A New Center
Therapists discuss how to best assist returning vets who have gait disorders associated with limb loss.
By Danielle Bullen
Veterans sacrifice greatly for their country, some even losing their extremities in combat. According to the Pentagon, about 6 percent of the casualties in the conflicts in Afghanistan and Iraq have returned home with one or more limbs amputated.1 New gait mapping technology, combined with the old-fashioned sweat equity of dedicated physical therapists, helps these wounded warriors adjust to their prosthetic legs and get on with their active lives.
Therapists at Washington's Walter Reed Army Medical Center and San Antonio's Center For the Intrepid treat servicemen and women from Operation Iraqi Freedom and Operation Enduring Freedom. ADVANCE spoke to two of them, Robert Bahr, MSPT, of the Military Advance Training Center at Walter Reed, and Captain Terrance Fee, PT, DPT, OCS, of the Center For the Intrepid, about rehabilitation technology, tools and the challenges of working with this unique patient population.
ADVANCE: What have been some of the advancements in lower-limb prosthetic technology?
Bahr: The Military Advance Training Center has the latest advancements in prosthetic wear. Oftentimes we have things before the market. Amputees can try different prosthetics. The majority of our patients are under age 30, and the standard model leg does not meet the needs of this younger population. Many of them chose mechanical legs so they can be in control.
Dr. Fee: The Center For the Intrepid provides rehabilitation as well as research and training. With our patient population we are able to test different prosthetic devices in order to compare products that best serve our patients. We have an amazing on-site prosthetic team who stay at the forefront of state of the art prosthetic device development and fabrication. Multiple prostheses are fabricated here, each based on each individual patient's needs and with their specific goals in mind. We work closely together as a team to ensure that each patient is trained to properly use their specific prosthesis in order to maximize their function and achieve their specific goals.
ADVANCE: Describe the rehab process. What exercises do you use?
Bahr: We start people within a few days of their arrival even before they've been fitted for their prosthesis. We have a three-pronged approach-cardiovascular exercises, core exercises and the strengthening of residual limbs. Patients start with balance exercises on balls. Once their sutures come out, they're casted for their prosthesis. Then they progress to walking by using parallel bars, walkers, crutches and finally canes.
Dr. Fee: Our multidisciplinary team that includes physicians, physical therapists, occupational therapists, prosthetists and recreational therapists work together to ensure patients are actively participating in strengthening and conditioning exercises. Our inpatient therapists start with exercises such as the upper-body ergometer to improve aerobic conditioning. We work on improving aerobic tolerance as many patients are deconditioned, having been bedridden for some time with other comorbid injuries. Lower-extremity exercises such as four directional hip exercises (extension, flexion, abduction, adduction) are started at bedside to strengthen the hips and pelvis in preparation for ambulating again. Initially, body weight and gravity are all that are needed, while rubber tubing and pulleys may be added later when tolerated. Core strengthening exercises are also started early on: bridges, planks, crunches, prone "superman" or "skydiver" back extension exercises. We start on a mat and progress to bolsters, physio balls, etc. We know that amputees have a higher incidence of back pain later in life, so lumbopelvic stability exercises are a must. When patients begin gait training, we work on standing tolerance and equal weight bearing into their sockets. Once ambulation endurance improves on level surfaces, we train on uneven terrain, like slopes, stairs and curbs that mimic situations patients will encounter in the real world. We also train people how to fall down as safely as possible, and how to recover.
ADVANCE: What are some tools you use to assess gait in patients newly fitted with prosthetics?
Bahr: At the gait lab, patients are photographed with markers on the limbs to capture how they move with their prosthetic legs. The gait lab gives physical therapists personalized recommendations for each patient.
Dr. Fee: Our goal is to obtain a smooth and efficient gait as possible. The basics never go away. Practice and repetition are key. A lot of what we do doesn't require anything too involved. Like everyone else, most of our gait training involves observing patients walking across the clinic floor while verbally correcting gait deviations. We are very fortunate to have an amazing gait lab on site. The CFI Military Performance Gait Lab is staffed by a superb research staff who assess patient gait and movement patterns using dozens of infrared cameras and multiple force plates set in the ground, treadmill and stairs. Gait assessment reports are then provided to each therapist to help with treatment planning. We also have a "CAREN"-a computer-assisted rehabilitation environment. This is a three-dimensional total immersion screen that gives patients and therapists a 360-degree view of their gait in different virtual reality environments and helps progress patients through progressively challenging gait and balance scenarios.
ADVANCE: How do you address balance dysfunction?
Bahr: When someone experiences a limb loss, they need to find a new center of gravity. We challenge them to recruit the muscles necessary to relearn their balance. Patients progress from sitting to kneeling to finally standing while wearing their prosthesis. Physical therapists and patients practice reaching techniques, sitting and reaching for a hand or cones beyond the center of balance. They also toss balls back and forth to work on finding the center of gravity.
Dr. Fee: Balance training is started before patients are fit for their prostheses. They practice being prone or supine on bolsters and then progress to sitting on physio balls. Therapists challenge balance manually or have patients reach in multiple planes with weights, rubber tubing or medicine balls. Single-limb standing balance exercises are started without the prosthesis to facilitate the patient's ability to do tasks in single-leg stance. Once they receive their prosthetic limb, patients must practice weight-shifting between their prosthetic leg and sound leg. Step-ups on a stool are a good way to do this. Patients stand on their prosthetic limb and slowly step up on a stool with their sound limb. This forces their body weight onto the prosthetic side. The residual limb hip must stabilize as the patient tightens the same side glutes and quads while pushing down into the floor.
Patients progress from standing supported by parallel bars to using a walker, crutches, canes, then unsupported. Within the parallel bars, they do heel-to-toe rocking motions, side-to-side shifting and diagonal patterns to get used to feeling the weight shift, eventually letting go of the handrails. On the floor, therapists place cones and ladders to create obstacles, forcing patients to make linear and lateral directional changes, progressing to 90- and 180-degree turns. Patients can stand on their prosthetic limb and rapidly roll a tennis ball under their sound foot in multiple directions. The prosthetic side must stabilize the body.
Physical therapists can also use a reflex hammer for proprioceptive training. They start with tapping on the toe, heel and medial/lateral side of sound foot followed by the prosthetic foot. They teach patients to associate the vibration in their prosthetic limb with their residual limb.
ADVANCE: What's the ultimate goal of rehab?
Bahr: They want to be able to carry on the activities they did prior to injury in the most efficient way. About six to ten percent of patients are able to stay in the military and continue their career. The goal of all patients is to lead a normal life. They want to be able to stand up and greet people face-to-face.
Dr. Fee: This is a young, active population. They want to get back to the life they were living before their amputation, running around with their kids, playing sports, maybe returning to the military. The goal is for each patient to function at the highest level they can so they re-integrate back into a healthy productive life. We have recreation therapy, community integration therapy and peer mentorship. New patients can see the potential displayed in their fellow patients who are a little further along in the rehab timeline. It is quite an eye-opener.
ADVANCE: What are the biggest challenges and rewards with working with these patients?
Bahr: We treat them in a common room. Patients who've been there longer will go up to newcomers and say, "I was like you three weeks ago." This makes them highly motivated. It's very rewarding when they leave here and get to continue with their lives.
Dr. Fee: We keep going until we maximize potential. We need to challenge them physically and make it fun and interesting and prevent boredom. We have an amazing multi-disciplinary team and a state-of-the-art facility. I don't know how many facilities like this exist in the rest of the world. This perfect rehab environment is a bridge to what they may face in real world.
