BKA Prosthesis Training

Ashley Webb

And the effects of Diabetes

History

62 y.o. Black Male 5’7” 177.7 lbs Poly-pharmacy Multiple diagnosis including diabetes

Hx Continued

April 21, 2006 underwent an below knee amputation (BKA) of his left lower extremity after developing necrosis in his distal foot that later turned into wet gangrene

Pt. had pre-prosthetic physical therapy

Admitted to skilled nursing facility for 30 days for prosthetic training on January 8, 2007

Goals: Independent with self stretching of left

knee Demonstrate a 5 ° increase of knee

extension Independent with donning prosthetic limb Ambulate 50 ft. with rolling walker and

supervision Negotiate 25 ft. obstacle course with rolling

walker and supervision Negotiate 2 standard 6 inch stairs with

hand rail and supervision

Plan

See pt. 4-5x/wk for 4 wks 45-60 minute treatment session

Strength training exercises Balance exercises Gait training with prosthesis Diabetes education

BKA in the literatureGuccione, A. (2000). Geriatric physical therapy. St. Louis, Missouri: Mosby.

Older adults (>55 y.o.) constitute the largest percentage of individuals with lower limb amputations

The elderly can become functional ambulators with prosthesis particularly if the level of ambulation is transtibial or lower

Considerations for prosthetic training Knee flexion contractures less then 10-15 ° are

considered for prosthesis Person’s with diabetes or PVD have decreased

tolerance to shear forces between the residual limb and the prosthesis.

ProsthesisLusardi, M., Berke, G., Psonak, R. (2001). Prosthetic gait. Orthopaedic physical therapy clinics of North America. (10) 77-114.

35% of amputations are ankle disarticulation or transtibial

75% of LE amputations are the result of complication s of neuropathy and vascular insufficiency in patients with diabetes

Many individuals with BKA who wear a prosthesis are able to reach a 6 on a FIM test which is equivalent to community ambulation

4 Factors Affecting the Quality of Prosthetic Gait

Individual Characteristics Performance characteristics of

prosthesis Fit and suspension of prosthesis Alignment of prosthesis during

functional activities

Other Considerations

Transtibial prosthesis requires a barrier of cotton of wool socks as an interface between skin and socket

Current trend: Our pt. had gel lined sock

Requirements for Prosthetic Rehab Pandian, G., Kowalske, K. (1999). Daily functioning of patients with an amputated lower extremity. Clinical orthopaedics and related research (36) 91-97.

Effective preprosthetic and prosthetic rehab programs include strategies to › strengthen muscles concentrically and

eccentrically to control all remaining joints of the residual limb

› improve cardiovascular endurance. › ability of muscles to generate effective force

at the muscle lengths typical of upright stance and through the ranges of motion required for ambulation is emphasized

› Strengthen intact LE› UE strengthening › Balance and coordination activities

Weight shifting onto prosthesis and energy efficient gait pattern are emphasized

Our Program Left LE hip abduction and flexion on mat

and standing in parallel bars Hip extension standing in parallel bars Quad sets (knee extension) on mat Trunk rotational/balance wand exercises

in sitting Kneeling on floor mat to getting up on

mat table (simulate getting up from a fall) Ambulating with prosthesis in parallel

bars

Gailey, R., Gailey, A., Sendelbach, S. (1995). Home exercise guide for lower extremity amputees. Miami, Florida: Advanced Rehabilitation Therapy, Inc.

Poor Gait PatternLusardi, M., Berke, G., Psonak, R. (2001). Prosthetic gait. Orthopaedic physical therapy clinics of North America. (10) 77-114.

Consider: Quality of gait improves as the

individual becomes more experienced ambulating with prosthesis

Is prosthesis donned and suspended correctly?

Problem with Prosthetic Gait

Vaulting – inadequate clearance of prosthesis Causes: › Individual weakness of hip flexors and

abdominals› Difficulty or fear of initiating knee flexion

Our Solution

Re-measurement of knee extension showing a decrease of 10 ° knee extension resulting in 20 ° total knee flexion contracture

Prothestist evaluated gait and made the following adjustments:› Limb was shortened 3/8 inch› Knee socket was adjusted for increased

knee flexion

Diabetic Education

Most common cause of lower limb amputation is peripheral vascular disease associated with diabetes

We discussed importance of and checked the patient’s skin integrity after every session

Non-Compliance to diabetes education Shobhana,R., Begum,R.,

Snehalatha, C., Vijay,V., Ramachandran, A. (1999). Patients’adherence to diabetes treatment. Journal of Associated Physicians India. 47(12)1173-5.

25% of the study group were adhering to the treatment regularly.

Only 37% followed Dietary prescriptions regularly

Home glucose monitoring was being done by 23%.

Non adherence was not related either to the age or duration of diabetes.

Non adherence was more in the lower socio-economic group and was inversely related to the educational status.

During ambulation with prosthesis for gait evalution, the patient developed a small friction rub on residual limb

All gait training with the prosthesis was stopped until skin integrity was intact

Wound did not heal for the next 2 weeks

Discharge

Independent with self stretching of left knee- can do however non-adherent

Demonstrate a 5 ° increase of knee extension –Unmet- lost range

Independent with donning prosthetic limb met Ambulate 50 ft. with rolling walker and

supervision-unable due to abrasion on stump Negotiate 25 ft. obstacle course with rolling walker

and supervision- unmet Negotiate 2 standard 6 inch stairs with hand rail

and supervision- unmet

References

Gailey, R., Gailey, A., Sendelbach, S. (1995). Home exercise guide for lower extremity amputees. Miami, Florida: Advanced Rehabilitation Therapy, Inc.

Guccione, A. (2000). Geriatric physical therapy. St. Louis, Missouri: Mosby.

Lusardi, M., Berke, G., Psonak, R. (2001). Prosthetic gait. Orthopaedic physical therapy clinics of North America. (10) 77-114.

Pandian, G., Kowalske, K. (1999). Daily functioning of patients with an amputated lower extremity. Clinical orthopaedics and related research (36) 91-97.

Shobhana,R., Begum,R., Snehalatha, C., Vijay,V., Ramachandran, A. (1999). Patients’adherence to diabetes treatment. Journal of Associated Physicians India. 47(12)1173-5.

Questions ?