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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 ?