Equipment for individuals with limb deficiency

Introduction 

Amputation is defined as removal of all or part of an extremity, and it causes a decrease in level of activities. The person who has had an amputation is in-need of a proper rehabilitation program as early as possible and generally require compensatory equipment to reach maximum functional independence.

The prescription of an appropriate assistive device or walking aid will involve a multidisciplinary team evaluating many different factors and also should involve the patient in this decision.

Risk assessment 

Risk factor assessment tools

The causes of falls vary for different age groups and can lead to serious outcomes. Risk factor assessment tools are utilised to identify the issues around the potential of falls for an individual patient.
Example gait and balance assessment tools  include; Timed up and Go (TUG), Berg Balance Scale (BBS), Tinetti Performance Oriented Mobility Assessment (POMA), Dynamic Gait Index, and Get Up and Go test. These assessment tools measure a person's ability to balance and to walk in an appropriate way. They determine how long the person can keep their balance during gait, as well as considering a few activities of daily living (ADL) while moving from one point to another.
The ulitmate aim of using these tools are to identify issues that can be taken into account in the management of this patient and so reduce their likelihood of experiencing a fall. Potential issues identified could include:

• Mental problems.
• Language difficulties.
• Short term verbal memory.
• Construct ability.
• Calculation problems.
  

Falls Risk Assessment and Management Plan (FRAMP)

FRAMP  is a comprehensive tool that evaluates a patient's risk of falls from the early stage of hospitalization. FRAMP uses three similar stages of assessment during a specific period of time which identifys the history of falls, use of walking aids, cognitive impairment and other urinary and fecal problems.
FRAMP explains important practice points for patients who are complaining from coagulopathy and under anticoagulant and antiplatelet therapy as they are more vulnerable for intracranial hemorrhage due to recurrent falls, as well as patients with osteoporosis who may develop more fractures as a result of falls.

Download the FRAMP template

Moreover, FRAMP includes individualized intervention for specific risks such as:

• Mobility risks.
• Functional ability risks.
• Medication/ Medical condition risks.
• Cognitive state risks.
• Continence/ elimination risks.

Each one of the above risks is assessing the level of a patient's ability to perform the test with an appropriate intervention for each problem.
FRAMP also provides a minimum intervention to be applied to all patients which are:

• Provision of information for the patient about their environment (Toilet, bed and ward) and the use of the call bell to facilitate their needs.
• Education of patients about mobility aids and to enable them to use it in the proper way.
• Improve their awareness about the conditions that increase their risks of falls in order to prevent it.
• Improve the quality of the surrounding environment to reduce the risk of falls (lighting and remove obstacles).
  

Wheelchairs

Manual Wheel chair

The WHO defined the manual wheel chair as: “Wheel Chair propelled by the user or pushed by another person, and it is appropriate when it meet the user needs and environmental condition”. According to WHO statistics 2008 ; 10% of 650 million Persons with disabilities (PwDs) are in need of a Wheel Chair, which reflects the huge need for a wheel chair and the resources needed to provide them.

Why the Wheel chair is important for PwDs

• To avoid immobility and being bed ridden.
• To prevent secondary complications.
• To involve their users in community activities.
• To increase the opportunity for education, employment, and social interaction.

The picture below shows the main components of a wheel chair.

According to the International Labor Organization  (ILO) PwDs have a low employment rate with 80 % or more unemployed in low resourced countries which makes their living conditions worse.

The majority of these PwDs are living in developing countries, so the infrastructure and living environment also present physical barriers to access. They also lack related rehabilitation Services, which reduces the level of awareness and education in the community, as well as limits the ability to meet the users needs in wheel chair design.

Type of Wheel Chairs:

There is huge variation in the type of the wheel chairs, and no single wheel chair will suit all users when considering their physical and environmental needs. The appropriate wheel chair for a user is the wheel chair which can to provide good safety and comfort, that fulfills the user’s physical and environmental needs to become mobile, healthy, and participate in the community.
Foldable wheel chairs are used for the transportiation. A wheel chair can have extra support padding or cushions to address postural needs. A wheel chair that will be used indoors will be different from the one used outdoors.

Wheel Chair Provision

According to the “Guidelines on the provision of Manual Wheel chairs in less resourced settings”  the wheel chair provision is depend on 4 components:

1. Design.
2. Production.
3. Supply.
4. Services and Delivery.

A proper design for wheel chair should match with the Physical and environmental needs for the users, to be able to match the stander through the production procedure, at the same time to facilitate an access for the users to have reliable supply for wheel chair and its spare parts, at the end the users have to be provided with services which include; participation in the wheel chair design, selecting, producing and training. The Diagram below can explain the wheel chair design process .

The design to produce a wheel chair or imported should be taken after answering the following questions:

• Do we have skilled manpower for production?
• Is the spare part and the material available?
• Is the machine and equipment for production available?

Functional Performance

A wheel chair's functional performance is how well it fulfills it's user's needs in their particular environment . So it is the performance of the wheel chair for a specific user in their specific environment.

The evaluation of wheel chair design for functional performance includes the evaluation of its static and dynamic stability, its rolling capacity and resistance, the access to repairs and spare parts, and its overall dimensions, mass and required turning space.

For example when a wheel chair user has a bilateral above knee amputation his Centre of Gravity will be further back. So a wheel chair for this user needs to have its rear wheel positioned farther back behind the center of gravity for the user in order to have a good functional performance for this user.

Pressure Relief

As an early stage for the rehabilitation of amputee patients postoperatively and especially with bilateral amputees, they will need to depend on the wheel chair, therefore they will might use it for long period during the day which might put them at risk of developing pressure sores if they don't follow instructions and complete appropriate exercises.

So, what is the most sensitive area for the pressure sore ?

How we can do the Pressure relief exercises ?
The use of an appropriately modified wheel chair with cushiosn can help in both decreasing the risk and in practicing the exercises. The common exercises used are:

• Independent push up.
• Leaning from side to side.
• Leaning forward.

Very Important: Don’t forget to instruct the patient to lock the brake while exercising.

The video below demonstrates pressure relief exercises :
http://www.naric.com/?q=en/content/pressure-relief-techniques-manual-wheelchair

Manual Handling Equipment

Equipment of manual handling 

When it’s difficult to avoid manual handling task it’s possible to reduce the complications and risk by converting working environment or system for the patient and caregiver good.
The provision of different types of equipment will functions and personnel who are playing an important roles in keeping safer handling for both carriers and patient.
These materials and handling equipment may in usage from one person to another due to the disability, age, severity of the case and socioeconomic status. These materials such as: transferring board, wheel chair, transferring sheet, stretcher, shower and bath equipment, standing hoist, transfer belt and other equipment.
The main group of the patients moving and handling tasks are:
- Sitting, standing and walking.
- Bed mobility.
- Lateral Transfer.
- Hoisting.

Handling and safety

 
The handling process it’s in direct relation with other consequences that appears during time of transferring and shifting of PwDs, the carriers, nurses or the caregivers maybe affected as a result for this continues handling process and this will lead to serious injuries like: LBP, disc problems and muscles strain.
According to the Health and Safety Authorities 2011 , to keep the safety for both patient and the caregiver a lot of issues should be under consideration:
- The surrounding environment, ergonomic and workplace design should match the needs for both, to decrease the incidence of injuries that usually results.
- Provision of appropriate manual handling equipment, the patient’s situation and degree of disability are determining the kind of equipment that it will be in the handling process.
- Qualified staff and trainees that assisting in the process of shifting and transferring techniques will increase better result achievement.
- Management committee to safer manual handling in the workplace: staff must follow the guidance that maintaining safer manual handling.

Early walking Aid (EWA)

The early working aid (EWA) is a temporary socket mainly made of inflatable bag, supported by metallic frame with padded safely rings and prosthetic or rocker foot .

The EWA has been used to help in the patient assessment and to start the treatment. One of the most important objective of the EWA is to help the patient to be ambulated in upright posture as early as the wound condition get stable which will reflect on the patient psychological status. Also the EWA can accelerate the rehabilitation process through starting the gait training and facilitate the prosthesis fitting.

The EWA help to improve the balance, the posture, and the sensory integration. The provided pressure from the air bag is playing a big role in controlling the oedema, and decreasing the pain.

• Types of EWA :
- Pneumatic using air bag.
- Vacuum Technique as LIC Tulip.
- Preformed Plastic Socket as LIC Femorett, LIC LEMA, and Hexilite temporary patellar tendon Weight bearing.
- Local Variations.

    

plastic socket EVA                                                                       pneumatic using airbag

• Application of EWA   :
According to (Enstgrom and Van de Ven 1999) ; the training with Pneumatic EWA can start 7 to 10 days postoperatively, with gradual increasing of the pressure and considering the wound condition.
Special consideration during the application:
- Usually starting the air inflation with 15 to 25 mmHg.
- Gradual increase of the pressure and it should not be inflated with air more than 40 mmHg.
- The patients’ attitude to amputation, stability, recovery, and comfort to adapt the pressure.
- Continue inspection and observation of the wound is needed.
- Weight bearing should be restricted to the physician order.

 Prostheses:

The prostheses prescription, type, component and production are passing through multidisciplinary team without forgetting to involve the patient according to specific factors. It had been explained in details at the Prostheses section of this course: http://www.physio-pedia.com/Prosthetics.

Walking Aids

The patient with Amputation will use a walking aid, either temporary or permeant to restore the functional ambulation and independency. The choice is depending on the level of fitness, strength, balance skills, and risk of falls. As well as the walking aid will help to control the allowed weight bearing on the injured leg, compensate the lack of balance, and decrease the risk of fall.

Named, Types, Advantages, Disadvantages, and Adjustment

Watch the video https://www.youtube.com/watch?v=inH0rdkTWTI explaining how to choose, use some assistive devices.
The table below is explaining the different type of walking aids, the advantages, the disadvantages and the adjustment guide  

Special Consideration on walking Aids

Our long term goal with amputee patients it to reach maximum functional independency without walking aids, a special consideration should be taken such as  :

• Some patients can’t achieve this goal due to the age or other medical problem.
• The ambulation using a walker is not a required step to shift the patient from parallel bar to crutches or cane, if the physical and medical condition allows.
• Usually using a single walking aid should be handled at the sound side, however it can be used at the Amputee side if the goal is to shift more weight to this side.
• The drill to ascend and descend the stair is to ascend with the sound leg, and descend with the amputee side (Up good and down bad).
• A proper selection of a walking aid with proper adjustment will speed up the rehabilitation process and improve the quality of the outcomes.

Other Equipment’s for Physiotherapy Units

Physiotherapy unit must be supplied by many essential equipment and materials which are important in the implementation of the treatment plan of the physiotherapy and prosthetic/orthotics as well. These materials are necessary before and after the prosthetic rehabilitation as well as in advanced gait training level.
The materials and equipment itself are classified into three different categories :