Equipment for individuals with limb deficiency

Original Editor - Ahmad Al-Mosa Al-Malkawi as part of the World Physiotherapy Network for Amputee Rehabilitation Project

Top Contributors - Leslie Angama, Tony Lowe, Admin, Kim Jackson, Tarina van der Stockt, Jess Bell, 127.0.0.1, Claire Knott and Amanda Ager  

Introduction 

Individuals with amputation are 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.

Wheelchairs

Manual Wheelchair

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

Wheelchairs are important for individuals with disability:

• To avoid immobility and being bedridden.
• 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 wheelchair.

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

The majority of these individuals with a disability 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 user's needs in wheelchair design.

Types of Wheelchairs

There is a huge variation in the type wheelchairs, and no single wheelchair will suit all users when considering their physical and environmental needs. The appropriate wheelchair for a user is the wheelchair which can provide good safety and comfort, that fulfills the user’s physical and environmental needs to become mobile, healthy, and participate in the community.

Foldable wheelchairs are used for transportation. A wheelchair can have extra support padding or cushions to address postural needs. A wheelchair that will be used indoors will be different from the one used outdoors.

Functional Performance

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

The evaluation of wheelchair 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 wheelchair user has a bilateral above-knee amputation his Centre of Gravity will be further back. So a wheelchair 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 wheelchair, therefore they will 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.

The diagrams below show the most sensitive areas for a pressure sore

Pressure relief exercises :

The use of an appropriately modified wheelchair with cushions 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

When it’s difficult to avoid manual handling it’s possible to reduce the related complications and risk by adapting the working environment or systems used for the benefit of the patient and caregiver.

This handling equipment will vary in usage from one person to another due to their disability, age, the severity of the case and socioeconomic status. Example equipment includes a transferring board, wheelchair, transferring sheet, stretcher, shower and bath equipment, standing hoist, transfer belt, and other equipment.

The main activities involved in patient moving and handling are:

• Sitting, standing and walking.
• Bed mobility.
• Lateral Transfer.
• Hoisting.
  

Handling and safety

Poor practice in the handling process can lead to serious injuries in the carer like LBP, disc problems, and muscles strain. According to the Health and Safety Authorities 2011 , for the safety of both patient and the caregiver many issues should be considered:

• The surrounding environment, ergonomic and workplace design should meet the needs of both the individual with a disability and the carers.
• The patient’s situation and degree of disability determine the kind of equipment involved in the handling process.
• Qualified staff and trainees assisting in the process of shifting and transferring.
• Staff must follow best practice guidance for safe manual handling.

Early Walking Aid (EWA)

The early walking aid (EWA) is a temporary socket made up of an inflatable bag, supported by a metallic frame with padded safety rings with a prosthetic or rocker foot .

The EWA has been used to help in patient assessment and to start the treatment. One of the most important objectives of the EWA is to help the patient ambulate in an upright posture as early as their wound condition allows which will help the patient's psychological status. Also, the EWA can accelerate the rehabilitation process by starting gait training and facilitating prosthesis fitting.

The use of an EWA helps to improve balance, posture and sensory integration. The pressure provided by the airbag also helps to control oedema and decreases pain.

Types of EWA :

• Pneumatic using airbags.
• 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 an airbag

Application of EWA   :

According to (Engstrom and Van de Ven 1999) ; training with a Pneumatic EWA can start 7 to 10 days postoperatively, with a gradual increase of the pressure, taking into consideration the wound condition.

Special consideration during the application:

• Usually starting the air inflation with 15 to 25 mmHg.
• Gradual increase of the pressure to a limit of 40 mmHg.
• Adapt the pressure according to the patients’ attitude to amputation, stability, recovery, and comfort.
• Continue inspection and observation of the wound as needed.
• Weight-bearing should be restricted according to the physician's order.

Information about the Pneumatic Post Amputation Mobility Aid

Prostheses

Please see the prosthetics page.

Walking Aids

A patient with an amputation can use a walking aid, either temporary or permanent to restore functional ambulation and independence. The choice of aid is dependent on the level of fitness, strength, balance skills, and risk of falls. In addition, the walking aid will help to control the allowed weight bearing on the injured leg, compensate for the lack of balance, and decrease the risk of a fall.

Named, Types, Advantages, Disadvantages, and Adjustment

Watch the video below explaining how to choose and use some assistive devices:

The table below explains different types of walking aids, the advantages, the disadvantages and the adjustment guide  

Special Considerations For Walking Aids

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

• Some patients can’t achieve this goal due to their age or another medical problem.
• Ambulation using a walker is not a required step to shift the patient from the parallel bar to crutches or cane if their physical and medical condition allows.
• Usually, when using a single walking aid it should be handled on their sound side, however, it can be used on the amputation 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.

The patient is usually taught how to hop with walking aids. This is especially true in the early stages but also for later stages if the prosthesis breaks down, skin breakdown on the residuum, the wheelchair can't fit in small spaces, or if the patient wants to traverse for short distances. However too much hopping in the early stages after the amputation is not advised due to the following reasons:

• Pain and oedema may result due to the dependent position of the limb
• Patients with vascular insufficiency of the sound limb, hopping may lead to skin breakdown of an already fragile foot
• If hopping is the only way of mobilising it can lead to postural changes like a pelvic tilt or spinal rotation
• Hopping at high speeds are dangerous as it may lead to falls or injuring the residuum
• People with OA or RA of their hands or weakness in the upper extremities
• Elderly population or patients feeling unsafe or do not have confidence with hopping
• A new bilateral amputee should avoid hopping on the original prosthesis of the other limb as it will increase pressure through the soft tissue of the residuum.

Other Equipment for Physiotherapy Units

There are many items of equipment that are required in the rehabilitation of amputees. Below is a table that outlines many of these and classifies them as essential, advanced and optional: