Exercise and sport for
amputees
Erin Kennedy
Physiotherapist, Westmead Hospital
2014
What does the research tell us
about amputees and physical
activity?
• The amputee population is largely elderly
with low levels of fitness or activity (Davies and
Datta, 2003).
• Those with limb absence could and should
engage in physical activity to improve their
health and social inclusion (Webster et al 2001).
• Common for amputees in a rehabilitation
program to achieve a level of physical
functioning which may not challenge them
to move beyond the basic goal of walking
(Deans et al, 2008).
A recent review of 12 articles in Prosthetics
and Orthotics International asked the
following questions:
• Are people with amputations
participating in physical activity?
• Are these people participating at the
same level as before their amputation?
• What are their motivations and
barriers to participation?
» Deans et al (2012)
And found….
• People with amputation are generally inactive.
– 68% of amputee population V 40% general
population
• There is a decrease in the level or leisure
activity following lower limb amputation.
• However, satisfaction with changed physical
status remains high.
• Likelihood of participating in physical activity
exercise and sport increased if they
participated prior to amputation.
• If they do return to physical activity they opt for
less strenuous activities where a prosthesis is
not required or not functionally dependent on a
prosthesis to participate
» Deans et al (2012)
Motivations for physical activity
include:
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Health benefits
Social interaction
Stress relief
Increasing self esteem
Improving body image
Mastery theory
– Mastery of prosthesis
• increased self efficacy
• increased prosthetic use
• Increased physical activity
» Deans et al (2012)
Barriers for physical activity
include:
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Physical limitation
Lack of confidence / embarrassment
Body image
attitude
Services
Climate/physical environment
Income
Stump pain
Prosthesis
» Deans et al 2012
So….
• How can we encourage our patients to
engage in regular physical activity?
– Setting goals
– Education
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Health benefits
Recommended daily activity
Appropriate forms of exercise
Looking after skin/stump
Address misconceptions
– Providing a positive environment
And…
• Which patient should be challenged
beyond walking?
– Those who were previously physically active and are medically
well
– Age range ??
– Level and number of amputations??
– K 3-4
• Community ambulation, able to vary cadence and perform
activities beyond basic locomotion
– Amp pro score
• > 37
– 6mwt
• > 250m
Gailey et al (2002)
How do we enable them to
realise their potential?
• First rehab them to walk well!!!
– Flexibility, strength, balance, specific gait exercises….
• Gait asymmetries due to tightness, weakness, impaired
balance (Kapp, 2004)
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altered base of support
decrease weight-bearing and stance time on prosthetic limb
increase stance time on the intact lower limb
increase double support time
asymmetrical step length with a shorter faster stride on the intact limb
longer stride on the prosthetic limb
lateral trunk bending toward the prosthetic side
reduced walking velocity.
These gait asymmetries will cause limitations in the amputees ability
to perform high-level mobility activities.
Flexibility
• General stretches
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Hip flexors
Glutes
Hamstrings
Quads
Adductors
Lower back
– Calf
Strength
• To successfully walk and take part in sports or physical
activity the amputee needs to be strong!
• Muscles critical to amputee mobility
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Hip extensors
Hip extensor and abductor muscle power have been found to
predict mobility. (Raya et al 2010, Powers et al, 1996).
Hip abductors
Knee extensors
Remaining plantar flexors
• Healthy amputees can increase residual limb hip and knee
strength with training (Nolan, 2009).
• Can assess/measure/strengthen LL power functionally (Raya et
al, 2010).
– STS, SIT, ↑↓Stairs can be used as measures of lower limb power, balance,
coordination, speed, and gait symmetry to determine their impact on
high-level mobility performance of lower limb amputees???
Glute training exercises
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Hip ext in prone (neutral and 30 abd)
Hip abd in SL with circles
TB in standing
Stair drills
Bridging +/- gym ball
Single leg bridge foam roller
Plank with hip ext
Crab walks +/- theraband
Quads training exercises
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Step ups/downs
Squats, +/- resistance
Bulgarian squats
lunges
Stair drills
– 2 at a time, sideways, grapevine
• Controlled SIT
Hamstring training exercises
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Bridging
Single leg bridging
Gym ball hamstring curls
Hamstring curls in 4pt kneeling
Hamstring pulses in prone
Core/abdo training
exercises
• TrA
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Supine crook lying establish core control
Bridging
Bird dog/superman
Standing with UL or LL TB
• Abdo crunches/obliques
• Abdo roll with gym ball
• plank
Balance
• Lower limb amputees typically present with
impaired balance due to motor and/or
sensory deficits.
• For lower limb amputees, hip strategies
need to be trained to work differently and
more efficiently in order to compensate for
the missing ankle strategy.
Buckley et al (2002)
Balance
• weight shift
– Straddle stance
– Step stance
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Side stepping
braiding
Step taps
Throwing and catching ball
Bouncing ball
Kicking and trapping ball
Wobble board
Walking drills
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Walking F/B/S
Walking along line
braiding
High knees
Monster steps
Ski walking
Walking with resistance
** concentrate on foot placement **
** don’t forget arm swing **
Endurance
• Running and Sports participation is
hard work so need to work on
endurance.
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Walking
Swimming
Cycling
Rowing machine
Arm cycle
When to teach the amputee
to run
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Walking well unaided
Amp pro >37
6mwt > 250m??
Good socket fit
Motivated -
The Comprehensive High-level
Activity Mobility Predictor
(CHAMP)
• CHAMP is a measure of agility typically used to test highlevel performers who tend to max-out their ratings on
other performance-based measures.
• This measure includes activities that are designed to test
motion in all three planes, like turning, cutting, side-toside movement, and backward running.
• It consists of four tasks and can be administered in 15-20
minutes.
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SLS
Edgren side step test
T-test
Illinois agility test
CHAMP
• Found to be
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Safe
Reliable
Valid
Clinically friendly
responsive performance based outcome measure of highlevel mobility
• Has the potential to direct rehabilitation goals and
treatment, determine when to return to high level
activity and aid in discharge planning.
Amputee Running Technique
• Prosthetic trust
– reaching out with the prosthetic limb and
knowing it will be there
– Get used to the impact of landing on prosthetic
side
• Training exercises
– Repeated single hops on
prosthetic side (TTA only)
– Side skip
» http://www.oandp.com/articles/2003-12_05.asp
Amputee Running Technique
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Backward thrust
– Forceful hip extension on heel strike
to propel body over prosthesis
– Accelerates body forwards
– Increases speed
• Training exercise
– Push down and pull back with limb at same time inside the socket
– Standing with hip flexed 90. Therapist provides few seconds of medium
resistance to extension then lets go and amputee drives heel to floor,
pushing into back wall of socket.
– Use glutes and hamstring muscle groups
» http://www.oandp.com/articles/2003-12_05.asp
Amputee Running Technique
• Sound limb stride
– Novice athletes will have
a shorter stride.
• Training exercise
– extend hip by pulling down and back into socket
– Leap from prosthesis onto sound side
– Focus on long stride with sound limb
» http://www.oandp.com/articles/2003-12_05.asp
Amputee Running Technique
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Stride symmetry
– Strive for equal stride length and frequency
• Training exercise
– Choose a comfortable jogging pace that produces equal
stride length for both limbs
– Concentrate on maintaining stability over prosthetic limb
– Relax and jog a little
» http://www.oandp.com/articles/2003-12_05.asp
Amputee Running Technique
• Arm swing
– Novice runners keep arms close to their bodies
– Encourages stride length and timing
• Training exercise
– Focus on arm swing and trunk rotation
• Shoulders relaxed
• Elbows flexed 90
• Hands…
– Should rise to shoulder level when driving forwards
– Should point just behind hip when driving backwards
» http://www.oandp.com/articles/2003-12_05.asp
Considerations!!
Socket design
• Well fitting prosthesis
– Comfort
• Shape, interface material, alignment, adapt to
forces imposed at the stump socket interface
– ROM
• Adequate hip/knee ROM
– Stability
– Adaptability to volume changes
• Constant challenge for endurance athletes
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Gailey and Harsh (2009)
Foot selection for running
• Considerations
– Residual limb length
• Clearance 17-25cm
– Distance
• Sprint: carbon fibre ‘J shaped’ foot
• Endurance: carbon fibre ‘C shaped’ foot
• Multisport carbon fibre foot with heel
– Athletes preference
– Athletes skill
• Novice V’s professional
•
Gailey and Harsh (2009)
Knee selection running
• Use of a prosthetic knee permits a more
traditional style of running with knee flexion
and extension.
• Endurance knees
• Mauch (single axis, hydraulic)
• Ossur total knee 2100 (polycentric hydraulic)
• Ossur 3R55 (poycentric, hydraulic swing)
• Gailey and Harsh (2009)
Equipment
• Small towel
– Perspiration constant problem
• Moist wipes
– Cleaning socket, liners, suspension sleeves immediately
after training/sport
• Skin dressings
– If abrasions or blister occur
• Extra stump socks
– Limb volume may change with muscular contractions,
altered diet, weight loss due to training.
• Elastic sleeve or auxillary suspension
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Gailey and Harsh (2009)
references
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Deans S, Burns D, McGarry A, Murray K and Mutrie N (2012) Motivations and barriers to prosthesis users participation in
physical activity, exercise and sport: a review of the literature. Prosthetics and Orthotics international 36(3) 269-269.
Czerniecki J, Gitter A, Munro C (1991). Joint moment and muscle power output characteristics of below knee amputees
during running; the influence of energy storing feet. J Biomech 24:63-75
Nolan L, Lees A (2000) the kinematic charateristic of above and below knee amputee long jumpers. Ergonomics. 43:16371650.
Nolan L (2009) Lower limb strength in sports active transtibial amputees. Prosthetics and Orthotics international. 33:230241
Wetterhahn K, Hansen C, Levy C (2002) effects of participation in physical activity on body image of amputees. Am J Phys
Med Rehab 81(3):194-201.
Davies D and Datta D (2003) Mobility outcomes following unilateral lower limb amputation. Prosthetics and Orthotics
International. 27:16-190.
Webster J, Levy C, Bryant P, and Prusakowski P (2001) sports and recreation for people with limb deficiency. Arch Phys
Med Rehab 82(3):88-44
Deans S, McFayden A and Rowe P (2008) Physical activity and quality of life: A study of lower-limb amputee population.
Prosthetic and Orthotic International 32(2):186-200.
Kapp S (2004) Ch 13:Visual analysis of prosthetic gait. In: Atlas of amputated and limb deficiencies: Surgical prosthetic
and rehabilitation principles. Rosemont IL. p 385-394.
Buckley, J O’Driscoll D, Bennett S (2002) Postural sway and active balance performance in highly active lower limb
amputees. Am J phys Med Rehab 81:13-20.
Powers C, Boyd L, Fontain C, Perry J (1996). The influence of lower extremity muscle force on Gait characteristics in
individuals with Below-knee amputations secondary to vascular disease. Phys therapy 76(4):369-377
Raya M, Gailey R, Fiebert I, Roach K (2010) Impairment Variables Predicting Activity Limitation in Individuals with Lower
limb amputation. Prosthetics and orthotics intrnational.34(1):73-84.
Gailey R (2003) http://www.oandp.com/articles/2003-12_05.asp accessed 20/3/14