by David Hills and Mary Tebb of the Dorset Orthopaedic Company
Introduction
Intense periods of prosthetic intervention with one-on-one physiotherapy have been proven to be extremely beneficial in optimising an amputee’s ability potential, most notably in the UK through the rehabilitation services offered in recent years by the Ministry of Defence at Headley Court.
I work as a prosthetist with my colleague and co-author Mary Tebb, who is a physiotherapist for Dorset Orthopaedic, at its Southern clinic in Ringwood, on the edge of the New Forest.
Dorset Orthopaedic celebrates its 30th birthday this year and is pleased to continue to lead the way with provision of private Prosthetics and Orthotics throughout the UK.
In addition to our everyday clinical work, both Mary and I act as expert witnesses, either individually or on occasions, together, which we find works extremely well with some of the more complex cases we see come into clinic.
Over the years, we have seen huge advances in both surgical techniques and prosthetic technology and we work closely with a number of eminent surgeons and designers to ensure our patients receive the best treatment to suit their needs.
We are now regularly caring for amputees who have undergone Osseointegration surgery, which allow us to attach some of the most advanced bionic technology directly to their skeletons.
But one of the most successful services added over the past couple of years is a multidisciplinary Residential Rehabilitation service at both our Southern clinic in Ringwood and our Midlands clinic in Burton-on-Trent.
These packages of care are tailored to suit each amputee’s individual needs and can vary between a week and several months, depending on the level of complexity.
With many of our patients going through complex legal cases, this service is designed to assist them personally, as well as their referrers, and is now a popular request of both solicitors and case managers who are keen to see their client back on their feet (as such), as soon as possible.
Many of our patients have suffered life changing catastrophic injuries and our goal is to try to bring some normality back to their lives with a combination of amputee specific physiotherapy and improved prosthetics.
We are in the very fortunate position where we can offer support through a programme specifically designed to help them return to some of their previous activities, often by finding alternative and innovative ways to achieve their goals. Below is a case study of an example of one such client.
Background
Sharon (not her real name), a 55 year old female, had been a transfemoral amputee for nine months when she was referred to us through her case manager. Her amputation was elective and resulted from failed knee replacement surgery over a number of opera tions.
She had done well through her local NHS centre who had provided her with a standard prescription microprocessor knee, enabling her to walk with a stick for around half a mile. She had other difficulties to contend with, such as the results of a gastric bypass, and she lived alone with only occasional family support. Her home town was fairly rural and she had a large dog which needed regular walks. Sharon was keen to return to work and was studying for a degree via the Open University.
Our policy at Dorset Orthopaedic is to conduct a joint initial consultation with all new clients. Attending this consultation would normally be the client, their case manager and/or a family member or friend, one of our prosthetists and a physiotherapist. This enables us to fully assess the client and discuss their aspira tions both in the near and distant future.
We are able to offer either a full expert witness report, initial needs assessment or consultation with brief letter of recommendations, depending on the request of the solicitor or case manager.
When we first met Sharon in the autumn of 2018, we prepared an initial needs assessment report for her solicitor, with suggestions on how to make improvements both to her prosthetics and also ideas how to support her in returning to some of the activities she had previously enjoyed.
Her prosthetist suggested she trialled a more advanced microprocessor controlled knee, namely the Ottobock Genium knee over a two-week loan period, in conjunction with several hours of amputee specific gait re-education and confidence building with her Physiotherapist.
Sharon was immediately astounded by her new leg – both the Genium and the socket fit resulted in her feeling that “I’ve got my leg back”. She was able to purchase one with an interim payment via her solicitor and Sharon was also offered a week’s rehabilitation, which commenced the following month.
Sharon’s week began with a physiotherapy and prosthetic review whereby both subjective and objective outcome measures were taken (See ‘Summary of Outcome Measures’ below) and minor adjustments were made to the lining of the socket. She was then put through a circuit session of 3 x one-minute stations, which comprised a variety of balance, lower and upper limb exercises.
That afternoon, she was able to abandon her crutch to walk around a local garden centre, including in and out of summer houses, discussing how one of these could work as a therapy room at home as Sharon did not want to be a regular gym user.
The last half hour was spent working on using the stair function of the Genium knee – Sharon had to learn to slide the foot back and quickly place it on the stair, enabling her to walk up the stairs in a normal step over step manner. This clearly identified the need for stronger hip extensor muscles but also demonstrated to her that relatively normal stair func tion could be achieved.
Day two was spent outdoors as Sharon had previously enjoyed spending time in the open air and wanted to reclaim her confidence outdoors either on her own, with her dog or with friends. In the morning, she was taken into the New Forest to try out a variety of accessible bikes under the care of a local bike hire company and she had a one-to-one session with an instructor, which allowed Sharon to try a number of different accessible bikes.
She tried a tricycle initially, then a side-by-side recumbent bike and went on to manage a single recumbent bike as shown below. Her Genium knee can be quickly and remotely changed from walking to cycling mode and this showed Sharon how cycling could be achieved independently, probably with a pedal-assist bike to aid her up steeper slopes.
That afternoon, Sharon was taken to a local beach to work on a skill all amputees have to learn, descending slopes. Sensors located in the Genium knee quickly sense changes in activity and with a slope, the knee gradually yields under load while the heel strikes the ground. Body weight is then transferred over the foot as the line of gravity passes over the midfoot and then off the toes. Microprocessor knees such as the Genium are superb for descending slopes and stairs as they allow a pre-set controlled yield, pro moting safety during a controlled descent.
So, in addition to the zig-zag slopes to the beach promenade, Sharon also had a go at walking on the sand and covered a 1.25-mile course.
Walking on sand and gravel is a particular challenge for amputees as a prosthetic foot does not fully adapt to this type of terrain in the way that a human foot does. A human foot will literally “mould” to the ground by virtue of its skeletal structure and the long and short muscles which control this action. The ligaments, tendons and muscles then give feedback to the brain which relays corrective actions back to the foot, constantly ensuring balance and stability.
Most prosthetic feet will allow a small amount of movement at the ankle and a little side-to-side for stability. However, the perception of this is transmitted up through the mechanics of the prosthesis and absorbed in the soft tissues of the stump, effectively massively decreasing feedback to the brain. With practise, over time, other sensory feedback loops can accommodate and safety on uneven terrain can be improved. We find many patients appreciate the support and time we can give them to master this type of activity.
From a prosthetic perspective, it’s important that the microprocessor controlled knee remains safe at times like this and more advanced versions, such as the Genium, are programmed in such a way to constantly monitor a user’s gait and prevent falls or stumbles. On day three of Sharon’s programme, a longer walk in the New Forest was planned. This was largely in drizzly rain but Sharon managed a challenging twomile loop with inclines, mud and small streams to step over. Her Genium knee is shower proof but following this trip she began considering a waterproof version for future outings.
On returning to the clinic, Sharon wanted to spend some time on working on how she would enter a consultant’s office the following week for an appointment – a consultant who had told her she would not be able to walk again if she chose to have her leg electively amputated. She had some fun with role-playing this event and it gave her a chance to perfect walking through the door, where she would have to take a step or two backwards to open it. More advanced microprocessor knees have in-built accelerometers which make them aware of directional change. This ensures the knee does not collapse when walking backwards or sideward.
The afternoon featured swimming at a local pool. Sharon wanted to see if she could manage to access and egress the pool safely and independently. She left her prosthesis behind in her locker and using crutches walked to the poolside. After some coaching, she was also able to exit from the side ladder of the pool. The main problem however was managing to carry her clothes and prosthetic leg to the locker while using crutches. This made us realise a water activity leg would be advantageous here, even if she decided not to take it into the water itself.
Throughout the week, Sharon worked with her physiotherapist on improving the quality of her gait pattern and on the morning of day four, she specifically did a variety of gait and balance challenges out in the car park — changing speed, stride length, direction, carrying a weight and resisted walking. This was followed by a relaxation half hour with guided imagery and contract-relax sessions to see what might work best for her. As amputees have considerably increased energy demands when walking, learning successful relaxation methods can be helpful to practise during the day.
In the afternoon of day four, Sharon was taken to a busy shopping centre to practise being in crowds, around a multi-storey car park and repeated use of escalators. She soon found ascending escalators was possible, but stepping onto a descending escalator was much more of a challenge. Sharon had a number of attempts at this and became more confident as time went on.
On the final day, Sharon went through a variety of gym ball exercises with her physiotherapist and then a home exercise programme featuring strength training two to three days a week, balance activities most days and and cardio-vascular activities, which we felt she could do independently. All outcome measures were repeated and a prosthetic review was also undertaken.
Discussion
It is interesting to note these improvements over just five days.
Improvements in confidence and gaining skills by focused repetition seem to have made some of the difference in Sharon’s case. We feel this is due to a combination of a better prosthetic knee, an improvement in socket comfort and the intensity of a weeklong programme of physical activities, which are all normal to everyday life.
Following a programme of residential rehabilitation such as this, our normal practise is to update the client’s case manager or solicitor and make recommendations for future care.
In Sharon’s case, we recommended provision of a water activity leg, which she would use for beach walking and paddling with her dog and using in or around a swimming pool. We felt justified in recommending an Ottobock Genium X3, which is fully waterproof and has the same characteristics as Sharon’s Genium everyday knee.
This would mean both prosthetic legs would feel identical in use, when walking on slopes and when ascending or descending stairs.
If a non-microprocessor knee were provided, safety would be compromised as these knees do not have the yielding and anti-stumble functions provided by advanced microprocessor knees such as the Genium or Genium X3. Hence if Sharon continued to walk in the manner she has now learnt, she would likely fall. An alternative would be a prosthetic leg with a fully locked knee. However, a locked knee would result in a different and unnatural walking pattern, which would have adverse effects on Sharon’s musculoskeletal system.
Following provision of a water activity leg, Sharon expressed a desire to return to our facility to try various water activities, such as kayaking, water-based exercises and going to the beach over a second intensive week.
Conclusion
Intensive rehabilitation at Dorset Orthopaedic is a service which has been offered to our clients for several years now. Initially these programmes have been for a week or two but, for some, they have returned on a number of occasions to assist in their re-integration back into society and the activities which they have previously enjoyed. Most have made significant gains both physically and psychologically feeling more confident and able to undertake activities they enjoyed pre-amputation.
For more information on how Dorset Orthopaedic can assist with the Rehabilitation of your clients and with the preparation of Prosthetic and Physiotherapy Expert Witness reports, Initial assessment reports or non-compliant assessments please contact; enquiries@ dorset-ortho.com 01425 481743 or 01283 227893
Additional notes About Mary Tebb:
Mary Tebb is a Senior Physiotherapist with more than 25 years’ experience, including in the USA and New Zealand. With Dorset Orthopaedic, much of her role sees her getting out of the clinic and into the wider community to help patients feel more confident in their day-to-day activities.
About David Hills:
David Hills is a Prosthetist who has worked with Dorset Orthopaedic for over 20 years and undertaken expert witness work for slightly longer. Working out of clinics located in Ringwood Hampshire, Harley Street London and Exmouth in Devon, David has experience fitting all levels of upper and lower level amputees with a special interest in complex multiple limb loss cases, Bionic technology and Paediatrics.
