What is high level rehabilitation?
High-level rehabilitation for amputee refers to the process by which an amputee (IWA) recovers to a level where she is able to participate in physical activity and/or sport. The main goal after lower limb amputation is to be able to walk again and once this The physical fitness achieved should be developed to such an extent that it can counteract the effects of a sedentary lifestyle on overall health. Since IWAs are often extended Once they can walk effectively, start sitting. Thereafter, opportunities to participate in recreational or competitive sports should be encouraged as personal goals; this may even lead to participation in pinnacle events such as the Paralympics.
Physical Fitness for General Health:
To combat the “lifestyle diseases” of ABBL and IWA, the basic physical fitness guidelines according to ACSM [1] are:
- Cardiovascular fitness: 30-60 minutes of moderate-intensity exercise 5 days a week, or 20-60 minutes of vigorous-intensity activity 3 days a week. This can be done in short bursts of at least 10 minutes at a time and accumulated over the day or session.
- Strength training: Strength training 2-3 days a week.
- Neuromotor Exercise: Also known as functional fitness training, 2-3 days per week are recommended. Motor skills such as balance, agility, coordination and proprioception should be trained. This is arguably more important to IWA than to ABBL.
In a study by Chin T et al. (2002) [2], IWA showed the same ability to improve physical fitness as ABBL. No studies have identified details of exercise prescriptions for amputees, so until such data exist it is possible to apply comparable but monitored prescriptions for IWA. However bear Keep in mind that there is research to support the fact that the higher the degree of amputation, the higher the energy requirements [2]. Compared to ABBL individuals, IWAs require considerably higher effort levels and therefore need to expend a lot of energy to achieve the same work rate. elevated heart rate This helps fight heart disease, diabetes and some cancers and can be done through swimming, hand cycling etc. This may be preferable when there are residual limb issues, but weight bearing exercises should be included if possible to allow for long term Mineralization of the legs. bones in the body, thus combating the development of osteoporosis. Examples of weight-bearing exercise include brisk walking, jogging, and light cycling. Brugaru et al (2011) [3] reviewed some studies on outcomes for amputees and concluded that exercise should be included in Amputee Rehabilitation Program. Interestingly, a training program specifically designed to improve hip strength improved the performance of a prosthetic walker sufficiently to afford running (Nolan 2012) [4]. Importantly, without continued training, these strong individuals deteriorate and become Many people revert to prosthetic walkers. Therefore, the importance of these components in all physiotherapy amputee rehabilitation is evident.
Exercise, especially for short periods of time, can improve bone mineral density (BMD), which is especially important in people with missing lower extremities. [5] Patients should be encouraged to start activities as early as possible to avoid BMD loss. [5] Rehabilitation programs should include Variety of exercises, later including multidirectional variations [5]
Physical fitness for sport participation and/or competition:
For amputees looking to improve their fitness and compete according to their level of competition, they may benefit from an athletic trainer specifically training them for performance. At all levels, prosthetists are helping to decide if and when to progress to Sports prosthetics can be helpful.
Who qualifies for High Level Rehab?
Although this usually refers to competitive or elite athletes, any amputee who has reached a functional level capable of walking effectively with a good gait pattern should be encouraged to undergo further improvement to allow participation in at least brisk walking, but possibly Jog or run. Awareness of considerations for high-level athletes should also be kept in mind, but are less important in participation-only populations (see below for specific considerations for high-level amputee athletes).
Rehab/training should be more intense and results-oriented once participation progresses to competition. The remainder of this article will focus on individuals who have reached the level of competition, including elite athletes.
The ideal high level rehabilitation team
An ideal high-level rehabilitation team around an amputee athlete would include physical therapists, prosthetists, coaches, and more strength and conditioning specialists for elite athletes. In a Walter Reed study of veterans with limb loss, patients saw Their rehabilitation team served as physically and emotionally motivating and supportive coaches, and daily interactions with all team members promoted self-confidence and self-advocacy [6].
Roles often overlap, and teams are most effective when decisions are made in partnership with each other and with the athletes. Broadly speaking, these roles can be described as follows:
Physiotherapist
Assessment
A basic assessment should be performed, including details of residual limb history, medications, and level of function (see Assessment of the Amputee). If this basic assessment has not already been done, it should be done at the beginning of any program.
Yellow flags should be assessed in the same way that the emotional state of the home environment and the expectations of the athlete are assessed.
Exercise readiness assessment should include residual and intact extremities: joint integrity and range of motion, strength, endurance, and flexibility should be assessed. General assessment should include gait (walking and running) cardiovascular fitness core strength balance proprioception As well as compensatory mechanisms and abnormalities, such as muscle imbalances. Previous injury history, including conditions prior to amputation, if applicable. This is especially important as previous injury has been identified as a risk factor for further hamstring injury (Forsekis et al (2011) [7] Petersen et al (2011) [8] Bahr (2013) [9] Freckleton et al. (2012) [10] and Henderson et al. (2010) [11])
Create a personal problem list and plan:
The information gathered from the assessment will allow a person to develop a list of issues specific to that individual and then develop a goal-directed plan for dealing with them
Basic strength and conditioning:
Achieving GrV should be the goal of basic strength and conditioning. All major muscle groups (including the upper body) should be rehabilitated, and specific movement training can be introduced as strength improves. For example, adding resistance at the end of a sprinter’s range and Develop good centrifugal strength to help prevent injury (Sebelien et al [12] Stanton et al (1989) [13] Schmitt et al (2012) [14]). Training can be done in the treatment room and at home in the gym, swimming pool and sports field
[15]
Core stability:
Core stability training is critical for amputees whose balance is impaired, resulting in reduced power output from the limb. Likewise, sport-specific training can be included, such as core training with a mobile support base for core training while performing sports such as running.
Gait training includes running gait:
Interestingly, most high-level athletes have gait abnormalities. It is more effective to identify these abnormalities early on when deciding to try to correct the gait pattern. If an athlete already exhibits a high level of gait abnormality, it is usually left undisturbed due to the reduced risk Improve performance by changing gait patterns. Gait abnormalities may simply be habitual, but are more often related to compensatory mechanisms such as joint stiffness, muscle weakness, and poor balance. Knowledge of ABBLs gait patterns is important when assessing gait in IWA, as is knowledge of common gaits Patterns of development in amputees.
To return to sport or start a sport assessment:
These performance metrics are usually determined by physical therapists, coaches, and strength and conditioning specialists.
Functional Training
Prosthetist
The requirements of the athlete and the condition of the residual limb and limb are very important to the prosthetist. Therefore, it is important to understand what the physical therapist finds at the time of the assessment. Prosthetic selection is made specifically taking all of this information into consideration.
Coach
Paralympic/amputee coaches must have a keen interest and knowledge of muscle function imbalances in gait and the risks faced by IWA athletes. Coaches, like other professionals engaged in high-level rehabilitation, have no researched guidelines to follow; each IWA demonstrates their individual Amputations and their individual compensation mechanisms and abnormalities. Training programs must be continuously modified and tailored to the individual – following a traditional training program without careful monitoring and evaluation often results in injury.
Strength and conditioning specialist
The importance of strength and conditioning specialists lies in the development of optimal conditioning for a particular sport or recreational activity. The physical demands of sport include aspects such as strength, power, stability, balance, and endurance, thus requiring intensive, individualized training High-level participation is recommended.
Likewise, ideally a physical therapist coaches a strength and conditioning specialist and a prosthetist in close collaboration.
Specific considerations for high-level amputee athletes
Muscle imbalance
In calf amputation (TTA), the intact leg was stronger than the amputated leg, but, as expected, this difference was smaller than in nonathletic participants (Nolan 2009) [20]. Increased energy absorption and energy production in the hip of the amputated leg compensates for the loss Plantar flexors on one side (Soares et al 2009)[21]. The workload of the intact limb is increased (energy absorption and production) in unilateral TTA, which is exacerbated when amputation is painful (Grumillier et al 2008) [22]. When training at performance level, train The load and demands on the intact limb are greater. This should be taken into account when designing the training program.
Compensatory Mechanisms
Princeton et al. (2011) [23] made some interesting findings on adaptation strategies in amputees: they found increased eccentric hamstring strength in the intact leg compared to the amputated leg in TTA, but the amputated More eccentric quadriceps strength in legs full legs.
When considering the above findings, the question arises, if compensation and adaptation occurs in walking gait, does it differ during locomotion? How will it affect the biomechanical demands of specific motor tasks? How is it different from a sports prosthesis? Sports like sit volleyball?
Consequently, compensatory mechanisms are often difficult to identify and vary markedly between athletes.
Special risks for high-level amputee athletes
Mechanical Overload: One of the greatest risks faced by lower limb amputees is overload. Overload due to compensatory mechanisms, and a non-optimal biomechanical position of the body due to the prosthesis. Our observation is that the hamstring muscles in intact limbs are particularly vulnerable Injuried. Studies have shown that load absorption at the knee joint of the intact leg is also an increased load during normal activities of daily living. This should be taken into account when designing conditioning procedures as well as for recovery purposes.
Physiological Overload: Athletes may require longer recovery times due to higher energy demands and less muscle mass available to physiologically generate force in the limb. Much depends on the level of amputation.
plan to address these issues
Strength Development: The same strength development principles apply to IWAs and ABBLs. The sport or activity chosen should determine the most important movements to be trained. Due to the body’s ability to compensate and adapt, the compensatory nature of exercise should be explicitly assessed mechanism. The type of prosthesis chosen is important. The load should only be increased if the exercise is performed in a biomechanically efficient manner. Selectively performing certain movements without prosthetics (especially for transfemoral (TF) amputations); such as plyometric jumping. Training load can be increased by making the exercise more complex, increasing resistance, increasing fatigue time, or increasing the speed of movement.
Stability: Core stability and hip stability are critical for amputees. The program should address both static and dynamic stability issues. Static stability is usually very good, but dynamic control and stability are poor due to the lack of motion of the prosthesis. be an athlete To do competitive movement control, you need to be advanced and have a solid foundation of endurance. Upper body compensatory mechanisms that address postural adaptation should also be monitored.
Endurance training: Because of the greater energy demands and increased mechanical load, it is important to determine the training load for endurance training based on the biomechanical application of the exercise. When an athlete begins to fatigue, the biomechanics adapt. e.g. in sprinter May fatigue first on the amputee side and start running with unequal stride patterns. From a cardiovascular perspective, the individual may still be able to continue, but by running in a biomechanically incorrect pattern, the mechanical overload on the health side increases for personal reasons Empirically, we have found that high-intensity interval training with shorter rest periods between repetitions is more conducive to better biomechanical performance.
Flexibility: Both the amputee side and the non-amputation side should have good flexibility. Range of motion of the joint closest to the amputation should be maintained.
FITT Principle
- Frequency: It has actually been found that weight loss days should occur more frequently during weight-bearing activities such as running compared to ABBL.
- Intensity: Please note that when choosing the training intensity, the maximum heart rate may be affected by the lack of active muscle mass, so the normal calculation of Max HR may not be correct. Weight training intensity should be carefully determined. Intact limbs may be overloaded Already higher than the amputated side. Proceed with caution, train at a lower intensity, and ensure that all available muscle mass is being used to its optimum capacity.
- Timing: As mentioned above, it is recommended to use biomechanically plausible motor pattern preservation to guide the duration of the training set.
- Type: As mentioned above, the type of exercise should be chosen based on the individual’s athletic ability and the type of sport or activity. Consideration of the type of prosthesis will influence the decision.
References
- ↑ Pescatello, L.S et al in American College of Sports Medicine (2014). ACSM’s guidelines for exercise testing and prescription.
- ↑ Jump up to:2.0 2.1 Takaaki, C et al. (2002). Physical fitness of lower limb amputees. Am J Med Rehabilitation. 81:321-325
- ↑ Brugaru M, Dekker R, Geertzen JHB and Dijkstra PU. (2011) Amputees and Sports – A Systematic Review. Sports Med. 41(9): 721-740.fckLRNolan L. (2009) Lower-limb strength in sports-active transtibial amputees. Prosthet Orthot Int. Sep;33(3):230-41.
- ↑ Nolan L (2012). A training programme to improve hip strength in persons with lower limb amputation. J Rehabil Med. Mar;44(3):241-8.
- ↑ Jump up to:5.0 5.1 5.2 Jenkinson ER. 2017. Examination Of The Rehabilitation Protocol Of Traumatic Transfemoral Amputees And How To Prevent Bone Mineral Density Loss. Honors Undergraduate Thesis. University of Central Florida
- ↑ Messinger S, Bozorghadad S, Pasquina P. Social relationships in rehabilitation and their impact on positive outcomes among amputees with lower limb loss at Walter Reed National Military Medical Center. Journal of rehabilitation medicine. 2018 Jan 5;50(1):86-93.
- ↑ Fousekis K, Tsepis E, Athanasopoulos S, Vagenas G. (2011). Intrinsic risk factors of non-contact quadriceps and hamstring strains in soccer: a prospective study of 100 professional players. Br J Sports Med. 45(9):709-714.
- ↑ Petersen J, Thorborg K, Nielsen MB, Budz-Jorgensen E, Holmich P. (2011) Preventive effect of eccentric training on acute hamstring injuries in men’s soccer: a cluster-randomised controlled trial. Am J Sports Med. 39:2296-2303.
- ↑ Bahr R. (2013) Preventing hamstring strains: A current view of the literature. Aspetar Sports Med J. 2013 (2).
- ↑ Freckleton G, Pizzari T. (2012) Risk factors for hamstring strain injury in sport; a systematic review and meta-analysis. Br J Sports Med. doi:10.1136.
- ↑ Henderson G, Barnes CA, Portas MD. (2010) Factors associated with increased propensity for hamstring injuries in English premier league soccer players. J Sci Med Sport. 13(4):397-402.
- ↑ Sebelien C, Stiller CH, Maher SF and Qu X. Effects of implementing Nordic hamstring exercises for semi-professional soccer players in Akershus, Norway. Orthop Prac; 26:2-14.
- ↑ Stanton P and Purdam C. (1989). Hamstring injuries in sprinting – the role of eccentric exercise. J Orthop Sports Phys Ther. 10(9):343-9.
- ↑ Schmitt B, Tim T and McHugh M.(2012) Hamstring injury rehabilitation and prevention of reinjury using lengthened state eccentric training: a new concept. Int J Sports Phys Ther. June;7(3):333-341.
- ↑ National Center on Health, Physical Activity and Disability (NCHPAD). Exercises for Amputees. Available from: https://youtu.be/pGubJvanSf8
- ↑ Bodyweight Muscle. Amputee Functional Workout-Plan (Beginner to Advanced). Available from: https://youtu.be/Mk1IzZ4ZQpo
- ↑ David Clonts. Functional Training for an Amputee Part 1 – Single Leg Deadlift. Feb 2015. Available from: https://youtu.be/XqFxtH5D77I
- ↑ David Clonts. Functional Training for an Amputee Part 2 – Pistol Squats. Available from: https://youtu.be/WCYvjcIGMKQ
- ↑ David Clonts. Functional Training for an Amputee Part 3 – Balance Check Exercises. March 2015. Available from: https://youtu.be/XV7gerb2kEE
- ↑ Nolan L. (2009) Lower-limb strength in sports-active transtibial amputees. Prosthet Orthot Int. Sep;33(3):230-41.
- ↑ Soares AS, Yamaguti EY, Mochizuki L, Amadio AC and Serrao JC. (2009) Biomechanical parameters of gait among transtibial amputees: a review. Sao Paulo Med J. Sep;127(5):3012-9.
- ↑ Grummillier C, Martinet N, Paysant J, Andre JM and Beyaert C. (2008) Compensatory mechanism involving the hip joint of the intact limb during gait in unilateral trans-tibial. J Biomech. Oct;41(14):2926-31.
- ↑ Prinsen EC, Nederhand MJ and Rietman JS. (2011) Adaptation strategies of the lower extremities of patients with a transtibial or transfemoral amputation during level walking: a systematic review. Arch Phys Med Rehabil. Aug;92(8): 1311-25.