1. And the effects of Diabetes

2.  62 y.o.  Black Male  5’7”  177.7 lbs  Poly-pharmacy  Multiple diagnosis including diabetes

3.  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

4.  Admitted to skilled nursing facility for 30 days for prosthetic training on January 8, 2007

5.  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

6.  See pt. 4-5x/wk for 4 wks  45-60 minute treatment session  Strength training exercises  Balance exercises  Gait training with prosthesis  Diabetes education

7.  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.

8.  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

9.  Individual Characteristics  Performance characteristics of prosthesis  Fit and suspension of prosthesis  Alignment of prosthesis during functional activities

10.  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

11.  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

12. › Strengthen intact LE › UE strengthening › Balance and coordination activities  Weight shifting onto prosthesis and energy efficient gait pattern are emphasized

13.  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

14. Gailey, R., Gailey, A., Sendelbach, S. (1995). Home exercise guide for lower extremity amputees. Miami, Florida: Advanced Rehabilitation Therapy, Inc.

15. Consider:  Quality of gait improves as the individual becomes more experienced ambulating with prosthesis  Is prosthesis donned and suspended correctly?

16.  Vaulting – inadequate clearance of prosthesis Causes: › Individual weakness of hip flexors and abdominals › Difficulty or fear of initiating knee flexion

17.  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

18.  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

19.  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.

20.  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

21.  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

22.  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.