Should the need for very early mobilization affect the prosthetic gait training and the standing function of elderly amputees? Amputee Case Study


Original Editor - Lynnette Wakefield

Title

Should the need for very early mobilization affect the prosthetic gait training and the standing function of elderly amputees? Amputee Case Study

Abstract

My case study outlines some of the pros and cons of early mobility with an elderly amputee and the application of the principles of Gailey and Gailey's prosthetic gait training program. It explores the interplay between early mobilization to reduce the high risk of complications in the elderly following amputation and the need to develop improved prosthetic gait in a safe and efficient manner in a patient with a high falls risk.

My discussion suggest that in this particular patient earlier introduction of weight transfer, balance and pelvic rotation training may have assisted with both safety and the earlier attainment of her goals of becoming a prosthetic community walker.

Key Words

Elderly, Transtibial, Gailey, 
Weight transfer, Balance, Pelvic Rotation, Early mobility

Client Characteristics

Demographics: 
My patient is a 77-year-old female retired schoolteacher who lives alone in her own home that has been modified for wheelchair access. She has two supportive adult daughters one of whom is a social worker. They both provide assistance with transport and shopping.

Medical Diagnosis and Comorbidities
: She has undergone a left trans-tibial amputation as a result of peripheral vascular disease. She also has had a myocardial infarct seven years ago and suffers from diabetes, high blood pressure and leg ulcers.


Previous Treatment: 
She has completed her pre-prosthetic rehabilitation as an inpatient at a specialist rehabilitation hospital and has been referred to the outpatient rehabilitation services for gait training following provision of her first interim prosthesis. Her previous treatment has been directed towards ensuring that she has adequate wheelchair skills for her discharge home, strengthening of her residual and remaining lower limb, upper limbs and core and transfer training and preparing her residual limb for prosthetic use with pain and oedema management techniques.

Examination Findings

Relevant Medical History and Systems Review - My patient has a history of
:

  • Myocardial infarct 7 years ago

  • High Blood Pressure managed with 10mg of perindopril daily
  • Diabetes - 1,000mg of metformin twice daily

  • Leg ulcers
•She has no respiratory or renal problems

  • Her hearing is good

  • She does wear glasses for both reading and longer distances

Subjective
: My patient reports she is managing well at home and that she is able to walk short distances within her home using a rollator frame. She is having difficulty when she is required to walk longer distances or over uneven ground. She doesn't feel stable enough on her prosthesis to manage without her frame and as result is she is spending most of the day in her wheelchair as she feels safer and it allows her to more easily complete her day to day tasks than using the rollator frame. Usually she is quite active in her community and socializes with friends by going to the movies, playing bowls and cards.

Service Related to current episode: She receives some assistance from her local council to manage her home maintenance and garden as well as heavier household task such as vacuuming and mopping floors. District nursing services are engaged to manage an ulcer on the intact limb.

Pain
: My patient complains of no residual limb pain except for some knee joint pain at the limits of extension but has complained of episodes of phantom limb pain usually at night. Since commencing on a pregabalin some 8 weeks ago these episodes have reduced in severity and number and are now very manageable

Claudication: 
There is no history noted of claudication symptoms in the right leg but there were significant issue with the left leg prior to amputation.

Psychological and Emotional State 
Whilst glad to be at home and regaining her independence with her personal activities of daily living she is anxious to progress her mobility and be more involved in her community and social activities such as playing bowls and cards and going to the movies.

Self-Reported Outcome Measures: 
Trinity Amputation and Prosthesis Experience Scales Revised demonstrates some anxiety about her ability to use her prosthesis

Patient Expectations: 
My patient expects to ambulate with her prosthesis for all her normal activities of daily living and to become a community walker able to participate in her usual hobbies and social activities.

Patient and Family Goals
: She would like to progress to being ambulant most of the time with her prosthesis with only a walking stick and be able to ambulate in her community.

Objective:<u</u>Physical Examination Tests and Measures

Cognition: 
Her standardized mini- mental state examination score is 30/30 and no issues with her memory or information processing have been noted.

Skin and Soft Tissue Condition
: Residual Limb skin condition is good with completely healed surgical scar, which is non-adherent. There are no tender areas on palpation. There is reduction in sensation over the distal end of the residual limb most notably around the scar line but skin perfusion is good. There is good coverage of the distal end of the tibia with redundant tissue and the residual limb is an appropriate shape for prosthetic fitting although it will more than likely reduce in overall volume over the next few months. The residual limb length is suitable for prosthetic fitting
. 
Her right leg has small ulcer above the ankle which is managed currently with dressing provided by the district nursing services every second day and this is reported to be healing.

Joints: All joint had full range of movement but there was some slight anterior knee pain at the end of extension range in the residual limb

Muscle Power
: Manual muscle testing revealed normal strength in all muscle groups of the upper limbs, right leg and residual limb and good core strength.

Hand Function
: My patient states she has no issues with her hands and her hand function is normal when tested objectively.

Balance: Sitting balance appeared normal and my patient can balance statically on both legs and her right leg for 5 minutes. Her dynamic balance in standing is significantly limited by inability to transfer weight to the left and she needs support of handrails to balance on the left prosthetic limb.

Transfers
: My patient performs all transfer independently with or without the use of prosthesis. During standing transfers using the prosthesis she does not transfer her weight onto the prosthesis effectively and is dependent on her right leg and arms for support.

Mobility
: She is independently mobile in self- propelled wheelchair around her own home and in her community. She can ambulate independently short distance on flat surfaces with prosthesis and rollator frame. Her timed up and go scores is 30 seconds.

Gait Analysis
: My patient is reluctant to shift weight onto the prosthetic limb and this is not due to pain. This produces a short stance time on the prosthetic limb and a shorter stride length on the right. She exhibited very little heel strike or toe off on the prosthetic side. This gait pattern is exacerbated by attempts to walk with less upper limb support.

Activities of Daily Living: 
She is independent in all self-care from a wheelchair base including donning and doffing her prosthesis. She does however have difficulty performing these tasks in standing, as she feels insecure unless she can hold onto her frame with both hands. She has assistance with shopping, transport, heavy household tasks, gardening and home maintenance.

Prosthetic Fit and Design
: My patient has been fitted with a prosthesis, which has patella tendon bearing supracondylar, socket with a pelite liner, cotton socks and a SACH foot. The socket fits well and the static alignment of the prosthesis is good

ICF Summary of Findings: 
Environmental
 - My patient's environment is that of typical suburb in a major capital city in Australia where people move about in this environment by either public transport or their own motor vehicle. Most walkways are paved however there is a requirement to manage steps, gutters and ramps. She lives alone and independently in her own hone unit, which has been modified, for wheelchair access. She has support from her family and community service to manage her day-to-day needs. Her local general practitioner and district nursing services assist with her medical needs and she has free access to good amputee rehabilitation services.
Personal Factors - My patient is a retired schoolteacher and glad to be at home and regaining her independence with her personal activities of daily living. She is anxious to progress her mobility and be more involved in her community activities such as playing bowls and cards and going to the movies. She would like to be community walker so she can resume her hobbies and social activities in the community.
Impairment of Body Function and Structures - 
My patient has a left trans-tibial amputation but has good muscle power, joint range and soft tissue condition of her residual limb. Her only structural issues related to the residual limb and amputation are some mild osteoarthritis in her left knee and some well managed phantom limb pain.
 My patient also had the following comorbidities, a history of myocardial infarct, diabetes and high blood pressure and a right leg ulcer. All are current well managed and stable and not posing restriction to her rehabilitation.

Activity and Participation Limitations - 
My patient's ambulatory activities are limited to walking on flat surfaces over short distance with a rollator frame and this limits her mobility to within her own home and impact on her use of her prosthesis for activities of daily living. She is independent in her activities of self- care but performs most tasks from her wheelchair as she finds this easier and feels safer as her standing dynamic balance is poor.
This mobility limitation also impacts on her engagement with her community as she is not able to drive or ambulate well enough to manage public transport and therefore has difficulty participating in her hobbies and social activities.

Clinical Hypothesis

My clinical hypothesis was is that my patient's is unable to progress her activities of daily living and gait as the focus of her rehabilitation has been on early mobility rather than prosthetic control, to weight shift and dynamic balance in standing. If these issues were addressed she would achieve her goals of independent gait with one stick.

Intervention

I chose to use techniques based on R Gailey and A Gailey's[1] gait training techniques modifying these for an elderly population by shifting them from a home based unsupervised program to one in clinic with supervision initially.

  • I started with weight transfer techniques working on firstly lateral and then anterior- posterior and finally diagonal weight shift in standing within the parallel bars. This was done firstly with bilateral arm support but working towards no arm support and ensuring good control of the prosthesis.

  • To address the anxiety and fear my patient experienced I then move this exercise to outside the parallel bars using only single arm support from the unaffected limb before asking her to complete this activity with-out supports to build confidence in her standing balance. Once this was achieved I asked her to practice standing at home without supports near her kitchen benches to continue to build her confidence in her balance and prosthetic control and to transfer this new skill to her home environment and to her activities of daily living.

  • I then work on making this standing balance more dynamic by asking her to complete the slow stool stepping exercise with the unaffected limb described by Gailey and Gailey[1] within the parallel bars focusing on gaining control and balance over the prosthetic limb during this dynamic movement.
  • I then progressed this from double arm to single arm support on the unaffected side support to mimic the balance she will require to walk with a single stick, which is her goal. I then shifted this activity external to the parallel bars to aide in confidence building and lastly to her home environment where she has a suitable rail installed on her front porch to ensure safety.
  • 
I then focused on transferring this control into her gait pattern firstly within the parallel bars where I asked her to focus on weight transfer and pelvic rotation reinforcing these verbal instruction with manual resistance at the pelvis whilst she learn the desired movement. I progress this technique from double arm support within the parallel bars to double arm support using one walking stick and one parallel bar and eventually to two then one stick.

Outcome

During this process I noted that her weight transfer, step time and step length became more even and her confidence improved to the point where she was happy to practice each activity at home and then integrated these gains into her day to day functional activities. For example she is now able to stand in her kitchen to cook and feels comfortable to walk with one stick inside her home on flat surfaces in a forward direction. Clearly I will now need to work on improving her confidence and abilities in multi- directional gait and in more challenging environments


Outcome Measures Her Trinity Amputation and Prosthesis Experience Scales Revised demonstrated less anxiety and her Timed Up and Go improved by 3 seconds.

Discussion

My patient goals is the "primary goal expressed by many elder amputees to regain independence in mobility'[2]. She had already achieved this using a wheelchair and a rollator frame. This early mobility is recommended by Engstrum and Van De Van as it has the advantage of assisting in minimize the high risk of complications following amputation experienced by many elderly amputees. Khadir[2] also indicates that there is a higher risk of falls in the elderly amputee and Engstrum and Van De Ven [3] argue that whilst walking with a frame provides a safer option for the elderly amputee they also suggest that it is not ideal as it places the amputee in a flexed posture, which inhibits the acquisition of weight transfer and balances skills.

Khadir [2]suggest that a measure approach to the progression of rehabilitation within the physiological limits of the elderly amputee is appropriate and that all activities must be undertaken with safety in mind. Kadhir[2] also indicates that good preparation prior to transfer and gait training is essential to minimize the risks of falls. It could be argued that; progressing my patient to independent mobility with a frame before acquiring sufficient weight transfer and dynamic balance skills in standing placed her at increased risk of falls. I argue that these techniques could have been included in this early rehabilitation phase with careful monitoring of responses to treatment and management of falls risks and that his may have improved both her safety and mobility.


To explore my hypothesis I chose to use some of the gait training activities outline by Gailey and Gailey[1] and Gailey and Clark[4] with an elderly patient; a population for which it was not originally designed. I modified the weight shift and stool exercises from a largely home exercise program to initially being supervised by myself to ensure their safety and graded their progression carefully to stay within the physiological capacity of my patient.
These exercises did still posed increased risks as they were more physiologically demanding and there was clearly a greater risk of falls than the previously prescribed supine and sitting based exercises, but they were far more functional and addressed the goals my patient wanted to achieve more effectively.

I do however acknowledge that progress needed to be closely monitored to prevent injury and were more time consuming for the therapist. This approach simplified instruction to my patient, which was also beneficial in light of her anxiety, and I found the focus on weight transfer, balance and pelvic rotation an effective way of establishing confidence and improvement in her standing activities and gait. Her Timed Up and Go scores and Trinity Amputation and Prosthesis Experience Scales Revised reflected this. I followed the principles of outlined by Gailey of ensuring efficient use of her new body and preventing future harm and was not concerned particularly about the esthetics of her gait pattern as this was not part of her primary goal. I did not therefore provide specific instructions to correct her step length, gait timing or toe off and heel strike deficits.

Whilst Cain [5] advocates for similar weight transfer and balance training she also indicates that "specific gait training is important to ensure correct biomechanics". 
Gait analysis of my patients did demonstrate that her gait pattern improved with equalization of step length and swing and stance phase times between the right and left lower limbs as well as developing clear heel strike and toes off phases in what had previously been a very flat footed prosthetic gait.
It could be argued that building this initial foundation of weight transference, dynamic balance and pelvic rotation may assist in minimizing some of the patient based gait deviation exhibited by many amputees and the need for more specific gait correction training at a later date.


My practice has changed and I will in the future focus my attention on these techniques earlier in the rehabilitation process to improve both patient safety, efficiency and the correct biomechanics of amputee gait.


References


  1. 1.0 1.1 1.2 R Gaily and A Gaily (1989); Prosthetic Gait Training Program for Lower Extremity Amputees.
  2. 2.0 2.1 2.2 2.3 S. A. Khadir; Older people with Amputations http://www.phsyio_pedia .com/Older _people _with _amputations
  3. Engstrum B and Van De Ven; Chapter 10, Gait Re-education and prosthetic functional activity; Therapy for Amputees
  4. R Gaily and C Clark; Chapter 23, Physical Management of Lower- Limb Amputee; Atlas of Limb Prosthetics.
  5. Cain A; Prosthetic Rehabilitation; http://ww.physio_ pedia.com/ Prosthetic_ rehabilitation