Ellie Thompson: From Patient to Prosthetic Professional

Ellie Thompson:
From Patient to Prosthetic Professional

Ellie Thompson has only ever known how to walk using a prosthesis. As a child, she was diagnosed with proximal femoral focal deficiency, or PFFD, a rare birth defect that affects the length of the femur and often leaves the person with a shortened limb and no knee cap.

Ellie has had to go through a lot of difficulties throughout her life. Her prostheses didn't include a knee until she was 10 or 11, so she learned how to do everything with a straight left leg. In school, her leg stuck straight out when she sat at her desk; she learned how to ride a bike by only pedaling with her right leg. She also had to deal with kids making fun of her because she was different.

While Ellie has gotten used to the challenges, the fact remains that it still takes more exertion and energy on her part (about 65 percent more) to walk across a room than it does for someone who doesn't rely on an above-knee (AK) prosthesis. She has to deal with constant back pain and all the limitations that come with wearing a transfemoral prosthesis. However, she has found enjoyment in helping fellow amputees as part of the Optimus Prosthetics staff.

Ellie started her career in the industry working for her prosthetist, where she learned the basics of prosthetic and orthotic fabrication. After two years, the company was purchased by Glenn Schober, CP and she worked 12 more years with Glenn, gaining patient care experience, until the business was sold. Ellie worked as a lab supervisor in Lima, OH until she became the first hired employee at Optimus Prosthetics in 2007. As fate would have it, Glenn joined the Optimus staff five years later as the Clinical Manager of the Dayton location, meaning Ellie is once again working for the person who introduced her to prosthetic patient care.

As a certified Prosthetic Assistant, Ellie spends most of her time working directly with patients. She enjoys this part of her job the most because she is able to show them there is hope, that life isn't over, that the limitations of being an amputee can easily be conquered with the right attitude. When she shows patients that she wears a prosthesis, it helps comfort them knowing that she can relate to what they're going through.

Because of this connection to patients and her high level of professionalism, Ellie has proven herself to be an invaluable asset to us at Optimus Prosthetics. We consider ourselves extremely lucky to be able to have such a determined and caring person like Ellie on our staff!

K-Levels: A Classification System with Issues

We've touched on Medicare audits before because of their invasiveness and inefficiency. A related and equally important story surrounds "K-levels." We want to discuss a little bit about what the K-level system is and what type of problems this system has.

The system was developed by the Centers for Medicare and Medicaid Services in response to highly advanced prosthetic technologies becoming more widely available. It was put in place to help CMS payers get the information they needed to determine which device is medically necessary on a per patient basis. The K-levels break down as such:

K0: The patient doesn't have the ability or potential to ambulate or transfer safely with or without assistance, and a prosthesis doesn't enhance their quality of life (not eligible for foot/ankle or knee unit)
K1: The patient has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at a fixed cadence (eligible for external keel, SACH feet or single axis ankle/feet; eligible for single axis, constant friction knee)
K2: The patient has the ability or potential for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs or uneven surfaces (eligible for flexible-keel feet and multi-axial ankle/feet; eligible for single axis, constant friction knee)
K3: The patient has the ability or potential for ambulation with variable cadence, can traverse most environmental barriers and may have certain exercise activity that requires prosthetic use beyond simple locomotion (eligible for flex-foot and flex walk systems, energy storing feet, multi-axial ankle/feet or dynamic response feet; eligible for fluid and pneumatic control knees
K4: The patient has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills exhibiting high impact, stress or energy levels, typical of prosthetic demands of the child, active adult or athlete (any ankle-foot system or any ankle-knee system appropriate)

However, there have been many concerns with the K-level system. Many industry professionals feel the methods used to classify a patient are subjective; they are easy to use in a clinical setting, but don't translate well to the real world. K-levels also don't take into account a patient's potential to shift between levels. But perhaps the biggest issue among O&P practitioners is that the system is vulnerable to fraud and misuse, two contributors to the Medicare audits resented by practitioners across the country.

There has been a push to find a better way to evaluate patients and ensure they have the right device they need for maximum functionality. Optimus Prosthetics will keep our patients and referring medical professionals up to date with any changes as they happen, so be sure to watch for updates in future newsletters.

Jim's Corner

Residual Limb Extension- Pushing and Pulling

Jim Scharf, PTA

The goal of "Jim's Corner" is to provide helpful information and be a resource for those helping patients fitted with prosthetics learn to use them correctly in order to enjoy a better quality of life as an amputee.

Last month I discussed the importance of the patient's residual limb extension. I would like to continue with this theme for one more month and add it to the concept of "pushing and pulling" within the socket. I have been preaching the importance of "pushing" down to strengthen the extensors, and the "posterior push into the back wall of the socket" for stance stability. Please refer to last month's column for why residual limb extension is required.

In gait, the femur moves forward and backward in relation to the pelvis. For the amputee patient the femur will have to "push" and "pull" within the socket. The patient will have to "push the socket forward" from a position of hip extension (terminal stance or toe off) into hip flexion for prosthetic swing. When the prosthetic foot makes contact with the ground (initial contact or heel strike) the patient's femur will have to "pull the socket backwards" from the hip in flexion into extension. This "pulling backward" will provide the posterior push or the pressure on the back wall of the socket to help maintain stability.

A logical first question would be "where do I start to prepare the patient for this pushing and pulling?" The best place to start is with the supine residual limb extension into the towel we covered in column 2. For review purposes:

Supine Hip Extension

The patient is to lie on their back with a large towel roll or a rolled up blanket under the residual limb. They are to push the residual limb down into the towel roll while they straighten their thigh at the hip, and if it possible, lift their buttocks up off the surface. Cue the patient not to compensate for hip weakness by over-recruiting the back.

Hold for 2-5 seconds. Repeat 5-15 times. Do 1-3 sets.

This is a great place to start the patient on the road to recovery and should be started as soon as possible. A large number of patients are unable to lie prone on their stomach due to other medical problems that make it difficult for them to breathe in the prone position. But if the patient can tolerate the prone position, the following are excellent exercises to perform.

Prone Stretch & Hip Extension

The patient is to lie prone and place a large towel roll or a rolled up blanket under the residual limb. Just lying in this position can be a great passive stretch. Then the patient is to lift the residual limb off the towel roll while keeping the pelvis flat on the surface. If it is too difficult for the patient to lie completely prone, you may place a small pillow under their hips for comfort. Decrease the use of pillow as able.

Hold for 2-5 seconds. Repeat 5-15 times. Do 1-3 sets.

Many amputee patients, especially the transfemoral/above knee patients, will have very weak hip extensors and never develop the use of their muscles to stabilize their prosthetic knee. As stated before, weak hip extensors result in poor residual limb extension which leads to difficulty with control of the prosthetic knee, resulting in:

Poor knee control.
Lack of confidence in the prosthesis and themselves.
A decrease in functional ability.
Fear to shift weight to the prosthetic side.
Knee will buckle right underneath them.

We have two great exercises to start the patient strengthening up the extensors in the way they will have to use their muscles "pulling" the prosthesis back into extension by pushing on the back wall of the socket. But how do we strengthen the muscles for "pushing" forward in the socket?

Prone Hip Flexion

Instead of a straight leg raise (which does not strengthen the muscles in a way the patient will have to use them) the patient is to lie prone and place a large towel roll or a rolled up blanket under the residual limb. Push the residual limb down into the towel roll and if able, lift the pelvis. If it is too difficult for the patient to lie completely prone, you may place a small pillow under their hips for comfort. Decrease the use of pillow as able.

Hold for 2-5 seconds. Repeat 5-15 times. Do 1-3 sets.

Now we have three good pre-prosthetic strengthening exercises (there are a lot of others), to strengthen the residual limb muscles in the way that they will have to use them for prosthetic use.

To combine the two concepts before the patient receives their prosthesis could be using a metronome to start to develop the rhythm that will be needed for prosthetic gait. For this drill the use of a hand held metronome is a tool that can be very helpful. There are free web sites, free apps (I use a free app on my phone) or metronomes that can be purchased at music stores.

Push & Pull with a Metronome

To perform the "push & pull metronome drill" stand the patient inside the parallel bars with their walker or another stable object to hold onto for safety. Start at a speed that is in line with the patient's abilities. You may have to start with a slow speed to help the patient learn how to perform. I prefer to use a 2/4 time for the rhythm. As the patient progresses we can increase the speed, or vary the speed for the changes in speed that are required in everyday life. Carefully monitor the patient for they can fatigue surprisingly quickly with this drill. Also watch for patient frustration. It is OK for the patient to start with a slow speed and then progress as able.

1. Start the patient with the residual up.

2. Then the patient is to "pull" the residual limb backwards all the way thru bringing the hip to full extension with the pelvis kept level.

3. Then when all the way backwards, "push" the residual limb all the way forward straight.

4. The patient is to try to match their "Push & Pull" to the "Tick Tock" of the metronome.

Since all amputee patients are much stronger with flexion (hip flexors) we want to establish good residual limb extension. Usually their flexors are so much stronger than their extensors. In my opinion the patient will probably want to compensate with the spine for a lack of strength and range of motion at the hip. I think we need to focus on the quality of the movement and proper amplitude of motion at the hip and not the spine.

Jim Scharf, PTA, Prosthetic Assistant/Gait Specialist

Jim has been a Licensed Physical Therapist Assistant since 1988. Jim has worked with lower extremity amputee patients throughout his career. He serves as a Gait Specialist and Liaison when prosthetic patients are meeting with their therapists. Feel free to contact Jim if he can assist you in any way at: jscharf@optimusprosthetics.com.

Ellie Thompson: From Patient to Prosthetic Professional

K-Levels: A Classification System with Issues

Jim's Corner: Residual Limb Extension- Pushing and Pulling

D = Dayton Area

C = Columbus Area

**Office Closed Nov. 28th and 29th for Thanksgiving**

Completing Course #1 - "Amputation & Prosthetic Overview"

No classes scheduled

Completing Course #2 - "Lower-Limb Prosthetics: Transtibial"

C - Tuesday, Nov. 5

Scioto Point - 12:00

C - Monday, Nov. 11

Summit's Trace - 12:00

D - Tuesday, Nov. 19

Southview Hospital - 12:00

C - Thursday, Nov. 21

Regency Hospital - 12:00

Completing Course #3 - "Lower-Limb Prosthetics: Transfemoral"

C - Wednesday, Nov. 6

Franklin Woods - 12:00

C - Thursday Nov. 7

Laurels of Norworth - 12:00

D - Wednesday, Nov. 13

Greene Memorial Hospital - 12:00

C - Wednesday, Nov. 13

Westminster-Thurber Retirement Community - 12:00

C- Thursday, Nov. 14

The Gables at Green Pastures - 12:00

D - Tuesday, Nov. 19

Wilmington Nursing & Rehab - 12:00

Course #4 - "Lower Extremity Amputee/Prosthetic Evaluation & Outcomes Measures"

C - Tuesday, Nov. 5 - Highbanks Care Center - 12:00

D - Monday, Nov. 11 - Kettering Medical Center - 12:00

C - Tuesday, Nov. 12 - Columbus Rehab and Subacute Institute - 12:00

Course #5 - "Lower-Limb Prosthetic Gait Training"

No classes scheduled

Course #6 - "Lower-Limb Prosthetic Gait Deviations"

D - Wednesday, Nov. 6 - Pinnacle Pointe - 12:00

D - Thursday, Nov. 7 - Neuro Rehab and Balance - 12:00

D - Monday, Nov. 25 - Crestview Manor - 12:00

Course #7 - "Upper-Limb Prosthetics"

D - Thursday, Nov. 14 - Otterbein by Atrium - 12:00

D - Thursday, Nov. 21 - Neuro Rehab and Balance - 12:00

Course #8 - Prosthetic Advances

D - Tuesday, Nov. 12 - Crossroads Rehab and Nursing - 12:00

Course #9 - "Partial Foot, Ankle/Knee/Hip Disarticulation, & Transpelvic Prosthetics"

D - Wednesday, Nov. 13 - Fidelity Home Health Care - 8:00 am

Course #10 - "Microprocessor Controlled Knees"

D - Wednesday, Nov. 13 - Fidelity Home Health Care - 9:00 am

Optimus Prosthetics, Dayton
8517 North Dixie Drive, Suite 100/300
Dayton, Ohio 45414
(937) 454-1900

Optimus Prosthetics, Columbus
3132 Olentangy River Road
Columbus, Ohio 43202

(614) 263-LIMB (5462)

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