hip flexor contracture occurs with able-bodied people but is more prevalent among people with lower-limb amputation. Prolonged sitting during the rehabilitation process that can continue at home due to decreased activity is common after amputation.26 The standard flexed bench alignment of the transfemoral socket can accommodate mild hip flexion contractures but reduces hip extension excursion.46 In the presence of limited hip extension range of motion, users attempt to advance the body over the prosthesis by exaggerating anterior pelvic tilt48,49 with accentuated lumbar paraspinal muscle use, leading to greater lumbar extension compared with able-bodied people.50 Such compensation may lead to lower back strains; people with both amputation and low back pain had weaker back extensors.51 Increased demand for hip and lumbar extension strength and range of motion might be met with extra training to guard against low back pain. Abdominal and hip flexor strength is also critical to maintain hip stability and protect end-range lumbar extension in double support phase of gait.52 In normal gait, stance phase hip extension occurs with rotation around the stance hip.37 Although often observed as contralateral forward pelvic rotation, the rotation occurs primarily at the hip. After amputation, hip extension and contralateral forward rotation around the prosthesis are greatly reduced compared with the sound limb,48 because transection through the femur minimizes transverse plane bony leverage. As a result, translation of rotary forces from the limb to the socket is greatly reduced because the femur rotates within the soft tissues of the thigh. Any looseness in socket fit reduces the translated forces even more. In fact, unlike sound side or able-bodied individuals, prosthetic stance phase is marked by internal, rather than external, torque,49 which decreases trunk counterrotation and arm swing. Less trunk rotation is needed to counterbalance pelvic rotation when the individual wears a prosthesis. Nevertheless, when pelvic rotation is decreased, trunk rotation for prosthesis users is also diminished by limited joint mobility, weaker abdominal strength, incoordination between pelvis and trunk, and habit. Lessened trunk rotation decreases the alternating forward momentum that normally drives arm swing, leading to decreased shoulder movement. The ipsilateral upper limb may be unconsciously held posterior to the hip axis to maintain a hip extension moment for enhanced stability (Fig. 27.8). For more experienced and usually healthier users who have more confidence in the prosthesis and have striven

27 • Advanced Rehabilitation for People With Microprocessor Knee Prostheses

711

is common due to prolonged sitting. Anteriorly directed hip mobilization can help restore hip extension and rotation range (Fig. 27.9).55 Additional mobilization of the sacroiliac and lumbar joints may also be beneficial. Soft tissue mobilization or trigger point therapy for the iliopsoas followed by stretching56 can help maintain hip flexor flexibility57 and can be performed in the prone position or with the patient lying prone with the sound foot on the floor to help maintain or increase hip range (Fig. 27.10). Hip mobilization may also result in gluteal strengthening.58,59 Once joint motion is optimized, weight-bearing gluteal strength must be increased. These muscles minimize lumbar extension and frontal plane gait compensations that typically result from hip weakness. In addition to residual limb hip abduction exercise performed side-lying against a bolster,60 the person can wear the prosthesis to perform closed chain exercises. Forward step-ups are a challenge; however, lateral step-ups on a low platform activate the gluteus medius.61 To progress a user’s efforts, increase the step height

Fig. 27.8 Reduced prosthetic side arm swing provides a hip extension moment but causes gait asymmetry.

to walk faster, prosthetic steps may be shorter than those of the sound limb.18,53 Multiple years of hip flexor stretching increases hip extension range.51 However, iliopsoas often atrophies and weakens,52 providing insufficient power to protect the hip and lumbar spine and to enable uniform step lengths. Increased lumbar rotation that compensates for limited hip rotation after amputation may exacerbate low back pain.50 Regardless of which step is shorter, coordination of trunk and pelvis is important to stabilize the lumbar spine dynamically and produce sufficient trunk and pelvic rotation to achieve symmetrical step length. Prosthetic solutions: The enhanced stance phase stability of an MPK obviates the need to use the arm to maintain a hip extension moment throughout stance and allows the user to spend more time on prosthetic single-limb stance, thus equalizing step lengths and restoring the normal external rotation torque in stance phase. A torque adaptor in the shank can augment the limited contralateral pelvic rotation around the prosthesis. Regardless of the type of knee unit, significant hip abductor strength is required for single limb stance on the prosthesis without contralateral pelvic drop or ipsilateral trunk lean. Training solutions: Developing symmetry in prosthetic gait requires a comprehensive approach that reduces underlying joint and muscular impairments to optimize functional outcomes.54 For the experienced wearer, the habit of keeping the arm behind the hip is likely to be ingrained. Focused training is required to restore normal trunk counterrotation and arm swing. To enable the user to walk with as much symmetry as possible, the person should have normal range of motion throughout the lower limb, particularly the hip. Anterior hip capsular tightness limiting hip extension range

Fig. 27.9 Anterior hip joint capsule mobilization.

Fig. 27.10 Hip flexor stretch.

712

Section III • Prostheses in Rehabilitation

gradually. Activities involving sustained stance on the prosthesis also develop prosthetic side hip strength, especially hip abductors. Standing on the prosthesis while pushing in the opposite direction against a wall is an example (Fig. 27.11A and B). More dynamic activities include standing on the prosthesis while using the sound limb to roll a ball on the floor, kicking against Theraband,62 reaching in different directions around a circle like the star excursion balance test,63 or maintaining the sound limb on a stool or unstable surface while throwing a ball (Fig. 27.12). Using one hand to lightly maintain balance is important for safety; however, if both hands are required, the activity is probably too difficult and should be modified. In addition to unilateral trunk bridging that focuses on gluteus maximus strengthening and control, hip extensor strength can be developed wearing the prosthesis while standing or simulating gait positions. One method to activate the gluteus maximus is to stand with hands in front pushing forward against a wall or kitchen counter, while leaning forward far enough to lift the prosthetic heel off the floor. As the trunk shifts forward over the forefoot, a hip flexion moment is created that must be maintained with hip extensors to keep the heel high (Fig. 27.13). Promoting forefoot loading facilitates gluteus maximus activation and trains the user to activate MPK functions. Developing sufficient prosthetic side hip power to take long sound-limb steps can be performed by standing with the prosthetic foot ahead of the intact foot facing a low stool. The wearer steps forward with the sound limb progressing to higher steps. This activity exaggerates the demands on the gluteus maximus and can be used to develop the power needed for more challenging activities (Fig. 27.14). Strengthening the gluteus maximus, the primary external rotator of the hip, is also vital in transforming the leg torque from internal to external rotation after initial loading. Activities described above such as the sound limb star balance excursion test or exaggerated step lengths to ever

higher steps increase gluteal strength and develop pelvic rotation around the prosthetic stance limb. Exercises that emphasize hip rotator strength include pressing the contralateral arm or leg back against a wall to promote isometric contralateral trunk rotation (see Fig. 27.11B). Active rotation around the prosthesis can be performed by turning the pelvis to point the sound foot as far around as possible in each direction and then maintaining the position, using the hands of a clock as a visual cue (Fig. 27.15A and B). Rotational activities can be progressed by pivoting on both

Fig. 27.12 Step standing with sound limb on an unstable surface.

Fig. 27.11 (A) Isometric hip abduction and (B) isometric hip external rotation against a wall.

27 • Advanced Rehabilitation for People With Microprocessor Knee Prostheses

713

Fig. 27.13 Pushing forward against a wall while rising onto the forefoot for hip extension and external rotation.

Fig. 27.14 Sound limb to high step.

heels to turn the toes in and out. Even more challenging is weight bearing through the forefeet while turning first one then both heels medially and laterally (Fig. 27.16A and B). Pivoting with weight on the toes develops hip strength and assists functional use of the MPK during turns and sidesteps. For effective neuromuscular reeducation and activation of the hip rotators, the therapist may use cueing or apply resistance through the sound limb (Fig. 27.17). Pelvic rotation contributes to the overall goal of uniform step length with

faster gait speeds although specific pelvic motions may become less symmetrical.48 More advanced gluteal strengthening activities can integrate trunk and upper extremity function through exaggerated elements of gait. One method is to face a wall, then press only the ipsilateral hand against the wall while simultaneously lifting the prosthetic heel off the floor and flexing the sound hip as high as possible (see Fig. 27.13). Avoid lumbar hyperextension to protect the back. Maintaining this

Fig. 27.15 Stepping and holding in hip rotation: (A) internal and (B) external.

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Section III • Prostheses in Rehabilitation

Fig. 27.16 Pivoting on both heels (not pictured) and toes from (A) internal to (B) external.

position with spinal stability activates the abdominal muscles and helps promote contralateral pelvic rotation around the prosthesis with upper trunk counterrotation and arm swing often impaired in gait. Spinal stabilization exercises increase prosthetic step length and gait speed.53 Strengthening the hip flexors of both limbs also helps protect the hip and spine as they extend in terminal stance phase. Hip flexion generates power through swing phase. Hip strengthening and functional proficiency are important for both legs because sound limb hip rotation adds impetus to prosthetic swing phase, trunk counterrotation, and arm swing. In addition to pelvic and trunk rotation training, additional practice may be necessary to make arm swing natural. Facilitating arm swing through the shoulders or with canes held in each hand by both user and therapist while walking in synchronicity can help. Pelvic and trunk rotation in gait can be progressed by having the user and therapist face each other while the user walks forward as the therapist walks backward resisting the pelvis or hands to integrate trunk counterrotation and arm swing (Fig. 27.18). Functional activities to develop transverse plane rotation and gait symmetry can eventually be used for independent practice by highly functioning individuals include tandem balancing (Fig. 27.19) and walking or grapevine walking to encourage rotation around each hip as well as decrease the base of support. Floor markers placed evenly apart can serve as visual cues for uniform step lengths, and a full-length mirror at the end of a walkway allows the prosthesis user to check the symmetry of arm movements and general symmetry. A metronome provides an audible cue to rectify asymmetric stance times. A treadmill can be used to train progressive and consistent gait speed on level and inclined surfaces. As the patient builds strength, confidence, and awareness of muscle function and the limit of stability, the ability to take normal-length steps during functional activities improves. As ability increases, additional challenges can be designed, such as stepping onto unstable surfaces.

Fig. 27.17 Resisted hip external rotation by therapist through the sound knee.

Other stance phase deviations discussed elsewhere in this text, such as wide base of support and lateral trunk lean or Trendelenburg, are unlikely to be affected specifically by MPK use but may benefit from the proposed training solutions. Regardless of prosthetic components, training is required to minimize gait deviations and maximize function. Swing phase: Gait asymmetry can be affected by the difficulty transitioning from stance to swing phase. For able-bodied individuals, ankle plantarflexion prior to swing phase raises the body, providing much of the propulsive power.37 Hip flexors contract to decelerate end range hip

27 • Advanced Rehabilitation for People With Microprocessor Knee Prostheses

Fig. 27.18 Resisted gait with cane.

Fig. 27.19 Tandem stance in a doorway.

extension, then initiate swing phase with the adductors. The flexing hip and the forward propulsion of the body create momentum that first passively flexes the knee from heel off to early swing then extends the knee through terminal swing when hip flexion is reversed by the hip extensors. When momentum is reduced, as in slow gait, the hamstring muscles flex the knee to assure toe clearance augmenting foot dorsiflexion.

715

Amputation eliminates active ankle plantarflexion. Work shifts to the iliopsoas muscle increasing power derived from the hip flexor group by over 50%.39 Without active knee flexion, the hip flexors must contract even stronger to supply sufficient momentum to advance the limb through swing phase. Unfortunately, the ipsilateral iliopsoas atrophies.52 Developing hip flexor strength can be difficult, especially with shorter amputation limbs. The new user can have difficulty advancing the limb, leading some to exaggerate hip flexion by kicking the leg laterally to initiate swing. Exaggerated kicking can lead to swing phase deviations like steppage (exaggerated hip and knee flexion) that can linger long after sufficient strength is restored. Non-MPK hydraulic knee users must also switch their knees from stance phase control knee flexion resistance to swing phase resistance. While unnatural at first, prosthesis users learn to perform the knee extension motion without much thought.64 However, swing phase is delayed and stance times asymmetric.45 When momentum is not directed forward, such as when turning or sidestepping, transition between stance and swing phase knee resistance can be ineffective resulting in occasional circumduction, hip hiking, or vaulting if adequate swing resistance is not activated. Knee collapse and falling may occur if stance resistance is not activated. Prosthetic solutions: For the MPK user, transition between resistance phases is initiated intrinsically in response to electronic sensors. In the C-Leg the user must achieve knee extension for 0.1 second with 70% body weight forefoot loading to disengage stance control and allow swing phase knee flexion. The amount of body weight required can be adjusted depending on the user’s needs. Default settings of the specific MPK determine what happens if the criteria are not met. For instance, the C-Leg defaults to stance phase control to protect the wearer from knee collapse, a significantly improved safety feature compared with non-MPK prostheses. Other MPK units like the Rheo Knee default to swing phase control to avoid toe drag in swing phase. Training solutions: To ensure that the user is comfortable bearing weight through the prosthetic forefoot, activities involving forefoot loading are critical. Pivoting can be practiced with weight on both forefeet to allow rapid swing phase action during turns (see Fig. 27.16B). Lateral weight shifts onto the toes with one or two quick bounces can help prepare for side-stepping. Forefoot bouncing can also be useful, and some MPKs like the Power Knee use forefoot bounces as mechanical cues to change knee resistance modes. Pushing off the forefoot to kick into swing phase can assist forward walking or the quick transition into swing phase necessary for a brief jog. For those with decreased pelvic and trunk motion, abdominal muscles may be recruited to assist swing phase, particularly for people with amputation limbs shorter than 57% of the sound length where hip flexors are weaker. Shorter limb length correlates with increased pelvic tilting during gait even after traumatic amputation.65 Core abdominal mobility exercises are even more important after hip disarticulation or higher amputations that deprive the user of all active hip motion. In addition, rapid stepping can improve coordination and hip flexion power necessary to increase gait speed and avoid obstacles.

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Stairs and Ramps Descents: Stairs and ramps remain difficult for even for experienced users. Descents and ascents pose different problems. As in walking, limited prosthetic knee flexion is a particular problem when descending stairs and declines. Limited shock attenuation is particularly evident upon landing on the prosthetic limb when descending stairs, curbs, or declines. Because the wearer descends stairs onto the heel, not the forefoot as able-bodied individuals do, more shock is transmitted to the extremity; the user commonly feels a jolt upon landing. Although the prosthetic limb is subjected to less vertical force than a normal limb upon landing, this force is more poorly attenuated without normal knee flexion and ankle dorsiflexion upon loading. The hip on the prosthetic side must exert greater extension force to help control the knee. On the sound limb, the relative lack of prosthetic knee flexion results in about 50% greater vertical impact forces as the body lowers from a greater height.66,67 In fact, all sound limb joints experience increased stress in gait, exposing the sound side to more risk of injury.30 As a result, most people with transfemoral or higher amputations instinctively take smaller steps of shorter duration to decrease ground reaction forces and muscle demand on ramps whether descending or ascending.68 The new wearer usually takes short prosthetic steps to prevent accidental collapse and compensates with longer sound-limb steps to maintain speed, making gait asymmetrical. Non-MPK hydraulic stance control knees provide graded resistance to knee motion beyond 20 degrees flexion, giving time for the sound limb to alight onto the next lower step in a step-after-step pattern. Nevertheless, most users still have noticeably decreased prosthetic stance time when descending stairs.67 Descending ramps is more difficult than stairs because in order to place the prosthetic foot flat on the ground without the normal ankle plantarflexion range, the prosthetic shank must be thrust forward downhill, creating a rapid, sizeable knee flexion moment. Knee flexion resistance in a non-MPK hydraulic stance control unit can be adequate on shallow ramps, but knee flexion resistance is not always sufficient on steeper ramps. Prosthetic users often hesitate when descending ramps. Prosthetic solutions: As in level walking, MPK sensors provide data used to adjust the real-time resistance needed for descent. For the typical MPK, full knee extension at terminal swing combined with prosthetic heel weight bearing triggers knee flexion resistance to match the individual’s body weight, angle of descent, and gait speed through a greater range of motion (30–35 degrees) than provided by non-MPK units.24 Slow, interrupted, or unsteady stair descent may cause insufficient momentum to create full knee extension, thereby leaving MPKs with swing phase resistance default settings unready to provide stance phase stability; this deficiency can lead to knee collapse. Collapse is less of a problem for the C-Leg, which defaults to stance phase knee resistance, even in knee flexion ranges of 36 to 55 degrees.66 Prosthesis users functioning at the Medicare K2 or K3 levels (see Table 27.2) performed better on stairs and declines with MPK compared with non-MPK hydraulic knees.69 After the MPK software is adjusted and the user develops confidence and balance through training, the wearer can descend steep declines with significantly longer

prosthetic steps that promote less asymmetry and faster speeds.24 Training solutions: To descend stairs, the MPK user must learn to place only the rear foot on the lower step and load substantial body weight through the heel (see Fig. 27.2). This foot placement triggers the graded knee flexion resistance needed while leaving the toes to angle down and progress to the next step as the knee bends. To step down stairs onto the heel in this manner can be anxiety producing for the new MPK user and should be practiced initially on the bottom step using a bannister with guarding. The prosthesis user can mitigate some of the impact shock to the residual limb by reaching the prosthetic leg down toward the next step so the foot meets the lower stair with less impact. This motion, referred to as pelvic anterior depression,70 can be practiced on level ground or by standing on a low platform to reach the heel forward and down with a pelvic motion before returning to the starting position. Taking long prosthetic steps when descending a ramp is unnatural to the person who has habitually used a nonMPK prosthesis. This habit may be overcome by training the MPK user to (1) utilize pelvic anterior depression in terminal swing, (2) activate the hip extensors to advance the body forward during initial loading, (3) rotate the contralateral pelvis around the stance hip in midstance, and (4) maintain weight bearing through the prosthetic forefoot in terminal stance. Training can include practice placing the prosthetic heel on targets placed on the floor around the individual. A banister provides safety during the training process until the new wearer develops confidence to progress to resisted training and finally unassisted declines. Ascents: Most people with transfemoral amputation ascend stairs in a step-to fashion. A similar gait pattern is used for steep inclines. When ascending, the wearer typically flexes the sound limb more to make up for the lack of prosthetic side elevation normally provided by ankle plantarflexion.68 In the community, some people ascend stairs two steps at a time with the sound limb to maintain the same speed as companions. Greater knee flexion, however, increases forces on all sound limb joints when climbing stairs.67 In the stance phase of ramp ascent, the prosthetic shank is thrust backward making it difficult to advance the body forward and causing a short step on the intact side. Prosthetic solutions: When ascending ramps, forefoot weight-bearing causes the shank to be thrust backward, exerting a strong knee extension moment. An MPK in the stair ascent mode gives less swing phase resistance to knee flexion to help the foot clear the edge of the next step. Software can be adjusted to the user’s needs. Once the foot is on the next step, however, the user must exert considerable hip extensor power to lift the body onto the next step, which is typically accomplished with the assistance of a hand on a bannister. In the absence of a bannister, step-over-step stair ascent is very difficult for most users. The Power Knee provides powered assistance to ascent. The user must stop at the bottom stair for 3 seconds to default to the standing state before ascending. Initiating knee extension activates the assisted knee extension function. Data sent wirelessly from sensors strapped to the sound leg help match prosthetic movement to the sound limb. At the top of the stairs, the user must pause again for 3 seconds

27 • Advanced Rehabilitation for People With Microprocessor Knee Prostheses

to reset the MPK before walking. The powered mechanism makes sounds noticeable to passersby; the noise bothers some users. The Genium uses a gyroscope and accelerometers to recognize that the user is ascending a step. A quick hip extension movement to drag the foot off the ground followed by quick hip flexion in a whipping motion lifts the foot to the next step with prosthetic hip and knee flexion. Once the foot is on the next higher step, the Genium provides maximal resistance preventing further knee flexion in the bent knee weight-bearing position. Use of the Genium has shown to improve step-over-step ability, though significant effort is still required by the opposite lower limb to raise the body and upper limbs to pull up on a bannister.71-73 Training solutions: Due to hip flexor weakness, the prosthesis user may have to elevate or tilt the pelvis posteriorly, using the abdominals to gain sufficient elevation and to compensate for limited prosthetic ankle dorsiflexion on stairs and inclines. If the user stops on a step, restarting swing phase up the stairs is difficult. Turning diagonally allows space for the foot to clear after a stop on the stairs without excessive hip hiking. Ascending step-over-step requires great hip extensor strength and usually the assistance of a bannister. Recent MPK designs, including the Power Knee and Genium, meet this challenge. The Power Knee only requires the user to initiate knee extension with the hip extensors. Step-over-step ascent with the Genium requires significant hip extensor strength and is recommended only for active users at the K3 to K4 levels (see Table 27.2). Sitting and squatting: Although navigating stairs can be difficult for people using prosthetic knees, any knee bending and straightening activities like rising from a chair or squatting demands compensatory movements, which imposes added stress to the sound limb. Many prosthetic knees require unloading the prosthesis to allow the knee unit to bend so that the user can sit at a speed similar to able-bodied individuals. As a result, many prosthesis wearers stand with 10% to 30% more body weight on the sound limb than on the prosthesis.47,74 Squatting with both legs can be useful. For instance, the prosthesis user may want to squat to reach down to a child or pick up something from the floor without bending from the waist to avoid low back pain, which occurs in more than 80% of people using transfemoral prostheses.52 After 30 degrees knee unit flexion, most MPKs provide insufficient flexion resistance to prevent collapse.66 Thus, for many users, sit-stand transitions and especially squatting become single-limb activities that place substantial stress on the sound limb. Potential solutions for sit-tostrand transitions and squatting follow. Prosthetic solutions: When the wearer begins to sit down, MPKs like the C-Leg and Rheo Knee provide controlled resistance to knee flexion activated by prosthetic weight bearing. MPKs allow symmetrical distribution of weight between the feet to reduce stress on the sound limb; resistance settings can be adjusted to the needs of the user. Whether using non-MPK or MPK, wearers continue to bear weight asymmetrically and sit slower than able-bodied individuals.74 To sit rapidly without adjusting the resistance, MPKs that have swing phase default settings can be off-loaded; this shifts stress to the sound limb as with non-MPKs.38 Although MPKs allow symmetrical weight bearing during stand-tosit transitions, the user must be trained to bear more weight

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on the prosthesis by pressing the thigh against the inner posterior socket wall with a hip extension force to off-load the sound limb. Most MPKs do not assist sit-to-stand activity; the user depends greatly on sound limb strength to rise. The Power Knee, however, assists user-initiated knee extension. A push up from the chair armrests activates the assisted sit-to-stand function. As compared with those wearing unpowered knee units, prosthesis users rising with the Power Knee move with greater symmetry with hip force closer to that exhibited by able-bodied individuals.74 To sit using a Power Knee, the user must pause to activate the default standing mode, then slowly lower the body to the chair. If the sitting motion is stopped midway, the Power Knee will support the user in a squat until the prosthesis is unweighted. Transferring the weight to the sound limb allows further knee unit bending. Some MPKs provide special function modes that allow squatting or prolonged standing. The C-Leg, for instance, permits prosthetic weight bearing with the knee unit flexed to any angle between 7 and 70 degrees allowing maximal support for squatting or bent-knee standing. The Compact knee, designed for K2 level users, offers the same function in a 0- to 30-degree range. This mode is activated by handheld wireless remote control unit, with predetermined physical cues such as bouncing quickly on the forefoot, but also more intuitively by lowering the body to the desired degree of knee flexion and then slightly straightening the prosthetic knee to turn on the maximal knee flexion resistance needed to squat.17 The Power Knee facilitates squatting by locking when the user stops the stand-to-sit motion at the desired degree of knee flexion.11 Training solutions: When sitting, the MPK user should place the hands on the arm rests to enhance safety and decrease the chance that the wearer will fall backward. Using arm rests, however, shifts the body weight backwards onto the heels rather than forward onto the forefeet as in able-bodied sit-to-stand transitions. For those who demonstrate the potential to stand unassisted, transferring weight forward over the forefeet can be practiced from surfaces of decreasing height as the person improves. The user’s hands can be positioned anteriorly or on the thighs while arising. Placing both feet behind the knees helps advance weight over the forefeet but can be difficult due to limited prosthetic ankle dorsiflexion. Keeping the spine straight minimizes patellar compressive forces and back pain. Practicing at different speeds on different seat heights and while holding objects of different weights can prepare the user for a range of functional activities. To develop the strength and control to squat, the user should practice single-limb squats with the sound limb. If unable, the wearer can start by performing a wall squat with a chair at hand for support. Methods to stimulate greater contribution of hip extensors on the amputated side will help in controlling the descent to the desired knee flexion angle. Squats on an unstable surface such as a cushion or tilt board performed between parallel bars and with appropriate guarding for safety, can be effective. Step-ups with the prosthesis leading also help enable knee unit extension through forceful hip extensor contractions. Gluteal strengthening exercises are essential. Fall protection: People with leg amputation have a greater risk of falling than do able-bodied individuals, with reported

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incidences of 20% to 32% during rehabilitation75,76 and 52% within the community.77 Falls occur when the wearer unexpectedly bears weight on the flexed prosthetic knee, as can happen when a user slips, stubs a toe, or steps on a rock unbalancing the prosthetic foot and causing the knee unit to bend. Stepping onto a flexed knee can also occur when the user turns, takes small sidesteps, or stops suddenly, preventing the knee unit from fully extending and activating stance phase control. When using a hydraulic non-MPK, tripping or stepping on an object leads to swing phase knee flexion resistance and increases the risk of falls.78 Slips may occur upon heel strike onto slick surfaces such as ice. A slip causes very high demand for gluteal muscle strength that must respond rapidly to the anteromedial shear upon landing.79 The muscles of prosthetic users, including postural muscles like the erector spinae and oblique abdominal muscles, do not consistently contract when walking and respond to slips and trips slower than the muscles of sound limbs or ablebodied people.79 The wearer may adapt to the risk of unexpected knee instability by taking shorter prosthetic steps, which results in slow, asymmetrical gait. Prosthetic solutions: Whether a stumble or fall will result from an unexpected step onto a flexed knee depends greatly on the MPK default setting. MPKs with swing phase knee resistance default settings require great compensatory movements; otherwise, falls occur even in younger people whose amputation etiologies were non-dysvascular.66 Knee collapse can also occur when knee unit flexion exceeds the 30- to 35-degree range programmed for stance phase resistance capacity.66 The Power Knee and C-Leg default to stance phase knee resistance and will prevent collapse even after swing phase is interrupted.78 In everyday situations, stance phase default C-Leg users reported significantly fewer stumbles and falls80 and a safer experience compared with non-MPK users.81 Training solutions: Because stumbling is unexpected, it is difficult to prepare the new user. However, most slips result from the foot sliding upon initial contact rather than in terminal stance. Thus the gluteal muscles are the most important group to strengthen and the hip flexors are a secondary concern. Consistent contraction of the core muscles throughout gait, not typically present in prosthesis users, should be developed and strengthened to allow stronger and faster response to postural disturbances.79 Methods for strengthening gluteal muscles and integrating abdominal contractions in gait have been presented in training solutions for asymmetric steps. Practice in functional activities encountered in real life also prepares users to respond to stumbles and falls. Obstacle courses should include different walking surfaces and stepping up, over, and onto obstacles. Carrying items and performing dual tasks can develop overall functional ability. With training, MPK users can negotiate obstacle courses quickly with fewer steps compared with those wearing non-MPK prostheses.82 Practice on outdoor terrain can enable the wearer to participate fully in daily activities. Other activities: The user may wish to participate in activities that require free-swinging knee function like biking or locked knee function like prolonged standing. Prosthetic solutions: Non-MPK hydraulic or pneumatic knees sometimes have a manual switch at the back of the knee that will switch the knee to different modes of function.11 MPKs offer various modes of function but eliminate

the need to operate a switch manually. A physical cue like pushing down on the toes three times followed by unweighting the leg for 1 second switches the mode of operation from walking to free swinging for biking or maximal knee resistance for prolonged standing.17 Regardless of whether wireless remote or leg movements are used to switch functional modes, an electronic signal, either a series of beeps or vibrations, confirms the change in setting to the user. Training solutions: The ability to remember how to switch modes, performing the physical cue, and hearing or feeling the confirming electronic signals varies among users. As with gait training, forefoot weight-bearing practice is a fundamental skill to develop. Having the user practice initiating the cues and perceiving the signals is important to the smooth, effective use of these MPK features. Although clinicians may focus on gait deviations that persist despite dedicated training for even the most experienced and high-level users, wearers themselves tend to focus more on their functional abilities. Even active prosthesis users typically take part in bouts of activity lasting less than 2 minutes and averaging only 17 steps per minute. Most wearers only engage in activity lasting more than 15 continuous minutes less than once per day.83 Functional ability and attitude toward the prosthesis are the strongest predictors of patient satisfaction.84 Prosthetic outcomes can be maximized through a clinical approach that addresses range of motion and strength impairments while integrating functional abilities to optimize participation in the pleasures and challenges of real life.

Outcomes Success of prosthetic fitting can be measured by objective factors, principally energy consumption, walking velocity, and step symmetry, as well as subjective responses such as falls history and quality of life questionnaires. Overall, prosthesis users perform somewhat better and report greater satisfaction when wearing MPK prostheses than with less sophisticated components. A few investigators compared function of people wearing prostheses with various units. Even in the presence of laboratory evidence regarding the biomechanical characteristics of MPK units, clinicians’ and wearers’ subjective reactions remain the mainstay of formulating prosthetic prescription and thus determining prosthetic rehabilitation outcomes.84,85 Physical characteristics appear to outweigh the importance of a particular prosthetic component in determining the individual’s performance. Review of combat-associated amputations reveals that function and amputation limb length are directly correlated, whereas energy consumption and length are inversely related.86 People with mid-length or longer thighs, however, showed no significant kinematic or kinetic gait differences.65 Gait studies: Laboratory comparisons of performance with prostheses equipped with the C-Leg and the Mauch Swing and Stance hydraulic knee unit generally indicate that subjects walked faster with the C-Leg by as much as 21% depending on terrain.18,80 Faster self-selected walking speed with a C-Leg did not necessarily come at higher energy costs.87 One research team, however, reported no significant differences in free walking speed.64 Faster gait speeds obtained with people after transfemoral amputation using

27 • Advanced Rehabilitation for People With Microprocessor Knee Prostheses

the C-Leg compared with non-MPK prostheses have also been documented in a case report of one person with bilateral knee disarticulations.88 Laboratory comparison of subjects wearing the Endolite Intelligent Prosthesis and non-MPK units reveal similar results as those involving C-Leg.89 A goal of prosthetic fitting is to enable the patient to walk as inconspicuously as possible. People wearing the C-Leg exhibited less step length asymmetry than when using a hydraulic non-MPK unit.18,40,45 Kinematic analysis of subjects walking with MPK units showed less delay between late swing phase knee extension and heel contact than with other units.45 Optimum rehabilitation restores the individual’s ability to walk greater distances without appreciable fatigue. In one study, subjects who wore prostheses with step counters and distance monitors took similar numbers of steps and walked for equivalent durations in the home and community environments whether using the C-Leg or Mauch knee units,83 whereas another group reported that wearing an MPK prosthesis was associated with greater physical activity in the community.90 Much research involves measuring oxygen consumption. Some investigators detected no significant difference in oxygen cost of walking when comparing performance of subjects wearing the CLeg and hydraulic non-MPK units,88 whereas others suggest that walking with C-Leg is more energy efficient.82,91,92 Although metabolic demand when wearing the microprocessor Adaptive Knee was comparable to that of a hydraulic non-MPK unit,93 use of the Intelligent Prosthesis was associated with slightly reduced oxygen consumption.94-97 Although use of different MPKs produced similar levels of oxygen consumption, the energy cost for young adults with traumatic amputation using MPK was much higher than required by the able-bodied control subjects.98 Metabolic demand with the Rheo Knee unit was slightly less than with the C-Leg.99 In general, any MPK reduces energy consumption modestly compared with a non-MPK, confirmed by laboratory comparison of adults walking with several types of MPKs.66 Performance in other ambulatory activities: Sit-to-stand transitions required less hip force for subjects wearing the Power Knee as compared with performance with the C-Leg or the Mauch Swing and Stance Control unit, although all participants relied primarily on the intact limb.74 The C-Leg offers more protection against tripping as compared with non-MPK units. Three subjects participated in a randomized study in which the examiner tugged on a cord in an attempt to cause prosthetic knee flexion. Unlike other knee units, the C-Leg either produced rapid knee extension or supported the wearer on the flexed knee.78 Performance on stair and ramp descent was safest with the C-Leg, as compared with the Rheo Knee, Adaptive 2 Knee, and Hybrid Knee.66 On hill and stair descent, MPK users exhibited smoother maneuvering over obstacles, fewer stumbles, and superior multitasking ability, allowing many to advance to a higher Medicare functional level.69 The Rheo Knee and the CLeg were associated with smoother gait and decreased hip power generation as compared with performance with the Mauch Swing and Stance Control units.97 Subjects who walked on a treadmill while solving mental problems swayed less when tested with the Intelligent

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Prosthesis, suggesting that it was not as cognitively demanding as less sophisticated knee units.100 Several research teams administered questionnaires to people who wore prostheses equipped with C-Legs. Respondents praised confidence, gait, and maneuverability,81 as well as overall satisfaction.22 Scores on the Prosthesis Evaluation Questionnaire were higher.80,82 Subjective response to the Intelligent Prosthesis was also favorable, with users preferring it to non-microprocessor units when walking at different speeds and greater distances with less fatigue.100 Survey respondents commended increased quality of life when wearing MPKs.90 Although many studies of adults wearing MPKs have been published, few have addressed issues such as mechanical durability, effect of unit weight on performance, and whether the cost of the units equates to substantially greater benefit. Ideally, future research would involve larger sample sizes. Nevertheless, at the present time, one can conclude that MPK units can improve the quality of life of many people with transfemoral amputation.

Prescriptive Cases Selecting the prosthesis that matches an individual’s needs requires taking into account the person’s general health, level and status of the residual limb, history of prosthetic use, features and limitations of the available prosthetic components, impact level of the intended use, and the individual’s functional level. Manufacturers recommend MPKs for low- to moderate-impact activities (Table 27.3) by users

Table 27.3 Impact Levels Levels

Target Activity

Typical Use

Low

Walking with small cadence variations

Daily walking with low foot forces. Examples: household tasks, gardening, shopping, and occasional non-impact sports such as golf and leisure walking.

Moderate

Walking with variable cadence

Daily walking of long durations with moderate forces. Examples: aerobics, jogging, sports like tennis, and vocational activities like lifting/carrying.

High

High cadence walking

Daily activities involving vigorous and repetitive actions with fast speeds and high loading forces. Examples: distance jogging, running, jumping, sports like basketball, and vocational activities like construction work.

Sport-Extreme

High-impact sports and activities

Daily activities with high or extreme forces common in repetitive, fast, and/or sustained activities. Examples: sprinting, longdistance running, active military service.

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at the Medicare K2 to K4 functional levels (see Table 27.2), regardless of insurance company policies. After transfemoral amputation many people may not attain the functional ability to become K3 community ambulators, who often average walking speeds > 0.8 m/s (1.8 mph) and negotiating steps and curbs.101 For K2 level walkers, MPK units like the C-Leg Compact with stance phase control only improve balance and walking on level and slopes may be sufficient.102-104 Prosthesis users who walk faster, traverse daily distances of 5 km (3.1 miles) including stairs, and engage in moderate-impact activities are at the K3 to K4 functional level, thus both stance and swing phase features

are recommended. In addition to matching prosthetic components to the individual’s physical and functional needs, another inescapable consideration is the cost of incorporating an MPK. Insurance will often reimburse the price of an MPK only for users at the K3 to K4 levels. The cases that follow highlight important considerations relevant to MPK prescription. Those with hip disarticulation or higher amputations can be considered at the K2 level if walking independently, regardless of speed, although Medicare K-levels are not intended for people other than unilateral transtibial and transfemoral amputation.

Case Example 27.1 The Active Athlete A 29-year-old 110-kg (245-lb) former college athlete has a transfemoral amputation resulting from a motorcycle accident 5 years ago. He has been using a non-MPK hydraulic knee prosthesis for his everyday life, which includes work as a sales representative during the week and recreational basketball and tennis on the weekends. He jogs proficiently using the skiphop style but has become interested in more sports activities and wants to run step-over-step and potentially compete in athletic contests. He is ready for a new prosthesis that can facilitate reaching his goals. What type of knee unit best matches his needs? His activities show K4 level functioning and would qualify him for reimbursement of an MPK prosthesis by many insurance companies.

Although an MPK prosthesis would be an excellent choice for his everyday activities, they are designed for low- to moderate-impact activities and could be overloaded by the sustained and high-impact nature of his intended sports. If he is going to proceed with only one prosthesis, one with a nonMPK hydraulic knee unit such as the Mauch Knee Plus may serve him best. Such a knee could be paired with a heavy-duty energy storing foot designed to absorb shock like the ReFlex VSP.

Case Example 27.2 A Risk to Fall? A 65-year-old woman underwent transfemoral amputation 4 years ago resulting from a thrombosis associated with peripheral vascular and cardiovascular disease. She was active prior to amputation. Her activity has increased since the amputation and she has returned to work as a school administrator using a weight-activated friction brake knee unit. She gardens and enjoys leisure walking in the community, although her strength and endurance limit her from walking as fast or as far as she would like. She has recently qualified for Medicare and wants a prosthesis that can help her reach her goals. What type of knee unit best matches her needs? Her activities demonstrate K2 level prosthetic functioning with K3 level potential. Medicare and her employer-based insurance may not approve an MPK prosthesis because her functional activities do not demand a varied cadence or fast walking speed. Her age and general health status may also mitigate against her efforts

to get reimbursed for the cost of an MPK prosthesis. However, community ambulating prosthesis users are at heightened fall risk.77 Falls within her age group have annual incidence rates from 19% to 60% with 27% reporting injury at the rate of 14.1/ 1000 person-months.105 Although current reimbursement practice often does not include an MPK for a K2 level patient/client, she would benefit from using an MPK prosthesis, particularly its stumble and fall protective features. Physical therapy can increase hip extension range of motion, strength, and gait speed59; use of an MPK prosthesis for a trial period has also allowed increases in walking speed of 14% to 25%.106 Physical therapy and prosthetic intervention may help her advance to walking speeds >0.8 m/s101 or distances >400 m107 that may help her achieve community walking speeds and qualify for reimbursement of a K3 MPK prosthesis.

27 • Advanced Rehabilitation for People With Microprocessor Knee Prostheses

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Case Example 27.3 Hemipelvectomy: Cost and Effectiveness Case 3: A 44-year-old man had a hemipelvectomy 3 months ago due to chondrosarcoma. His incision has healed and he is ready for fitting. He has never used a prosthesis but was very active until 1 year ago when he underwent tumor resection and internal hemipelvectomy and suffered a bout of depression. After the resection, he limited activity to working in an office and curtailed most sporting activities other than occasional walks in the park. Since his amputation, he has returned to work as an accountant and is adept with crutches, which he uses for light sports activities such as soccer with his children. He uses a wheelchair for traversing long distances. He complains that it is difficult to rise from a chair or hold something in his hands while using crutches. He lives with his wife and teenage sons in a suburban two-story house. He is insured through his employer and his prosthetist is confident that an MPK prosthesis will be covered by insurance. His goals are to continue work and family life with greater ease.

References 1. Murphy EF. Lower Extremity Components, In American Academy of Orthopaedic Surgeons. In: Orthopaedic Appliances Atlas. Ann Arbor, MI: J.W. Edwards; 1960:2. 2. McAleer J. Mobility redux: post World War II prosthetics and functional aids for veterans, 1945 to 2010. J Rehabil Res Dev. 2011;48: vii–xvi. 3. Filippi P. US Patent 2,305,291. December 15, 1942. 4. Henschke U, Mauch H. US Patent 2,490, 806, December 13, 1949. 5. Erback JR. Hydraulic prostheses for above-knee amputees. J Am Phys Ther Assn. 1963;43:105–110. 6. Endolite. User manuals and technical information, and history available at. http://www.endolite.com/products/knees/. Accessed 7 February 2018. 7. Aeyels B, Peeraer L, Vander Sloten J, Van der Perre G. Development of an above-knee prosthesis equipped with a microcomputercontrolled knee joint: first test results. J Biomed Eng. 1992; 14:199–202. 8. Bar A, Ishai G, Meretsky P, Koren Y. Adaptive microcomputer control of an artificial knee in level walking. J Biomed Eng. 1983;5:145–150. 9. Berry D. Microprocessor prosthetic knees. Phys Med Rehabil Clin N Am. 2006;17:91–113. 10. Dietl H, Kaitan R, Pawlik R, Ferrara P. The C-Leg®: a new system for fitting of transfemoral amputees. Orthopadie Technik. 1998;49: 197–211. € 11. Ossur. User manuals and technical information available at: https:// www.ossur.com/americas. Accessed February 7, 2018. 12. Innovations Freedom. LLC. User manuals and technical information available at: Knees. http://www.freedom-innovations.com. Accessed 7 February 2018. 13. Fillauer Europe (Centri AB and Nabtesco). User manuals and technical information available at: http://fillauer.eu/prosthetics-lower. Accessed February 7, 2018. 14. Devlin M, Sinclair LB, Colman D, et al. Patient preference and gait efficiency in a geriatric population with transfemoral amputation using a free-swinging versus a locked prosthetic knee joint. Arch Phys Med Rehabil. 2002;83:246–249. 15. Seymour R. Prosthetics and Orthotics: Lower Limb and Spinal. Baltimore. Maryland: Lippincott Williams & Wilkins; 2002:144–159 213, 230-4. 16. Taghipour H, Moharamzad Y, Mafi AR, et al. Quality of life among veterans with war-related unilateral lower extremity amputation: a long-term survey in a prosthesis center in Iran. J Orthop Trauma. 2009;23:525–530. 17. Otto Bock Health Care. User manuals, technical information, and mobility grading system available at: https://www.ottobockus.com/ prosthetics/. Accessed February 7, 2018. 18. Segal AD, Orendurff MS, Klute GK, et al. Kinematic and kinetic comparisons of transfemoral amputee gait using C-Leg® and Mauch SNS prosthetic knees. J Rehabil Res Dev. 2006;43:857–870.

What type of knee unit best matches his needs? As a previously active adult who is able to walk after hemipelvectomy, he is comparable to the K2 functional level. His status has been changing and his medical and prosthetic prognoses remain unclear. He may achieve K3 level functioning. An MPK prosthesis would allow him to descend stairs and slopes with safety on two legs and walk without crutches and thus free the upper limbs for normal functions at work and social functions. However, most MPK prostheses will not provide assistance for this man in rising from a chair or ascending stairs at the same pace as his peers. Difficulty rising from a chair, walking, and negotiating stairs are complicated by fit problems common to people with hemipelvectomies who fluctuate in body weight. He may benefit from a temporary prosthesis with a non-MPK to determine his level of prosthetic use before expending the cost of an MPK prosthesis.108

19. Zamiska N. Bionic knee ‘learns’ how to walk. Wall Street Journal online, July 6, 2004. http://online.wsj.com/ad/article/philips/ SB108907039283655627.html Accessed July 7, 2011. 20. Birnbaum I. The ‘Maserati’ of microprocessor prosthetics costs $120,000. Motherboard 2016, Sep 28. Available at https:// motherboard.vice.com/en_us/article/jpgagx/luxury-prosthetics. Accessed 18.02.05. 21. Brodtkorb TH, Henriksson M, Johannesen-Munk K, Thidell F. Costeffectiveness of C-leg compared with non-microprocessor-controlled knees: a modeling approach. Arch Phys Med Rehabil. 2008;89 (1):24–30. 22. Seelen HAM, Hemmen B, Schmeets AJ, et al. Costs and consequences of a prosthesis with an electronically stance and swing phase controlled knee. Technol Dis. 2003;21:25–34. 23. Graham LE, Datta D, Heller B, Howitt J. A comparative study of conventional and energy-storing prosthetic feet in high-functioning transfemoral amputees. Arch Phys Med Rehabil. 2007;88:801–806. 24. Hafner BJ, Willingham LL, Buell NC, et al. Evaluation of function, performance, and preference as transfemoral amputees transition from mechanical to microprocessor control of the prosthetic knee. Arch Phys Med Rehabil. 2007;88:207–217. 25. Martin J, Pollock A, Hettinger J. Microprocessor lower limb prosthetics: review of current state of the art. J Prosthet Orthot. 2010;22:183–193. 26. Stepien JM, Cavenett S, Taylor L, Crotty M. Activity levels among lower-limb amputees: self-report versus step activity monitor. Arch Phys Med Rehabil. 2007;88:896–900. 27. Hargrove LJSA, Lipschutz RD, Finuncane SB, Kuiken TA. Real-time myoelectric control of knee and ankle motions for transfemoral amputees. J Am Med Assoc. 2011;305:1542–1544. 28. Richards JD, Pramanik A, Sykesand L, Pomeroy VM. A comparison of knee kinematic characteristics of stroke patients and age-matched healthy volunteers. Clin Rehabil. 2003;17:565. https://doi.org/ 10.1191/0269215503cr651oa. 29. Kellis E, Liassau C. The effect of selective muscle fatigue on sagittal lower limb kinematics and muscle activity during level running. J Orthop Sports Phys Ther. 2009;39:210–220. https://doi.org/ 10.2519/jospt.2009.2859. 30. Creylman V, Knippels I, Janssen P, Biesbrouck E, et al. Assessment of transfemoral amputees using a passive microprocessor-controlled knee versus an active powered microprocessor-controlled knee for level walking. Biomd Eng Online. 2016;15(Suppl 3):142. 31. Hafner BJ, Askew RL. Physical performance and self-report outcomes associated with use of passive adaptive, and active prosthetic knees in persons with unilateral, transfemoral amputation: randomized crossover trial. J Rehabil Res Dev. 2015;52:677–700. 32. Simon AM, Ingraham KA, Fey NP, et al. Configuring a powered knee and ankle prosthesis for transfemoral amputees within five specific ambulation modes. PLoS One. 2014;9:e99387.

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33. Kaufman KR, Frittoli S, Frigo CA. Gait asymmetry of transfemoral amputees using mechanical and microprocessor-controlled prosthetic knees. Clin Biomech (Bristol, Avon). 2012;27:460465. 34. Uchytil J, Jandacka D, Zahradnik D, et al. Temporal-spatial parameters of gait in transfemoral amputees: comparison of bionic and mechanically passive knee joints. Prosthet Orthot Int. 2014;38:199–203. 35. Wong CK, Ehrlich JE, Ersing JC, et al. Exercise programs to improve gait performance in people with lower limb amputation: a systematic review. Prosthet Orthot Int. 2016;40(1):8–17. 36. Psonak R, Lusardi MM, Jorge M, Nielsen CC. Transfemoral prostheses. In: Orthotics and Prosthetics in Rehabilitation. 3rd ed St Louis, MO: Saunders Elsevier; 2013. 37. Olney SJ, Eng J, Levangie PK, Norkin CC. Gait. In: Joint Structure and Function. 5th ed. Philadelphia, PA: F. A. Davis; 2011. 38. Nolan L, Lees A. Functional demands on the intact limb during walking for active trans-femoral and trans-tibial amputees. Prosthet Orthot Int. 2000;24:117–125. 39. Sadeghi H, Allard P, Duhaime M. Muscle power compensatory mechanisms in below-knee amputee gait. Am J Phys Med Rehabil. 2001;80:25–32. 40. Kaufman KR, Levine JA, Brey RH, et al. Gait and balance of transfemoral amputees using passive mechanical and microprocessorcontrolled prosthetic knees. Gait & Posture. 2007;26:489–493. 41. Raya MA, Gailey RS, Fiebert IM, Roach KE. Impairment variables predicting activity limitation in individuals with lower limb amputation. Prosthet Orthot Int. 2010;34:73–84. 42. Jaegers SMHJ, Arendzen JH, de Jongh HJ. Changes in hip muscles after above-knee amputation. Clin Orthop Rel Res. 1995;319:276–284. 43. Jandri
c S. Isometric hip muscle strength in posttraumatic below-knee amputees. Vojnosanit Pregl. 2007;64:807–811. 44. Burger H, Valencic V, Marincek C, Kogovsek N. Properties of musculus gluteus maximus in above-knee amputees. Clin Biomech. 1996;11:35–38. 45. M^ aaref K, Martinet N, Grumillier C, et al. Kinematics in the terminal swing phase of unilateral transfemoral amputees: microprocessorcontrolled versus swing-phase control prosthetic knees. Arch Phys Med Rehabil. 2010;91:919–925. 46. Peterson AO, Comins J, Alkjaer T. Assessment of gait symmetry in transfemoral amputees using C-Leg® compared with 3R60 prosthetic knees. J Prosthet Orthot. 2010;22:106–112. 47. Nadollek H, Brauer S, Isles R. Outcomes after trans-tibial amputation: the relationship between quiet stance ability, strength of hip abductor muscles and gait. Physiother Res Int. 2002;7:203–214. 48. Sjodahl C, Jarnlo G-B, Soderberg B, Persson BM. Pelvic motion in trans-femoral amputees in the frontal and transverse plane before and after special gait re-education. Prosthet Orthot Int. 2003;27:227–237. 49. Goujon-Pillet H, Sapin E, Fod
e P, Lavaste F. Three-dimensional motions of trunk and pelvis during transfemoral amputee gait. Arch Phys Med Rehabil. 2008;89:87–94. 50. Morgenroth DC, Orendurff MS, Shakir A, et al. The relationship between lumbar spine kinematics during gait and low-back pain in transfemoral amputees. Am J Phys Med Rehabil. 2010; 89:635–643. 51. Friel K, Domholdt E, Smith DG. Physical and functional measures related to low back pain in individuals with lower-limb amputation: an exploratory pilot study. J Rehabil Res Dev. 2005;42:155–166. 52. Kulkarni J, Gaine WJ, Buckley JG, et al. Chronic low back pain in traumatic lower limb amputees. Clin Rehabil. 2005;19:81–86. 53. Corio F, Troiano R, Magel JR. The effects of spinal stabilization exercises on the spatial and temporal parameters of gait in individuals with lower limb loss. J Prosthet Orthot. 2010;22:230–236. 54. World Health Organization. Classifications: International Classification of Functioning, Disability and Health (ICF). http://www.who.int/ classifications/icf/en/. Accessed July 12, 2018. 55. Hoeksma HL, Dekker J, Ronday HK, et al. Comparison of manual therapy and exercise therapy in osteoarthritis of the hip: a randomized clinical trial. Arthritis Rheum. 2004;51:722–729. 56. Ingber RS. Iliopsoas myofascial dysfunction: a treatable cause of "failed" low back syndrome. Arch Phys Med Rehabil. 1989; 70:382–386. 57. Selkow NM, Grindstaff TL, Cross KM, et al. Short-term effect of muscle energy technique on pain in individuals with non-specific lumbopelvic pain: a pilot study. J Man Manip Ther. 2009;17:E14–E18.

58. Yerys S, Makofsky H, Byrd C, et al. Effect of mobilization of the anterior hip capsule on gluteus maximus strength. J Man Manip Ther. 2002;10:218–224. 59. Wong CK, Varca MJ, Stevenson CE, et al. The impact of a 4-session physical therapy program emphasizing manual therapy and exercise on the balance and prosthetic walking ability of people with lower limb amputation: a pilot study. J Prosthet Orthot. 2016;28(3): 95–100. 60. Ries JD, Vaughan V, Lusardi MM, Jorge M, Nielsen CC. Early rehabilitation in lower-extremity dysvascular amputation. In: Orthotics and Prosthetics in Rehabilitation. 3rd ed. Saunders Elsevier: St Louis, MO; 2013. 61. Mercer VS, Gross MT, Sharma S, Weeks E. Comparison of gluteus medius muscle electromyographic activity during forward and lateral step-up exercises in older adults. Phys Ther. 2009;89:1205–1214. 62. Gailey RS. Ten exercises to maximize the performance of your prosthetic feet. In Motion. 2001;11:1–3. 63. Leavey VJ, Sandrey MA, Dahmer G. Comparative effects of 6-week balance, gluteus medius strength, and combined programs on dynamic postural control. J Sport Rehabil. 2010;19:268–287. 64. Williams RM, Turner AP, Orendurff MS, et al. Does having a computerized prosthetic knee influence cognitive performance during amputee walking? Arch Phys Med Rehabil. 2006;87:989–994. 65. Baum BS, Schnall BL, Tis JE, Lipton JS. Correlation of residual limb length and gait parameters in amputees. Injury. 2008;39:728–733. 66. Bellmann M, Schmalz T, Blumentritt S. Comparative biomechanical analysis of current microprocessor controlled prosthetic knee joints. Arch Phys Med Rehabil. 2010;91:644–652. 67. Schmalz T, Blumentritt S, Jarasch R. A comparison of different prosthetic knee joints during step over step stair descent. Orthop Teknik. 2002;7:586–592. 68. Vrieling AH, van Keeken HG, Schoppen T, et al. Uphill and downhill walking in unilateral lower limb amputees. Gait & Posture. 2008;28:235–242. 69. Hafner BJ, Smith DG. Differences in function and safety between Medicare Functional Classification Level-2 and -3 transfemoral amputees and influence of prosthetic knee joint control. J Rehabil Res Dev. 2009;46:417–434. 70. Adler SS, Beckers D, Buck M. PNF in Practice: An Illustrative Guide. 2nd ed. Berlin, Germany: Springer; 200082. 71. Bellmann M, Schmalz T, Ludwigs E, Blumentritt S. Stair ascent with an innovative microprocessor-controlled exoprosthetic knee joint. Biomed Tech (Berlin). 2012;57:435–444. 72. Bell EM, Pruziner AL, Wilken JM, Wolf EJ. Performance of conventional and X2® prosthetic knee during slope decent. Clin Biomech (Bristol, Avon). 2016;33:26–31. 73. Lura DJ, Wernke MW, Carey SL, Kahle JT, et al. Crossover study of amputee stair ascent and descent biomechanics using Genium and C-Leg prostheses with comparison to non-amputee control. Gait & Posture. 2017;58:103–107. 74. Highsmith MJ, Kahle J, Carey SL, et al. Kinetic asymmetry in transfemoral amputees while performing sit to stand and stand to sit movements. Gait & Posture. 2011;34:86–91. 75. Pauley T, Devlin M, Heslin K. Fall sustained during inpatient rehabilitation after lower limb amputation: prevalence and predictors. Am J Phys Med Rehabil. 2006;85:521–532. 76. Gooday HMK, Hunter J. Preventing falls and stump injuries in lower limb amputees during inpatient rehabilitation: completion of the audit cycle. Clin Rehabil. 2004;18:379–390. 77. Miller WC, Speechley M. The prevalence and risk factors of falling and fear of falling among lower extremity amputees. Arch Phys Med Rehabil. 2001;82:1031–1037. 78. Blumentritt S, Schmalz T, Jarasch R. The safety of C-Leg®: biomechanical tests. J Prosthet Orthot. 2009;21:2–15. 79. Yang J, Jin D, Ji L, et al. The reaction strategy of lower extremity muscles when slips occur to individuals with trans-femoral amputation. J Electromyograph Kinesiol. 2007;17:228–240. 80. Kahle JT, Highsmith MJ, Hubbard SL. Comparison of nonmicroprocessor knee mechanism versus C-Leg® on prosthesis evaluation questionnaire, stumbles, falls, walking tests, stair descent, and knee preference. J Rehabil Res Dev. 2008;45:1–14. 81. Berry D, Olsen M, Larntz K. Perceived stability, function, and satisfaction among transfemoral amputees using microprocessor and nonmicroprocessor controlled prosthetic knees: a multicenter survey. J Prosthet Orthot. 2009;21:32–42.

27 • Advanced Rehabilitation for People With Microprocessor Knee Prostheses 82. Seymour R, Engbretson B, Kott K, et al. Comparison between the C-Leg® microprocessor-controlled prosthetic knee and nonmicroprocessor control prosthetic knees: A preliminary study of energy expenditure, obstacle course performance, and quality of life survey. Prosthet Orthot Int. 2007;31:51–61. 83. Klute GK, Berge JS, Orendurff MS, et al. Prosthetic intervention effects on activity of lower-extremity amputees. Arch Phys Med Rehabil. 2006;87:717–722. 84. Kark L, Simmons A. Patient satisfaction following lower-limb amputation: the role of gait deviation. Prosthet Orthot Int. 2011;35:225–233. 85. Van der Linde H, Hofstad CJ, Geurts AC, et al. A systematic literature review of the effect of different prosthetic components on human functioning with a lower-limb prosthesis. J Rehabil Res Dev. 2004;41:555–570. 86. Fergason J, Keeling JJ, Bluman EM. Recent advances in lower extremity amputations and prosthetics for the combat injured patient. Foot Ankle Clin. 2010;15:151–174. 87. Orendurff MS, Segal AD, Klute GK, et al. Gait efficiency using the C-Leg®. J Rehabil Res Dev. 2006;43:239–246. 88. Perry J, Burnfield JM, Newsam CJ, Conley P. Energy expenditure and gait characteristics of a bilateral amputee walking with C-Leg® prostheses compared with stubby and conventional articulating prostheses. Arch Phys Med Rehabil. 2004;85:1711–1717. 89. Chin T, Machida K, Sawamura S, et al. Comparison of different microprocessor controlled knee joints on the energy consumption during walking in trans-femoral amputees: intelligent knee prosthesis (IP) versus C-Leg®. Prosthet Orthot Int. 2006;30:73–80. 90. Highsmith MJ, Kahle JT, Bongiorni DR, et al. Safety, energy efficiency, and cost efficacy of the C-Leg for transfemoral amputees: a review of the literature. Prosthet Orthot Int. 2010;34:362–377. 91. Schmalz T, Blumentritt S, Jarasch R. Energy expenditure and biomechanical characteristics of lower limb amputee gait: the influence of prosthetic alignment and different prosthetic components. Gait & Posture. 2002;16:255–263. 92. Jepson F, Datta D, Harris I, et al. A comparative evaluation of the Adaptive knee and Catech knee joints: a preliminary study. Prosthet Orthot Int. 2008;32:84–92. 93. Buckley JG, Spence WD, Solomonidis SE. Energy cost of walking: comparison of "Intelligent prosthesis" with conventional mechanism. Arch Phys Med Rehabil. 1997;78:330–333. 94. Chin T, Sawamura S, Shiba R, et al. Effect of an Intelligent Prosthesis (IP) on the walking ability of young transfemoral amputees: comparison of IP users with able-bodied people. Am J Phys Med Rehabil. 2003;82:447–451. 95. Taylor MB, Clark E, Offord EA, Baxter C. A comparison of energy expenditure by a high level trans-femoral amputee using the Intelligent Prosthesis and conventionally damped prosthetic limbs. Prosthet Orthot Int. 1996;20:116–121.

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96. Datta D, Heller B, Howitt J. A comparative evaluation of oxygen consumption and gait pattern in amputees using Intelligent Prostheses and conventionally damped knee swing-phase control. Clin Rehabil. 2005;19:398–403. 97. Johansson JL, Sherrill DM, Riley PO, et al. A clinical comparison of variable-damping and mechanically passive prosthetic knee devices. Am J Phys Med Rehabil. 2005;84:563–575. 98. Kaufman KR, Levine JA, Brey RH, et al. Energy expenditure and activity of transfemoral amputees using mechanical and microprocessor controlled prosthetic knees. Arch Phys Med Rehabil. 2008;89: 1380–1385. 99. Heller BW, Datta D, Howitt J. A pilot study comparing the cognitive demand of walking for transfemoral amputees using the Intelligent Prosthesis with that using conventionally damped knees. Clin Rehabil. 2000;14:518–522. 100. Datta D, Howitt J. Conventional versus microchip controlled pneumatic swing phase control for trans-femoral amputees: user’s verdict. Prosthet Orthot Int. 1998;22:129–135. 101. Wong CK, Gibbs W, Chen E. Use of the Houghton Scale to classify community and household walking ability in people with lower limb amputation: criterion-related validity. Arch Phys Med Rehabil. 2016;97(7):1130–1136. 102. Burnfield JM, Eberly VJ, Gronley JK, et al. Impact of stance phase microprocessor-controlled knee prosthesis on ramp negotiation and community waling function in K2 level transfemoral amputees. Prosthet Orthot Int. 2012;36:95–104. 103. Eberly VJ, Mulroy SJ, Gronley JK, et al. Impact of a stance phase microprocessor-controlled knee prosthesis on level walking in lower functioning individuals with a transfemoral amputation. Prosthet Orthot Int. 2014;38:447–455. 104. Wong CK, Rheinstein J, Stern MA. Benefits for adults with transfemoral amputations and peripheral artery disease using microprocessor compared with nonmicroprocessor prosthetic knee. Am J Phys Med Rehabil. 2015;94:804–810. 105. Wong CK, Chihuri S, Li G. The risk of fall-related injury in community-dwelling people with lower limb amputation: a prospective cohort study. J Rehabil Med. 2016;48:80–85. 106. Kannenerg A, Zacharias B, Pobsting E. Benefits of microprocessorcontrolled prosthetic knees to limited community ambulators: systematic review. J Rehabil Res Dev. 2014;51:1469–1496. 107. Hahn A, Lang M, Stuckart C. Analysis of clinically important factors on the performance of advanced hydraulic, microprocessorcontrolled exo-prosthetic knee joints based on 899 trial fittings. Medicine (Baltimore). 2016;95:e5386. 108. Yari P, Dijkstra PU, Geertzen JHB. Functional outcome of hip disarticulation and hemipelvectomy: a cross-sectional national descriptive study in the Netherlands. Clin Rehabil. 2008;22:1127–1133.

28

Athletic Options for Persons With Limb Loss☆ CAROL PIERCE DIONNE and JOSHUA THOMAS WILLIAMS

LEARNING OBJECTIVES

Upon completing the chapter, the reader will be able to do the following: 1. Discuss the relationship of physical exercise and sports to the overall health and wellness of people with limb loss. 2. Describe barriers that contribute to lack of participation in athletics for persons with physical challenges. 3. Identify organizations that support athletic participation for persons with physical challenges including limb loss. 4. Compare and contrast the different sports and recreational activities available for persons with limb loss. 5. Describe prosthetic components available to assist in active participation within a variety of sports.

“Games, sport, that is what we must have.” Sir Ludwig Guttman,1 Founder, Paralympic Games

Introduction The importance of participation in sports, recreation, and/or physical activity for all people is well understood. Numerous authors have extolled the virtues of being physically active for both physical and mental health, as well as the prevention of “hypokinetic diseases,” such as obesity, diabetes, hypertension, and cardiovascular disease. Benefits for individuals who regularly participate in sports or recreational activities include maintenance of normal muscle strength, flexibility, and joint function.2,3 These benefits are essential in slowing the functional decline often associated with normal aging and/or the presence of a disabling condition such as limb loss. The importance of participation in sports, recreation, and physical activity is true for both able-bodied and those with physical challenges such as limb loss. In fact, health organizations’ recommendations for physical activity are the same for both able-bodied people and those with physical challenges.4,5 In addition, most epidemiologic studies have concluded that athletes with physical challenges are most likely at no higher risk for injury than their able-bodied counterparts during performance of sportsrelated activities.6-8 In addition to the physical benefits, participation in sports or recreational activities has a significant psychological benefit for both able-bodied people and individuals with physical challenges. Body image and quality-of-life outcome scores have improved in individuals with physical ☆

The authors extend appreciation to Mark Anderson, whose work in prior editions provided the foundation for this chapter.

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challenges who participate in physical activity and sports.9-11 Steptoe and Butler have shown that participation in regular sport or vigorous recreational activity has favorable effects on the emotional state of adolescents.12 Many psychological constructs, such as improved social acceptance, improved physical self-concept and selfesteem, increased self-efficacy and self-confidence, and a greater locus of control, build upon the physical performance accomplishments of the athlete with a physical challenge.13 Therefore regular participation in sports and recreational activities can help one achieve goals relating to not only physical function such as reversing deconditioning secondary to impaired mobility, optimizing physical functioning, and promoting overall well-being,14 but also goals related to psychological well-being such as confidence and coping behaviors.15 Even though the benefits of participation in sports and physical activity are well recognized, there remains a disconnect between knowledge and action. More than half of the adults with disabilities in the United States do not participate in any leisure-time physical activity compared with one third of adults without disability.16 This reinforces the notion that, on average, people with a disability, including those with limb loss, are more inactive than the general population.17 Therefore, to impact the general health of those with limb loss, it is important to understand the barriers that prevent this population from participating more in sports and recreation, as well as the motivators that can facilitate them in moving toward a more active lifestyle.

Barriers and Motivation The most common barriers18,19 to sports participation for individuals with a physical challenge are lack of financial

28 • Athletic Options for Persons With Limb Loss

support, unsuitable local facilities, lack of access, and health concerns. Additional barriers may include transportation issues, a lack of sports offerings for those with physical challenges, and a lack of a peer group with which to participate.19 Only 10% of those with a physical challenge report a lack of motivation as a barrier to participate. Among those with a physical challenge who do regularly participate, reasons given for participation include health benefits, a feeling of accomplishment after participation, and developing and maintaining lasting social contacts.19 Recommendation from physicians or other health care professionals was another facilitator to participate. Although it clearly influences performance, it is unclear whether age, level of limb loss, and etiology of limb loss influence sports participation following amputation surgery.20 Most studies that investigated physical activity, sports, and recreation among those with limb loss have a study population that is younger than 65 years of age and have experienced limb loss due to nonvascular circumstances.20 However, the general population of people with limb loss includes a large number of individuals who are older than 65 years old and have experienced limb loss due to a vascular condition.20 Regardless, it does appear that a history of sports participation prior to amputation surgery increases the likelihood of sports participation following limb loss. Therefore, older age, limb loss due to vascular complications, and a previously sedentary lifestyle may all also serve as barriers in participating in sports, recreation, and/ or physical activity following limb loss. As previously stated, a patient’s physician or other health care provider may have a large influence on decisions to participate in sports, recreation, and physical activity. Therefore the remainder of this chapter will describe various athletic activities and the opportunities for active engagement in sports and recreation available to persons with limb loss. This will assist the reader in developing resources for their patients that help to promote health and wellness within this population.

Organizational Support for Sports or Recreation Participation Sports for athletes with physical challenges are governed by various disabled sports organizations and national governing bodies that are disability specific. In the United States, several organizations exist to support and develop athletes with limb loss.

DISABLED SPORTS, USA21 Disabled Sports, USA is a national organization created to “improve the lives of wounded warriors, youth, and adults with disabilities by providing sports and recreation opportunities.”22 Their motto is, “If I can do this, I can do anything!” and its mission is “to provide national leadership and opportunities for individuals with disabilities to develop independence, confidence, and fitness through participation in community sports, recreation, and educational programs.”22 Disabled Sports, USA is composed of a nationwide network of more than 120 community-based chapters that

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offer a variety of sports/recreational programs through a grassroots approach that allows local chapters to identify specific needs within each community.22 Disabled Sports, USA community partners offer more than 50 different sports, including skiing, snowboarding, biathlon, kayaking, water skiing, sailing, scuba, surfing, rafting, outrigger canoeing, fishing, hiking, golf, athletics, archery, cycling, running/wheeling, rock climbing, equestrian, and others.22

AMPUTEE COALITION23 The Amputee Coalition is a national organization created in 1986 to “work to provide people with limb loss and limb difference, their families and caregivers the resources they need to recover, readjust, and live life fully with limb loss/difference.”24 The Amputee coalition contains a network of more than 350 support groups and coordinates the National Limb Loss Resource Center (NLLRC).24 The NLLRC supports programs and publications “designed to help people return to an active lifestyle and function as a productive member of society.”24

CHALLENGED ATHLETE FOUNDATION25 The Challenged Athlete Foundation’s mission is “to provide opportunities and support to people with physical challenges, so they can pursue active lifestyles through physical fitness and competitive athletics.”26 Their vision includes reaching out “to the physically challenged community by providing inspiration, awareness, and mentoring.”26 The organization provides a variety of grants, camps and clinics, community outreach, and educational programs to work toward their overall mission.25

US AND INTERNATIONAL PARALYMPIC COMMITTEES27,28 The US Paralympic Committee sanctions and conducts competitions and training camps to prepare athletes to represent the US at the Summer and Winter Paralympic Games. The Paralympic Games are the major international multisport event for athletes with physical challenges and are second to only the Olympic Games in number of athletes participating. These Paralympic Games are organized and conducted under the supervision of the International Paralympic Committee (IPC) and other international sports federations. For athletes with limb loss, there are opportunities to compete in a variety of different Summer and Winter Paralympic sports. The US Paralympics Committee also offers an Emerging Sport Program, which is designed to identify, recruit, track, support, and retain Paralympic-eligible athletes with physical challenges seeking to become internationally competitive. The success of this program depends on the collaboration between community and military programs, partner organizations, military and veteran facilities, and national governing bodies. Athlete recruitment and identification begin at the local level. Potential athletes are identified in a variety of ways, including military sport camps, site coordinators for specific sports or events, community programs, coaches, technical officials, or current athletes. Once an athlete is identified as having high-performance potential, the Emerging Sports

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manager facilitates appropriate communication between athlete(s) and local program(s), as well as with the appropriate Paralympic sport coaches and high-performance directors. Assistance is provided to these athletes by way of connections to local training resources, participation in select emerging and/or national US Paralympics Team camps and competitions, as well as information regarding able-bodied competitions, events, and other general sport program opportunities for developing and emerging athletes.

Sport Classification29 The IPC and other organizations involved with sport for athletes with physical challenges use a functional classification system that is designed to create equal and fair competition within each sport. Athletes with a physical challenge undergo an evaluation by a classification panel made of two to three trained evaluators. This evaluation results in the athlete being placed into a classification category for competition that is based on their ability to perform within the sport. Classifications are specific to each sport. Athletes with the same classification will then compete against others within their same classification category, but will not compete against athletes with physical challenges in a different classification. This is similar to age or weight categories within able-bodied sports.

Summer Paralympic Sports Summer Paralympic sports available to those with limb loss include archery, badminton, athletics (track and field), boccia, cycling, canoeing, equestrian, fencing, triathlon, powerlifting, rowing, wheelchair rugby, sailing, shooting,

swimming, table tennis, tennis, sitting volleyball, taekwondo, and wheelchair basketball. Each sport has its own unique set of requirements, which may necessitate a modification of the traditional rules of the sport to allow the athlete with physical challenge to compete.

ARCHERY30 Archery has been a medal sport since the first Paralympic Games in Rome in 1960. Athletes with physical disabilities demonstrate their shooting precision and accuracy from either a standing or seated (wheelchair) position, in men’s and women’s categories. Paralympic competition format is identical to that of the Olympic Games. Paralympic archers shoot 72 arrows from a distance of 70 m at a target of 122 cm using a recurve bow (Fig. 28.1A) or from a distance of 50 m at a target of 80 cm using a compound bow (Fig. 28.1B). For competitions other than the Paralympics, athletes shoot at each of four distances. Thirty-six arrows are shot at each distance. The two longest distances use a 122-cm target; the two shorter distances use an 80-cm target (approximately 36 inches). Distances are 90, 70, 50, and 30 m for men and 70, 60, 50, and 30 m for women. Depending upon the athletes’ classification, their level and number of amputations, and their functional ability, the athlete may use either a recurve bow or a compound bow. Archery competition is open to male and female athletes with upper- or lower-extremity amputation/limb loss. Most athletes with limb loss will be classified into the “open” division. This classification includes athletes in wheelchairs who have relatively normal arm function and athletes who compete while standing but have impairments that affect their balance, arms, and/or trunk.29 Specialized devices are also available to assist athletes with upper-extremity prostheses in drawing back the bow and releasing the string.

Fig. 28.1 (A) Archery recurve bow. (B) Archery compound bow. (A, Courtesy Disabled Sports, USA. B, Photos taken and given with permission from O. Raiber and J. Williams OUHSC.)

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BADMINTON30 Disabled badminton is played by people with many different disabilities, including those with both upper- and lowerextremity limb loss. Participants may compete either standing or in a wheelchair. The sport is scheduled to make its Paralympic debut at the 2020 games in Tokyo. Badminton provides players of different disabilities and backgrounds an opportunity to participate in a common sport. Although more common in Europe, most people in the United States become involved in badminton through word of mouth and people introducing others to the sport. It is a growing sport with an increasing number of participants taking up the game either socially, competitively, or both. Both men and women in all age groups participate in badminton. For badminton, there are two classification levels for athletes who compete in wheelchairs (WH1 and WH2) and three classification levels for athletes competing while standing (SL3, SL4, and SU5).29

ATHLETICS (TRACK AND FIELD)30 Athletic events are open to athletes in all disability classes and have been a part of the Paralympic program since the first Paralympic Games in Rome, Italy, in 1960. Events include track (running distances from 100 m to 10,000 m and 4  100-m and 4  400-m relays), throwing (shot put, discus, and javelin), jumping (high jump, long jump, and triple jump), pentathlon (athlete competes in 5 events: long jump, shot put, 100-m run, discus, and 400-m run), and the marathon. The rules of Paralympic track and field are almost identical to those of its nondisabled counterpart. Paralympic track and field competition is open to male and female athletes with upper- and/or lower-extremity single or multiple limb loss. Prosthetic devices may be used, or the athlete with limb loss may compete in the wheelchair events. Prosthetic devices used for track and field have been specifically developed to withstand the demands of sports competition (Fig. 28.2). A large variety of classifications exist for track and field. Track events and field events are classified separately. For athletes with limb loss competing with a prosthesis, there are seven different classifications (T45–T47 and T61–T64).29 For athletes with limb loss competing in a wheelchair, four different classifications exist (T51– T54).29 Likewise, athletes can compete in standing field events under the F42 to F46 or F61 to F64 classifications or in wheelchairs under the F51 to F57 classifications.29

CANOEING30 Canoeing made its Paralympic debut in the summer of 2016 in Rio de Janeiro. The sport is identical to the competition in which able-bodied athletes compete. Men and women may compete in kayaks using a double-bladed paddle over a 200m course. Additional competition and recreational events, including both kayaks and outrigger canoes such as va’as boats, are available at the international level, but are currently not a part of the Paralympic competition. Athletes competing in canoeing compete in one of three different classifications (KL1, KL2, or KL3).29

Fig. 28.2 Track and field event. (Photos taken and given with permission from O. Raiber and J. Williams OUHSC.)

CYCLING30 Cycling was first introduced as a Paralympic sport in 1984 in Mandeville, England, and involved only those athletes with cerebral palsy. However, it was not until 1992 that athletes with limb loss competed at the Paralympic Games in cycling. At the 2004 Paralympic Games in Athens, handcycling (for wheelchair users) made its debut as a medal event. Athletes compete in both track (velodrome) and road events. Track events generally consist of sprints as short as 200 m to time trials and pursuits up to 4 km. Relay races consisting of three-person teams are also contested on the track. Competition on the roads consists of time trials and road races. In time trials, athletes start individually in staggered intervals, racing mostly against themselves and the clock. Road races consist of mass starts. Distances vary based on the host country’s discretion, ranging from 5 to 65 km in length. Paralympic cycling competition is open to male and female athletes with upper- and/or lowerextremity single or multiple amputation/limb loss. Most athletes with limb loss will compete in classifications H1 to H5 if handcycling or classes C1 to C5 if bicycling.29

EQUESTRIAN30 Equestrian made its debut appearance at the Paralympic Games in 1996, with riders from 16 countries competing. By the Paralympic Games in 2008 in Beijing, that number had grown to 73 riders from 28 countries. Riders compete in two dressage events: a championship test of set movements and a freestyle test to music. There is also a team test for three or four riders. Competitors are judged on their display

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of horsemanship skills demonstrated through their use of commands for walk, trot, and canter. Paralympic equestrian competition is open to male and female athletes with upperand/or lower-extremity single or multiple limb loss who are classified into one of five groups (Ia–IV).29

FENCING30 Fencing has been part of the Paralympic Games since 1960. Athletes compete in wheelchairs that are fixed to the floor. They rely on ducking, half-turns, and leaning to dodge their competitors’ touches. However, fencers can never rise up from the seat of the wheelchair. The first fencer to score five touches is declared the winner. Athletes play the best out of three rounds and compete in single and team formats. Weapon categories for men include foil, epee, and sabre. Women compete in foil and epee. Paralympic fencing competition is open to male and female athletes with upperand/or lower-extremity single or multiple limb loss. Most athletes with limb loss will fall into classification category A for fencing.29

TRIATHLON30 Triathlon is an emerging sport that is quickly gaining popularity and was first included in the Summer Paralympic Games at the 2016 games in Rio de Janeiro. The sport is similar to the able-bodied version with athletes competing in the “sprint” distances of a 750-m swim, a 20-km cycling event, and a 5-km running event. The sport is governed by the International Triathlon Union, and national championships are held in more than 27 different countries. Paralympic triathlon is open to male and female athletes with upper- and/or lower-extremity single or multiple limb loss. There is a single classification category for athletes competing in wheelchairs (PT1) and three different categories for ambulatory athletes (PT2–PT4).29

POWERLIFTING30 Powerlifting is one of the fastest growing Paralympic sports. Paralympic athletes have been competing in powerlifting since 1964; however, it was initially offered only to lifters with spinal cord injuries. Currently, athletes from many different disabled sports groups participate in the sport, assimilating rules similar to those of nondisabled lifters. Athletes compete only in the bench press (Fig. 28.3), and they draw

lots to determine order of weigh-in and lifts. After the athletes are categorized within the 10 different weight classes (male and female), they each lift three times (competing in their respective weight class). The heaviest “good lift” (within the weight class) is the lift used for final placing in the competition. Paralympic powerlifting competition is open to male and female athletes with upper- and/or lower-extremity single or multiple limb loss. Based on disability, there is only one classification category for powerlifting. There is currently a move to include the single-arm press in powerlifting competitions for those individuals with upper-extremity amputation, with the hope of making this a Paralympic sport.

ROWING30 Rowing is a relatively new Paralympic sport, making its first appearance in Beijing in 2008. The sport was selected for Paralympic inclusion in 2005, just 3 years after adaptive rowing made its debut on the world championship level in 2002. The rowing events include the men’s and women’s single sculls, the trunk-arms double sculls, and the legstrunk-arms mixed four with coxswain. Paralympic rowing competition is open to male and female athletes with upper- and/or lower-extremity single or multiple limb loss, and most athletes with limb loss will classify as a TA or LTA-PD classification level.29

RUGBY30 Another sport gaining a lot of popularity recently is wheelchair rugby. Originally called “murderball,” it was developed in the 1970s and originally included only athletes with quadriplegia. However, the sport has currently opened up to athletes with a variety of different disabilities. Wheelchair rugby was a demonstration sport at the 1996 Paralympic Games in Atlanta and was subsequently included as a medal sport in the 2000 Sydney Games. The International Wheelchair Rugby Federation (IWRF) is the governing body of the sport and has developed rules that combine elements of able-bodied rugby, handball, and basketball. The sport is played on a regulation basketball court, where two teams of four athletes compete. Like wheelchair basketball, athletes are grouped by demonstrated playing ability, rather than strictly by medical classification. Wheelchair rugby is open to both males and females with upper- and/ or lower-extremity single or multiple limb loss. Athletes are classified into one of four sport classes (0.5, 1.5, 2.5, or 3.5), and the total number for sports class “points” on the court at any one time may not exceed eight.29

SAILING30

Fig. 28.3 Powerlifting. (Photos taken and given with permission from University of Central Oklahoma Endeavor Games.)

Sailing first became a medal sport for the 2000 Paralympic Games in Sydney, Australia. Three boat types raced at the 2008 Paralympic Games in Beijing: the 2.4mR, a singleperson keelboat; the SKUD-18, a two-person keelboat; and the Sonar, a three-person keelboat, along with the high performance SKUD-18 m, which must include one female and one person deemed a Functional Classification System “1,” or severely disabled, such as an athlete with quadriplegia. Sailors are seated on the centerline for Paralympic events,

28 • Athletic Options for Persons With Limb Loss

but the boat can be sailed with or without either of the seats and configured to suit different sailors’ needs. Because of its design and control, the 2.4mR was selected for single-person races. The boat’s ease of use allows for a level playing field, making tactical knowledge the dominant factor in competition. The Sonar uses a versatile crew-friendly design that is accommodating to athletes with physical disabilities. It is used by sailors of all experience and ability levels, from the novice to international competitors. Paralympic sailing competition is open to male and female athletes with upper- and/ or lower-extremity single or multiple limb loss. Seven different classification levels exist for sailing.29

SHOOTING30 Shooting, divided into rifle and pistol events, air and .22 caliber, has been a Paralympic sport since 1976. The rules governing Paralympic competition are those used by the International Shooting Committee for the Disabled. These rules take into account the differences that exist between disabilities, allowing ambulatory and wheelchair athletes to compete shoulder to shoulder. Shooting matches athletes of the same gender, with similar disabilities, against each other, both individually and in teams. Paralympic shooting competition is open to male and female athletes with upper- and/or lower-extremity single or multiple limb loss who may be classified into one of six different classification categories based on both type of disability and the shooting event.29

SWIMMING30 Swimming for men and women has been a part of the Paralympic program since the first Paralympic Games in 1960 in Rome, Italy. Races are highly competitive and among the largest and most popular events in the Paralympic Games. Paralympic swimming competitions occur in 50-m pools and, while competing, no prostheses or assistive devices may be worn. Athletes compete in the following events: 50-, 100-, and 400-m freestyle; 100-m backstroke; 100m breaststroke; 100-m butterfly; 200-m individual medley; 4  100-m freestyle relay; and 4  100-m medley relay. Paralympic swimming competition is open to male and female athletes with upper- and/or lower-extremity single or multiple limb loss. Different classification categories exist for breaststroke compared with the other three events. There are 10 different classification levels for the majority of the events, with 9 different classification levels for breaststroke. Lower classification number (i.e., 1 vs. 7) indicates a more severe limitation as it relates to swimming.29

TABLE TENNIS30 Table tennis has been a part of the Paralympic program since the inaugural Paralympic Games in 1960. Rules governing Paralympic table tennis are the same as those used by the International Table Tennis Federation, although they are slightly modified for players using wheelchairs. Athletes must use the same quick technique and finesse in the games of competitors from various disability groups, including men’s and women’s competitions, as well as singles, doubles, and team contests. All matches are played best-of-five

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games to 11 points. Paralympic table tennis competition is open to male and female athletes with upper- and/or lowerextremity single or multiple limb loss. There are five classification levels for those using wheelchairs to compete and five different classifications for those who stand to compete.29

TAEKWONDO30 Taekwondo will make its Summer Paralympic Games debut at the 2020 games in Tokyo. Taekwondo includes both kyorugi (sparring) and/or poomsae (forms), but only kyorugi will be included in the Tokyo 2020 Games. Kyorugi consists of three 2-minute rounds with a 1-minute rest period between each round. Athletes score points similar to the able-bodied version, and the athlete with the most points at the end of three rounds is the winner.31 Taekwondo is open to both males and females with upper-extremity single or multiple limb loss and full use of both lower extremities. Although four different classification categories exist (K41– K44),29 only a combined K43 to K44 category will compete in the Tokyo Games.31 In addition, athletes compete in one of three different weight classes.

WHEELCHAIR TENNIS30 Wheelchair tennis first appeared at the Paralympic Games in Barcelona in 1992 and is played on a standard tennis court and follows many of the same rules as tennis. However, in wheelchair tennis, a player is allowed to let the ball bounce twice, if necessary, before hitting a return shot and the doubles court lines are used for both singles and doubles. In addition, the athlete’s wheelchair is considered to be a part of the body, so rules applying to the player’s body apply to the chair as well. Paralympic wheelchair tennis competition is open to male and female athletes with upper- and/or lower-extremity single or multiple limb loss. Most athletes with limb loss will compete in the open classification category.29

SITTING VOLLEYBALL30 Instituted in 1976 as a standing Paralympic sport, Paralympic volleyball has become exclusively a sitting sport. Paralympic volleyball follows the same rules as its able-bodied counterpart, with a few modifications to accommodate the various disabilities. In sitting volleyball, the net is approximately 3½ feet high and the court is 10  6 m with a 2-m attack line. Players are allowed to block serves, but one buttock “cheek” must be in contact with the floor whenever they make contact with the ball. Paralympic volleyball competition is open to male and female athletes with upper- and/or lower-extremity single or multiple limb loss. Athletes will compete in gender-specific teams with six athletes being on the court at any one time. Athletes are classified as “minimally disabled” (MD) or “disabled” (D), and at least five of the six athletes on the court at any one time must have a D classification.29

WHEELCHAIR BASKETBALL30 Basketball has been a part of the Paralympic Games since 1960 and originally played only by men with spinal cord

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injuries. Currently, both men’s and women’s teams throughout the world, with a variety of disabilities, compete in the sport. Many of the same rules from its able-bodied counterpart apply in the wheelchair game. Although plays and tactics are similar, special rules, such as those to accommodate dribbling from a wheelchair, are also in place. The sport is governed by the International Wheelchair Basketball Federation. The International Wheelchair Basketball Federation governs all aspects of the game, including court size and basket height, which remain the same as in ablebodied basketball. Athletes in this event are grouped by demonstrated playing ability, rather than strictly by medical classification. Athletes are classified into one of five categories (1.0, 2.0, 3.0, 4.0, or 4.5), and a team of five players is allowed to have a total of only 14 classification points on the court at any one time.29 Paralympic basketball competition is open to male and female athletes with upper- and/or lower-extremity single or multiple limb loss.

Winter Paralympic Sports Just like the Summer Paralympic Games, the Winter Paralympic games are held every 4 years following the conclusion of the Winter Olympic Games in the host city of the Olympics. Paralympic athletes with limb loss compete in six winter sports: alpine skiing; biathlon; cross-country skiing; curling; snowboarding, and sled (sledge) hockey.

ALPINE SKIING30 Paralympic alpine skiing competition is open to male and female athletes with amputation. There are four individual events in alpine skiing: downhill, which started as a demonstration event at the 1980 Paralympic Games in Norway; slalom; giant slalom, which was introduced as a demonstration event in 1984; and super-G. Mono-skiing was

introduced in both alpine and Nordic events in 1988 at the Games in Innsbruck, Austria. Skiing equipment varies, depending on the athlete’s level and number of amputations. Athletes with double-leg limb loss above the knee (transfemoral) typically use two skis with two outriggers but may also choose to sit-ski in a mono-ski (Fig. 28.4A). Athletes with single transfemoral amputation often use one ski with two outriggers (see Fig. 28.4B). Athletes with double-leg below-knee (transtibial) amputation and those with single-leg transtibial amputation may use two skis with two ski poles. Athletes with double-upper-extremity amputations, regardless of level, ski with two skis but no ski poles, whereas single-upper-extremity amputee athletes use two skis and one ski pole. If athletes have one upperextremity and one lower-extremity amputation, they may use ski equipment that facilitates the athletes’ best function. Seven different classification categories exist for standing skiers (LW1, LW2, LW3, LW4, LW5/7, LW6/8, and LW9), and three different categories exist for sit-skiers (LW10, LW11, and LW12).29

NORDIC SKIING30 Paralympic Nordic skiing is a Winter Paralympic sport consisting of two events: biathlon and cross-country skiing. Biathlon combines elements of cross-country skiing and target shooting. Athletes ski three 2.5-km loops (7.5 km total), stopping after the first two loops to shoot at five targets (10 targets total). One minute is added to the athlete’s finishing time for each miss. Biathlon has been a part of the Paralympic Winter Games since 1992. Cross-country skiing started with the Paralympic Games in Sweden in 1976. Cross-country races range from 2.5 to 20 km depending on disability and gender. Paralympic Nordic skiing competition is open to male and female athletes with limb loss. Classification categories exist for those with lowerextremity impairments (LW2, LW3, and LW4), those with

Fig. 28.4 (A and B) Alpine skiing. (Courtesy Disabled Sports, USA.)

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upper-extremity impairments (LW5/7, LW6, and LW8), those with both upper- and lower-extremity impairments (LW9), and sit-skiers (LW10–LW12).29

CURLING30 Paralympic curling is a wheelchair sport that was introduced at the 2006 Paralympic Winter Games. As in ablebodied curling, teams are composed of two competitors who throw “stones” by hand or by the use of a stick towards a target at the opposite end of the ice. However, there is no sweeping and only competitors in wheelchairs are allowed to compete. The object of the game is to get a team’s stones as close to the center of the target (the “house”) as possible. Six ends are played, with a possible extra end if the teams are tied after six. Paralympic wheelchair curling competition is open to male and female athletes with limb loss.

SLED (SLEDGE) HOCKEY30 Sled hockey is a variation of ice hockey in which the athletes compete on the ice by means of a sled. Just as in ice hockey, sled hockey is played with six players (including a goalie) at a time. Players propel themselves on their sled by use of spikes on the ends of two three-foot-long sticks, enabling players to push themselves and shoot and pass the puck. Rinks and goals are regulation Olympic size, and games consist of three 15-minute stop-time periods. Sledge hockey became a medal sport in the 1994 Paralympic Games. Paralympic sled hockey competition is open to male athletes with lower-extremity limb loss, and there is only one classification category in sled hockey.29

SNOWBOARDING30 Snowboarding debuted at the Winter Paralympic Games in 2014 in Sochi. Athletes with disability may compete in one of four different snowboarding disciplines: snowboard cross head-to-head, banked slalom, snowboard cross time trial, and/or giant slalom. Only snowboard cross time trial was included in the 2014 Paralympic Winter Games; however, medals were awarded in both time trial and banked slalom at the 2018 Pyeong Chang Games. Athletes may use specialized equipment to adapt the snowboard and/or use orthopedic aids to allow them to compete (Fig. 28.5). Snowboard is open to males and females with upper- and/or lower-extremity single or multiple limb loss. Classification categories exist for athletes with unilateral lower-extremity impairment (SB-LL1), bilateral lower-extremity impairment (SB-LL2), and upper-extremity impairment (SB-UL).29

Non-Paralympic Sports and Recreational Activities for Individuals With Limb Loss Individuals with limb loss may use Paralympic sports activities for noncompetitive purposes such as physical activity and/or recreation such as swimming, skiing/snowboarding, equestrian, archery/shooting, water sports, and/or weight lifting. Although these Paralympic sports are popular

Fig. 28.5 Snowboarding. (Courtesy Disabled Sports, USA.)

among individuals with limb loss, there are many other sports and recreational activities available to this population. Many of these sports require little or no adaptation for participation by those with limb loss, allowing participation and/or competition between able-bodied and individuals and those with limb loss.

FISHING32 Fishing is a sport that can be enjoyed by anyone. There are many different types of specialized equipment available to the disabled angler such as rods, reels, line, rod holders, and tackle, as well as easy cast and electric fishing reels for individuals who may have difficulties casting and reeling in a fish. There are also harness rod holders that can mount on a wheelchair or the side of a boat and allow an individual with limited use of their arm(s) to participate in recreational fishing. Pontoon boats can provide easy accessibility for those in wheelchairs. The Paralyzed Veterans of America sponsors a variety of fishing tournaments for people with disabilities, and there are disability fishing groups and clubs that cater for children with disabilities who enjoy fishing. They offer several bass fishing tournaments where those interested in fishing can learn new skills or improve old ones. The Paralyzed Veterans of America Bass Tour offers Team/Open Competition, pairing disabled anglers with able-bodied boat partners. Those who prefer not to fish from a boat can participate in the Bank Competition. Both novice and experienced anglers can compete for significant cash and other prizes. Fishing Has No Boundaries, Inc. is another nonprofit organization for all persons with disabilities that has grown into a national organization with 23 chapters in 11 states. Fishing Has No Boundaries enables thousands of people with disabilities to participate fully in the recreational activity of fishing.

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HUNTING32

TRAIL ORIENTEERING34 AND CLIMBING35

As with fishing, hunting is a recreational activity that can be enjoyed by all, and any disability can be offset by adaptive hunting equipment and adaptive hunting techniques. There are many different types of adaptive equipment that can be used by either gun or bow hunters with either upper- or lower-extremity limb loss. This includes hunting blinds that are more wheelchair friendly, protective clothing to make cold weather hunting more enjoyable, adaptive tree stands, tripod-mounted crossbow or gun rests, and wheelchairbased gun rests. Federal, state, and local governments are providing easier access to thousands of acres of trails, parks, and wilderness areas. There are organizations and clubs with programs for persons with disabilities who want to participate in hunting activities.

Conventional orienteering combines fast running with precise navigation, typically through forests or over moorland. Trail orienteering is a discipline of the sport designed so that people with disabilities could have meaningful orienteering competitions. It completely eliminates the element of speed over the ground but makes the map-interpretation element more challenging. Able-bodied people can compete on equal terms with the physically challenged. Depending on the level of difficulty, up to five control markers are placed at each site, and only one will correspond exactly with the control description and control circle position. Sites are chosen so that they can be seen from a wheelchair-navigable path or area, but they may be quite a distance into the forest or over unnavigable terrain. The only special equipment needed is a compass. An escort can give the competitor physical help—pushing a chair, holding and orienting the map and compass, and even marking the control card with the decision according to the competitor’s instructions. However, it is an important rule that escorts must not help in the decision-making process; they can give as much physical help as may be necessary but must not offer advice or opinions to the competitor. For serious competitions, escorts are “swapped” so they do not know the competitor they are helping. Along with trail orienteering, other ambulatory sports/ activities may be appropriate for individuals with amputation. For those who enjoy the outdoors, hiking, mountain climbing, rock climbing, and ropes courses are popular (Fig. 28.7). These activities are easily done with able-bodied friends and can be done safely as long as normal outdoor precautions are observed. For those activities that require additional training or practice, there are many qualified instructors available at most recreational areas for lessons or instructions to increase enjoyment and reduce the likelihood of injury while participating in these sports.

GOLF33 Just about anyone, regardless of ability level, can participate in golf. This makes it one of the best sports for people with disabilities, especially those with limb loss (Fig. 28.6). Anyone with limb loss can successfully play golf, including those with lower-extremity prostheses, where a torsion absorber and rotator allow them to pivot to finish their swing. For those with upper-extremity amputation, they may play with just one arm, or, if they play with one arm and a prosthesis, there are a number of pieces of adaptive hardware that allow them to attach their prosthetic arm to their club, allowing them to swing with both hands. If they are unable to walk a full 18-hole course, they may play golf from a seated position on a single-rider golf cart. Numerous other devices exist to help golfers with amputation tee-up and retrieve their ball, better grip the club, and aid their game.

SKY DIVING36 Skydiving is a sport that can involve skydivers who have one or more amputated limbs. Because of their prosthetic devices, amputee skydivers often have to compensate for the change in weight with the positioning of their body for both themselves and other divers in a formation. Many of these individuals begin skydiving in tandem, making jumps while attached to a certified jump instructor. However, as individuals become more experienced, many progress to solo (accelerated free fall) jumps. Modifications to prosthetic devices, particularly lower-extremity prostheses, may need to be made because of the forces incurred during landing after the jump.

Additional Water Sports and Activities

Fig. 28.6 Golfing. (Courtesy Disabled Sports, USA.)

Besides swimming, there are numerous other water sports in which individuals with amputation may participate. These include surfing, windsurfing, water skiing, kayaking, and scuba diving (Fig. 28.8). Surfing for individuals with amputation can be a fun and exciting sport.37 Individuals

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Fig. 28.7 Rock climbing. (Courtesy Disabled Sports, USA.)

Fig. 28.9 (A) Prosthetic liner. (B) Prosthetic socket. (A, Photos taken and given with permission from CP Dionne OUHSC. B, Photos taken and given with permission from CP Dionne OUHSC.) Fig. 28.8 Scuba diving. (Courtesy Disabled Sports, USA.)

may begin surfing while lying on the board, progressing to seated, quadruped, kneeling, and finally standing. Once standing, individuals may choose to surf with or without their prosthetic device (Fig. 28.9). Until recently, windsurfing38 has been an inaccessible sport to people with limb loss. However, equipment modifications have made windsurfing accessible to people with all types of disabilities. One may begin to windsurf in a fixed or swivel seat attached to the windsurfing board. Outriggers or

flat-bottom pontoons can be attached to the sides of the windsurfing board to provide additional stability. A standing rail can be used on the board for someone to stand with an instructor for support. One or two sails can be used so that instructors can be on the windsurfing board to help assist. Such adaptations open the sport up to men and women with all types of disabilities, including amputation. Water skiing39 has been adapted so that physically disabled individuals can participate and compete. Competition is held in three events (slalom, tricks, and jumping) for individuals with upper- and lower-extremity limb loss regardless

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of amputation level. The skiers compete with the same water ski equipment used by able-bodied skiers; however, the use of a prosthetic device is optional. Kayaking may be done solo or in tandem. To avoid entrapment, individuals with lower-extremity amputations should not wear a regular prosthesis in the kayak. A water-sports prosthesis that can be strapped to the outside of the boat for easy access is recommended. For those with upperextremity amputations, one-handed paddles may be used, or individuals may practice paddling using heavy tape or rubber rings to secure their grip on the paddle, because conventional terminal devices are not designed to hold paddles. Rowing prosthetics also are available for amputees using other types of water crafts. For safety, wetsuits, helmets, and flotation devices are recommended for all participants. Scuba diving can be an excellent recreational activity for individuals with amputation. Because of the buoyancy provided by the water, mobility issues are significantly reduced, and scuba diving can be taught to swimmers with both upper- and lower-extremity limb loss with virtually no modifications. For some, scuba diving represents total freedom because it affords one the opportunity to move about without an assistive device in a barrier-free, gravity-free environment. Many individuals choose to scuba dive without their prostheses, but water-sport prostheses are available if desired. As with able-bodied divers, the same basic safety and equipment concerns apply to everyone.

Prosthetic Components for Athletes With Limb Loss Historically, individuals with limb loss were considered disabled. Without exception, they were marginalized in activities of everyday life, most notably so, in participation in recreational and competitive sports. Exoskeletal prosthetics, essentially the only choice of artificial limb design available at the time, were heavy and difficult to manage while attempting to throw a ball or walk at a varied pace required in any skilled sport. With the advent of inclusion of people with all levels of ability, people with limb loss are currently part of the societal mainstream. Most people with limb loss receive rehabilitation to improve overall function to return to the family, a workplace, and, more recently, sport-related activity. Moreover, motivated people with limb loss have formed sport enthusiast groups that have created the market demand for improvement and acceleration of modifications to everyday-use prosthetic limbs and creation of more sport-specific designs.

Prosthetic Components for Athletes With Lower Limb Loss Lower-limb prosthetics are commonly composed of a means of suspension, a prosthetic socket, joint articulation (as needed), shaft (or pylon), and foot. Prosthetics have now become modular in construction such that the athlete can still use the prosthetic socket of choice and interchange certain components to meet the demands of a specific sport.40-42 Even recreational athletes with limb loss can enjoy sports using their usual prosthetics with additional

or interchangeable modification. However, committed athletes with limb loss must consider the biomechanical demands of their sport and apply the components that allow safe and competitive participation and choose prosthetic components accordingly. For example, triathletes may choose to use a swimming prosthetic leg or opt not to use a prosthesis during the swimming portion of the competition. In addition, prosthetic design has advanced to the creation of sport-specific prosthetics, such as for swimming and track and field competition. However, affordability for these devices poses an obstacle to common accessibility.42 Once the residuum has sufficiently recovered from amputation surgery and “matured” to be able to accept the shear, torsion, and load demands of a desired sport, athletes with limb loss can be fitted with prosthetics to help meet the rigors of training.43,44 Considerations must be made for sports that demand high levels of shear, such as those that involve running or cutting. These excessive forces increase the risk of soft tissue breakdown, pain, time out of the prosthesis, and away from the sport.41 High levels of activity also increase added perspiration within the prosthetic socket, increasing the risk of infections and related skin problems.40 Regardless of choice of prosthetic components, proper prosthetic management and aggressive skin care are essential in sport.

SUSPENSION AND SOCKETS If people recovering from limb amputation surgery set a goal for participation in sport, they should closely consult with the rehabilitation team, composed of the surgeon, physical therapist, occupational therapist, athletic trainer, and specifically the prosthetist to create a prosthesis to meet that goal. Added prosthetic suspension (cuff, straps, sleeve) may be required for the prosthesis to remain intimate to the residual limb, in light of expected changeable limb volume during play. The residuum skin must be protected during participation in recreational sports, as well as everyday activities. Gel liners or sleeves provide a protective socketresiduum interface to minimize shear and other loading factors, particularly during the early phases of recovery or during repetitive movements in play.41 Thus gel liners are also recommended for the higher-level athletes. Special accommodation for boney areas at the socket-residuum interface should be considered and is usually warranted. Total surface–bearing prosthetic sockets are recommended because they are designed to disperse forces evenly over the entire surface area of the residuum-socket interface to minimize risk for soft tissue breakdown.

PROSTHETIC KNEE JOINTS There are a variety of computerized knee joints on the market that are designed for user-matched walking speeds. However, there has not yet been a computerized knee joint designed to withstand the rigors of “stop-start” running, cutting, jumping, or swimming.44 The athlete with transfemoral limb loss can choose to use a mechanical running limb because it is a simpler, more reliable knee joint design that can be controlled in “real time.” However, the athletes usually depend on the energy-storing running foot and the power of the hip extensors to substitute for natural knee function, or these athletes can choose to use no articulation at all, such as when competing in track and field events.43,45

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LOWER LEG/FOOT/ANKLE COMPONENTS Prosthetics have become modular in construction such that the athlete can still use the socket of best fit and change out the prosthetic components to minimize risk and maximize performance. Application of the appropriate prosthetic foot to maximize efficiency towards symmetric step lengths during varied walking speeds enables the recreational amputee to participate in higher levels of activity.40 In some cases, prosthetic foot/ankle/knee components can be interchanged using a “quick-release” coupler for use in specific sport-like activities.46,47 Forces untoward residuum health must be minimized with proper selection of prosthetic components. Pylons, special-designed prosthetic ankles, and heels that absorb and dissipate energy during loading are important considerations. Athletes with either transtibial or transfemoral limb loss who are required to run or sprint typically use an energy-storing foot.47 This specialized foot is constructed of materials that essentially “store” the energy during locomotion and transfer energy with significant efficiency to propel the athlete forward in walking or running gait. This particular prosthetic foot is posteriorly attached to the prosthetic socket. For the athletes involved in running or sprinting, these high-performance carbon fiber foot components (a.k.a. “blades”) have become essential (Figs. 28.10 and 28.11). This design enables the athlete with bilateral or unilateral, transtibial or transfemoral limb loss to participate and successfully compete in sports never before considered. However, there are limitations to these designs. For those who play sports on uneven ground and need ankle designs that simulate foot pronation and supination, athletes must depend on the older, mechanical designs to compete with less risk for injury and falls.47

Fig. 28.11 Carbon fiber foot. (Photos taken and given with permission from O Raiber and J Williams OUHSC.)

Athletes With Upper Limb Loss Although there are fewer people with upper-extremity limb loss than with lower-extremity limb loss, there is a growing number of those who are competing in sports who require skilled use of the arms and hands. As with lower-extremity prosthetics with high levels of technologic applications, so too the advanced upper extremity prosthetics pose even a more daunting obstacle for pragmatic use in sport. So, prosthetic designers have created with use of the humanpowered prosthesis terminal devices that are used to throw and catch a ball or hold a bow and arrow.47 The devices do not simulate human anatomy but are designed for function, not cosmesis.

Children With Limb Loss in Sport Prosthetic design for children with limb loss is typically made simpler in design when the child is small. However, as the child develops and grows, more complicated, adultlevel components are added.45 Current pediatric knee components usually provide control, shock absorption, and freedom to move like a growing child. Use of carbon-fiber energy-storing prosthetic feet is considered the norm. Components must be light, yet strong and sufficiently durable to enable the young athletes to compete (Fig. 28.12).

Prosthetics in Sports: What Is Best? Fig. 28.10 Prosthesis without knee articulation. (Photos taken and given with permission from O Raiber and J Williams OUHSC.)

Despite many advances in the design and composition of either upper- or lower-extremity prosthetic limbs, there is no tangible evidence as to which component designs are

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References

Fig. 28.12 Pediatric components. (Photos taken and given with permission from University of Central Oklahoma Endeavor Games.)

Fig. 28.13 Prosthesis with a foot. (Photos taken and given with permission from CP Dionne OUHSC.)

best suited for any one particular sport or consumer group. According to systematic review, there are several studies whose aims were to determine the effectiveness of a group of prosthetic foot-ankle or knee joint designs, but, due to the poor quality and incomparability of research designs, no conclusions could be drawn.47 However, due to additional, national-level funding of research, technology has currently advanced prosthetic designs that are sports specific, tailored to those at the most elite level of competition,48 but these prosthetics are cost-prohibitive to the everyday athlete with limb loss. Thus it is currently individualized, case-by-case, expert opinion that drives the decisions made in prosthetics for those in competitive sport49 (Fig. 28.13).

1. Whitteridge D, Guttmann L. 3 July 1899 – 18 March 1980. In: Biographical Memoirs of Fellows of the Royal Society. London: The Royal Society; 1983:226–244. 29. 2. Pringle D. Winter sports for the amputee athlete. Clin Prosthet Orthot. 1987;11(3):114–117. 3. Nolan L. Lower limb strength in sports-active transtibial amputees. Prosthet Orthot Int. 2009;23(3):230–241. 4. Center for Disease Control and Prevention. United States Department of Health and Human Services. 2008 Physical activity guidelines for Americans. Available at www.health.gov/paguidelines/guidelines. Accessed February 28, 2018. 5. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health: A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA. 1995;273 (5):402–407. 6. Kegel B, Malchow D. Incidence of injury in amputees playing soccer. Palaestra. 1994;10(2):50–54. 7. Weiler R, Van Mechelen W, Fuller C, Verhagen E. Sports injuries sustained by athletes with disability: A systematic review. Sports Med. 2016;46:1141–1153. 8. Fagher K, Lexell J. Sports-related injuries in athletes with disabilities. Scan J Med Sci Sports. 2014;24:e320–e331. 9. Tater Y. Body image and its relationship with exercise and sports in Turkish lower-limb amputees who use prosthetics. Science Sports. 2010;25:312–317. 10. Deans SA, McFadyen AK, Rowe PJ. Physical activity and quality of life: A study of a lower-limb amputee population. Prosthet Orthot Int. 2008;32(2):186–200. 11. Groff DG, Lundberg NR, Zabriskie RB. Influence of adapted sport on quality of life: Perceptions of athletes with cerebral palsy. Disabil Rehabil. 2009;31(4):318–326. 12. Steptoe A, Butler N. Sports participation and emotional well-being in adolescents. Lancet. 1996;347:1789–1792. 13. Hutzler Y, Bar-Eli M. Psychological benefits of sports for disabled people: A review. Scand J Med Sci Sports. 1993;3:217–228. 14. Murphy NA, Carbone PS. Promoting the participation of children with disabilities in sports, recreation, and physical activities. Pediatrics. 2008;121:1057–1061. 15. Webster JB, Levy CE, Bryant PR, et al. Sports and recreation for persons with limb deficiency. Arch Phys Med Rehabil. 2001;82(3 Supp1):38–44. 16. Rimmer JH, Wolf LA, Sinclair LB. Physical activity among adults with a disability- United States, 2005. MMWR Morb Mortal Wkly Rep. 2007;56(39):1021–1024. 17. Modan M, Peles E, Halkin H, et al. Increased cardiovascular disease mortality rates in traumatic lower limb amputees. Am J Cardiol. 1998;82(10):1242–1247. 18. Finch N, Lawton D, Williams J, et al. Disability survey 2000: Survey of young people with a disability and sport. Available at www.sportengland. org. Accessed on April 15, 2011. 19. Jaarsma EA, Dijkstra PU, Geertzen JHB, Dekker R. Barriers to and facilitators of sports participation for people with physical disabilities: A systematic review. Scand J Med Sci Sports. 2014;24:871–881. 20. Bragaru M, Dekker R, Geertzen JHB, Dijkstra PU. Amputees and sports: A systematic review. Sports Med. 2011;41(9):721–740. 21. Disabled Sports USA. Available at www.disabledsportsusa.org. Accessed on February 21, 2018. 22. Disabled Sports USA. Available at www.disabledsportsusa.org/about/ our-mission/. Accessed on February 21, 2018. 23. Amputee Coalition. Available at www.amputee-coalition.org. Accessed on February 21, 2018. 24. Amputee Coalition. Available at www.amputee-coalition.org/aboutus/history. Accessed on February 21, 2018. 25. Challenged Athlete’s Foundation. Available at www.challengedathletes. org. Accessed on February 21, 2018. 26. Challenged Athlete’s Foundation. Available at www.challengedathletes. org/mission-and-history/. Accessed on February 21, 2018. 27. International Paralympic Committee. Available at www.paralympic. org. Accessed on February 28, 2018. 28. United States Paralympic Committee. Available at www.paralympic. org/united-states-america/. Accessed on February 28, 2018. 29. International Paralympic Committee. Classification Introduction. Available at www.paralympic.org/classification. Accessed February 28, 2018.

28 • Athletic Options for Persons With Limb Loss 30. International Paralympic Committee. Sports. Available at www. paralympic.org/sports. Accessed February 28, 2018. 31. World Taekwondo. Standing Procedures for Taekwondo Competition at Olympic Games. Available at www.worldtaekwondo.org/rules/. Accessed on February 28, 2018. 32. Disabled Sports USA. Take it Outside- Hunting, Fishing Adapt to Meet Physical Abilities and Enhance Experience. Challenge Magazine. 2005;10(2):29–31. 33. Disabled Sports USA. Golf is for Everyone. Challenge Magazine. 2005;10 (1):23–26. 34. Braggins A. Trail Orienteering. Available at www.trailo.org. Accessed February 28, 2018. 35. Disabled Sports, USA. Rock Climbing. Available at www. disabledsportsusa.org/sport/rock-climbing. Accessed on February 28, 2018. 36. Amputee Skydiving. Available at www.atwiki.assistivetech.net/index. php/amputee_skydiving. Accessed on April 16, 2011. 37. AmpSurf. Available at www.ampsurf.org. Accessed February 28, 2018. 38. ActiveAmp. Sports and Activities for the Active Amp. Available at www. activeamp.org/sport_dir.htm. Accessed February 28, 2018. 39. Water Skiers with Disabilities Association. Available at www. usawaterski.org/pages/divisions/wsda/main.asp. Accessed on February 28, 2018. 40. Prince F, Allard P, Therrien RG, McFadyen BJ. Running gait impulse asymmetries in below-knee amputees. Prosthetics and Orthotics International. 1992;16:19–24. 41. Lyon CC, Kulkarni J, Zimerson E, Van Ross E, Beck M. Skin disorders in amputees. Journal of the American Academy of Dermatology. March 2000;42:501–507.

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42. Klute GK, Berge JS, Orendurff MS, Williams RM, Czerniecki JM. Prosthetic intervention effects on activity of lower extremity amputees. Archives of Physical Medicine & Rehabilitation. May 2006;87:717–722. 43. Tazawa E. Analysis of torso movement of transfemoral amputees during level walking. Prosthetics and Orthotics International. 1997;21: 129–140. 44. Van der Linde H, Hofstad CJ, Geurts AC, Postema K, Geertzen JHB, van Limbeek J. A systematic literature review of the effect of different prosthetic components on human functioning with a lower-limb prosthesis. Journal of Rehabilitation Research & Development. 2004;41(4): 555–570. 45. Wind WM, Schwend RM, Larson J. Sports for the physically challenged child. Journal of the American Academy of Orthopaedic Surgeons. 2004;12:126–137. 46. May BJ, Lockard MA. Prosthetics & Orthotics in Clinical Practice A case Study Approach. Philadelphia: FA Davis; 2011. 47. Bragaru M Dekker R, Geertzen JHB. Sport prosthesis and prosthetic adaptations for the upper and lower limb amputees: An overview of peer reviewed literature. Prosthetics and Orthotics International. 2012;36:290–296. 48. Horton’s Orthotics & Prosthetics. How advanced prosthetics are changing the world of sports and its athletes. Available at http://www. hortonsoandp.com/how-advanced-prosthetics-are-changing-theworld-of-sports-and-its-athletes. Accessed on June 21, 2018. 49. Nolan L. Carbon fibre prostheses and running in amputees: A review. Foot and Ankle Surgery. 2008;14:125–129.

29

Rehabilitation for Children With Limb Deficiencies JOAN E. EDELSTEIN and SUSAN ANN DENNINGER

LEARNING OBJECTIVES

On completion of this chapter, the reader will be able to do the following: 1. Relate developmental milestones to the habilitation of children with congenital limb deficiency and rehabilitation of those with amputation. 2. Describe how prostheses can be designed to accommodate longitudinal and circumferential growth so that fit remains comfortable and the child can attain maximum function. 3. Outline the ways a clinician can address psychosocial concerns for infants, toddlers, school-age children, and adolescents. 4. Compare prosthetic options for children of various ages who have upper- or lower-limb deficiencies. 5. Specify the training goals for children of various ages fitted with upper- and lower-limb prostheses. 6. Design a habilitation program for an infant born with multiple limb deficiencies.

Ellen, who was born without a left forearm and hand, Bobby, age 4, who caught his foot in a powered lawn mower, and Pedro, age 12, who is recovering from femoral sarcoma have different skeletal, neuromuscular, learning, and psychosocial challenges from those of adults with amputation. Children share some rehabilitation issues with adults, particularly the basic components of the prosthesis and the essential elements of postoperative care. However, other considerations are unique. Because children are smaller than adults, the choice of prosthetic components is not as broad. Youngsters grow and develop through the rehabilitation process. In addition, young people legally, financially, and emotionally depend on adults for their medical, surgical, and rehabilitation care. Clinicians concerned with comprehensive management of children with limb deficiencies need to consider the causes of limb deficiency, the relationship of developmental milestones to prosthetic selection and use, and the psychosocial factors that affect children to design optimal programs.1 Care of the infant born with a limb anomaly is habilitation, whereas management of someone who undergoes amputation because of trauma or disease is rehabilitation. However, unless the distinction is relevant, habilitation and rehabilitation are used interchangeably in this chapter. Similarly, limb deficiency is used to designate both congenital and acquired limb absence. The overall goal of physical therapy is to facilitate the normal developmental sequence and prevent the onset of secondary impairments and functional limitations such as contractures, weakness, and dependence in self-care.

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Comprehensive Considerations in Childhood The philosophy of this chapter is that the child with a limb deficiency is first and foremost a person, with the beauty, delight, and promise inherent in all young people.

CLASSIFICATION AND CAUSES OF LIMB DEFICIENCIES The International Organization for Standardization approved a system of limb deficiency classification in 1989 (Fig. 29.1).2 Congenital limb anomalies are described anatomically and radiologically as transverse, in which no skeletal elements exist below the level of normal development, or longitudinal, in which a reduction or absence of elements is present within the long axis of the limb with normal skeletal elements usually present distal to the affected bone (see Fig. 29.1). This system replaces older terms, such as phocomelia (distal segments attached to the torso), amelia (complete absence of a limb), and hemimelia (partial absence of a limb). Childhood limb deficiency is caused by congenital malformation, trauma, and cancer and other diseases. In the U.S. population, the incidence of congenital deficiency has remained stable.3 Among those born with anomalies, transverse deficiency of the upper limb, especially the left, is the most common.4 The overall prevalence of limb deficiency among 161,252 newborns was 0.7 per 1000 births. Thirty percent of the defects were caused by genetic factors, 35%

29 • Rehabilitation for Children With Limb Deficiencies

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Shoulder total

Upper arm total

Upper arm middle third

Forearm total

Longitudinal Tibial total Tarsus partial Ray 1 total

Forearm upper third

Carpal total Carpal partial Phalangeal total Phalangeal partial

A

B

1

Fig. 29.1 (A) International Organization for children with Standardization/International Society for Prosthetics and Orthotics system for classifying upper-limb congenital limb deficiencies. Lower-limb transverse deficiencies are named in a similar fashion. Levels can also be described by naming the absent bone(s). (B) Lower-limb longitudinal limb deficiency. The shaded area represents missing segments. (Reprinted with permission from Murdoch G, Wilson AB, eds. Amputation: Surgical Practice and Patient Management. Oxford, UK: Butterworth Heinemann; 1996:352.)

by vascular disruption, 4% by teratogens, and 32% by an unknown cause.5 Powered lawn mowers6-8 and all-terrain vehicles9 are responsible for many traumatic amputations among children and adolescents. Preserving limb length is a crucial factor in mature limb length.10 Replantation of the severed body part or its revascularization has met with satisfaction by most young patients.11 Some patients with tumor are treated by various limbsparing procedures, and others undergo amputation. Long-term outcome is similar, although more patients with amputation used walking aids and were less satisfied, as children, with their status.12-15

All children, not just those with limb deficiency, display varying rates of neuromuscular development. Chronologic age cannot provide a complete picture of a child’s developmental level. In this chapter, milestones pertaining to upperand lower-limb development are related to habilitation of children with limb disorders. Physical conditioning programs, especially active sports, are important to enhance general health and endurance, particularly for those who wear a prosthesis. Play and games increase coordination and improve strength. Swimming is particularly beneficial because it does not traumatize the limbs and does not require a prosthesis; nevertheless, some children may be reluctant to display an anomalous limb.

DEVELOPMENTAL MILESTONES

ACCOMMODATING GROWTH

Motor skills develop in a predictable sequence, with wellestablished milestones that mark achievement of important functional abilities.16-18 In the absence of cerebral maldevelopment or malformation, the infant born with a limb anomaly or a young child who undergoes amputation demonstrates physical control at approximately the same time as an unaffected child does. However, limb deficiency often alters how the developmental tasks and activities are performed. For example, the 5-month-old infant who has only one intact leg will develop a distinctive style of crawling. Therapists who conduct initial evaluations of these children focus on muscle strength, range of motion, gross motor patterns, coordination, attention span, and interests.

All children grow, regardless of congenital anomalies or amputations. Prosthetic planning should incorporate measures to maintain comfortable socket fit and symmetric limb length. The preschool-age child may need a new prosthesis almost yearly. Those in grade school often require a new prosthesis every 12 to 18 months, and teenagers outgrow prostheses every 18 to 24 months. Longitudinal growth is typically more rapid than circumferential growth, a troublesome fact for children with lowerlimb deficiency. Reconstructive surgery, especially circular (Ilizarov) fixation, suits children with minimal length discrepancy, whereas amputation remains preferable for those with severe limb loss. Too short a lower-limb prosthesis disturbs the quality and efficiency of gait and substantially

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increases energy cost. In contrast, an upper-limb prosthesis that is slightly short will probably not present a noticeable asymmetry and will have little effect on bimanual activities. Endoskeletal prosthetic components facilitate lengthening and substitution of more sophisticated components. Vigorous play causes considerable wear of the mechanical parts of prostheses. These parts are also vulnerable because of their small size and the sand, grass, and mud that children find inviting. Youngsters are likely to wear out prostheses from everyday use before circumferential growth necessitates a change. Signs of an outgrown socket include a tendency of the residual limb to slip out of the socket, pain or skin reddening caused by socket tightness, and a flesh roll around the margin of the socket. Socket liners are a convenient way to accommodate circumferential growth; as the child grows, liners can be removed. Alternatively, the prosthesis can be fitted with several layers of socks; the child eventually wears fewer socks to accommodate the added residual limb girth. Flexible sockets fitted to extra-thick frames are another way to accommodate growth. To fit the larger residual limb, a new flexible socket is made and material is ground from the frame. Prosthetic alignment should complement the immature skeleton and joint capsules. Children with surgical amputations through the bony diaphysis or metaphysis may have terminal bony overgrowth (Fig. 29.2). As these children grow, terminal periosteal new bone may protrude beneath the terminal subcutaneous tissue and skin. Without treatment, a bursal sac forms and the skin becomes ecchymotic and hemorrhagic. The underlying bone then ruptures the bursal sac, and infection can occur. Overgrowth is a particular problem when the adolescent growth spurt begins.

Fig. 29.2 Bony overgrowth of the fibula in the transtibial amputation limb of a 7-year-old child. In the original amputation surgery, the fibula was slightly shorter than the tibia. (Courtesy J.E. Edelstein.)

Customary treatment is excision of the periosteal sac, transection of the distal 2 to 3 cm of bone, and primary closure of the incision. Children may require this procedure several times during the growth period.19 Another approach is continuous skin traction, which can be used to maintain skin and soft-tissue coverage over the distal end of the residual limb until skeletal growth is complete. The difficulties of keeping distal force on the limb day and night usually preclude this method. Disarticulation preserves the distal epiphyseal plate and thus is not associated with overgrowth. Near-normal range of joint motion is an important determinant of effective prosthetic use in children with limb deficiencies, as well as in adults with amputation. Active therapeutic exercise designed to increase joint excursion is preferable to passive stretching, especially in the presence of congenital contracture.

POSTOPERATIVE CARE Postoperative care is simpler for young children who undergo amputation than for adolescents and adults. Ordinarily the residual limb presents little or no edema and the wound heals rapidly. Phantom limb sensations are commonly experienced by adults with amputation, but little literature is available that discusses the impact phantom limb sensations and pain might have on pediatric patients. Phantom pain is associated with the extent of preoperative pain and is generally short lived.20 The prevalence of phantom limb pain varies depending on the cause of amputation. In pediatric traumatic amputation the prevalence of phantom limb pain ranges from 12% to 83%, 3.7% to 20%, and 48% to 90% for traumatic, congenital, and oncology-related amputation, respectively.21 Symptoms are highly variable, ranging from the perceived ability to voluntarily move the phantom limb, to sharp pain, to tingling sensations. Furthermore, these symptoms typically last for minutes but can be almost constant and can be highly distressing. Episodes typically occur in the afternoon and evening and may be triggered by physical (e.g., bumping/injuring the amputated limb or long periods of walking or standing) and psychosocial (e.g., meeting new people or stress) triggers.21 Treatment for phantom limb sensations varies based on the individual’s symptoms, age, and impact on their function. Desensitization techniques such as rubbing or massaging the uninvolved limb at similar points to those in which they are experiencing the phantom limb sensation of the amputated limb can be used to control symptoms.1 A pain diary may help older children and adolescents to cope with phantom pain from traumatic amputation. The majority of research for nonpharmacologic treatments has focused on mirror therapy in pediatric cancer. Mirror therapy uses the facilitation of an illusion of the unaffected limb, thus helping to reorganize the somatosensory cortex of the brain to reduce phantom limb pain/sensations.1,21,22 Pharmacologic treatments are usually managed by a pain management team. At this time, no one medication is standard of practice, but several pharmacologic treatments have demonstrated effectiveness. Gabapentin, tricyclic antidepressants, and opioids have all demonstrated usefulness in treating phantom limb pain. Wang and colleagues found that preoperative use of gabapentin in pediatric patients with oncology-related amputation had a beneficial impact on postoperative pain intensity

29 • Rehabilitation for Children With Limb Deficiencies

and phantom limb pain prevention when compared with a placebo.23 Other agents such as nerve blocks or epidural catheters have also been described in pediatric postoperative pain management protocols.20,21

PSYCHOSOCIAL FACTORS IN HABILITATION AND REHABILITATION Habilitation amounts to more than selecting a suitable prosthesis and devising appropriate training. All children have personalities that develop along with their physical growth. Optimal emotional development occurs when parents and clinicians promote wholesome interactions.24 The essential message is that the child has a unique personality and that independence commensurate with age can be fostered.25,26

Infants Infants learn trust when their basic needs are met. The baby with limb anomaly has as much need for trusting, responsive care as does the infant with intact limbs. Infants respond to the anxieties of parents and others who interact with them. Successful habilitation depends on the parents’ replacing the expectation of a “perfect” infant with the reality of a baby who happens to have a limb deficiency. Birth of a baby with a limb deficiency can elicit intense emotion. Because such an event is rare in any hospital, medical staff may display shock and feelings of helplessness or revulsion. Some parents characterize the first few weeks after birth as a nightmare. They believe they are alone with a unique and hopeless problem when questions go unanswered or evaded. Reactions of the infant’s grandparents, siblings, and other family members influence habilitation. Mourning for the loss of the ideal child is part of the coping process.1 Newborns are too young for prosthetic fitting; nevertheless, early referral to a specialized clinic is highly desirable. The core team is composed of a pediatrician, physical therapist, occupational therapist, and prosthetist. The team should be able to draw on the expertise of psychologists, social workers, orthopedists, and engineers, depending on the needs of the child and family.2 Effective clinical team management involves the family in rehabilitation decisions and weighs management recommendations in light of the immediate impact on the child’s welfare and the long-term consequences on his or her appearance and function as an adult. An important resource is the Association of Children’s Prosthetic-Orthotic Clinics (9400 West Higgins Road, Suite 500, Rosemont, IL 60018-4976; http://www.acpoc.org). The association, founded in 1958, has held an annual interdisciplinary conference since 1972. The clinical team creates an atmosphere in which parents and their youngster are welcome, encouraging conversation about feelings and obtaining answers to questions. The team’s approach aims to maximize the child’s function, while learning the parents’ style of dealing with unexpected events. Team members should empathize with parents’ grief, which can bear little relation to the extent of the infant’s disability. Some parents resist holding the baby, hide the deformity, avoid direct contact, or withdraw into silence. When clinicians hold the baby, parents usually realize that the infant really is lovable. Rather than denying any difference, the team fosters the attitude that, yes, they know the child is different, but they recognize and accept the infant for who the person is and what he or she can do.

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Case Example 29.1 A Newborn With Congenital Transradial Limb Deficiency Mr. and Mrs. M. anticipated the birth of their second child with great eagerness. Mrs. M. had excellent prenatal care and an easy pregnancy. During a routine second trimester ultrasound, Mr. and Mrs. M. were told that the ultrasound demonstrated that their infant had a left transradial limb deficiency. The obstetrics team referred Mrs. M. to high-risk obstetrics and genetic counseling. After repeat ultrasounds throughout the remainder of the pregnancy, the team ruled out further congenital abnormalities. The family was referred to a Family Connections program where they were able to connect with other parents of children with congenital limb deficiency prior to the infant’s birth. The couple prepared their 2-year-old daughter for her new role as “big sister,” encouraging her to feed her dolls bottles and push them in a stroller. Mrs. M. struggled to bond with the infant during her pregnancy and opted not to decorate the nursery or accept gifts in fear that something would go wrong. She was anxious and depressed that this infant’s birth would be different than her first and was fearful of a potential neonatal intensive care unit (NICU) stay and complications. Maternal grandparents flew in from out of town to be with the family for the birth of the baby. S.M. was born a few days later in a regional hospital equipped with a NICU. She was a healthy, term infant with lusty lungs. The obstetric nurse wrapped her in a receiving blanket and presented her to her anxious, but very proud, parents. Mrs. M. was wheeled to her room. S.M. had no immediate medical concerns and was therefore able to stay with her mother and avoid the NICU. Once settled in her room, Mr. and Mrs. M. unwrapped the baby and were able to visualize the left transradial limb deficiency for the first time. The couple cried and consoled each other as they grieved the fact that their daughter would have a disability and was not “perfect.” A child-life specialist was consulted to help their older daughter prepare to see her new sister and explain, in a way she could understand, why her baby sister was missing her hand. A physical therapist was consulted the next day to assist the parents in proper positioning and simple range of motion exercises. Mrs. M. was silent, turning her head to the wall, tearful, and refusing to participate in the baby’s care. Mr. M. attempted to engage with the physical therapist and learn how to care for his daughter’s arm but was clearly distracted by how upset and depressed his wife was. Discharge to home with the baby is planned for the next morning. QUESTIONS TO CONSIDER

▪ Given Mrs. M.’s depression, how should the attending physician and medical team proceed?

▪ What impact do you think prenatal counseling and support had for this family?

▪ How might the grandparents and older sister help Mr. and Mrs. M. when they return home with their new daughter?

▪ What is the most constructive response the physical therapist can give when first meeting S. M. and her parents?

▪ How can the physical therapist facilitate positive immediate and long-term family interaction?

Families may be interested in seeing pictures or examples of the type of prosthesis that the child will probably use. However, expectations regarding the extent of prosthetic restoration may be unrealistic. Parents should understand what prosthetic and surgical possibilities exist so they can make rational decisions for their child. Infants usually

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receive the first prosthesis at approximately 6 to 9 months of age.21-28 Comparing the performance of children fitted with an upper-limb prosthesis before 1 year of age with those fitted later indicates no difference in satisfaction with the prosthesis nor functional use.27 Some parents find it difficult to accept the prosthesis, believing that it draws attention to the limb deficiency. The team can also help parents of children who undergo amputation because of trauma or disease cope with feelings of guilt and shock. Team members assist the family in realizing that they were not negligent in protecting the child against injury or not recognizing symptoms of a disease process early enough to prevent amputation. In addition to clinical team management, families benefit from participating in peer support groups in which they can share concerns, exchange information, and observe children of various ages playing with and without prostheses. Some groups publish newsletters that share information with those who live too far from the meeting site. The Amputee Coalition (900 East Hill Avenue, Suite 390, Knoxville, TN 37915; www.amputee-coalition.org) is a peer advocacy organization that produces a magazine, monographs, and videos; has annual conferences; operates the National Limb Loss Information Center; and sponsors a youth camping program, national peer network, and limb-loss education and awareness program, among many other activities. Parental acceptance of and active cooperation in the training program are the most important factors in its success and largely determine whether the child regards the prosthesis as a tool in daily activities.1 Families need to learn skin care, prosthetic operation, maintenance, and the capabilities and limitations of the prosthesis. Outpatient training is preferable to avoid homesickness. The constant presence of one or both parents during therapy sessions enables the entire family to learn about prosthetic use and maintenance. Putting a prosthesis on an active child is a skill that takes time for parents to master. Scheduling appointments after naps and meals is generally more productive than attempting to coerce a tired, hungry child to participate in therapy. Clinicians should incorporate many brief activities in the treatment session, recognizing that young children have short attention spans. Therapists who treat infants need to interpret nonverbal indications of comfort or discomfort and satisfaction or dissatisfaction with the prosthesis. The infant who coos, smiles, and engages in play is probably content with the prosthesis and the function it offers, whereas a cranky, crying person may be contending with an ill-fitting socket. As with all patients, the clinician must frequently examine the skin, with particular attention to persistent redness, indicating high pressure, and irritation, which may signal dermatitis.

Case Example 29.2 A Child With Congenital Transradial Limb Deficiency S.M. eats heartily, allows her older sister to sprinkle talcum powder on her, and is developing normally. She smiles and gurgles when someone approaches her. By 6 months, she is sitting independently and can use both arms to clutch stuffed toys. She grabs the railings of her crib, attempting to pull herself to standing. The physical therapist

recommended that the family take S. M. to a rehabilitation center that specializes in caring for children with amputations. At the center, Mr. and Mrs. M. overcame their initial hesitation and now participate enthusiastically in a peer support group in which a dozen parents of children with limb deficiency trade advice and provide emotional support. Mr. and Mrs. M. are concerned about unwelcome comments regarding their daughter’s appearance, both with an empty sleeve and with the possibility of a hook terminal device substituting for the absent hand. They tried to persuade the clinical team to provide S.M. with an infant passive mitt, which would disguise the anomaly. The therapist showed Mr. and Mrs. M. that the mitt has no prehensile capability. One of the members of the support group extolled the virtues of a myoelectric hand, so Mr. and Mrs. M. then argued that S.M. should be provided with “only the best,” regardless of cost. Support group members pointed out that S. M. was too small for myoelectric fitting but might be a candidate in another year or two. S.M. is fitted with a simple transradial prosthesis consisting of infant voluntaryopening hook, wrist unit, socket, and infant harness. The prosthesis does not have a cable. QUESTIONS TO CONSIDER ▪ What activities in the clinic would help S.M. to acclimate to her new prosthesis? ▪ What activities would be appropriate for a home program for the first week after prosthetic fitting? ▪ What types of bimanual activities can be accomplished with a transradial prosthesis with a passive hand rather than a cable-controlled terminal device? ▪ What toys can be recommended to the grandparents that will help S.M. to incorporate the prosthesis in her play time? ▪ How can the prosthesis facilitate S.M.’s physical and psychological development?

Toddlers Toddlers must develop self-control to acquire the autonomy necessary to cope with their environment. The interval between 1 and 3 years of age is characterized by the development of language and functional communication, assertion of independence, and interpersonal control. Children as young as 3 years should be informed of any impending surgery, whether to revise a congenital anomaly or treat disease or injury. Doll play can help the child to understand surgery and rehabilitation. Special dolls that depict amputations at various levels, with and without prostheses, are available from A Step Ahead Prosthetics (132 Newbridge Road, Hicksville, NY 11801, www.weareastepahead.com). Children must resolve feelings of deprivation and resentment that accompany the visible alteration of their bodies. Mobility, control, exploration, initiative, and creativity are prime emotional developmental milestones for older toddlers and young school-age children. Parents and professional staff should encourage the child’s independence. Facile use of a prosthesis can help youngsters to achieve their psychological potential. Children compare themselves with others and ask, “Where is my other hand (or leg)?” Patients form two body images, one with and the other without the prosthesis. Parents should give a simple, truthful answer,

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clearly stating that the child will not grow another hand, saying something like “You were born this way.” Similarly, toddlers who undergo amputation need a realistic answer to the question, “What happened to you?” The child may engage parents in a power struggle regarding prosthetic wearing. A firm yet gentle approach with a range of acceptable choices usually enables the youngster to incorporate autonomy needs while gaining prosthetic proficiency. The clinical team should respect the parents’ comments and involve the family in all aspects of care. The waiting room should have a variety of safe toys to make visits more pleasant. Parents should be present during the child’s examination and prosthetic fitting to increase communication and thereby reduce anxiety and maximize effectiveness of the prosthetic prescription and fitting process.

School-age Children School-age children need to become industrious and engaged in planning and executing tasks. The upper- or lower-limb prosthesis can be instrumental in fostering this important psychological task. The clinical team can help to prepare the child and family for encounters with teachers, scout masters, clergy, and other adults. In group experiences, the student may have to deal with feelings of social devaluation. The teacher or other group leader is in a position to bolster the child’s sense of selfworth. The first day at school or camp can be the occasion when the child displays the prosthesis and demonstrates its function. The presentation usually dispels the mystery of the appliance and shows that the prosthesis is simply a tool that makes it easier for its wearer to engage in certain activities. The teacher should be aware of the appearance of the residual limb, the child’s function with and without the prosthesis, any environmental or programmatic adaptations that may be advisable, and how to cope with prosthetic malfunction. Anticipating awkward situations helps to develop coping strategies. For example, in a circle game, classmates may be reluctant to hold hands with someone who wears an upper-limb prosthesis. If the teacher holds the child’s prosthetic hook, the other students are likely to realize that it is not scary or unacceptable to do so. School officials may be concerned about the ability of a child with a prosthetic leg to maneuver in the classroom and playground. Classmates’ natural curiosity should be dealt with through honest, simple answers. Although teasing is inevitable, the young student who feels secure understands that taunts are merely crude expressions of interest. Among school-age children with limb deficiencies, demographic variables (such as age, sex, socioeconomic status, and degree of limb loss) are not significant predictors of self-esteem. In contrast, social support, family functioning, self-perception, and microstressors affect the child’s adaptation. Many school-age and older children respond favorably to scouting, camping, and other group recreational activities. Sports programs, such as skiing, horseback riding, and track events, are fun and give children with disabilities pride in athletic achievement. Older Children and Adolescents Adolescents face the critical step of developing a satisfying identity within themselves and with their peers. The teenager may select times when prosthetic wear is not desirable

(e.g., eschewing an upper-limb prosthesis during a football game or discarding the leg prosthesis when swimming or playing beach volleyball). Adults should nurture young adults so they develop sufficient self-esteem to make satisfying decisions about when to use or remove the prosthesis. Teenagers with limb loss must cope with being visibly different. Young adults have to adapt to a culture designed for those who do not have a disability and must evaluate whether people relate to them as individuals or as people with handicaps. During adolescence, feelings such as “Why did this happen to me?” are often intensified. Adolescents constantly reexamine their body image; group showering after physical education class may be especially stressful for those with limb loss. Other developmental concerns in which limb loss plays a role are choosing a vocation, obtaining a driver’s license, and engaging in sexual activity. The family and clinical team need to be sensitive to concerns about privacy, confidentiality, and independence. Adolescents with bone cancer who undergo an amputation typically pass through a stage of initial impact when they learn that the treatment plan includes amputation. This news may be met with despair, discouragement, passive acceptance, or violent denial. Informing the adolescent of the rehabilitation process and the achievements of others can be helpful. The next stage is retreat, during which the adolescent experiences acute grief. Anger may be part of the coping process. The goal of grieving is relinquishing hope of retrieving the lost object. The staff can reinforce the patient’s strengths and encourage maximal independence. The third stage is acknowledgment, when the adolescent is willing to participate in rehabilitation and has incorporated the changed appearance into his or her body image. Reconstruction, the final stage, involves the return to developmentally appropriate activities, such as school, sports, and dating.

Case Example 29.3 An Adolescent With Osteogenic Sarcoma E.K., who is 15 years old, is scheduled tomorrow to have surgical ablation of his right arm at the level of the humeral epicondyles to remove an osteogenic sarcoma. Six months ago, he fractured his right radial head. Although the fracture healed well, he noticed persistent tenderness at the elbow with a firm mass that was increasing in size. His physician referred him to an orthopedist. After a series of bone scans and biopsies, the orthopedist confirmed the diagnosis of osteogenic sarcoma and recommended immediate amputation. E.K. and his parents refused the surgery and traveled to four clinics in the surrounding states seeking advice regarding treatment of the tumor. They explored alternate methods of treatment, including herbal preparations to shrink the sarcoma, en bloc resection with implantation of an endoprosthetic elbow joint, and amputation of the arm distal to the epicondyles. After meeting with the clinical team at the children’s medical center and speaking with several patients who had had surgery and rehabilitation, they reluctantly agreed to amputation during his summer vacation. An excellent student, E.K. is also the shortstop on his high school varsity baseball team and plays the tuba in the Continued

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Case Example 29.3 (Continued) marching band. For the past two summers he has been a counselor at a sports- and computer-oriented camp. The family is committed to devoting all its financial and emotional resources to enable E.K. to resume a full agenda of academic and recreational activities. E.K. has compiled considerable information from the internet regarding prostheses. QUESTIONS TO CONSIDER ▪ What postoperative management would foster wound healing and enable E.K. to become accustomed to a prosthesis? ▪ How can the occupational therapist and physical therapist help E.K. to cope with loss of his dominant hand? ▪ Compare the advantages of a cable-controlled prosthesis with a prosthesis having a myoelectrically controlled terminal device and cable-controlled elbow unit. ▪ What terminal device would be most suitable for E.K.? ▪ How can the clinical team guide E.K. when he returns to school in September? ▪ In what recreational activities can E.K. engage after his amputation?

age when the child can manipulate objects with one hand while the other hand stabilizes the toy. Simultaneous sitting and manipulating are still challenging at this age. Increased trunk strength enables the baby to reach unilaterally and bilaterally. Bilateral coordination at 4 months allows the infant to reach objects at the midline. Two-handed holding of a bottle typically occurs at approximately 4.5 months.18 By the fifth month, the infant can transfer toys from one hand to the other and is thus aware of the usefulness of holding objects. The youngster’s dominant interests are in getting food, exploring surroundings, and making social contact with those who feed, hold, and provide care. Holding a large ball encourages the infant to clasp objects between the arms. Manipulating blocks or beads promotes stabilization of proximal body parts to allow fine movements with distal parts. Although a baby with intact limbs can get to the quadruped position and shift weight from side to side,18 the infant who is missing one or both arms will probably find that crawling is impossible and will have difficulty coming to a sitting position and pulling to a standing position. Six months is generally considered the optimal age for upper-limb prosthetic fitting (Fig. 29.3). The baby with unilateral amputation has achieved good sitting balance, can free the sound hand for manual activities while sitting,

Rehabilitation and Prosthetic Decision Making Not all children with limb deficiency benefit from prostheses. With certain upper-limb anomalies, the remaining portion of the limb is more functional when bare than it would be if it were covered by a prosthesis.24 Some children who are born with bilateral arm absence generally use their feet to play and can do almost everything they need to without using complicated and heavy prostheses.17,24,28

REHABILITATION OF CHILDREN WITH UPPER-LIMB AMPUTATION Because functional use of an upper-limb prosthesis often involves control of a terminal device (substitute for the missing hand), the prosthetic design and the rehabilitation program should be appropriate for the child’s level of motor, cognitive, and perceptual development.

Infants Prosthetic fitting and training should complement an infant’s development. Although a prosthesis usually is not fitted until babies are at least 6 months of age, earlier developmental accomplishment paves the way for successful prosthetic use. The average 2-month-old infant can hold objects with both hands. The baby who lacks one or both hands typically attempts to hug a stuffed animal with the forearms or upper arms, capitalizing on the tactile sensitivity of the skin. The normal 3-month-old child can bring grasped objects to the mouth. Three months is also the age when babies attempt two-handed prehension, although this skill is not perfected until the child attains sitting balance at age 6 to 9 months.1 The 4-month-old infant props on the forearms, shifts weight to reach, and usually enjoys shaking noisy rattles by using rapid elbow flexion and extension. An important developmental step is reached at approximately the same

Fig. 29.3 Infant prosthetic hands. (A) Greek Series Hands are soft and flexible. (B) Infant mouthing on toy with Alpha hand. (A and B, Courtesy TRS, Inc., Boulder, CO.)

29 • Rehabilitation for Children With Limb Deficiencies

and is actively engaged in exploring the environment. The prosthesis restores symmetric limb length and enables the infant to hold stuffed animals and similar toys at the midline. The prosthesis also accustoms parents to the concept that a prosthesis will likely be a permanent part of their child’s wardrobe. Fitting can assuage parental guilt or shame regarding their infant’s abnormal appearance by replacing negative reactions with a constructive device that enhances the baby’s development. Many parents seek a prosthetic hand to disguise the limb anomaly. Early fitting provides experience that will be the basis for the young person’s later decision regarding whether to continue with prosthetic use. Fitting earlier to a rapidly growing infant makes the maintenance of socket fit difficult. In addition, a younger baby may find the prosthesis a hindrance during rolling maneuvers. Infants who are much older than 6 months may resist a prosthesis that deprives them of using the tactile sensation at the end of the residual limb. Initial fitting after 2 years tends to result in greater rejection of the prosthesis because by then the child has developed compensatory techniques. At 8 months, most babies sit while manipulating objects with both hands by using gross palmar grasp and controlled release. A prosthesis aids in clasping large objects and stabilizing smaller ones while the sound hand explores them. By 15 months, most children can place a pellet in a small container and use crayons for scribbling and a spoon for feeding. These skills can also be performed with a prosthesis. The first prosthesis is usually passive (i.e., it does not have a cable or other operating mechanism). The terminal device may be a hook or a passive mitt. The hook is covered with pink or brown resilient plastic to disguise its mechanical appearance. The plastic also blunts the impact of the hook as infants explore with it, swiping themselves and others in the vicinity. The hook may be a voluntary-opening design without a cable. Parents can place a rattle or other object in the hook to acquaint the baby with prehension on the deficient side. A few children start with the Child Amputee Prosthetics Project (University of California at Los Angeles, Los Angeles, CA) terminal device (Fig. 29.4), which functions in the voluntary-opening mode. Some infants have a voluntary-closing hook on the first prosthesis (Fig. 29.5); in the absence of a cable, the hook holds the toy secured with tape or a rubber band. The three options offer little difference in function. A fourth terminal device option is the

A

B

Fig. 29.4 Children’s terminal devices. (A) Voluntary-closing hand. (B) CAPP (Child Amputee Prosthetics Project) voluntary-opening terminal device (A, Courtesy TRS, Inc., Boulder, CO. B, Courtesy Fillauer Companies, Inc., Chattanooga, TN.)

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Fig. 29.5 Voluntary-closing terminal devices on prostheses. (A) LiteTouch hand. (B) Adept hook. (Courtesy TRS, Inc., Boulder, CO.)

infant passive mitt. The mitt has a less mechanical appearance than other terminal devices but has no prehensile function; objects can be taped to it for the amusement of the baby. The absence of a hooked configuration hampers use of the mitt when the baby attempts to pull to standing at the side of the crib or playpen. Whatever the design, the terminal device is generally fitted into a wrist unit at the distal end of the socket. The thermoplastic socket may be custom molded to a plaster model of the child’s residual limb. A fabric sock protects the skin from pressure concentration imposed by the socket. A snug fit is needed around the humeral epicondyles to stabilize the prosthesis on the child’s residual limb. Depending on the rate of growth, changes may be needed every 2 to 4 months. If the anomaly is higher, the first prosthesis usually does not have an elbow unit even if the limb anomaly is comparable with transhumeral amputation. Increasingly, prosthetic components, especially for children, are being created by three-dimensional (3D) printing.29 Medical application of 3D printing is additive manufacturing

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in which 3D objects, such as a prosthetic hand or socket, are created under computer control. The object is made by successively adding viscous plastic or other material. Alternative prosthetic fabrication is either subtractive, in which material is removed, as from a plaster model of the body part, or molded over a plaster model. 3D manufacturing dates from the 1980s. In most prosthetic applications, the patient’s limb is scanned with a handheld device or photographed by a digital camera, thereby recording its shape and enabling the creation of a digital model of it. The rapidity of the 3D process is ideal for accommodating the need to create a larger socket or hand30-33 when the patient has outgrown the previous device. The process has also been used to make a transhumeral prosthesis.34 Regardless of the level of limb loss, the prosthetic socket is suspended on the infant’s torso by a harness, which typically has more straps than an adult harness. The toddler harness inhibits the infant’s attempts to remove the prosthesis, whether deliberately or inadvertently during rolling and crawling. Clothing problems arise when a prosthesis is worn. The rigid parts of the prosthesis can cause holes in fabric. Shirts and blouses worn over the prosthesis should be loose fitting. Raglan sleeves are roomier than sleeves set at the natural shoulder line; the latter can interfere with cable operation. Training the infant fitted with a passive prosthesis usually begins with two sessions in a 1-week period and then at periodic follow-up appointments. The first meeting should be held when the baby is well rested and content. The therapist or parent puts the prosthesis on the infant, who is then placed on the floor with various toys. The therapist encourages the parents to play with and handle the baby while the infant is wearing the prosthesis. The baby may ignore the prosthesis because its socket eliminates the sense of touch and because the length of the prosthesis feels awkward. Parents should present large toys that require the use of both arms. The basic prosthesis allows the infant to cuddle a teddy bear, swat at a dangling toys, and use both upper limbs for rolling and crawling. Training involves instructing the parents, siblings, and other caregivers to gain familiarity with the prosthesis, care for the infant’s skin by making certain that the socket and harness do not exert undue pressure, and provide toys that require bimanual prehension (Box 29.1). Placing a rattle or other noise maker in the terminal device is another way to acquaint the infant with grasp on the side of limb deficiency. At the end of the session, the therapist and parent remove the prosthesis to inspect the child’s skin for signs of irritation from the socket or harness.

Parents learn how to apply the prosthesis and how to encourage full-time wear except during baths, naps, and bedtime. The youngster may be awkward when sitting and moving while adjusting to the weight of the prosthesis. Toys suitable for the child’s developmental level, such as large balls, dolls, stuffed animals, balloons, xylophones, and other noisy and colorful objects, provide incentives for enjoying the prosthesis. Parents can put a mallet or other toy in the hook so that the infant can obtain pleasure from using the prosthesis. Push and pull toys are appropriate when the child is able to stand and cruise.21 Arranging blocks is a good activity for the new prosthesis wearer.35 Printed instructions, augmented by audiotapes or videotapes, are useful guides for the family. Instructions can address parental concerns regarding the possibility that the child may catch the prosthesis on table legs or use it to strike themselves or others; children recover balance readily, and peers are usually able to defend themselves. At the second training session, ideally a few days later, the therapist can assess the parents’ experiences. Donning and doffing the prosthesis should be reviewed. Initially, the child may tolerate the prosthesis only for a few minutes. It should be frequently applied during the day. Eventually, the youngster should be able to wear it most of the day, except when sleeping and bathing. Subsequent follow-up sessions focus on the adequacy of prosthetic fit and the child’s readiness for the addition of a cable to the prosthesis or substitution of a myoelectrically controlled prosthesis for a passive one, or, in the case of the child with transhumeral amputation, the addition of an elbow unit.

Toddlers When the child is between the ages of 15 and 18 months, control cables may be added to traditional, body-operated prostheses (Fig. 29.6). Active control may not become

Box 29.1 Prosthetic Training Goals for Infants Therapy sessions are designed to increase the infant’s ▪ Comfort with the prosthesis ▪ Wearing tolerance ▪ Ability to clasp large objects ▪ Ability to use the prosthesis to aid in sitting and crawling Parents of an infant with a prosthesis should do the following: ▪ Apply and remove the prosthesis correctly ▪ Care for the child’s skin ▪ Care for the prosthesis ▪ Recognize and report to the clinical team any problems with the prosthesis or child

Fig. 29.6 Toddler with congenital transverse upper limb difference using a body-powered prosthesis. (From Le JT, Scott-Wyard PR. Pediatric limb difference and amputations. Phys Med Rehabil Clin N Am. 2015;26 [1]:95–108.)

29 • Rehabilitation for Children With Limb Deficiencies

Box 29.2 Prosthetic Training Goals for Toddlers Therapy sessions are designed to increase the toddler’s ▪ Control of the terminal device ▪ Control of the elbow unit ▪ Use of the prosthesis in bimanual prehension ▪ Use of the prosthesis in functional activities Parents of toddlers with prostheses should do the following: ▪ Provide toys that require bimanual prehension ▪ Encourage use of the prosthesis as an assistive device ▪ Inspect the skin to determine whether the prosthesis causes undue irritation

reliable until the toddler is approximately 2.5 years of age, when the understanding of cause and effect is well established. Readiness for the cable is indicated when the child wears the prosthesis full time, can follow simple instructions, has an attention span of at least 5 minutes, and will allow the therapist and prosthetist to handle him or her. A toddler who resists instruction from someone other than the parent may be too immature to learn to control the prosthesis. If the prosthesis has a voluntary-opening hook, it should be fitted with a half- or a quarter-width rubber band to facilitate opening. The tension in the terminal device should be sufficient to let the child hold objects but not so great that opening the hook is difficult. Young children appear to use the voluntary-closing hook with as much ease as the more traditional voluntary-opening terminal devices. Box 29.2 summarizes the goals of prosthetic training for toddlers. The training environment should be quiet, with a low table holding a few toys that require bimanual grasp, such as large beads and a string with a rigid tip. For the child with unilateral amputation, the terminal device serves to hold an object, such as a bead, while the child threads the string through the bead. The therapist is on the child’s prosthetic side, holding the child’s forearm at 90 degrees of elbow flexion, the optimal position of cable operation. This position also keeps the terminal device and the grasped object within the child’s view. The adult moves the child’s forearm forward, flexing the shoulder, tensing the cable, and causing the hook to operate. When the arm is moved back (shoulder extension), the terminal device changes position. A voluntary-opening hook opens with shoulder flexion, whereas a voluntary-closing hook closes with shoulder flexion. The therapist encourages the child to help with the control motion. With either design, the initial training involves placing a toy in the hook and encouraging the child to discover how to keep it in place. With a voluntary-opening hook, the child simply relaxes to allow the rubber bands or springs to keep the hook fingers closed. The voluntaryclosing hook requires that the wearer exert tension on the control cable by the harness to keep the hook closed. Children use the same control motions as do adults, namely shoulder flexion or shoulder girdle protraction for terminal device operation. The toddler may revert to the earlier practice of opening the terminal device with the sound hand; eventually he or she will find that cable operation is more efficient, allowing more complex bimanual play maneuvers. Reaching for objects with the sound hand is the child’s initial preference. To provide the child the necessary

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practice with the prosthesis, the therapist or parent should offer large objects or toys that require bimanual grasp to operate. Another technique to encourage prosthetic use is to have the child hold one object in the sound hand and another in the prosthesis. For example, two hand bells are twice as tuneful as one. With some young patients, prosthetic training merely involves using the terminal device as a stabilizer rather than as a prehensile tool; for example, the child may lean the prosthesis onto a replica of a mailbox while placing objects in the slot with the sound hand. The prosthesis also serves to stabilize paper while the child draws and colors pictures. Although children as young as 18 months have been fitted with myoelectrically controlled transradial prostheses, those who are at least 3 years of age have an easier time learning to contract the appropriate flexors and extensors to close and open the hand (see Fig. 29.6). The prosthesis is heavier, more fragile, and needs more maintenance than does a cable-operated device. To prepare the child for a myoelectric prosthesis, weight should be gradually added to the passive prosthesis. Rudimentary training begins with practice with the prosthesis off the arm. At first, the therapist may place an electrode on the sound forearm and ask the child to flex and extend the wrist to close and open the fingers of the prosthetic hand. The therapist then places an electrode on the forearm on the amputated side and encourages the child to discover that contraction of the forearm musculature on that side achieves the same results. Motorized toys can be used to help the child practice deliberate contraction of flexors and extensors to cause an electric train, for example, to go backward and forward, depending on which electrode is stimulated. When the child gains reasonable proficiency, the prosthetic socket can be made with the electrodes embedded in it. Care must be taken to achieve and maintain snug fit so that the electrodes are in constant contact with the skin. Empirical evidence is lacking regarding functional differences between cable- and myoelectrically operated prostheses for children.36 Fitting a myoelectrically controlled transradial prosthesis before the patient is 2 years old has been associated with greater long-term acceptance.37-39 Whether the prosthesis is cable or myoelectrically controlled, practice to gain prosthetic proficiency is the same. The beginner experiences many instances of dropping objects while learning the amount of muscle contraction or cable tension needed to maintain suitable terminal device closure. The ability to close the terminal device around an object develops before active release. Grasping an object from the tabletop is difficult. Children attempting to put objects into their mouths discover that the change in shoulder position alters the tension on the control cable. Similarly, children who drop toys and try to retrieve them from the floor discover how to hold the shoulder to maintain adequate cable tension. Those who are wearing myoelectrically controlled prostheses also notice that the prosthesis is easier to operate in some forearm positions than in others. Moving pegs on a board affords the child practice in opening and closing the terminal device. Tossing a beanbag or playing card games are useful for teaching terminal device opening and closing. Cutting paper is another satisfying activity. The child holds the paper in the terminal device and uses the scissors in the sound hand. Prosthetic training

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should acquaint the child with objects of various textures, sizes, and shapes. Resilient foam toys are easier to grasp than are those made of rigid material. Playing with sewing cards, nested barrels, and snap-apart beads; removing objects from a drawstring bag; opening a zipper; removing loose clothing; opening small boxes of raisins; opening and closing felt-tipped pens; and playing the xylophone entice the child to attempt grasping, holding, and releasing motions with the terminal device. Moving checkers or other markers from one location to another on a game board is a good drill. The prosthesis is helpful when swinging and climbing on the playground, rolling a wheelbarrow or doll carriage, jumping rope, and riding a tricycle. Children with unilateral amputation usually regard the intact limb as the dominant one. Many children with unilateral amputation refer to the prosthesis as the helper, which correctly identifies its role as a device that assists the intact hand. Functional training depends on the child’s ability to reach the mouth, waist, hips, feet, and perineum. Feeding, dressing, writing, and personal hygiene are incorporated at the appropriate times. Thirty-month-old children can throw and catch a ball, start uncomplicated dressing, and eat with a spoon with little spillage. Children play in sand, earth, and water and engage in rough-and-tumble activities, which can damage the prosthesis and the skin. Daily inspection and attention to minor problems help to avoid major prosthetic repairs and skin disorders. A 2-year-old with transhumeral amputation may have a prosthesis with an elbow unit, although mastery of the elbow-locking cable is unlikely to occur before the third birthday. Strategies to self-manage donning and doffing the prosthesis can be introduced to children as young as 3 years. Most find removing the prosthesis easier than donning it. At 3 years of age, the child may begin to be curious about the rotational possibilities of the wrist unit. Objects of various shapes within reach oblige the child to turn the terminal device in the wrist unit to the suitable position. Most objects can be manipulated with the terminal device in the pronated position; however, paper and other thin items are more easily managed with the terminal device in midposition, and small balls are best cradled in the terminal device when it is rotated to the supinated position. Holding the handlebars of a tricycle or manipulating hand controls in other wheeled toys helps the child to learn how to use terminal device rotation in the wrist unit. Prosthetic activities for the toddler should include eating, drinking, dressing, and managing crayons and other writing implements. Threeyear-olds blow soap bubbles, pull up pants, pull a belt through loops in pants, and fill a cup with water from a spigot. Throughout the toddler phase, work periods should alternate with free play that may or may not involve the prosthesis. Weekly training sessions are effective. Parents should inspect the axilla; persistent redness indicates that the harness is applying undue pressure. The home program should include written suggestions regarding activities to promote bimanual prehension, instructions concerning the care of the prosthesis and the care of the child’s skin, terminology pertaining to parts of the prosthesis, and ideas regarding clothing that will not impede prosthetic function.

School-age Children An important consideration for the growing child is a socket large enough for comfortable fit and adequate prosthetic control. The 4-year-old child is usually coordinated enough to grasp fragile objects without breaking or crushing them. With a voluntary-opening hook, the child must maintain tension on the control cable to prevent the hook fingers from snapping shut. A voluntary closing terminal device necessitates application of gentle tension on the cable rather than forceful shoulder motion. With a myoelectrically controlled hand, the child must contract flexors minimally so that the fingers close on the object without undue pressure (Fig. 29.7). Four-year-olds can pour from containers, peel a banana, sharpen a pencil with a handheld sharpener, sew, hammer nails, and apply adhesive bandages (Fig. 29.8). The average 5-year-old can open a milk container and sweep with a brush and dust pan. Box 29.3 summarizes the goals of prosthetic training for school-age children. Performing an activity with the sound hand may facilitate accomplishing the same task with the prosthesis.40 Assessing the ability of a child to grasp various objects may include stringing four large beads, opening four 35mm film cans, separating three nested screw-top barrels, assembling 10 interlocking beads, and separating a fivepiece notched plastic block. More challenging activities are using a sewing card, stringing small beads, sticking an adhesive bandage to the table, cutting a paper circle and gluing it to another paper, and opening a small package of facial tissues. The most demanding tasks include cutting modeling plastic with a knife and fork, discarding five playing cards from a hand of 10 cards, lacing a shoe and making a bow, and wrapping a book. Card games often fascinate children in elementary school. Maintaining several cards in the terminal device and then releasing the desired card involves a gradation of tension on the control cable for prostheses equipped with a voluntary-opening or -closing terminal device. Card playing is more difficult with a myoelectrically controlled prosthesis because the child must contract the forearm flexors and extensors with the correct amount of force at the appropriate time. The 5-year-old should be independent in dressing, except for small buttons, shoelaces, and pullover shirts and sweaters. The child also needs to learn how to take care of the prosthesis, keep it clean, and ask for help when parts malfunction. Skin inspection is an essential part of training. Older Children and Adolescents Many are able to incorporate the prosthesis into school activities. A myoelectric hook terminal device (Fig. 29.9) may be practical for the teenager who is interested in repairing bicycles and cars. Sports prostheses, such as those with a terminal device designed to hold a basketball, give wearers more opportunities to participate in group activities (Fig. 29.10).41 Teenagers may find that playing a musical instrument is pleasurable. Simple adaptations, such as fingering a trumpet with the sound hand and supporting it with the prosthesis, can open a world of enjoyment to the musician. Older adolescents should have vocational exploration, vocational assessment, and, when indicated, job training. Obtaining a driver’s license is a meaningful event

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Fig. 29.7 (A) Myoelectric prosthesis. (B) Girl contracting forearm muscles to operate a myoelectrically controlled terminal device. (Courtesy Otto Bock Orthopedic Industry, Inc., Minneapolis, MN.)

for most teenagers. The use of a prosthesis does not influence the capacity to drive, although those with upper-limb deficiency are more likely to use adaptive devices when driving than those with lower-limb deficiency.42,43 Some adolescents with unilateral limb deficiency seek escape from parental control by abandoning their prostheses, preferring to manage with the intact limb. Peer acceptance and social integration appear to be more important for adolescents than the functional benefits that may be achieved with prosthetic use.44 Certain activities are more easily accomplished without the prosthesis or cannot be done with a prosthesis. For example, prostheses are not worn when

Fig. 29.8 Bimanual activities. (A) Playing a toy saxophone. (B) Blowing bubbles. (C) Girl wearing right prosthesis while eating watermelon (A, Courtesy TRS, Inc., Boulder, CO. B and C, Courtesy Otto Bock Orthopedic Industry, Inc., Minneapolis, MN.)

showering. Individuals with transradial amputation may prefer to stabilize objects in the antecubital fossa, using elbow flexion, rather than use a prosthetic terminal device. Simple equipment adaptation can facilitate one-handed performance, such as the use of a book holder, guitar pick band,

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Box 29.3 Prosthetic Training Goals for Schoolage Children Therapy sessions assist the school-age child to do the following: ▪ Maintain proper prosthetic fit ▪ Grasp firm and fragile objects without dropping or crushing them ▪ Open and close the terminal device reliably ▪ Don and doff the prosthesis independently ▪ Dress independently ▪ Recognize when the prosthesis needs repair or alteration Parents of school-aged children with prostheses should do the following: ▪ Be independent in daily activities and play

Fig. 29.9 Myoelectric Greifer terminal device on right transradial prosthesis. (Courtesy Otto Bock Orthopedic Industry, Inc., Minneapolis, MN.)

or camera grip. Some individuals become facile with the remaining upper limb, learning to hit a baseball and folding laundry with one hand. Most people develop strategies that enable them to perform all desired activities.45 Function of children fitted with unilateral upper prostheses can be measured by the Prosthetic Upper Extremity Functional Index administered to parents and older children46 or the similar University of New Brunswick Test of Prosthetic Function.47 Results from formal testing compare favorably with questionnaires regarding prosthetic use.48 Older children report quality of life about the same for those who do and do not wear prostheses,49 with prostheses used for specific activities.50 Overall, children with upper-limb deficiency are as socially competent as able-bodied peers.51

REHABILITATION OF CHILDREN WITH LOWER-LIMB LOSS Children with lower-limb deficiencies deserve clinic team management similar to that described for those with upper-limb deficiencies. Early referral to a clinical team is equally important for the family with a child who has a lower-limb amputation or limb deficiency. Peer support is also invaluable for parents who need to share concerns, suggestions, and camaraderie with others who are coping with a similar situation. Treatment should suit the patient’s

developmental stage so that prosthetic use fosters achievement of key milestones.52 Parents serve as the primary instructors of their children, with the guidance of the physical therapist and other members of the clinical team.

Infants Sitting balance is a major guide to lower-limb prosthetic fitting. The average age when babies accomplish independent sitting is 6 months. Sitting depends on postural control and antigravity muscle strength. Sitting balance and trunk stabilization are also important for freeing the hands to explore the environment. Box 29.4 summarizes the goals of rehabilitation of infants with lower-limb malformation or amputation. Infants who are 5 to 7 months of age discover the mobility possibilities of crawling and creeping, moving from supine to four-point and sitting positions, and moving to the hands and knees from the sitting position. Crawling involves the alternate action of the opposite arms and legs in a manner similar to walking. Hip extensors strengthen during crawling and kneeling. Rocking on four points before launching into crawling is another important precursor to walking. Most babies are able to overcome gravity to pull up to a standing position and rise from kneeling to standing at approximately 8 months. When pulling to a standing position, the baby expends great energy bouncing and actively disturbing balance. Bouncing gradually gives way to shifting weight from side to side. The initial standing posture is wide based, with the hips abducted, flexed, and externally rotated. The base accommodates the child’s new center of gravity position, which is higher than when crawling. Maintaining upright posture depends on sufficient maturity of the visual, proprioceptive, and vestibular systems. Stepping movements are common among 7-month-olds who are supported. Cruising along furniture is a preferred mode of locomotion when the child is approximately 10 months old. Cruising strengthens the hip abductors. The typical nondisabled child stands alone at approximately 11 months and walks alone at 12 months.18 The urge to walk is the culmination of the endless pulling and standing activity that has occupied the baby for several preceding months. Some infants undergo surgery either to transform a congenitally anomalous limb into one that is more suitable for a prosthesis or as part of the treatment of a limb that has been involved in trauma or in the presence of tumor. Skin grafting in these instances does not result in adverse functional outcome.53 Another intervention applicable to a few children is limb lengthening using an Ilizarov apparatus.54,55 For children born with proximal focal femoral deficiency (PFFD), where there is shortening of the thigh with an intact foot, a knee rotationplasty is often performed. This involves sectioning the limb and rotating the distal portion posteriorly; the foot thus serves as a partial leg, enabling fitting with a transtibial prosthesis (Fig. 29.11).56,57 Very few children with myelodysplasia undergo amputation of lower limbs that have severe contractures or have intractable ulcers.58 Regardless of the etiology of limb deficiency, the goal of prosthetic fitting is to facilitate the child’s attainment of motor milestones. The infant who is missing a lower limb should have prosthetic restoration at approximately 6 months, when the baby has enough trunk control for sitting and is ready to pull to a standing position. A simple

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Fig. 29.10 Activity-specific terminal devices. (A) Girl playing volleyball with Barrage terminal device. (B) Girl downhill skiing with right Downhill Racer Ski terminal device. (C) Girl mountain biking wearing a transradial prosthesis with Swinger terminal device. (D) SuperSport terminal device. (C, Courtesy of M.A. Sweezy and TRS, Inc., Boulder, CO.)

prosthesis fosters symmetric sitting balance and aids the baby’s attempts to pull to standing. In addition, the prosthesis equalizes leg length, adds weight to the anomalous side, and obviates the tendency to compensate with a one-legged standing pattern. Reducing the weight asymmetry inherent in limb deficiency facilitates rotational control of the trunk. The prosthesis enables standing and walking. Otherwise,

the world is circumscribed by the confines of the stroller or playpen, and the deficiency becomes a source of shame. Fitting before 6 months might hinder the baby’s efforts to turn from prone to supine position and back again. The first prosthesis includes a solid-ankle, cushion-heel (SACH) foot, the smallest foot manufactured (Fig. 29.12). Rubber-soled shoes give the infant more traction and are

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Box 29.4 Prosthetic Training Goals for Infants With Lower-Limb Deficiency Therapy sessions are designed to facilitate the infant’s ▪ Comfort with the prosthesis ▪ Wearing tolerance ▪ Ability to stand by leaning against a table ▪ Ability to cruise around furniture ▪ Ability to walk with and without support from a doll carriage or other supporting toy Parents of infants with lower-limb prostheses should do the following: ▪ Apply and remove the prosthesis correctly ▪ Care for the child’s skin ▪ Care for the prosthesis ▪ Recognize and report any problems with the prosthesis

therefore preferable to leather-soled shoes. The prosthesis must be comfortable when the baby stands, sits, squats, crawls, and climbs. A silicone socket liner (Fig. 29.13) is desirable to protect sensitive skin from chafing in the socket. The toddler with transfemoral amputation may start with a prosthesis having a locked knee (Fig. 29.14).59,60 Another type of knee joint available to the pediatric population is a polycentric knee (Fig. 29.15). The use of a four-bar linkage system allows for the axis of motion to be posterior during stance, allowing greater stability, and anterior during swing to assist in clearance. Polycentric knee units are being

incorporated into prostheses for young toddlers and often into the child’s first prosthesis. Teenagers are often fitted with hydraulic-, pneumatic-, or microprocessor-controlled knees that allow for greater variability of movement and physical activities. The drawbacks to hydraulic and pneumatic knees are added weight, cost, and intricacy of adjustments which is why they are typically reserved for the adolescent population. During the first training session, the therapist and parent confirm that the prosthesis fits comfortably, without redness of the residual limb. Most of the handling of the child should be done by the parent, rather than the therapist, so that the family gains confidence in managing the child at home. Useful equipment includes a play table, an elevated sandbox, a floor mat, a rolling stool, a full-length mirror, steps, and a ramp. The parent should encourage the child’s standing on both feet by first supporting the trunk and then gradually reducing the support. The young child gains prosthetic tolerance and standing balance by being near the table. Initially, the child may lean the torso against the table while manipulating toys that require use of both hands. Toys should be moved to places on the table where the child has to reach in different directions, shifting weight. Eventually, the child will move along the periphery of the table to place objects in the desired location. When first learning to walk with a prosthesis, the child moves cautiously. Initially, the child takes small steps and has a wide base, keeping the trunk upright and arms abducted. The new prosthesis wearer resembles normal peers who begin walking with

Fig. 29.11 (A) A child with proximal focal femoral deficiency after rotationplasty (B). Same child from figure A, now wearing prosthesis. The presence of ankle function offers superior control and function over a mechanical prosthetic knee. (From Le JT, Scott-Wyard PR. Pediatric limb difference and amputations. Phys Med Rehabil Clin N Am. 2015;26[1]:95–108.)

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Fig. 29.12 Children’s prosthetic feet. (A) Solid-ankle, cushion-heel (SACH) foot. (B) SACH feet adaptable for crawling and walking. (C) Flex Foot Junior. (D) Boy running while wearing transtibial prostheses with Runner Junior feet. (A and D, Courtesy Otto Bock Orthopedic Industry, Inc., Minneapolis, MN. [B] € Courtesy TRS, Inc., Boulder, CO. C, © Ossur.)

increased hip and knee flexion, full-foot initial contact, short stride, increased cadence, and relative foot drop on the sound side in swing phase.16-18 At home, a sturdy table that is chest high to the child encourages standing balance and cruising during play with toys placed on the table. Raised sandboxes, blocks, finger paints, and pans of water with floating toys all promote standing balance. A playpen is a good environment to enable the baby to pull to standing, cruise the perimeter, and sit when the baby wishes. Balls are useful in prosthetic training. Kicking a ball requires balance on one leg and flexion of the other leg. The baby starts by holding on to a stable object with both hands, then with one, and eventually letting go. Throwing a ball requires good balance and usually

sustains the infant’s interest. Wheeled toys, such as a doll carriage, enable the child to walk with a modicum of support. Placing toys where the child must take a few steps to reach them fosters independent walking. Young children frequently revert to crawling and sitting on the floor as they grow accustomed to the prosthesis. Falling is seldom a problem, inasmuch as the child generally lands on the buttocks as an able-bodied child would. When the child falls or tries to retrieve a toy on the floor, the parents and therapist should let the young person explore the movement and not be overly protective. Just as other children learn to walk by supporting themselves on furniture, the child who wears a prosthesis should have the same experience to develop confidence. Parallel bars, walkers, and

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Fig. 29.13 Silicone socket liner suspension system. Uses a pin-locking € mechanism to attach to the distal end of the socket. (© Ossur.)

Fig. 29.14 Single-axis knee units with manual lock. (Courtesy Otto Bock Orthopedic Industry, Inc., Minneapolis, MN.)

harnesses are seldom advisable for children with unilateral amputation or bilateral transtibial amputation. A prosthesis imposes weight-bearing loads on portions of the leg not ordinarily used for this purpose. Consequently, building tolerance to prosthetic wear is important so that skin over weight-bearing areas can adjust to the pressure. During the first week, most infants tolerate 1 hour of wear, after which the prosthesis should be removed and the skin examined. After a 10- to 15-minute rest period, the prosthesis can be reapplied for another hour. Signs of fatigue, limping, and the avoidance of standing on the prosthesis indicate that the prosthesis is irritating and should be removed. The infant with a transfemoral prosthesis should be checked to determine whether skin near the proximal part of the prosthesis is irritated by urine or feces, which may leak from the diaper.

Toddlers By 15 months, toddlers are upright and mobile. The heel-toe sequence replaces flat-foot contact during the second year. Neurologic maturation, changes in physique, and improved strength are evident as the child’s base of support narrows. Muscular activity has matured into the adult pattern. Goals for rehabilitation (Box 29.5) reflect the developmental activities of a preschool-age child. Young children with transfemoral amputation who were fitted with a prosthesis having an articulated knee used the prosthesis successfully.61

Another milestone expected of all children, including the child with a prosthesis, is running, which begins between 2 and 4 years of age. The flight phase (double float), the period when both feet are off the ground, occurs by strong application of propulsive force during late stance. The prosthetic foot offers much less energy storage and release compared with the gastrocnemius. Consequently, the child with a prosthesis adopts an asymmetric running gait that emphasizes propulsion on the sound side. Two-year-olds can kick a ball accurately, steer a push toy, and jump. As with running, jumping with a prosthesis is primarily an action of the sound side. Games of throwing and catching a ball or beanbag and tossing darts help the toddler to refine balance with the prosthesis. The 3-year-old will probably leap, jump, gallop, climb stairs step over step, and ride a tricycle. The tricycle pedal may have a strap to secure the prosthetic foot. Jumping from a step and hopping are other toddler stunts. Playground equipment, such as a jungle gym, slide, swing, seesaw, sandbox, and tunnels, is enticing. Children with unilateral transtibial amputation achieve an almost normal gait and have no difficulty in climbing inclines and stairs. Opportunities for kneeling, managing various types of chairs, and getting to and from the floor are additional elements in rehabilitation. The child will need help in removing and donning the prosthesis.

School-age Children and Adolescents By 4 years of age, most children can descend stairs step over step, ride a bicycle, and roller skate (Fig. 29.16). Five-yearolds skip rope and play dodgeball. Accurate kicking demonstrates balance on one foot while transferring force to the ball. By age 6 years, most children can don and doff the prosthesis independently. They can start, stop, and change direction with ease, as well as skip and hop for long distances. The child moves toward independence in prosthetic management as well, taking more responsibility for donning and doffing, skin inspection, and maintenance of the prosthesis (Box 29.6). Minimal difference exists between the gait performance of children wearing Syme prostheses and those with transtibial prostheses.62,63 Children who undergo lower-limb amputation after 5 years may respond favorably to balance and gait training similar to that appropriate for adults.64 Video games that involve weight shifting, such as bowling and tennis, improve balance in an engaging manner.65 Physical therapy emphasizes dynamic stability, weight shifting, control of the prosthetic foot, and, in the case of the child with transfemoral amputation, the knee unit (Fig. 29.17). The C-leg can be fitted to adolescents who are tall enough to accommodate the size of the microprocessor-controlled knee unit.66 Sports are particularly useful for developing self-esteem, as well as strength and coordination. Most children with amputations take part in physical education classes at school, sometimes with modified activity. Carbon acrylic or graphite reinforcements enable the prosthesis to withstand high stresses. The child should understand that shoes must always be worn; the plantar surface of most prosthetic feet is not durable enough to withstand abrasion by a sidewalk, and the alignment of the foot is intended for a shoe.

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Fig. 29.15 Polycentric knee units used to provide stability and aid in initiation of smooth gait pattern. (A) Total Knee Junior. (B) 3R66 Knee Joint for € Children. (A, © Ossur. B, Courtesy Otto Bock Orthopedic Industry, Inc., Minneapolis, MN.)

Box 29.5 Prosthetic Training Goals for Toddlers With Lower-Limb Deficiency Goals of rehabilitation for toddlers with lower-limb deficiency include the following: ▪ Full-time wear of the prosthesis, except for bathing and sleeping ▪ Use of the prosthesis in age-appropriate ambulatory activities Parents of toddlers with lower-limb prostheses should do the following: ▪ Encourage use of the prosthesis ▪ Provide toys and equipment that require age-appropriate activities ▪ Inspect the skin to determine whether the prosthesis causes undue irritation

Teenagers who sustained amputation in an earthquake displayed similar quality of life, although those with transtibial amputation achieved higher levels of activity than those who had transfemoral amputation.67

Some activities are more easily performed without a prosthesis or do not require a prosthesis. Children should learn how to use crutches as an alternate mode of locomotion when the prosthesis is being repaired. Bathing is facilitated either by sitting on the shower floor or by using a sturdy bath seat. Most people prefer to swim and scuba dive without a prosthesis. They hop or use crutches to get from the dressing room to the water’s edge. Sports prostheses, such as a swimming prosthesis with a fin in place of the foot, can be constructed. Bicycling, skiing, and mountain climbing are other sports that can be enjoyed with or without a prosthesis.

REHABILITATION OF CHILDREN WITH MULTIPLE LIMB AMPUTATION Babies who have lower-limb deficiency, together with anomalies of one or both upper limbs, generally do best by being fitted first with simple lower-limb prostheses to

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Fig. 29.16 Boy wearing transtibial prosthesis pedaling an adaptive bike. (Courtesy Otto Bock Orthopedic Industry, Inc., Minneapolis, MN.)

Box 29.6 Goals for School-age Children and Adolescents With Lower-Limb Deficiency In later childhood and adolescence, rehabilitation includes the following: ▪ Monitoring and maintaining proper prosthetic fit ▪ Inspecting the skin ▪ Donning and doffing the prosthesis independently ▪ Dressing independently ▪ Engaging in the full range of ambulatory activities with the prosthesis ▪ Recognizing when the prosthesis needs repair or alteration Parents of school-age children and adolescents with lower-limb prostheses should do the following: ▪ Encourage the young person’s independence ▪ Provide opportunities for sports participation

foster sitting balance. The introduction of upper- and lowerlimb prostheses simultaneously is apt to overwhelm the infant and family. When both upper limbs are anomalous, a simple bilateral fitting counteracts the tendency toward development of positional scoliosis. The baby with bilateral upper-limb deficiency should receive prostheses after independent walking is established; otherwise, prostheses make it more difficult to crawl, move about on the floor, and pull to standing with the chin for support. Those with bilateral upper-limb deficiency become quite skillful with foot prehension. The extent to which foot use should be encouraged is

Fig. 29.17 (A) Boy wearing transfemoral prosthesis with hydraulic knee kneeling to pick up a ball. (B) Same child wearing a prosthesis fitted with a modular hydraulic sports knee. (Courtesy Otto Bock Orthopedic Industry, Inc., Minneapolis, MN.)

controversial. Foot prehension is so rarely observed in public that the child who does use the feet may experience unwanted stares. Nevertheless, feet have the tactile sensation and considerable dexterity that prostheses lack. Children with bilateral longitudinal deficiencies have partial or complete hands; they would be encumbered by wearing prostheses. Functional activities with and without prostheses should be introduced according to the physical and emotional maturity of the child. Adaptive aids may be required for some functions, such as personal hygiene. Infants with trimembral or quadrimembral limb deficiency move about by rolling along the floor. They need

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Case Example 29.4 A Child With Traumatic Transfemoral Amputation P.J., who is 4.5 years old, was riding his bicycle on the street in front of his home at twilight when an automobile turned the corner and struck him. In the police statement, the driver said he did not notice the child. P.J.’s father rushed him to the local hospital, where the boy was admitted to have his leg and thigh wounds debrided and dressed. Despite meticulous care at the hospital, the thigh wound became necrotic. The attending pediatrician arranged a consultation with the surgeon, who advised amputation at the transfemoral level immediately proximal to the femoral condyles. The family consented to the surgery, which proceeded uneventfully. P.J.’s amputation wound was covered with an Unna dressing and healed rapidly. He is scheduled to come to the prosthetic clinic this morning. QUESTIONS TO CONSIDER

▪ Describe the postoperative program that will enable P.J. to achieve the most rapid rehabilitation.

▪ What components (foot, shank, knee unit, socket, and suspension) would suit P.J. in his first prosthesis?

▪ Outline the steps in training P.J. to use his prosthesis. ▪ In addition to walking on level surfaces, what other

activities should the physical therapist include in the initial rehabilitation program? ▪ How will P.J. resume riding his bicycle? ▪ What knee unit would suit P.J. when he enters junior high school?

opportunities to look at objects and manipulate toys with their mouths and their residual limbs. Most infants develop good sitting balance and can scoot along on their buttocks. Because of the drastic reduction in body surface, these children can easily become overheated. They should be dressed very lightly to enable heat dissipation. Young children with bilateral transfemoral deficiency usually begin with a pair of prostheses that do not have knee units. They may walk indoors without any assistive devices; however, few are willing to venture outdoors and across streets without at least one cane. In adolescence, many find that a wheelchair provides more efficient mobility. Those with bilateral hip disarticulations may be able to walk with prostheses at home but usually rely on a wheelchair for community travel.

Summary Habilitation or rehabilitation of children with limb deficiencies can be most gratifying. The physical therapist, together with all members of the clinical team, should design the program to assist the child in achieving developmental milestones associated with maturing upper- and lower-limb function. Psychosocial factors govern the behavior of all children, although it appears that those with limb deficiency behave in a comparable manner to able-bodied peers. Peer support is very helpful for children and parents. Clinic team members need to recognize the basis for parental distress while fostering realistic expectations for the child’s function

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by demonstrating that the child is lovable regardless of the condition of the limbs.

References 1. Stanger M. Limb deficiencies and amputations. In: Campbell SK, Palisano RJ, Orlin MN, eds. Physical Therapy for Children. 4th ed. T. Louis; 2014. 2. Fisk JR. Terminology in pediatric limb deficiency. In: Smith DG, Michael JW, Bowker JH, eds. Atlas of Amputations and Limb Deficiencies: Surgical, Prosthetic, and Rehabilitation Principles. 3rd ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2004:779–781. 3. Dillingham TR, Pezzin LE, MacKenzie EJ. Limb amputation and limb deficiency: epidemiology and recent trends in the United States. South Med J. 2002;95:875–883. 4. Jain S, Lakhtakia PK. Profile of congenital transverse deficiencies among cases of congenital orthopaedic anomalies. J Orthop Surg (Hong Kong). 2002;10:45–52. 5. Le JT, Scott-Wyard PR. Pediatric limb differences and amputations. Phys Med Rehabil Clin N Am. 2015;26:95–108. 6. Conner KA, et al. Pediatric traumatic amputations and hospital resource utilization in the United States, 2003. J Trauma. 2010;68:131–137. 7. Nguyen A, et al. Lawn mower injuries in children: a 30-year experience. ANZ J Surg. 2008;78:759–763. 8. Vollman D, Smith GA. Epidemiology of lawn-mower-related injuries in children in the United States, 1990–2004. Pediatrics. 2006; (11):273–278. 9. Bhatta ST, et al. All-terrain vehicle injuries in children: injury patterns and prognostic implications. Pediatr Radiol. 2004;34:130–133. 10. Griffet J. Amputation and prosthetic fitting in paediatric patients. Ortyhop Traumatol Surg Res. 2016;102:S161–S175. 11. Lindfors N, Marttila I. Replantation or revacularisation injuries in children: incidence, epidemiology, and outcome. J Plast Surg Hand Surg. 2012;46:359–363. 12. Ginsberg JP, et al. A comparative analysis of functional outcomes in adolescents and young adults with lower-extremity bone sarcoma. Pediatr Blood Cancer. 2007;40:964–969. 13. Robert RS, Ottaviani G, Huh WW, et al. Psychosocial and functional outcomes in long-term survivors of osteosarcoma: a comparison of limb-salvage surgery and amputation. Pediatr Blood Cancer. 2010;54:990–999. 14. Ottaviani G, Robert RS, Huh WW, et al. Functional, psychosocial and professional outcomes in long-term survivors of lower-extremity osteosarcomas: amputation versus limb salvage. Cancer Treat Res. 2009;152:421–436. 15. Hopyan S, Tan JW, Graham HK, et al. Functional and upright time following limb salvage, amputation, and rotationplasty for pediatric sarcoma of bone. J Pediatr Orthop. 2006;26:405–408. 16. Edelstein JE. Developmental kinesiology. In: Smith DG, Michael JW, Bowker JH, eds. Atlas of Amputations and Limb Deficiencies. 3rd ed. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 2004:783–788. 17. Campbell SK. Understanding motor performance in children. In: Campbell SK, Palisano RJ, Orlin MN, eds. Physical Therapy for Children. 4th ed. St. Louis: Elsevier; 2014. 18. Cech D, Martin S. Functional Movement Development across the Life Span. 3rd ed. St. Louis: Elsevier; 2012. 19. Fixsen JA. Major lower limb congenital shortening: a mini review. J Pediatr Orthop. 2003;12:1–12. 20. Burgoyne LL, Billups CA, Jiron JLJR, et al. Phantom limb pain in young cancer-related amputees: recent experience at St. Jude children’s research hospital. Clin J Pain. 2012;28:222–225. 21. DeMoss P, Ramsey LH, Karlson CW. Phantom Limb Pain in Pediatric Oncology. Frontiers in Neurology. 2018;9. Article 219. 22. Anghelescu DL, Kelly CN, Steen BD, et al. Mirror therapy for phantom limb pain at a pediatric oncology institution. Rehabil Oncol. 2016;34:104–110. 23. Wang X, Yi Y, Tang D, et al. Gabapentin as an Adjuvant Therapy for Prevention of Acute Phantom-Limb Pain in Pediatric Patients Undergoing Amputation for Malignant Bone Tumors: A Prospective DoubleBlind Randomized Controlled Trial. Journal of Pain and Symptom Management. 2018;55:721–727.

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24. Andrews L, Anderson L, Fairbain S, Downing L. Care planning for children with lower limb amputation. Nurs Child Young People. 2012;24:14–19. 25. Mandacina S, Uellendahl JE, Edelstein JE. Special considerations with children. In: Carroll K, Edelstein JE, eds. Prosthetics and Patient Management. Thorofare, NJ: Charles Slack; 2006:181–190. 26. Cohen J, Edelstein JE. Limb Deficiency. In: Moroz A, Flanagan SR, Zaretsky H, eds. Medical Aspects of Disability for the Rehabilitation Professional. 5th ed. New York: Springer; 2017:383–414. 27. Huizing K, Reinders-Messelink H, Maathuis C, et al. Age at first prosthetic fitting and later functional outcome in children and young adults with unilateral congenital below-elbow deficiency: a cross-sectional study. Prosthet Orthot Int. 2010;34:166–174. 28. Meurs M, Maathuis CG, Lucas C, et al. Prescription of the first prosthesis and later use in children with congenital unilateral upper limb deficiency: a systematic review. Prosthet Orthot Int. 2006;303:165–173. 29. Ten Kate J, Smit G, Breedveld P. 3D-printed upper limb prostheses: a review. Disabil Rehabil Assist Technol. 2017;12:300–314. 30. Burn MB, Ta A, Gogola GR. Three-dimensional printing of prosthetic hands for children. J Hand Surg Am. 2016;41:e103–e109. 31. Zuniga JM, Peck JL, Srivastava T, Pierce JE, Dudley DR, et al. Functional changes through the usage of 3D-printed transitional prostheses for children. Disabil Rehabil Assist Technol. 2017;8:1–7. Nov. 32. Gretsch KF, Lather HD, Peddada KV, Deeken CR, Wall LB, Goldfarb CA. Development of novel 3D-printed robotic prosthetic for transradial amputees. Prosthet Orthot Int. 2016;40:400–403. 33. Zuniga JM, Peck J, Srivastava Katsavelis D, Carson A. An open source 3D printed transitional hand prosthesis for children. J Prosthetics & Orthotics. 2016;28:103–108. 34. Zuniga JM, Carson AM, Peck JM, Kalina T, et al. The development of a low-cost three-dimensional printed shoulder, arm, and hand prostheses for children. Prosthet Orthot Int. 2017;41:205–209. 35. Shimokakimoto T, Ueno T, Akimichi N, Suzuki K. Building blocks system for a prosthesis training of a child with congenital amputee. Conf Proc IEEE Eng Med Biol Soc. 2016;5034–5037. 36. Carey SL, Lura DJ, Highsmith MJ. Differences in myoelectric and bodypowered upper-limb prostheses: systematic literature review. J Rehabil Res Dev. 2015;52:247–262. 37. Routhier F, Vincent C, Morissette MJ, et al. Clinical results of an investigation of paediatric upper limb myoelectric prosthesis fitting at the Quebec Rehabilitation Institute. Prosthet Orthot Int. 2001;25: 119–131. 38. Egermann M, Kasten P, Thomsen J. Myoelectric hand prostheses in very young children. Int Orthop. 2009;33:1101–1106. 39. Toda M, Chin T, Shibata Y, Mizobe F. Use of powered prosthesis for children with upper limb deficiency at Hyogo Rehabilitation Center. PLoS One. 2015. eo131746. 40. Romkema S, Bongers RM, van der Sluis CK. Intermanual transfer effect in young children after training in a complex skill: mechanistic, pseudorandomized, pretest-posttest study. Phys Ther. 2015;95: 730–739. 41. Walker JL, Coburn TR, Cottle W, et al. Recreational terminal devices for children with upper extremity amputations. J Pediatr Orthop. 2008;28:271–273. 42. Burger H, Marincek C. Driving ability following upper limb amputation. Prosthet Orthot Int. 2013;37:391–395. 43. Fernandez A, Lopez MJ, Navarro R. Performance of persons with juvenile-onset amputation in driving motor vehicles. Arch Phys Med Rehabil. 2000;81:288–291. 44. Vasluian E, de Jong IG, Janssen WG, Poelma MJ, et al. Opinions of youngsters with congenital below-elbow deficiency, and those of their parents and professionals concerning prosthetic use and rehabilitation treatment. PLoS One. 2013;. e67101. 45. de Jong IG, Reinders-Messelink HA, Tates K, Janssen WG, Poelma MJ, et al. Activity and participation of children and adolescents with unilateral congenital below elbow deficiency: an online focus group study. J Rehabil Med. 2012;44:885–892.

46. Korkmaz M, Erbahceci F, Ulger O, Topuz S. Evaluation of functionality in acquired and congenital upper extremity child amputees. Acta Orthop Traumatol Turc. 2012;46:262–268. 47. Burger H, Brezova D, Vidmar G. A comparison of the University of New Brunswick Test of Prosthetic Function and the Assessment of Capacity for Myoelectric Control. Eur J Phy Rehabil Med. 2014;50:433–438. 48. Burger H, Brezovar D, Marincek C. Comparison of clinical test and questionnaires for the evaluation of upper limb prosthetic use in children. Disabil Rehabil. 2004;26:911–916. 49. James MA, Bagley AM, Brasington K, et al. Impact of prostheses on function and quality of life for children with unilateral congenital below-theelbow deficiency. J Bone Joint Surg Am. 2006; 88:2356–2365. 50. Buffart LM, Roebroeck ME, van Heijningen VG, et al. Evaluation of arm and prosthetic functioning in children with a congenital transverse reduction deficiency of the upper limb. J Rehabil Med. 2007; 39:379–386. 51. Hermansson L, Eliasson AC, Engstrom I. Psychosocial adjustment in Swedish children with upper-limb reduction deficiency and a myoelectric prosthetic hand. Acta Paediatr. 2005;94:479–488. 52. Chambers HG. Pediatric gait analysis. In: Perry J, Burnfield JM, eds. Gait Analysis: Normal and Pathological Function. 2nd ed. Thorofare, NJ: Slack; 2010:341–363. 53. Parry IS, Mooney KN, Chau C, et al. Effects of skin grafting on successful prosthetic use in children with lower extremity amputation. J Burn Care Res. 2008;29:949–954. 54. El-Sayed MM, Correll J, Pohlig K. Limb sparing reconstructive surgery and Ilizarov lengthening in fibular hemimelia of Achterman-Kalamchi type II patients. J Pediatr Orthop B. 2010;19:55–60. 55. Walker JL, Knapp D, Minter C, et al. Adult outcomes following amputation or lengthening for fibular deficiency. J Bone Joint Surg Am. 2009;91:797–804. 56. Busse JW, Jacobs CL, Swiontkowski MF, et al. Complex limb salvage of early amputation for severe lower-limb injury: a meta-analysis of observational studies. J Orthop Trauma. 2007;21:70–76. 57. Sakkers R, van Wijk I. Amputation and rotationplasty in children with limb deficiencies: current concepts. J Child Orthop. 2016;10:619–626. 58. Benedetti MG, Okita Y, Recubini E, Mariani E, Leardini A, Manfrini M. How much clinical and functional impairment do children trated with knee rotationplasty experience in adulthood? Clin Orthop Relat Res. 2016;474:995–1004. 59. Jeans KA, Karol LA, Cummings D, Singhal K. Comparison of gait after Syme and transtibial amputation in children: factors that may play a role in function. J Bone Joint Surg Am. 2014;96:1641–1647. 60. Andrysek J, Naumann S, Cleghorn WL. Design characteristics of pediatric prosthetic knees. IEEE Trans Neural Syst Rehabil Eng. 2004;12:369–378. 61. Andrysek J, Naumann S, Cleghorn WL. Design and quantitative evaluation of a stance-phase controlled prosthetic knee joint for children. IEEE Trans Neural Syst Rehabil Eng. 2005;13:437–443. 62. Geil M, Coulter C. Analysis of locomotor adaptations in young children with limb loss in an early prosthetic knee prescription protocol. Prosthet Orthot Int. 2014;38:54–61. 63. Feick E, Hamilton PR, Luis M, Corbin M, Salback NM, et al. A pilot study examining measures of balance and mobility in children with unilateral lower-limb amputation. Prosthet Orthot Int. 2016;40:65–74. 64. Tofts LJ, Hamblin N. C-Leg improves function and quality of life in an adolescent traumatic trans-femoral amputee: a ase study. Prosthet Orthot Int. 2014;38:413–417. 65. Chu CK, Wong MS. Comparison of prosthetic outcomes between adolescent transtibial and transfemooral amputee after Sichuan earthquake using Step Activity Monitor and Prosthesis Evaluation Questionnaire. Prosthet Orthot Int. 2016;40:58–64. 66. Michielsen A, Van Wijk I, Ketelaar M. Participation and quality of life in children and adolescents with congenital limb deficiencies: a narrative review. Prosthet Orthot Int. 2010;34:351–361. 67. Edelstein JE. Rehabilitation without prostheses. In: Smith DG, Michael JW, Bowker JH, eds. Atlas of Amputations and Limb Deficiencies. 3rd ed. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 2004:745–756.

30

Prosthetic Options for Persons With Upper Extremity Amputation☆ SUSAN SPAULDING and TZUREI CHEN

LEARNING OBJECTIVES

On completion of this chapter, the reader will be able to do the following: 1. Describe potential functional outcomes for individuals with various levels of upper extremity amputations or limb deficiency. 2. Describe preprosthetic care goals and associated prosthetic interventions. 3. Discuss and document clinical-reasoning factors related to prosthetic options (i.e., no prosthesis, passive functional prosthesis, restorations, body-powered, externally powered, hybrid, or activity-specific prostheses) with interdisciplinary colleagues. 4. Explain the purpose of the prosthetic socket. 5. Compare terminal device options for use in functional activities (e.g., voluntary closing and voluntary opening hooks; single degree-of-freedom, multiarticulating, and passive hands; and activity-specific terminal devices). 6. Explain donning and suspension techniques with upper extremity prostheses. 7. Describe the movement strategies necessary for control of transradial and transhumeral bodypowered prostheses. 8. Describe various methods to acquire a signal for control of externally powered prostheses. 9. Identify potential sources of noise and methods to reduce noise in the myoelectric signal. 10. Compare dual-site and pattern recognition externally powered control systems. 11. Explain the basic control schemes for operation of transradial and transhumeral externally powered prostheses.

Prosthetic management of individuals with upper extremity amputations presents all health professionals, including prosthetists and therapists, with a set of unique challenges. For those wearing an upper extremity prosthesis, the terminal device (TD) of the prosthesis is not covered or obscured by clothing in the same way that a lower extremity prosthesis is “hidden” by pants, socks, and shoes. The person with upper extremity amputation must cope with not only physical appearance changes, but the loss of some of the most complex movement patterns and functional activities of the human body. In addition, upper extremity limb loss deprives the patient of an extensive and valuable system of tactile and proprioceptive inputs that previously provided “feedback” to guide and refine functional movement.1,2 Even the simplest tasks related to grasp and release become challenging. The ability to position the prosthetic limb segments in space, as well as the ability to maintain advantageous postures needed to manipulate objects, challenge the medical community to continuously improve the functional and aesthetic outcomes of prostheses for patients in this population.3–5

Many of these design challenges have been addressed with new and emerging technologies. These new technologies have made it possible, in some circumstances, to successfully “fit” a patient with high-level amputation who previously would have little or no reasonable expectation to succeed with traditional technology and fitting techniques.6,7 Advanced socket interface designs and material science have afforded prosthetists the ability to offer stronger, more stable platforms for all levels of amputation, while in most cases saving substantial amounts of weight. Similarly, more innovative suspension strategies and interface materials have increased the functional ranges of motion a patient can comfortably achieve.8 These advancements have had a profound and positive effect on the comfort, function, and compliance of both body-powered and externally powered prostheses at all levels of amputation. Furthermore, the huge strides made in the externally powered arena have in large part been driven by these advancements and technologic breakthroughs.

☆

Amputations to the upper extremity can be classified or named by the limb segments affected (Fig. 30.1). The most

The authors extend appreciation to John R. Zenie, whose work in the prior edition provided the foundation for this chapter.

Length of the Residual Limb 759

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Natural rotation

Shoulder disarticulation 55°

100° 140° 180° Residual rotation of amputee 0° 60° 100° 120°

Short transhumeral Transhumeral Long transhumeral Very short

Elbow disarticulation

Short transradial Transradial Long transradial Wrist disarticulation Transcarpal Phalangeal Fig. 30.1 Classification of upper extremity amputation and residual limbs. (From Murdoch G, Wilson AB. Amputation: Surgical Practice and Patient Management. Oxford, UK: Butterworth; 1996:308.)

distal are at the finger, partial hand, or transcarpal levels. Amputations that separate the carpal bones from the radius and ulna are referred to as wrist disarticulations. Amputations that occur within the substance of the radius and ulna are classified as transradial amputations. When the humerus is preserved but the radius and ulna are removed, the amputation is referred to as an elbow disarticulation. Those that leave more than 30% of humeral length are designated as transhumeral amputations. Residual limb length less than 30% of the proximal humerus is treated like shoulder disarticulation because of the lack of humeral lever arm. More proximal amputations that invade the central body cavity, resecting the clavicle and leading to derangement of the scapula, are described as interscapulothoracic (forequarter) amputations. For those with transverse amputations of the forearm, the length of the residual limb affects the amount of functional elbow flexion and functional forearm pronation and supination that will be retained independent of prosthetic intervention.1 Articulations between the radius and the ulna along the entire forearm are necessary to provide for natural anatomic movements in supination and pronation; as the level of amputation moves proximally from the styloid process of the radius toward the elbow, the ability to perform and to use pronation and supination during functional activities is progressively lost (Fig. 30.2). In addition, not all available transverse motion can be fully captured in the prosthetic socket. When the residual forearm is extremely short, all transverse motion is essentially lost, and it is difficult to gain any active functional forearm rotation for prosthetic use. Amputations at the level of the elbow (elbow disarticulation) derive little functional benefit from the added length

0

2

Short

Medium

4

6

Long Disarticulation 8

10

Inches Fig. 30.2 Potential for pronation and supination of transradial residual limbs of differing lengths. (From Taylor CI. The biomechanics of control in upper extremity prosthetics. Orthot Prosthet. 1981;35:20.)

because the length of the limb limits options for cosmetic and functional placement of elbow units within the prosthesis without substantially improving functional leverage. Although the primary concern of surgeons who perform an upper extremity amputation is adequate closure of the wound, they must also consider the potential advantages of a fairly long lever arm, balanced by an understanding of the space requirements for prosthetic components. Provided that adequate skin and tissue viability are not compromised, consideration should be given to adequate room for a full array of prosthetic componentry.

Etiology of Upper Extremity Amputation The etiology of upper extremity amputations varies widely. The earliest recorded use of limb prostheses was that of a soldier who reportedly amputated his own limb around 484 BC.9 One of the earliest known prostheses was fabricated of copper around 300 BC.10 These early attempts at prosthetic management predate early surgical considerations for lifesaving reasons by many decades. Ambrose Pare (1510–1590), whom many consider the father of modern orthopedic surgery, contributed significantly to the advancement of amputation surgery.11 It is believed that Pare performed the earliest upper extremity amputation, an elbow disarticulation, late in 1536. The incidence and prevalence of upper extremity amputation over the past several centuries is attributed to advances in the pharmacologic and surgical management of disease and trauma.12 Upper extremity trauma related to industry, mechanized farming, and armed conflict has been the catalyst for medical and prosthetic advancements in the 20th century.13 In all individuals living with upper limb loss, approximately 8% (n = 41,000) of the persons with upper extremity amputations were categorized as major (i.e., excluding fingers).14 Because the number of upper extremity cases is relatively small in comparison to lower extremity cases, many prosthetists who are highly skilled and qualified in

30 • Prosthetic Options for Persons With Upper Extremity Amputation

lower extremity prosthetic care have far less experience and confidence when dealing with complex upper extremity management. Furthermore, in the area of externally powered prosthetics, fewer still have the additional education and certifications to work with these complex systems. Upper limb loss occurs due to trauma, dysvascular conditions, cancer, and congenital limb deficiency. The primary cause of acquired upper extremity amputation is trauma,14,15 Upper extremity accounts for approximately 70% of all trauma-related amputations. Some causes of traumatic amputation include explosions, fireworks, gunshot wounds, traffic accidents, and farm/work-related accidents.13 More trauma-related amputations occur among males than females.14,15 More than 29 million Americans are living with diabetes.16 Of all persons with amputations due to diabetic complications, the number of patients with an upper extremity amputation is small (3%) in comparison to all total amputations.17 Other causes of upper extremity amputation are the various sarcomas, as well as congenital limb deformities, including amelias and phocomelias.14,18,19 About 70% of all upper extremity amputations occur in persons younger than 64 years of age.14 These amputations are most often performed on those between 20 and 40 years old.17

Preprosthetic Care All patients with upper extremity amputation, regardless of cause, require some degree of prosthetic management. Early postoperative care goals include strengthening of the joints proximal to the residual limb, core strengthening, psychosocial support, and care of the residual limb including edema control, wound healing, pain control, and desensitization.20 Shrinkers, immediate postoperative prostheses, and preparatory prostheses facilitate these goals. Care is most effective when coordinated through a multidisciplinary team—the surgeon, physiatrist, prosthetist, nurses, physical and occupational therapists, counselors, and others as necessary.21,22 The earlier a patient can be evaluated, fitted with a prosthesis, and trained, the more likely a positive rehabilitation outcome occurs. Malone and colleagues23 1984 review of the literature reported the “advantages to early post-op fitting include decreased edema, decreased postoperative pain and phantom pain, accelerated wound healing, improved patient rehabilitation, decreased length of hospital stay (and perhaps of hospital costs), increased prosthetic use, maintenance of some continuous type of proprioceptive input through the residual limb, and improved patient psychological adaptation to amputation.” Malone et al.23 found a difference in rehabilitation success between patients fitted within 30 days of surgery and those fitted more than 30 days after surgery. Specifically, all 13 of the patients who had job-related injuries and were fit with a prosthesis within 30 days of surgery returned to work, whereas only 15% (3/20) of the patients who had job-related injuries but were fit with a prosthesis more than 30 days of surgery returned to work.23 Most professionals agree that there is a fairly short window of opportunity within which the prospects for successful rehabilitation are greatest, although there is disagreement about the duration of this “optimal

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Fig. 30.3 The postoperative upper extremity prosthesis can help to improve edema control, wound healing, pain control, desensitization, proximal joint and core strengthening, and psychosocial adaptation. (Courtesy of Hanger Clinic, Austin, TX.)

rehabilitation” period. Most patients are first interested in restoring their body image24 and independent bimanual function. Brenner suggests an ideal timetable for fitting a prosthesis after wrist disarticulation or transradial amputation (Table 30.1).25 The timing and type of prosthesis depend on the level of residual limb healing, comorbidities, and patient-centered factors (Fig. 30.3). Regardless of the type of intervention, rehabilitation should focus on the patient and his/her desires. The rehabilitation postoperative goals are to enhance upper extremity strengthening, residual limb healing, psychosocial support, restoration of body image and independent bimanual function, and return to the patient’s desired lifestyle. Once the wound site is adequately protected and bandaged, compressive wraps or shrinkers should be used when an early postoperative or preparatory prosthesis is not appropriate. In most cases, multidirectional shrinker garments control volume and shape the residual limb more effectively than other methods, including elastic bandages.26 When donned properly, shrinkers have less tendency to migrate or shift position on the residual limb and therefore are more effective at creating the consistent distal to proximal pressure gradient. The compressive garment should terminate proximal to the joint above the amputation site when possible. With the transhumeral amputation, this requires the shrinker to

Table 30.1 Timelines for Prosthetic Fitting After Amputation Type of Prosthesis

Postoperative Application

Immediate or early postoperative prosthesis

24 h to 14 days

Preparatory/training body-powered prosthesis

2–4 weeks

Definitive body-powered prosthesis

6–12 weeks

Preparatory/training electronic prosthesis

2–12 weeks

Definitive electronic prosthesis

4–6 months

Reprint with permission from Krajbich JI, Pinzur MS, Potter BK, Stevens PM. Atlas of Amputations and Limb Deficiencies. 4th ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2018.

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include a modified shoulder cap. Such a device is rarely commercially available and usually requires custom fabrication. Due diligence must be exercised to ensure that appropriate tension and compression gradients are achieved and maintained. The nature of any volume management protocol in and of itself begins the limb maturation and desensitization process simultaneously. In addition, effective and timely volume management influences more than the residual limb volume and shape; compression with shrinkers has been used by clinicians to help manage phantom pain.27

Prosthetic Options Depending on the patient's lifestyle and physical condition, the prosthetic team can make a number of recommendations. These include not providing a prosthesis, designing a passive prosthesis or cosmetic restoration, designing a body-powered or externally powered or hybrid system, or designing an activity specific prosthesis (Fig. 30.4). The physician, prosthetist, therapist and patient must consider the benefits and limitations of the various prosthetic options to best meet patients’ needs. The team should consider prostheses as tools intended to enable patients to achieve participation similar to that of a nondisabled person.28

NO PROSTHESIS A significant percentage of patients with upper extremity amputations elect not to use a prosthesis on a regular basis. In many cases this decision can be traced to poorly implemented prosthetic care or lack of prosthetic training.29,30 Some individuals report that the prostheses they have been exposed to are uncomfortable, heavy, and too slow during use or difficult to don and suspend. Advanced materials have enabled prosthetists to create lighter, stronger, and

None

Externally Powered

Activity Specific Upper Limb Amputee Prosthetic Options Passive

Hybrid

Body Powered

Fig. 30.4 Upper limb prosthetic options. (From Melton DH. Physiatrist perspective on upper-limb prosthetic options: using practice guidelines to promote patient education in the selection and the prescription process. JPO. 2017;29:40–44.)

more comfortable systems,31,32 as well as extremely cosmetic restorations.21,33 Despite these advancements, not all individuals with amputations integrate a prosthesis into their body image or lifestyle. The physiatrist should follow patients who choose not to use a prosthesis initially at regular intervals (often yearly) to ensure that their functional and occupational needs are being met, because these may change over the life span. Given the rate of technologic development, new components or devices are likely to become available to address problems the patient might have had at an earlier time. Consideration of adaptive tools and resources such as “One-Handed in a Two-Handed World” and the Amputee Coalition should be discussed to address each patient’s needs.34,35

PROSTHETIC PRESCRIPTION Assessment of persons with upper extremity amputations should include complete evaluation of the level of amputation, residual limb condition, upper extremity musculoskeletal condition, cognitive ability, and presence of degenerative conditions or comorbidities.36 Practitioners must identify the patient’s perspectives and priorities about his/her own needs for control, durability (maintenance), function (speed, work capability, type of grip, ruggedness, high grip force, visibility), comfort (harness, weight, effort), cosmesis (appearance), and reliability.37 When asked, “what is the goal of the upper limb prosthesis?,” the answer always depends on the goals of the wearer.38 Satisfaction with a prosthesis is associated with clear clinician-patient communication,39–41 the relationship with their prosthetist, and focused attention to patient preferences.42,43 Recognizing patient priorities helps in balancing the benefits and limitations of the various prosthetic options. Invariably, the prosthetist and the patient make a compromise between form and function when selecting various components and design features of the prosthesis.37,44–46 For example, realistic appearance and optimal function may be on opposite ends of the spectrum when selecting a prosthetic hand. Although a passive hand provides a realistic appearance, it does not allow for an active grasp. Repeated discussions with the family and patient about the benefits and limitations of each element of the prosthesis are necessary to maintain realistic expectations. When formulating the rehabilitation and prosthetic treatment plans to enhance functional outcomes, the team should consider the influence of adaptive equipment on prosthetic component selection. For example, kitchen and bath adaptive equipment may meet the functional needs without complicating the prosthetic prescription. Furthermore, surgical interventions should also be considered, because functional potential is largely determined by surgical procedures.17 Ultimately, the functional outcome of the rehabilitation and prosthetic interventions depends on the patient’s perspective of function. The clinic team must clearly understand the patient’s vocational, recreational, and aesthetic functional needs during this decision-making process. The prosthetic prescription (Box 30.1) includes a base code and add-on codes. Prosthetic and orthotic L-codes within the Healthcare Common Procedural Coding System (HCPCS) allow for patient specificity in which the team may select various combinations of codes to address

30 • Prosthetic Options for Persons With Upper Extremity Amputation

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Box 30.1 Elements of the Upper Limb Prosthetic Prescription

Table 30.3 Example of a Prescription for an Upper Extremity Body-Powered Prosthesis

▪ Socket type ▪ Test sockets ▪ Interface (e.g., liner, socks, sheaths, foam insert, roll-on liner) ▪ Control system (passive-functional, body-powered, externally

Base Code

Add-On Codes

L6110: Below elbow, molded socket, (muenster or northwestern suspension types)

L6680: Upper extremity addition, test socket, wrist disarticulation or below elbow L6687: Upper extremity addition, frame type socket, below elbow or wrist disarticulation L7403: Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material L6706: Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined L6704: Terminal device, sport/ recreational/work attachment, any material, any size L 6615: Upper extremity addition, disconnect locking wrist unit L6616: Upper extremity addition, additional disconnect insert for locking wrist unit, each L6675: Upper extremity addition, harness, (e.g., figure-of-eight type), single cable design L6655: Upper extremity addition, standard control cable, extra

powered, hybrid, or activity specific)

▪ Suspension mechanism (e.g., harness, anatomic, suction, lanyard, or pin)

▪ Components: terminal device, glove, wrist, elbow (if applicable) and shoulder (if applicable)

patient-specific needs. HCPCS L-code base codes imply the design (e.g., preparatory or definitive), the control, and often basic elements of the prosthesis. For example, the myoelectric prosthesis base code (Table 30.2) includes the electrodes, cables, two batteries, and a charger. L-codes also include (1) the initial patient evaluation; (2) consultation with the physician or nurse practitioner; (3) measurements, casting, and scanning; (4) parts cost; (5) shipping, receiving, and restocking charges; (6) fabrication; (7) fitting trial appointments; and (8) follow-up appointments or adjustments for 90 days after the patient goes home with the completed prosthesis.47 The add-on codes state specific elements of the prosthesis such as the type of socket interface (e.g., socks, foam insert, gel insert), suspension mechanism (e.g., harness, suction, roll-on liner, and pin), TD, wrist unit (if applicable), elbow unit (if applicable), and shoulder unit Table 30.2 Example of a Prescription for an Upper Extremity Externally Powered Prosthesis Base Code and Description L6935: Below elbow, external power, self-suspended inner socket, removable forearm shell, Ottobock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device

Add-On Codes and Descriptions L6680: Upper extremity addition, test socket, wrist disarticulation or below elbow L6687: Upper extremity addition, frame type socket, below elbow or wrist disarticulation L7403: Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material L7007: Electric hand, switch or myoelectric controlled, adult L6881: Automatic grasp feature, addition to upper limb electric prosthetic terminal device L6882: Microprocessor control feature, addition to upper limb prosthetic terminal device L6629: Upper extremity addition, quick disconnect lamination collar with coupling piece, Ottobock or equal L6890: Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustment L7499: Upper extremity prosthesis, not otherwise specified

(if applicable).45 Tables 30.2 and 30.3 provide examples of two prostheses with different components and types of control. However, some design elements may be similar between them: both include test sockets, frame type socket design, and acrylic laminations. If the rehabilitation goal requires the prosthesis to be as lightweight as possible, the team may select an endoskeletal design (Fig. 30.5). Using endoskeletal components and/or lightweight materials requires less suspension and less harnessing and may enhance comfort for the user. Endoskeletal prostheses have a tubular structure connecting the socket to the components, which is covered by a protective foam, whereas exoskeletal prostheses have a rigid outer shell that provides structure and shape.48 Although endoskeletal prostheses are lighter in weight, currently available upper limb componentry is limited and not as durable as lower limb endoskeletal componentry. Therefore most upper limb prostheses are exoskeletal. Both endoskeletal and exoskeletal components may be operated passively or through cable and harnessing (body-powered). An interdisciplinary approach is necessary due to the specialization and complexity of the necessary skills and knowledge when working with this small population of individuals with upper limb loss. The rehabilitation team (e.g., physician, nurse, psychologist, prosthetist, physical therapist, occupational therapist, social worker, and pharmacist) has shared treatment goals toward improving the patients’ quality of life. This interdisciplinary rehabilitation team approach is well recognized in upper extremity rehabilitation.31,49–53 Clear chart note documentation from all team members is necessary to enhance interdisciplinary communication/collaboration and best meet the rehabilitation goals. Box 30.2 lists information that must be documented in the patients’ charts.45

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Fig. 30.5 Example of a light-weight endoskeletal prosthesis. (Courtesy Steeper Group.)

Prosthetic Socket Upper extremity prosthetic sockets secure the prosthesis onto the residual limb and extend the control function (movement and direction) of the distal components (e.g. wrist, TD). Depending on the control system, a secure socket might provide the transmission of force and motion needed for body-powered TD operation and/or stabilization of surface electrodes on the skin for myoelectric control.

Prosthetic sockets are designed according to the skin condition and amount of soft tissue; residual limb length and shape; and the patient-specific functional needs. Critical elements for effective socket designs include comfort, cosmesis, stabilization, suspension, anatomic contouring, contralateral/ipsilateral involvement, range of motion (ROM), and vocation/avocational/personal needs.54 These critical elements are interrelated and sometimes inversely related. For example, a higher anterior socket trimline to the cubital fold often provides more socket stability but reduces elbow joint flexion ROM. Weighing the advantages and disadvantages of each element to meet the patient-specific needs is part of the practitioner’s clinical reasoning. Socket “fit” refers to the stability of the socket on the residual limb and the comfort from the patient’s perspective. Patient comfort with the socket interface plays a major deciding role in whether a patient will use their prosthesis.55 Strategically placed socket pressures reduce residual limb movement inside the socket,56 consequently improving rehabilitation outcomes.57 Socket pressures were evaluated using the Tekscan pressure measuring system.58,59 Daly et al.58 found that pressure did not correlate well with socket discomfort scores, although they reported a potential limitation in the reliability of the sensor technology with curved surfaces. Whereas Schofield et al.59 found unique pressure distribution patterns among four transhumeral participants. Both studies reported that the amount of tolerable pressure varied for each individual patient. These studies reinforce examination of tolerance to forces as an important part of the evaluation. In addition, the prosthetist must find a balance between the individual patient’s ability to tolerate pressure and the amount of stability the socket will provide when identifying where and how much pressure to place around the residual limb.

Box 30.2 Supporting Documentation for an Upper Limb Prosthesis and Prosthetic Training Physician or Nurse Practitioner Documentation

▪ The cause, date, level of limb loss, include right or left or bilateral; ▪ The patient’s preamputation level of independence and function, ▪ ▪ ▪ ▪ ▪

as well as the potential to return or increase in function when successfully using a prosthesis; Comorbidities that could interfere with function of the prosthesis; Pain interference of function (including residual pain); Adequate neurologic and cognitive ability to operate the prosthesis effectively; The type of prosthesis being prescribed (preparatory or definitive); Rehabilitation treatment plan describing the long-term and shortterm goals and the anticipated timeline for recovery.

Prosthetist Documentation

▪ The individual’s perspectives about his/her ▪ Vocational and avocational needs including information about ▪ ▪ ▪ ▪ ▪ ▪

the specific activity or activities that the prosthesis will be used for Motivation to use the prosthesis Lifestyle: habits, interests, opinions Social network support Use environment Hand dominance Perspectives and priorities with respect to function, cosmesis, reliability, comfort, and cost

▪ Functional assessment of the need for function, cosmesis, ▪ ▪ ▪

durability, protection, support, control, and perceived ability to learn and use a prosthesis Myotesting results: minimum microvolt threshold and whether this would allow operation of a myoelectric prosthesis Prosthetic treatment plan describing the long-term and short-term goals, barriers and facilitators of desired outcomes, and interdisciplinary communication Patient-specific justification for each element of the prosthesis

Therapist Documentation

▪ Occupational/functional evaluation of activities of daily living, ▪

▪ ▪ ▪

instrumental activities of daily living, and vocational and avocational needs The individual’s perspectives about his/her ▪ Motivation to use the prosthesis ▪ Lifestyle: habits, interests, opinions ▪ Social network support ▪ Use environment Occupational/functional assessment of the client’s need for function, cosmesis, durability, protection, support, control, and perceived ability to learn and use a prosthesis Myotesting results: minimum microvolt threshold and whether this would allow operation of a myoelectric prosthesis Therapy treatment plan describing the short-term and long-term goals, type, amount, intensity, duration and frequency of therapy visits, complicating factors, and interdisciplinary communication

30 • Prosthetic Options for Persons With Upper Extremity Amputation

One of the most significant factors that affect socket fit is limb volume. Reducing residual limb volume during the early postoperative and preprosthetic care phases is essential because variations in residual limb volume affect stabilization, anatomic contouring, and suspension which then affect comfort and function of the prosthesis for the patient. Limbs with large longitudinal contours or bulbous distal contours are least desirable because these adversely influence the ability to capture the skeletal structures. In these cases, surgical reconstruction may be necessary to remove the redundant tissues.60 Upper extremity sockets often provide suspension to avoid use of harnessing. Suspension may be provided through anatomic shape, suction, harness, or roll-on liner and pin. Selection of suspension method is determined by the residual limb condition and the functional needs of the individual, such as ease of donning and the weight of objects being manipulated. Influences on the advancement of socket designs can be attributed to advances in material science and upper extremity prosthetic specialists.31 Most contemporary upper extremity prosthetic socket designs use some type of flexible interface with a rigid frame exterior. The interface material is often composed of a high–silicone content conformable elastomer. These elastomers have dramatically improved patients’ perceptions of fit and function with regard to comfort.32,61 In summary, the socket secures the prosthesis to the patient’s body. The prosthetist needs to ensure that the socket (a) matches the patient’s anatomy; (b) is comfortable and stable; (c) provides suspension and ROM; (d) is easy to don/doff; and (e) supports the patient’s vocational, avocational, and personal needs. Alignment between the socket and the distal components needs to be considered to reduce compensations at the proximal joints. Socket fit is an ongoing dynamic process. The prosthetist makes changes to the socket over a patient’s life span as the patient’s body condition changes (e.g., weight, atrophy).

Passive Functional Prostheses and Restorations This category of prostheses consists of systems that do not have the ability to actively position a mechanical elbow in

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space or actively provide grasp and release. However, the passive operation of the components does not render the prosthesis as idle as the name might suggest. The term “passive” refers to the mechanical operation of the components. These devices are extremely functional in terms of supporting objects or stabilizing items during bimanual tasks and activities.21,62 They appear to be important for social integration63 and psychosocial well-being.64 Low body image is associated with depression and general anxiety in individuals with upper extremity amputation.65 The absence of operational mechanical components generally results in a lightweight prosthesis. Lighter weight prostheses generally require less suspension. These systems most frequently have a self-suspending design and use a realistic-appearing hand as a TD. Suspension may be achieved with specific socket interface geometry, suction, roll-on liner, and pin/lanyard. The finish of these devices varies widely. Production polyvinyl chloride (PVC) cosmetic gloves provide a cost-effective short-term outcome for patients; short term because PVC readily stains and deteriorates in ultraviolet light. Silicone gloves provide an added benefit of longevity, because they can be cleaned with soap and water. In general, the additional cost of silicone is mitigated by its superior cosmesis, durability, and increased coefficient of friction. Many individuals seek out aesthetic, or transparent, restorations (Fig. 30.6). These restorations require greater investments in time and financial resources. Options to enhance the aesthetic appearance may include enhanced or acrylic nails, skin shading, and the addition of hair. Laser scanning and computer modeling may create near perfect “mirror” images of high-level amputations, such as shoulder disarticulations and scapulothoracic amputations. This investment is most often rewarded with an aesthetic, natural, and transparent-appearing body image. The appearance of a prosthesis can be described from three perspectives: the passive cosmesis based on the static visual appearance, the cosmesis of wearing based on the aesthetics while wearing the prosthesis such as while walking, and the cosmesis of use based on the appearance during activity performance.24 Although patients may not voice their insecurities about the cosmesis (transparency) of wearing or using a prosthesis, they often avoid activities

Fig. 30.6 Aesthetic restorations address the psychosocial needs of individuals by reducing social stigma and enhancing community participation to € optimize healthcare outcomes. (A) Woman working in customer service. (B) Skin restoration with tattoos (A, © Ossur. B, Courtesy of Otto Bock Health Care, www.ottobockus.com.)

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Section III • Prostheses in Rehabilitation

that require unnatural movements. During training, the patient needs instruction about how to move in a natural way with and without their prosthesis.24

Partial-Hand Prostheses The human hand is used for prehension, stabilization, pushing, pulling, communication, mobility, balance, and sensory feedback to perform activities throughout our day. Each part of the hand plays a role for grasping. The thumb allows for opposition with the fingers; the second and third phalanges allow for fine grasp; and the fourth and fifth phalanges provide power grip. Although individuals have a variety of priorities, common activity limitations include cutting meat, peeling vegetables, trimming nails, fastening buttons, opening packages, and carrying bulky items.66 Berger et al. found that fewer than half of individuals who underwent partial-hand amputation returned to their same job even with prosthetic restoration (n = 48).67 Although the greatest impairment was associated with partial or complete thumb amputation, multiple finger amputation also reduces the likelihood of returning to the same job.67,68 The partial-hand amputation presents design challenges for the prosthetist because of its long residual limb length. Longer residual limb length reduces the amount of space to place components, sometimes resulting in a bulky and less aesthetically appearing prosthesis. In addition, the prosthetist aims to preserve open sensate areas to allow sensation (and sometimes mobility) while finding enough area to distribute socket pressures to achieve a secure “fit” between the limb and the prosthesis. Because of these challenges, surgical reconstruction may be preferred.62 Preoperative consideration of the sensation and mobility of remaining functional digits should not be understated. If functional range and sensation are inadequate, the surgeon may consider a more proximal level of amputation. The patient, surgeon, prosthetist, and therapist should discuss the prosthetic design challenges, surgical interventions, and hand function in advance to avoid unrealistic expectations and to achieve optimal outcomes.69 Partial-hand prostheses may be categorized as active or passive (static or adjustable).70 Passive-static tools (oppositional posts) are most useful when either the thumb is remaining and fingers are missing or when fingers are missing and thumb is remaining.71 They allow the patient to regain grasp and release capability of the affected limb and can be fabricated for heavy-duty activities, depending on the condition of the residual limb. Passive-static hands (aesthetic or transparent) are shaped to appear as a “typical” hand and allow for reduced social stigmatism, as described earlier. Users of prosthetic hands consider appearance and function a priority.70 When designed to match the individual’s specific needs, passive prostheses enhance activity performance (Fig. 30.7). Active partial-hand prostheses include both bodypowered and externally powered partial-hand prosthetic options. Body-powered partial-hand prostheses allow independent and immediate operation of each finger such as playing the piano (Fig. 30.8A) and performance of heavyduty activities in dusty environments (see Fig. 30.8B). Externally powered advancements of small electric componentry permits electric control despite lack of clearance with long residual limbs (Fig. 30.9).

Fig. 30.7 Passive partial finger prosthesis designed to enable use of a keyboard. (Courtesy Regal Prosthesis Ltd.)

Disarticulation Considerations Disarticulation amputations provide a long lever. Their anatomy allows for suspension and preserves rotational control for functional performance. However, the disadvantages of disarticulations for prosthesis use include reduced clearance between the end of the socket and the prosthetic componentry. Reduced clearance means that there is limited space for batteries and fewer component options. For wrist disarticulation, the reduced clearance may lead to a difference in arm length with the wrist and prosthetic hand unit secured, which negatively affects functional performance. For elbow disarticulation, the reduced clearance requires the use of body-powered external locking elbow hinges. The finished prosthesis with outside locking hinge technology is less ideal for a few reasons: they are bulky, making it difficult to fit into shirt sleeves; they lack durability; and they do not include options for flexion assist or externally powered options. At the shoulder disarticulation level, the clinical team needs to consider many more variables. Here, the rehabilitation goals not only include grasp and stabilization of objects for bimanual function but also body image and postural symmetry (Fig. 30.10). If the surgeon removes the bony anatomy (styloids or condyles) or leaves hypersensitive distal tissues,25 the benefits (self-suspension and rotation control) of disarticulation are lost. Therefore additional bony length should be removed to improve functional performance when using a prosthesis. The ideal residual limb length is the compromise between form and function—the benefits of having a longer limb with costs of reduced cosmesis and loss of functional control.

Transradial and Transhumeral Considerations Componentry for transradial and transhumeral prostheses is selected based on functional needs, patient’s habitus, and level of amputation. For transradial level limb loss, the lateral

30 • Prosthetic Options for Persons With Upper Extremity Amputation

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Fig. 30.8 Body-powered active partial-hand prostheses operate with immediate response and require no battery power. (A) Professional piano player who had lost his fingers in an accident. He had not sat down at a piano since his accident, 2 years prior. (B) Demonstrating the ability to hold heavy and bulky loads in dusty environments. (A, Courtesy Didrick Medical. B, Courtesy Naked Prosthetics.)

Fig. 30.9 Externally powered active partial-hand prostheses are designed based on the remaining digits and the functional needs of the individual. The multiarticulating iLimb allows for single-digit € operation. (© Ossur.)

epicondyle is typically the bony landmark used for reference length measurements. On the contralateral side, the measurement is taken from the lateral epicondyle to the radial styloid. On the affected side, the measurement is taken from the lateral epicondyle to the distal end of the residual limb. To accommodate the length of a quick disconnect unit, a difference of at least 5.7 cm is needed, whereas 8.9 cm or more of difference is sufficient to allow for an electric wrist rotator (M. Lang, personal communication, February 2, 2018). At the transhumeral level, the acromium is typically the bony landmark used for reference length measurements. The measurement is taken from the acromium to the distal aspect of the olecranon on the contralateral side and from the acromium to the distal end of the residual limb on the affected side. To accommodate all potential internal locking elbow units, 14 cm of space must be present beyond the distal residual limb. Certain elbow units are more compact and will fit within 10.2 cm while

Fig. 30.10 Prosthetic care of individuals with shoulder disarticulation presents complex functional and aesthetic needs. (Courtesy Advanced Arm Dynamics.)

maintaining symmetry. Additional skeletal length significantly enhances suspension and force distribution, especially at the transhumeral level. Therefore M. Lang recommends that the length of amputation should not be dictated solely by the availability of components. For individuals with a short residual humerus, a bodypowered prosthetic system may not be realistic, and even an externally powered prosthesis may be difficult or problematic to fit, suspend, and control. When the residual humerus is very short (