Adolescent Sarcoma Patients' Intense Rehabilitation with Exercise program.

The Adolescent Sarcoma Patients' Intense Rehabilitation with Exercise (ASPIRE) program is a rehabilitation/training concept for amputees that evolved from a research project which took place at The Hospital for Special Surgery in New York City from 1986 to 1992.

Background

Past research (Otis, Lane & Hillyer, 1984; Otis, Lane & Kroll, 1985) on patients at Memorial Sloan-Kettering Cancer Center who had undergone either limb-sparing surgery or amputation for bone cancer, showed that net energy cost (NEC), or volume of oxygen used per meter walked per kilogram of body weight, of those individuals with a lower limb amputation was significantly greater than that of the non-disabled control group; while preferred velocity (VEL), or speed of walking, was significantly slower. In addition, percent of maximum aerobic capacity (MAC) required for this same group to ambulate at preferred velocities was increased. Indeed, many having above knee (A/K) amputations needed greater than 50% of MAC just to walk at their preferred speed. Increased oxygen requirement such as this makes it impossible to sustain any kind of activity, putting this group of individuals at a disadvantage. In their study, Pitetti, Snell and Stray-Gundersen (1987) found those with lower limb amputations, wearing their prostheses, expended from 20-100% more energy per kilogram of body weight to ambulate than did their non-disabled counterparts walking at the same speed.

In 1984, and, indeed, in many places at the present time, traditional rehabilitation of patients having a lower limb amputation consisted of teaching skin care and wrapping techniques for the residual limb, strengthening exercises for sound and residual limbs, and basic gait training to enable them to accomplish activities of daily living (ADL). Expectations for the future were fairly limited; those who wished for a more active lifestyle had to pursue this on their own. As the explosion of state-of-the-art technology in prosthetics had only just begun, many patients reluctantly accepted the fact that because they were wearing an artificial leg they could not expect to be either as comfortable or as active as they had been.

Treatment for bone cancer by this time had also improved. With better diagnostic and surgical techniques and the addition of adjuvant chemotherapy, the survival rate for these younger individuals with amputations (the median age for diagnosing osteogenic sarcoma being 17-18 years) had risen from 17% in 1972 to 70% in 1984. It was mainly the plight of these teenagers that stimulated the idea of training them as athletes. Would this improve their efficiency while walking, and perhaps enable them to participate in sports again?

In 1986 a research project was started at The Hospital for Special Surgery. The primary aim was to study effects of aggressive aerobic training on energy cost measurements of individuals with amputations. It soon became apparent, however, that before participating in such a study, most individuals first needed help emotionally and prosthetically. Therefore, the program was divided into three components--psycho-social support, prosthetic care, and rehabilitation/training.

Psycho-Social Support

Psycho-social support included introducing a role model as early as possible. Where an exact match could not be found, specially made videotapes were used to demonstrate abilities of other similar individuals. One benefit of videotapes is that they can be viewed again and again. They are also available immediately.

Patients were informed about the sequence of events they could expect after surgery--postoperative care, rehabilitation, prosthetic fitting, and how they could expect to spend the rest of their lives. One of the most frequently heard complaints from patients who had been treated initially in other institutions was lack of information; so, a 35-min videotape (Rossbach & Pline, 1992) was produced which gives a general overview of postamputation care through the dramatized lives of four patients. This commercially available tape is an efficient, convenient method of disseminating information in situations where patient education departments are unavailable. An adult selfhelp support group was started and continues to meet to discuss problems of common interest.

Prosthetic Care

To enable patients to participate in more aggressive exercise programs, prostheses had to be comfortable, lightweight, energy-efficient, and durable. They also had to be fabricated in ways that the normal changes in alignment necessary as amputees participate in more aggressive training could be facilitated. Whenever possible, patients with above-knee and below-knee amputations were fitted with flexible, total contact, suction sockets which help eliminate inefficient pistoning of the prosthesis and allow maximum use of residual muscles. Such sockets also provide the most complete sensory feedback and control of the prosthesis in gait and functional activities. The above-knee sockets were ischial containing. Energy storing feet were prescribed. These are made of a variety of materials which provide a flexible keel to absorb the energy of footfall, store a varying portion of the force exerted on them, and return a percentage of that force at terminal stance to initiate the next step. Hydraulic knee joints are preferred for the above-knee amputee; titanium and carbon composite materials are used to reduce weight, while at the same time providing strength.

Subject Characteristics

Eligibility criteria for the study included--

* All participants had to be between the ages of 7-75.

* All cancer patients had to be tumor-free and off chemotherapy.

* All cancer patients who had received chemotherapy agents adversley affecting the heart had to have an echocardiogram evaluated by their cardiologists.

* All non-tumor patients had to have their physician's permission to participate.

* All participants had to be wearing their definitive prosthesis and had to have been wearing a prosthesis for a minimum of one year.

* All participants had to have previously received traditional rehabilitation.

All participants were tested for oxygen consumption and stride analysis before starting the exercise program and at regular intervals thereafter.

Methods

A Douglas bag technique was used to measure energy cost at rest, and at three different speeds during paced walking--free, 80% of free (slow), and 120% of free (fast), around a 19.8m track (see Figures 1, 2). Speed of walking was controlled by a series of flashing lights set around the perimeter of the track; participants were asked to walk one meter behind the last light. After they had achieved a steady state, expired air was collected in the Douglas bag via a mouthpiece (the nose having been occulded with a nose clip). This sample was then analyzed for oxygen and carbon dioxide content, and the volume measured by spirometer. Heart rates were measured at regular intervals with an Exercentry[TM] heart-rate monitor.

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Stride analysis was accomplished using a switch stride analyser to measure stride length, single limb support time (time spent on each foot while the contralateral one was in the air), and double support time (amount of time spent with part of each foot on the ground). Energy cost measurements included net energy cost (NEC), amount of oxygen required per meter walked per kilogram of body weight, velocity (VEL), speed walked in meters per minute, normalized energy rate (NER), amount of oxygen required per minute to maintain a level of kinetic energy, and heart rate (HR).

Training Program

The six-month supervised training program consisted of three weekly sessions, each of one-hour duration. One half-hour was devoted to muscle strengthening using progressive resistance exercise machines. These machines, which can be found in health clubs and sports medicine departments, use a variety of exercise modes to increase strength in muscles of the extremities and trunk. Examples include variable resistance machines where resistance is altered throughout the range of motion, free weights (concentric or eccentric resistance), and variable or isokinetic machines, where the angular velocity of movement is controlled. The remaining half-hour focused on aerobic conditioning where heart rates were elevated through exercise to between 60 and 75% of maximum, utilizing the following equation--

WHR = (I) [(220-CA)-BHR] + BHR 

WHR = Working Heart Rate; BHR = Basil Heart Rate; I = Intensity; CA = Chronological Age 

To improve endurance while ambulating, a treadmill was the piece of equipment of choice for this portion of the program. However, this was impossible to achieve immediately. Therefore, cycle ergometers, rowing machines, and upper body ergometers were used alone or in combination until the participant could complete the entire half hour on the treadmill.

Results

Of 116 participants who started the program, 74 (63.8%) completed three months; ages ranged from 7 to 68 years. Reasons for amputations included cancer, 44 (59.5%), trauma, 21 (28.4%), diabetes, 2 (2.7%), and congenital, 7 (9.5%). Significant improvements in NEC, NER, VEL, and RHR were shown. In addition, symmetry of gait improved in the A/K but not the B/K groups. However, B/K's (which included six bilaterals) were initially closer to normal.

Outcomes

Successful conclusion of the study showed that a program consisting of muscle strengthening and aggressive aerobic conditioning can reduce the amount of energy individuals wearing prosthetic limbs use to ambulate, thus making ADL easier and participation in sport possible. Because it is no longer necessary to wait a year before starting such a program, rehabilitation can be more aggressive immediately. Although each patient's program may differ slightly due to individual differences, the following post-amputation regimen was found to be ideal:

* Apply a lightweight rigid dressing or a lightly compressing ace bandage at the time of surgery to reduce swelling in the residual limb, which in turn increases circulation and hastens healing. Replace the cast with the ace bandage as soon as it loosens. Teach patients how to wrap residual limbs themselves, as the bandage must be reapplied each time it gets loose or slips. Pay special attention to shaping the distal end, apply equal tension all the way up to the groin, and secure around the waist on the A/K, and above the knee on the B/K. Use elastic stump-shrinkers also.

* Start physical therapy on the first postoperative day to prevent flexion contractures, improve circulation, and increase strength. Teach ambulation with a walker or crutches as soon as possible.

* Cast the patient for the preparatory prosthesis after the third day post-operatively, and where possible, deliver the prosthesis within 48 hours. Start basic gait training with minimal weight bearing immediately. Ideally, this all takes place before discharge from the hospital. Make preparatory A/K prostheses with an ischial-containing, adjustable socket, a simple knee joint, an energy storage foot, and lightweight components. TES belts, made of neoprene, seem to provide comfortable suspension. Make B/K prostheses with a fenestrated pelite-type liner. Patients then use a pull sock to slide the residual limb into the liner which can now be made to fit more intimately, encouraging shrinkage.

* Use a cycle ergometer for aerobic conditioning before suture removal in addition to routine rehabilitation, once out of the hospital.

Primary short term goals include:

* Understanding of prosthetic components and simple maintenance (i.e., shoe height and the prosthetic foot, knee mechanism, cleanliness of the socket, etc.);

* Care of residual limb (i.e., wrapping techniques, cleanliness, and skin integrity);

* Improved balance;

* Improved strength;

* Improved endurance.

Primary long-term goals include:

* Smooth efficient gait;

* ADL independence (i.e., curbs and stairs, uneven ground, bathtubs and showers, carrying packages, etc.);

* Productive physical lifestyle (i.e., being able to return to school or job, run a household, enjoy hobbies, etc.);

* Advanced gait activities (i.e., running and participation in other sports).

The aim is to try and develop a smooth, efficient, and normal looking gait pattern and return the patient to a physical and productive lifestyle. By incorporating general principles of muscle strengthening, flexibility, and cardiovascular training, as well as specific gait training techniques and functional strengthening of the residual limb, these goals can be achieved. The program gradually incorporates advanced gait activities, including hopping, skipping, running, jumping, and participation in sports.

Functional strengthening involves principles of closed kinetic chain exercises. These are exercises performed when the foot, in this case the prosthetic foot, is in contact with the ground. Examples include squats, both single and double leg, balance board and weight shifting exercises, and leg press. Performing weight-bearing exercise on the prosthetic side in a functional manner, teaches the muscles of the residual limb control of the prosthesis during walking, as well as in other functional activities, including running and other sport activities.

Closed kinetic chain exercises and weight-bearing exercises force the muscles in the residual limb to act in a synergistic cocontraction mode. The synergistic action of two or more muscle groups around a joint acts to stabilize it to perform a specific action. In gait, and in other functional daily activities, our muscles work primarily synergistically to move our bodies through space. Principles of closed kinetic chain exercises for the lower extremities are based on the idea that leg muscles work primarily when our feet are on the ground (Panarello, 1991). Therefore, it is important to learn the neuromuscular control of a residual limb in a weight-bearing mode.

Primary muscle groups which need to be trained and strengthened in individuals having an A/K amputation are the hip extensors (to provide push off and initial propulsion in gait), hip abductors (to provide pelvic stability and lateral control of the prosthesis), and hip flexors (to provide forward propulsion of the prosthesis in the swing phase of gait) (New York University Post-Graduate Medical School, 1983). Those having a B/K amputation must also strengthen the quadriceps, hamstrings, and gastrocsoleus muscles. In addition, to develop a normal looking gait pattern, both groups must train paraspinal extensor and abdominal muscles. Cardiovascular training, sometimes overlooked, must be included in this aggressive training program. Whether the amputation is due to trauma, peripheral vascular disease, or cancer, effects of the amputation of a limb can signficantly compromise the cardiovascular function.

Initial gait training includes:

* Manual cueing (i.e., indicating working muscles during a stride sequence by touching them, initiating weight change during gait by manually pushing, etc.);

* Verbal cueing (i.e., same as manual cueing but using voice commands);

* Videotape feedback;

* Visual feedback with a mirror; and,

* Treadmill work.

Advanced gait training includes:

* Plyometrics (i.e., single and double leg hopping and jumping to develop explosive power and strength;

* Hop/skip running (i.e., the simplest form of running which involves the following sequence-- --stepping forward with the sound leg --hopping on the sound leg while swinging through the prosthetic leg --shifting weight to prosthetic side --immediately transferring weight to sound side;

* Leg over leg running (i.e., mimics the able-bodied reciprocal running pattern with full weight transfer to the prosthetic side during the swinging forward of the sound side. Asymmetry between the sound and prosthetic side will always appear in stride length and the amount of time spent on each foot; and,

* Sports competition (i.e., track, distance running, etc.).

Keys to successful training/rehabilitation include:

* Appropriate selection of prosthetic components (i.e., for expected lifestyle, age, availability of prosthetic service, etc.);

* Correct fitting and alignment of prosthesis;

* Good communication between prosthetist, therapist, physician, and patient;

* Aggressive physical therapy/training; and,

* Motivated patient.

Conclusion

A multidisciplinary approach to rehabilitation of individuals who have had amputation of a lower limb, or limbs, is the optimal form of treatment. This includes psychosocial support, improved prosthetic care, traditional rehabilitation, followed by cardiovascular training, aggressive strengthening of the sound and affected limb, and aggressive gait training. Philosophy of aggressive gait training means not limiting goals of ambulation to basic walking on level surfaces. To function minimally in daily life one needs to be able to walk at varying speeds, on various surfaces, to run and to jump. Participation in recreational and competitive sports requires a much higher level of fitness. Before development of energy storage feet and hydraulic knee components, only someone with a single B/K amputation had the capability of running with any semblance of normal gait pattern. With proper components and incorporating dynamic balance exercises, plyometric jumping drills, ballistic kicking, and aggressive training on the treadmill, as well as specific teaching of use of the prosthetic limb, it is now possible for most A/K amputees to develop the confidence and skills to run with an efficient leg-over-leg gait.

The main purpose of any rehabilitation program is not to torture patients with repetitive exercises, but rather to prepare them for re-entry into the mainstream. The icing on the cake for many participants in ASPIRE has been to test new found abilities in a variety of sporting events. Each year the juniors compete in the Sports Ability Games of the Junior Orange Bowl in Miami, as well as in The New York State Parks Games for the Physically Challenged.

For many of them it is the first time they have been away without a parent, and perhaps the first time they have had to put their prostheses on by themselves. It is a chance for them to be with others in the same boat, and they take advantage of it by, as one ten-year-old put it, "crawling under the covers and talking about our operations"--a custom-made junior self-help support group!

A second self-help support group has been added to the program for parents with very young children with limb deficiencies. This group, which meets on an as needed basis, has appreciated two teenage role-models who have attended some of the meetings and shared experiences of growing up with a physical disability. Both indicated that participation in sports had boosted their self-confidence and given them unexpected opportunities to travel.

As skill in the sports arena improves, worry about cosmetic appearance of the prosthesis is put into perspective; in fact, many are proud of their space age appearing appendages and wear them without a cosmetic cover. ASPIRE has been lucky enough to have been adopted by a Road Runners Club (Plainview Old-Bethphage), which raises funds through their races. ASPIRE athletes regularly participate in two of these races, one a 10K, the other a 50 mile Ocean to Sound Relay Race. Althogh mainly for able-bodied runners, both have divisions for several disability groups. Each year a significant number of ASPIRE athletes compete in the Amputee Nationals; many hold current world records, and fifteen ASPIRE athletes participated in the Paralympic Games held in Seoul and Barcelona. ASPIRE is not, however, only about sports. It is about being able to do what one wants to do, and that only happens with training.

This program improves confidence, coordination, strength, endurance, and body image. It requires dedication, discipline, and drive on the part of the participant and the health care provider or coach. It is more than worth the effort because achieving physical proficiency reduces feelings of helplessness, and excelling at sports counteracts the feeling of being disabled. As modern technology and training methods improve, amputees will be able to compete on a more equal level with their nondisabled peers.

One simply has to look at athletes who went to Barcelona for the Paralympic Games to see what can be achieved. Such role models train with the same dedication as their non-disabled counterparts, often with little support or encouragement, as they prove nothing is impossible.

Selected References

New York University Post-Graduate Medical School. (1983). Lower limb prosthetics, (pp99-102). New York: New York University Press.

Otis, J.C., Lane, J.M., & Hillyer, C.D. (1984). Energy consumption in postoperative osteogenic sarcoma patients. In E.Y. Chao & J.C. Ivins (Eds.), Tumor Prosthesis for Bone & Joint Reconstruction (pp 465-469) New York: Thieme Stratton.

Otis, J.C., Lane, J.M., & Kroll, M.A. (1985). Energy cost during gait in osteosarcoma patients after resection and knee replacement and after above-the-knee amputation. Journal of Bone and Joint Surgery, 67A, 606-611.

Panarello, R.A. (1991). The closed kinetic chain in strength training. National Strength and Conditioning Journal, 13(1), 30-31.

Pitetti, K.H., Snell, P.G., Stray-Gundersen, J. & Gottschalk, F.A. (1987). Aerobic training exercises for individuals who had an amputation of the lower limb. Journal of Bone and Joint Surgery, 69 (6), 914-921.

Rossbach, P.G. (Producer), & Pline, NJ (Director). (1992). All in their stride [Film]. Plainfield, NJ: Patient Education Press.