Joseph Roche BankstownLidcombe Hospital 28417 Clinical question Hip abductor strength training article LL amputee changes in mm compositionfunction Falls incidencerisks LL amputee ID: 606434
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Slide1
Literature Review – Hip abductor significance in Lower Limb Amputees
Joseph Roche
Bankstown-Lidcombe
Hospital
28/4/17Slide2
Clinical questionHip abductor strength training articleLL amputee changes in mm composition/functionFalls incidence/risksLL amputee biomechanics
Clincal
implications/discussions
OverviewSlide3
For LL amputees…- Does isolated hip abduction strengthening alone improve function in LL amputees? Clinical QuestionSlide4
“A single blind, cross-over trial of hip abductor strength training to improve timed up and go performance in patients with unilateral, trans-femoral amputation,”Pauley T, Devlin M, Madan-Sharma P (2014) J Rehabil Med vol46 pp264-278
Critical Article AppraisalSlide5
VASCULAR TFAs>65 years old (mean 67)Fitted with prostheses for >6 months (mean 7.3 years)Not involved with concurrent exercise programAble to complete all testing proceduresBASELINE CHARACTARISTICS:
Supine hip abductor strength difference
No significant difference for Activities Specific Balance Confidence Scale (ABC), TUG, 2MW, Houghton Scale or abduction strength in sitting/side lying between groups
Participants
http://
www.ledbrookclinic.co.uk
/
fred
-
bradley
-above-knee-amputee/Slide6
EXPERIMENTALCycle ergo warm-upSeated Machine “Cybex”3x 10RM / 2x per week~8 week programWhen able to complete 3x10, 2.5kg progression
CONTROL
Table mounted arm ergo 2x/week
Rx DescriptionSlide7
Eligibility Criteria:
Random
Allocation:
Concealed
Allocation:
Baseline
Comparibility
:
Blind
Subjects:
Blind
Therapists:
Blind Assessors:
Adequate
Follow-up:
Intention
-to-treat:
Between-group comparisions:Point Estimates and variability:PEDRO SCORE: 7/11Slide8
Cross OverEC group (n=9): 67 day experimental, 55 day washout, 69 day control phaseCE group (n=8): 66 day control, 49 day washout, 63 day experimental phaseRandomisedNHMRC classification level II (High quality RCT)
Method
GROUP 1
GROUP 2
Control
Control
Exp
ExpSlide9
(Experimental group relative to control)Primary Outcome:Mean of 17% improvement in TUG >half the subjects achieved minimal detectable difference of 5.7 second change (schoppen et al)
Secondary outcomes:
7% improvement in 2MW12% improvement in ABC
11% improvement in seated hip
abd
strength
ResultsSlide10
No outcome measures of physical balance taken (only confidence questionnaire)Subjects provided monetary reimbursement for transport as well as “modest honorarium”Strength benefits suggested to drop off during washout, but no follow-up as to whether participants sought independent strength training program post intervention periodSmall sample size (n=17)LimitationsSlide11
Dynamometry Considerations
Fulcrum at hip joint
Effort lever of mm’s
Load lever of where force is applied
The longer the lever (more distal the dynamometer) the harder it is to produce the same amount of force.Slide12
TFAs+TTAs (n = 12/12)(Sherk et al 2010):Glute medius +
glute
minimus atrophied up to 30% (note range 0-30%) in comparison with intact side.Relationship between stump length and level of atrophy
Statistically significant difference of LL body fat percentage between amputees and normal
Changes in LL tissue following amputationSlide13
TFAs (Ryser et al 1988):“Capactiy for isometric torque production by the abductors on the prosthetic side is as much as 30% less than the intact side.”
Affected
vs Intact StrengthSlide14
Elderly TTAs (n = 23)(Nadollek et al 2002):Centre of pressure (COP) measured in different static positions.
Found a statistically significant relationship between hip abductor strength and:
WB on affected limbReduced medio-lateral COP excursion under amputated limb
Gait (stride length,
stance:swing
ratio, double support)
Hip abductor strength and lateral controlSlide15
Is important!Is commonly poor for LL amputees2x training sessions per week beneficialShould be trained for life So hip a
bductor strength…Slide16
Elderly NH Residents (not amputees)(Wolfson et al 1995):“Subjects with a history of falls have less than half the LL strength of non-fallers.”
Direct relationship demonstrated between strength and risk of falls.
LL strength and fallsSlide17
TTAs and TFAs (n = 41)(Wong et al 201,):Subjects: Age range 34-82 (mean 56.9)Mostly male TTAs of vascular origin
Findings:
56.1% of subjects had falls
29.3% had recurrent falls
fall frequency correlated to
injury severity (p = 0.008)
Significant correlation between injury and
ABC (p = 0.001)
Falls incidence in AmputeesSlide18
TFAs (James and Oberg, Murray, and Zuniga et al):Longer stance phase on intact side (longer swing on affected)Larger BOSCorrelation between
BOS and pelvic displacement
Increased double support timeSelf selected comfortable walking speed 29% slower than normal comparison
Common Gait FindingsSlide19
- Jaegers et al (1995) Slide20
COM displacement laterallyShoulders/trunk lean to counterbalanceloading of affected leg
step length
Hip abductor moment throughout stanceSlide21
Sub-acute and longstanding TTAs/TFAsDealing with inpatients over a 1-4 week periodUsually less active, b/g of vascular issuesTrain Isolated/Part Practice/Whole task
Strong focus on task specificity in training
No parallel bars…
My patients may benefit from a 2x/52, 10RM hip
abd
strength training regime!
My current
exp
/biases
Photo by: Daniel
Treacy
, Previous Senior Amputee PT at BNK
©
2017 Australian Physiotherapists in Amputee Rehabilitation.Slide22
How will this change the way I manage amputees?What are people doing in other areas for Strength testing?Training strength on affected LL before/after prosthesis?Keeping up to date with EBP within their dept/individual PD?
DiscussionSlide23
Sherk vD, Bemben mg, Bemben DA. interlimb muscle and fat comparisons in persons with lower-limb amputation. Arch Phys med
rehabil
2010; 91: 1077–1081.Bohannon rW. reference values for extremity muscle strength obtained by hand-held dynamometry from adults aged 20 to 79 years. Arch
Phys
med
rehabil
1997; 78: 26–32.
Schoppen
T,
Boonstra
A,
groothoff
JW, de
vJ
,
goeken
Ln,
eisma WH. The Timed “up and go” test: reliability and validity in persons with unilateral lower limb amputation. Arch Phys med rehabil 1999; 80: 825–828. Jaegers Sm, Arendzen JH, de Jongh HJ. Prosthetic gait of unilateral transfemoral amputees: a kinematic study. Arch Phys med rehabil 1995; 76: 736–743.Ryser DK, Erickson rP, Cahalan T. isometric and isokinetic hip abductor strength in persons with above-knee amputations. Arch Phys med rehabil 1988; 69: 840–845ReferencesSlide24
Nadollek H, Brauer S, isles r. outcomes after trans-tibial amputa- tion: the relationship between quiet stance ability, strength of hip abductor muscles and gait. Physiother
res
int 2002; 7: 203–214.Wolfson L, Judge J, Whipple r, King m. Strength is a major factor in balance, gait, and the occurrence of falls. J
gerontol
A
Biol
Sci
med
Sci
1995; 50 Spec no: 64–67.
Wong CK;
Chihuri
ST; Li
GRisk
of fall-related injury in people with lower limb amputations: A prospective cohort study. J
Rehabil
Med. 2016; 48(1):80-5 (ISSN: 1651-2081)
Pauley T, Devlin M, Madan-Sharma P. A single blind, cross-over trial of hipabductor strength training to improve timed up and go performance in patients with unilateral, transfemoral amputation. J Rehabil Med 2014; 46: 264-278References (cont)