High level rehabilitation of amputees
- 1 What is high level rehabilitation?
- 2 Who qualifies for high level rehabilitation?
- 3 The ideal high level rehabilitation team
- 3.1 Physiotherapist
- 3.2 Prosthetist
- 3.3 Coach
- 3.4 Strength and conditioning specialist
- 4 Specific considerations for high level amoutee athletes
- 5 Resources
- 6 References
What is high level rehabilitation?
High level rehabilitation in amputees refers to the process whereby individuals with amputations (IWAs) are rehabilitated to the level that they are able to participate in physical exercise and/or sport. The primary obejctive after a lower limb amputation is to be able to walk again and once this achieved, physical fitness should be developed to the extent that it will counteract the effects of a sedentary lifestyle on general health. Recent studies detailing the adverse effects of prolonged sitting in able bodied bi-limbed individuals (ABBLs), should be stressed, as IWAs frequently prolong periods of sitting once they are able to walk effectively. Thereafter, the opportunity to participate in sport recreationally or competitively should be encouraged as a personal goal; this may even lead to participation at a pinnacle event like the Paralympic games.
Physical Fitness for General Health:
The basic physical fitness guidelines according to the ACSM  in order to combat “lifestyle diseases” for ABBLs and IWAs are:
- Cardiovascular Fitness: 30-60 minutes of moderate activity for five days a week, or 20-60 minutes of vigorous activities three days a week. This can be performed in short bursts of at least 10 minutes at a time and accumulated over the day, or in one session.
- Strength Training: 2-3 days a week of strength training.
- Neuromotor Exercise: Also known as functional fitness training is recommended 2-3 days per week. Motor skills like balance, agility, coordination and proprioception should be trained. It could be argued that this may be even more important for IWAs than for ABBLs.
In a study by Chin T et al (2002) , IWAs show the same the ability to improve physical fitness as ABBLs. There are no studies which determine exercise prescription details for amputees, so until such data exists it may be possible to apply comparable, but monitored prescriptions to IWAs. However, bear in mind that there is research supporting the fact that the higher the level of the amputation, the higher the energy demand  . IWAs require considerably elevated levels of effort and thereby energy expenditure to effect the same work rates compared with ABBL individuals. Elevation in heart rate which assists with combating heart disease, diabetes and certain cancers can be achieved through swimming, hand cycling etc, and this may be preferable during times when there are stump problems, but if at all possible, weight bearing exercise should be included to allow for mineralisation of the long bones in the body and thereby to combat the development of osteoporosis. Examples of weight bearing exercises include fast walking, jogging, running and to a lesser extent cycling.
Brugaru et al (2011)  reviewed a number of studies on amputee outcomes and concluded that sport should be included in an amputee rehabilitation programme. Interestingly, a training programme designed specifically to improve hip strength resulted in sufficient improvement in prosthetic walkers, to afford running (Nolan, 2012)  . Importantly, without ongoing training these strengthened individuals deteriorated and many returned to being prosthetic walkers only. The importance of these components in all physiotherapy amputee rehabilitation is therefore apparent.
Physical Fitness for Sports Participation and/or Competition:
In amputees who would like to advance their fitness levels and enter competition, depending on the level of the competition, they may benefit from a sports coach to specifically train them for performance. At all levels, the value of a prosthetist in helping to decide if and when to progress to a sports prosthesis is helpful.
Who qualifies for high level rehabilitation?
Although this usually refers to competitive or elite athletes, any amputee who has reached the level of function where they are able to ambulate effectively with a good gait pattern should be encouraged to develop further improvements to allow for participation in at least fast walking, but possibly jogging or running. Cognisance of considerations for high level athletes should also be borne in mind but are not as important in the participation-only population group (see Specific considerations for high level amputee athletes below).
Once participation progresses to competition, rehabilitation/training should be more intense and outcome-focussed. 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
The ideal high level rehabilitation team around the amputee athlete should include the physiotherapist, the prosthetist, the coach and in more elite athletes the strength and conditioning specialist . The roles often overlap and the team is most effective when decisions are made in collaboration with each other and with the athlete. In broad terms though, the roles could be described as follows:
Basic assessment should have taken place including details of the stump, medical history, medication, level of function etc. (see Assessment of the Amputee). If this basic assessment has not been done, it should be done at the start of any programme.
Yellow flags should be assessed like home circumstances, emotional state and an assessment of expectations from the athlete.
Sport readiness assessment should include both the residual and intact limbs: joint integrity and range of movement, strength and endurance and flexibility should be assessed. Overall the assessment should include: gait (walking and running), cardiovascular fitness, core strength, balance, proprioception and compensatory mechanisms and anomalies like muscle imbalances. History of previous injury, including prior to amputation if appropriate. This is particularly important as previous injury has been identified as a risk factor for further hamstring injury (Forsekis et al(2011) , Petersen et al (2011) , Bahr (2013) , Freckleton et al (2012)  and Henderson et al (2010) )
Formulation of an individual problem list and plan:
The information gleaned from the assessment will allow one to develop a problem list specific to that individual and thereafter a goal directed plan to deal with those proble
Basic strength and conditioning:
Attainment of GrV+ should be the goal of basic strength and conditioning. All major muscle groups (including upper limbs) should be rehabilitated and sport specific training could be introduced as strength developed. Examples would be increasing resistance at the end of range for sprinters and developing good eccentric strength to help prevent injury (Sebelien et al , Stanton et al(1989) , Schmitt et al (2012) ). Training could be in the physiotherapy rooms and at home, in the gym, in the pool and in situ on the sports field
Core stability training is critical in amputees where balance becomes compromised, resulting in diminished limb power outputs. Again sport specific training could be included like core training over a moving base of support, progressing to core training while performing the sport eg running.
Gait training, including running gait:
Interestingly, most high level athletes have gait anomalies. Identification of these anomalies at an early stage is more effective when it is decided to try to correct gait patterns. If the athlete is already performing at a high level, gait anomalies are often left as is, due to the risk of decreasing performance by changing gait patterns. Gait anomalies may be habitual only, but are more often linked with compensatory mechanisms from joint inflexibility, muscle weakness, poor balance etc. Knowledge of gait patterns in ABBLs is important when assessing gait in IWAs, as is knowledge of common gait patterns which develop in amputees.
Return to sport, or Begin sport assessment:
These performance markers are often decided between the physiotherapist, the coach and the strength and conditioning specialist.
The requirements of the athlete and the condition of the stump and limb are very important for the prosthetist. Knowledge of the physiotherapist’s findings at assessment is therefore important. Choice of prosthesis is made specifically with all this information in mind.
Paralympic/amputee coaches must have a deep interest and good knowledge of muscle function, imbalances, gait and the risks posed to an IWA athlete. The coach, like other professionals involved with high level rehabilitation has no researched guidelines to follow; each IWA presents with their individual amputation and their individual compensatory mechanisms and anomalies. Training programmes must be constantly revised and tailored for the individual - following traditional training programmes without careful monitoring and assessment, commonly leads to injury.
Strength and conditioning specialist
The importance of a strength and conditioning specialist is to develop optimal conditioining for the specific sport or recreational activity. The physical demands of sport include aspects like strength, power, stability, balance and endurance and therefore an intensive individualised conditioning programme is recommended for high level participation.
Again, the ideal scenario is for the physiotherapist, coach, strength and conditioning specialist and prosthetist to work closely together.
Specific considerations for high level amoutee athletes
In transtibial amputations (TTA) the intact leg is stronger than in the amputated leg, but as would be expected, the difference is less than it is in non sports participators (Nolan, 2009) . Increased energy absorption and energy generation at the hip of the amputated leg, compensates for the loss of plantar flexors on that side (Soares et al 2009). There is an increased work load in the intact limb (energy absorption and generation) in unilateral TTA and this intensifies when the amputated limb is painful (Grumillier et al 2008) . When training at performance level, the training loads and demands on the intact limb are even greater. This should be taken into consideration when training programmes are designed.
Prinsen et al. (2011)  made some interesting findings regarding adaptation strategies in amputees: They found that eccentric hamstring power was increased in the intact compared with the amputated leg in TTA, but that eccentric quadriceps power was greater in the amputated compared with the intact leg.
When one considers the above finding, the question arises that if the compensation and adaption occur with walking gait, will it differ during sport movements and how will it impact the biomechanical needs of the specific sport task? How will it differ with sport prostheses or in the context of a sport like sitting volley ball etc?
Compensatory mechanisms are therefore often difficult to identify and obviously vary between athletes.
Specific Risks for high level amputee athletes
Mechanical Overload: One of the greatest risks for lower limb amputees is overload. Overload due to compensatory mechanicisms and putting the body in a non-optimal biomechanical position due to the prosthesis. Our observation is that the hamstring muscle in the intact limb is particularly vulnerable to injury. Research has shown that the load absorption in the knee joint of the intact leg is also increased load during ordinary activities of daily living. This should be considered in the design of conditioning programmes as well as for recovery purposes.
Physiological overload: Due to the higher energy demand and less muscle mass available to generate forces in the limb, physiologically the athlete might need longer recovery times. This is highly dependant on the level of the amputation.
Programmes to address these considerations
Strength development: The same principles of strength development apply for IWAs as for ABBLs. The sport or activity chosen should determine the most important movements to train. Due to the human body’s ability to compensate and adapt, the movements should be clearly evaluated for compensatory mechanisms. The type of prosthesis selected is important. Only when a movement is done in a biomechanically efficient manner, should load be increased. Electively certain movements may be performed without a prosthesis (especially for trans-femoral (TF) amputations); such as plyometric jumping. Training load can be increased by either making the movement more complex, increasing the resistance, increasing time to fatigue or increasing the speed of movement.
Stabilisation: Core stability and hip joint stability is crucial in amputees. Programmes should address static stability and also dynamic stability. Frequently static stability is excellent but dynamic control and stability is poor due to the lack of movement in the prosthesis. When the athlete performs competitive movements, the control should be advanced and with a large endurance base. Upper body compensatory mechanisms to address postural adaptations should also be monitored.
Endurance training: Due to the greater energy demand and the increased mechanical load, it is important to determine the training load for endurance training on the biomechanical application of the sport. When an athlete starts to fatigue, the biomechanics adapt. For instance in sprinting, the athlete may first fatigue on the amputation side and then start to run with an unequal stride pattern. From a cardiovascular point of view the individual might still be able to continue, but by running in a biomechanically incorrect pattern, mechanical overload on the sound side is increased Out of personal experience we have found that high intensity interval training, with short rest periods in between reps, is more conducive to better biomechancial performance.
Flexibility: Both sides, the amputated side as well as the non amputated side should have good flexibility. Range of movement flexibility of the joint closest to the amputation should be maintained.
- Frequency: Practically it has been found that unloading days should occur more frequently in weight bearing activities such as running than for ABBL.
- Intensity: Be aware that when selecting training intensity, maximum heart rate might be affected due to the lack of active muscle mass and therefore normal calculation of Max HR may not be correct. Weight training intensity should be determined carefully. Overload on the intact limb is likely to already be higher than on the amputation side. Err on the side of caution and train with less intensity and ensure that all available muscle mass is functioning at optimal capability.
- Time: As described above it is recommended to use biomechanically sound movement pattern retention to guide the duration of a training set.
- Type: As described above the type of exercise should be selected based on the movement competency of the individual as well as on the type of sport or activity. The consideration of prosthesis type will impact on the decision.
Robert Gailey – DVD set: Functional training and running series: Functional Prosthetic training for transtibial or transfemoral amputees. Advanced rehabilitation therapy.
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