Multiple Amputee

Question:

I have a 23 year old female client who is a multiple amputee. She has no right arm from the shoulder, the left arm is gone from just above the elbow, one leg is missing from below the knee and one just from above the knee. She is obese and does not use any prosthetics. She is quite mobile getting in and out of her electric wheelchair, and she says she can get into a pool although not swim a full length. I have thought of assisting her with cardio in the pool using some floating devices. I would like some ideas on what movements I can do in the pool or equipment I can use. Please help.

Answer:

The big plus in this situation is that your client can get into the pool and swim. I have seen a man with no legs but with two complete arms swim in a pool by tethering himself to the pool edge. He would swim for about a half hour each day and was able to pull himself out of the water to return to his wheelchair. Since your client can swim, this might be a way to do some cross training for cardio, as long as she can get in and out of the pool safely.

In order to perform cardiovascular training effectively in the water, it is necessary to have adequate strength to move through the water fast enough to raise the heart rate. The first objective is to develop the muscle power around the joints that are available, namely the hips, one knee and shoulders, by using the properties of water. Then you can progressively work to move her from the streamlined horizontal movement of swimming through to resistive training in a vertical position. This should build up sufficient strength to work on cardiovascular training while at the same time train for better postural alignment of the spine and upper back.

When training in a vertical suspended position, it is necessary to use some form of flotation equipment. This allows the client to concentrate on specific exercise rather than swimming to stay afloat. By adapting to different pieces of flotation equipment, training can be progressively increased to target for overall improvement. You will need to help with correct placement of the equipment and should supervise all exercises for correct postural alignment. For safety reasons, these exercises should initially be performed in a shallow depth where you have a safe base of support to be available in case of any emergency.

Begin with a life jacket

The client can swim, so she is used to a horizontal position. The life jacket will allow her to start the exercise regimen lying on her back with her head and neck supported. This position uses the buoyancy of water for support and resistance of water to begin training. These exercises can be done in a stationary position, and you should be ready to offer manual assistance if her muscles are not sufficiently strong.

Lying on the back, side scissor

Press the legs out to the sides and back to the midline to use the abductor and adductor muscles. Progress to targeting the abductors specifically by pressing out firmly against the water, and then allow the legs to float back together. The abductor muscles (or gluteus medius) act as stabilizers for the hip joint, so they are important for maintaining alignment in this area.

While lying on the back, retract the shoulder blades together to stretch the chest and start working on upper back stabilization and posture. Use the partial arm to sweep across the top of the water, from a position level with the shoulder, down to the side and slightly to the back. Cue squeezing both shoulder blades down together. Take time to relax in this position and stretch the torso and breathe diaphragmatically.

Hang in a vertical position, front back scissor

Allow the legs to swing alternately forward and back to target the gluteus maximus, to extend the hip and the illiposoas and rectus femoris (one of the large quadriceps muscles) to flex the hip. Progress to targeting the gluteus maximus only (the motor muscle) by pushing one leg back and relax forward for several repetitions, then repeat on the other side. Use the arm to swing back and relax forward to a vertical position. If possible, cue to alternately squeeze the shoulder blades in opposition to the leg swing.

Swimming (using the life jacket) between these stationary exercises will help start on cardio conditioning and keep your client warm. To start working on core strength and posture, try to move from the back lying position down to the vertical position while doing any of these exercises.

Progress to using a belt around the waste

As water skills improve, incorporate a belt around the waist. This equipment will allow work in several body positions with fewer encumbrances than the life jacket. However, two major considerations must be addressed when using a belt. The first is balance. The loss of one complete arm will cause an imbalance with the upper body. Therefore, the type of belt will be critical to performance. You may need to experiment. A solid foam belt may cause a lopsided effect, whereas a block belt (one where the blocks can be moved into place to balance the body) might be the best bet. Additionally, blocks can be taken off if there is too much buoyancy, or they can be added for more buoyancy. Speedo has a six-block belt that allows this feature.

The second consideration when using the belt is floating. Because your client is obese, she may require some form of weight to help keep the limbs down to allow safe body positions. Here, soft weights (experiment with one or two pounds) could be placed around the lowest part of the legs using Velcro or a buckle system to fasten. Once sufficient abdominal strength has been developed to keep the legs in position, the weights should be removed. If weights need to be used on the limbs, you must be ready to help with support to place the body in the correct positions.

Try these three body positions to check the belt positioning: 

• Vertical position, with the limbs straight down.
• Seated position, legs level with the hips.
• Side lying position, keeping the legs in line with the body. Try both sides to feel the difference.

Work in the vertical position

The life jacket exercises can be repeated with an increased amount of resistance since the body will be deeper in the water. Once mastered in a stationary position, try traveling the movements using the action-reaction effect. With the forward scissor moves, the power phase is to push back against the water. Conversely, power forward to move backward. It will probably be easier to move forward than backward, so use the left arm to assist by scooping forward. Next, initiate movement to the right side by powering inward with the right thigh and outward with the left. Reverse this for the opposite direction, and incorporate the left arm to help pull along.

Once travel has been mastered, add some fun and challenge. Use a squish ball to float in front of the body. Push it forward with the arm, and see how quickly your client can catch up with it. Try pushing it sideways. If you can get a few laughs, it is good core training and another way to get the heart rate up.

Progress to the seated position

Repeat the upper body training by squeezing the muscles around the shoulders together. Hold the scapula in retraction for several seconds and then release. Sit tall and breathe. This requires engaging the abdominal core to hold the seated position. Repeat this while staying in good posture. The left arm can again be used to pull back and down through the water to depress the scapulae and open and stretch the chest.

Try the side scissor move from seated down to vertical and back to seated again. Use the in-out move for several repetitions in each position and to get from one to the other.

Side lying

Try the front-back scissor move while lying on the left side using the arm to help balance. Now scissor kick on the right side. This will require more balance. Once the move is mastered on both sides individually, scissor side to side without stopping. This will engage the abdominals and help raise the heart rate. Side lying can be used to power down the side scissor move into the water using several repetitions with each leg in turn. The left arm can be used with the same type of movement.

Once the belt is truly comfortable and abdominal strength has been improved, a forward to back pendulum movement can be incorporated into the workout. The client can start lying on her back and swing through to about a 45 degree angle on her stomach. The work is swinging forward from this angle to the start position. NOTE: Take care that the client does not go past the 45 degree angle, resulting in her face going into the water. Recovery position is lying on her back.

Incorporate the noodle as your third device

It may take a long time to get there, but a noodle is the third device to use for amputees. The noodle can be used in a horse riding position, vertical or seated. This changes the position for buoyancy on the body and will require superior balance skills. The noodle is best used on its own but can be used in conjunction with a belt A noodle can provide training for cardio, strengthening and stretching and can incorporate a fun element into the workout. Training to recover to a vertical position must be given at the start of any session in case of falling off or in case limbs become entangled with the noodle. Remember, a noodle is NOT a legal PFD.

More progressions

• Once all of these strength/cardio exercises have been mastered, overload can be added to the training in the form of more resistance.
• You may be able to attach a small paddle to the left arm to overload upper body strengthening.
• The same overload principle could apply to the legs if someone could come up with a “fin” attachment.
• A tether loop can be used around the client’s waist while you hold it for resistance or to work against each other.
• To add buoyant resistance, cuffs can be attached to the legs using buckles to fasten, but remember, this will require superior strength to keep down in a vertical position.

I hope some of the above ideas will help your client gain muscle, improve her cardiovascular strength, lose some weight and, most importantly, enjoy working in the water. Please remember these are only ideas and will require adaptation. Your client sounds like she has great perseverance and is motivated to train. Some days everything will work, and some days nothing will go right. Just keep trying.