Oct 20, 2015
Back in Action
Timothy Baldwin

By blending his athletic training skills with the science of prosthetics, this author is helping amputees re-enter the world of sports participation.

The following article appears in the November 2015 issue of Training & Conditioning.

Regaining an active lifestyle can be a challenge for amputees. They undergo basic physical therapy following amputation, but it typically ends once they can safely ambulate in their prostheses. If they want to return to athletic and fitness endeavors, they have limited opportunities.

About five years ago, the University of California, San Francisco’s Department of Orthotics and Prosthetics (O&P) wanted to bridge this gap and give amputees their lives back. This ambition led to the formation of the Amputee Comprehensive Training (ACT) Program, a daylong clinic held every November since 2011.

The mission of the ACT Program is to maximize the physical and functional potential of those who have lost limbs. Our comprehensive team incorporates a diverse series of training modalities and advanced gait analysis equipment to motivate a community of amputees to get active again.

It’s amazing to see how far we’ve come in just a few years. Getting the program off the ground has helped me grow as an athletic trainer, and the lessons I’ve learned can apply to sports medicine providers in all settings.

LAYING THE GROUNDWORK

The ACT Program started to take shape in late 2010. Alex Hetherington, CP, a Prosthetist in the Department of O&P, was looking for ways to incorporate O&P into amputee rehab and make it more like the rehab of able-bodied athletes. For instance, a basketball player returning from an ACL tear tackles both limb strengthening and sport-specific skills in their recovery. This latter focus on preparing for future activity was missing from most amputee rehabs.

Alex collaborated with Matthew Garibaldi, CPO, Director of the O&P Department, and they eventually came up with the idea for the ACT Program. The first hurdle in getting it off the ground was obtaining funding. The O&P budget comes from the UC system’s Orthopaedic Surgery Department. Alex and Matt wanted the ACT Program to be free for amputees, so they worked hard with the department to cover the cost of facility rental and compensation for any invited presenters.

Once funding was acquired, Alex and Matt had to find a space to house the ACT event. Fortunately, the O&P clinic is across the street from the Bakar Fitness and Recreation Center at Mission Bay, a four-story fitness facility. Alex and Matt spoke with the managers, who were happy to let us rent the space.

Another administrative necessity was spreading the word about the event. Alex and Matt invited their patients from the O&P clinic to attend and put advertisements for the ACT Program in multiple O&P magazines. They also partnered with the Challenged Athletes Foundation, which specializes in working with athletes with physical challenges, and Össur, an orthotics and prosthetics company, to reach a larger population of amputees.

ADDING ATs

Early in the planning process, Alex and Matt realized the ACT Program lacked a professional who was knowledgeable about stage three and four rehabilitations, especially pertaining to sports and high-level activities. They identified athletic trainers as an ideal fit for this role.

This is where I got involved. While interviewing in the summer of 2011 for a position as an athletic trainer in the Department of O&P and the PlaySafe program, which is a nonprofit athletic training outreach initiative that offers contract coverage to local high schools, Matt asked if I was interested in being a part of the ACT Program. I instantly jumped on board.

Athletic trainers benefit the active amputee population in a number of ways. For starters, we have a different mission and background than orthotists and prosthetists. Most O&P professionals have degrees in engineering, so they see angles, dimensions, and the capabilities of a prosthesis. However, athletic trainers look beyond mechanics, and we work to rehabilitate the amputee as a whole for better use of their prosthesis.

In addition, athletic trainers’ knowledge of anatomy goes a long way with amputee patients. Once we know what musculature an individual is lacking, we can determine how to compensate for it. Take an above-knee amputation, for example. The patient loses their quads and hamstrings, but athletic trainers can help them adapt using core strengthening and glute and hip flexor activation.

A final skill athletic trainers bring to the table is a continuum of care. Surgeons, physical therapists, and O&P professionals are often limited to one stage of the rehab process. But athletic trainers can provide prehab prior to amputation, guide the individual through the initial stages of rehab, continue to work with them as they go through physical therapy, and take over completely when physical therapy is over. This consistent care is especially important with new amputees as they grow, change, and adjust to their prostheses.

Once I was hired, I began working with patients in the O&P clinic and partnered with a prosthetist on a comprehensive assessment and training plan for the ACT Program. To better understand the current state of rehabilitation, I surveyed a number of our clinic’s amputees, both athletes and non-athletes. Working closely with them allowed me to determine which exercises were optimal for this population. I also studied amputation levels and observed amputee gait and traditional training programs.

Additionally, I dove in headfirst to learn how to build the prostheses used by our patients. Within a few months, I could perform most prosthesis tech work and maintenance. Getting my hands dirty helped me better understand the mechanisms and capabilities of the devices.

Accounting for all of this information and following a systematic analysis (and some trial and error), I created Focused Amputee Strength Training (FAST). This is an individualized strength training program designed to address the main issue I observed in amputees: muscular imbalances. Its goal is to help active amputees compensate for musculature that is unused or no longer available by developing core strength, gluteal activation, and balance with modified exercises.

AT THE CLINIC

We draw 60 to 80 amputees at a typical ACT clinic, ranging in age from seven to over 65. We’ve had participants from New York, Florida, Texas, and even the Bahamas. Most of our attendees are lower-limb amputees, but we also get a small number of upper-limb amputees at each clinic.

The events are staffed entirely by volunteers, typically numbering between 60 and 70. The two athletic trainers from my O&P clinic participate, in addition to professionals from other UCSF clinics and San Francisco General Hospital. However, a large majority of our volunteers are family members of the amputees.

The day starts with teaching an activity for three or four hours. One of our frequent morning sessions is a running clinic. Each amputee partners with a volunteer, and they are funneled to either a beginner or advanced course. The beginner course is a how-to clinic for amputees who are new to running, and we guide them through the motions step by step. The advanced session is for amputees who already know how to run but want to fine-tune their mechanics.

In the afternoon, participants go through a series of assessments to improve their mobility. They start by meeting with physical therapists, who perform manual muscle testing and range-of-motion evaluations. Then, they rotate to me or another athletic trainer, and we assign specific FAST exercises based on the physical therapist’s recommendation.

The most important thing we consider when determining a patient’s FAST protocol is their overall goal with the training. Some participants simply want to go to the mall without feeling exhausted afterward, while others want to train for the Paralympics.

All FAST protocols begin with a four-page handout I created that lists a variety of exercises to address the general deficiencies seen in amputees. I meet with each patient to see where they are in their recovery and pick different exercises from the handout for them to concentrate on. Then, I show them how to complete each movement. The amputees receive take-home programs, and I follow up with them to see how they are progressing.

Since every amputation and prosthesis is unique, we individualize each FAST protocol. With creativity, almost any exercise can be adapted for any patient.

For example, one of the first amputees I worked with was a mixed martial artist who specialized in Brazilian jiu-jitsu. He was an above-knee amputee who lacked core and glute activation on his amputated side. To address his glutes, I had him do squats and lunges with TRX ropes. Using his upper body, he would lift himself into a squat or lunge position. Then, I taught him how to finish the movements by activating his glutes when he reached a certain angle.

To work the athlete’s core, I had him do modified planks called “leg drags.” Standard planks are difficult for above-knee amputees because their prostheses lack the ability to lock their knee in a prone position. However, with leg drags, the athlete would lift himself to a plank position and let his legs drag behind him. Then, he’d use his upper body to walk a certain distance. He developed his core strength by keeping himself from rotating too heavily one way or the other.

Following the FAST session, we bring our clinic attendees to the UCSF Human Performance Center, where they undergo instrument-assisted gait analysis. Clinical specialists place markers on them to record and evaluate their running gaits. We go over everyone’s gait analysis as a group at the end of the day, and each amputee gets a copy of their session to take home on a flash drive.

Finally, we like to introduce a new skill through a group activity. In 2014, the Amp1 basketball team-a stand-up amputee squad-held a basketball camp, which was a great way to teach new skills of cutting and jumping.

BUILDING A BOND

When helping amputees regain an active lifestyle, the physical component is obviously significant. However, the ACT Program also addresses the mental and emotional barriers they have to overcome. The initial stages of grieving over their limb loss and lack of mobility can be a heavy burden and impede motivation.

The ACT Program seeks to alleviate this burden by fostering a community where amputees can support each other. It’s not uncommon for some participants to be more reserved than others. For many, it’s their first time seeing another person with a prosthesis. Sometimes, all it takes to get them involved is a veteran amputee asking them to partner up, or they may be inspired by seeing another amputee fall and get back up during an activity. That simple bond and camaraderie can be infectious enough to help motivate people to overcome their shyness and fear.

Another way we try to acknowledge and overcome any mental barriers is by building trust between our ACT Program practitioners and our active amputees. However, when I meet a patient for the first time at an ACT clinic, this isn’t always easy to do.

I’ve found the best way to gain trust is to listen well. Hearing the concerns of the amputees, repeating them back, and explaining how I can help builds a bond. It also allows me to create an individualized program. This is no different than taking a strong history when working in a traditional athletic training setting.

At the 2014 ATC clinic, I had the chance to put my listening skills to good use. One of the amputees in attendance was a man in his mid-60s who used a motorized chair. He didn’t like being in public due to discomfort and embarrassment but came to the clinic because his wife made him.

He told me about his lifestyle, and I listened as he listed all the things he could no longer do. As an active person, I related how difficult it would be for me to not be able to do the things that I loved, and I could sympathize with how he was feeling.

The activity that afternoon was yoga. After 25 minutes of listening to the man’s concerns and explaining how we could address them, I suggested we get down on the yoga mat, and he agreed. As we started to try some basic poses, he quickly became more comfortable. I was holding him to help him balance, but I let go after a while and allowed him to do the poses on his own.

Once the man realized he could do the movements independently, he got excited and wanted to try more difficult poses. By the time the session ended, he was dripping sweat and exhausted, but he had a big smile on his face and said he loved every minute of it. I think taking the time to listen and understand his concerns helped pave the way for him to have that experience.

SKILLS TRANSFER

Many athletic trainers may think they’re unable to work with active amputees because they have limited (or no) training or knowledge of the O&P field. However, many of the skills developed in more traditional athletic training settings transfer well to providing care for this population.

The biggest overlap for me has been my communication skills. Through PlaySafe, I provide athletic training services to a local high school once a week. Because I see these athletes and coaches so infrequently, I have to maintain contact with them via email, texting, and phone calls. Likewise, since I may only see ACT clinic attendees once a year, I must communicate with them effectively to stay updated on their progress and any adjustments that have been made to their training or prostheses.

Much of my knowledge about rehab also carries over to working with active amputees. When I first started working with the ACT Program, there wasn’t much information available on the type of rehab we were looking to provide, so I relied on many of my past athletic training experiences when designing protocols.

For instance, when I worked with NCAA Division II athletes in graduate school, I had to make minute changes to their movement mechanics to help them achieve the same performance results while exerting less energy. This is similar to assessing the way advanced amputees use their prosthesis and identifying any micro changes needed to compensate for deviations.

Athletic trainers interested in O&P work can get involved in a number of ways. To start, volunteering at an O&P clinic can give you a glimpse into this unique world. This is especially easy if you already work in a hospital setting. If you enjoy the field, becoming a Certified Fitter of Orthotics is a great way to become more knowledgeable. It also makes you more appealing to O&P clinics, which use athletic trainers to help with brace fitting and work with amputees.

Looking ahead, we’ll likely make some tweaks to the ACT Program as it continues to grow. One way is by expanding our offerings. For example, I’m working on developing a FAST protocol directed toward proprioceptive training. Amputees can have a difficult time understanding where their prosthesis is in space because it’s not attached to their skeletal anatomy, and I’m curious to see if proprioception training can help with this.

In addition, we’d like to expand our reach by drawing bigger crowds. To do this, we’re thinking of changing the venue to AT&T Park-home of the San Francisco Giants-or making it a weekend-long program.

I tell everyone my favorite day at work is when we hold the ACT Program clinic. It’s the only day of the year when more than 100 people arrive with a smile and leave eight hours later with even bigger ones. The joy of working in the amputee community can be infectious, and I feel fortunate to be a part of the ACT Program.

SCALED DOWN

When we first started the University of California, San Francisco’s Amputee Comprehensive Training Program, our goal was to hold one clinic a year due to limitations in funding, time, and staff. However, we’ve expanded our offerings to include smaller clinics several times a year.

These sessions are usually half-day events, and we strive to hold them quarterly. Because they are only a few hours long, we generally attract a more local crowd and less than a dozen attendees.

Our goal with the smaller clinics is to teach a specific skill or activity. In the past, we’ve done sit volleyball, cycling, and yoga.

One of our most popular small clinics focused on teaching amputees how to fall correctly. By utilizing the mechanics taught in jiu-jitsu and hapkido, amputees learned skills in falling at varying angles to prevent injury. Although this skill isn’t about returning to sports, it prepares amputees for incidents that are going to happen. Plus, feeling more secure in falling may give them the confidence to be more aggressive or take more risks in their activities.


Timothy Baldwin, MS, ATC, is an Athletic Trainer and Certified Fitter of Orthotics in the Department of Orthotics and Prosthetics at the University of California, San Francisco, where he customizes braces and works in the Amputee Comprehensive Training Program. As a member of the PlaySafe staff in the UCSF Orthopaedic Institute, Baldwin also serves as an outreach athletic trainer to Balboa High School in San Francisco. He can be reached at: [email protected]
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