Effectiveness of Supported Angel Heel Treadmill Rehabilitation on hip fractured patients
Physiotherapist
DECLARATION
I, the undersigned Fatih Serkan YILDIRIMER (print name), a student of the Faculty of Public Health of Debrecen University, being fully aware of my legal liability, do thereby declare and certify with my signature that my thesis, entitled
EFFECTIVENESS OF SUPPORTED ANGEL HEEL TREADMILL REHABILITATION ON HIP FRACTURED PATIENT
is my own original work and that the printed and electronic literature referred to in it was used in accordance with the international rules of copyright.
I understand that in the case of a thesis, it is considered plagiarism when:
● quoting word for word without quotation marks and referring to literature without proper citation.
● referring to content without citing the literature
● presenting previously published ideas of other authors as one degrees own.
I, the undersigned, declare that I have been informed of the concept of plagiarism.
I understand that in case of plagiarism, my thesis will be rejected.
.
1. Abstract
The physiotherapists still use the traditional and old methods in patients with hip injury post- surgery. The recovery using the old techniques has been observed to be not too beneficial for these group of patients. Therefore, there is an urgent need for the development of an effective method using which patients with hip fractures can be helped to regain their ambulation independently. The Angel Heel Treadmill is a new technique that has been said to be effective, however, not many studies have been conducted to prove its efficacy. In this study, a total of 16 patients were enrolled who were randomly assigned to the control group and the intervention group. The intervention group received physical exercise training along with walking practice on the treadmill while the control group were only subjected to physical training. The intervention was continued for a total of 5 weeks. The outcomes of the intervention demonstrate that the angel heel treadmill intervention could significantly increase the gaiting speed and stride length among the patients in the experimental group. Also, the full cycle had considerably decreased since the gaiting speed had increased. Therefore, our results suggested that angel heel treadmill intervention is an effective method using which the physiotherapists can help their patients to regain their gaitting pattern.
2.Introduction
2.1. The structural anatomy of Femur
The femur is the largest bone in the body and only bone in the thigh and thus is also known as the thigh bone. Femur forms ball and socket joint with the hip.The femur is the longest, strongest and heaviest bone in the human body. The function of the femur is to transmit weight from the hip bone to tibia. The hip bone takes art in the articulation of the hip joint and is a significant part of the pelvis. The fusion of the pubis, ischium and ilium results in the cup- shaped socket formation, which is called as the acetabulum, which superiorly articulates with the femur head to form the hip joint. The tibia’s proximal end is hugely expanded and the two sides of this form the lateral and medial condyle of the tibia. The articulation of the lateral and the medial condyle area of the femur results in the formation of the knee joint. Anatomically, the femur is divided into three different regions namely: proximal, shaft and distal femur.
Proximal; Greather trochanter, Lesser trochanter, Intertrochanteric crest, Inter trochanteric line, Quadrate tubercle
Distal and shaft; Lateral and medial condyles, Lateral and medial epicondyles, Trochlear groove, Intercondyler fossa, Gluteal tuberosity, Linea aspera, Adductor tubercle
Proximal femur forms the head of the femur and neck of the femur. The center of the femur is called fovea capitis that plays a major role in the supply of blood. The shaft of the femur is slightly medial slanted and improves the stability. Naturally, the femur has two angels: angle of inclination and torsion angle. The angle of inclination that forms between the intersection of a line that is going down through the shaft of the femur and a line that's going through the neck of the femur. So, typically in normal adults, we have an angle of inclination of between a 120 to 135 degrees. But if this angle increases more than 135 degrees, it is referred as Coxa valga and if this angle decreases less than 120 degrees, then it is refersred as Coxa Vara. Angle torsion(anteversion of femur) is formed by looking at the relationship between the axis of the femoral head and neck and the femoral condyles. Approximately, 10 to 15 degrees is the normal angle that is called anteversion.
2.2. Hip Fractures
Hip fractures can be very dangerous, especially for the elderly population. The death rate and morbidity risk are too high. The life- time risk of hip fracture has been accounted for 40 % to 50 % among women while it is 13 % to 22 % among men. Hip fractures can affect more than one area of an individual’s ability, which includes functioning, mobility, physical performance, cognition, and social function, all of which are important for life quality. Most patients with hip fracture experience decreased mobility in the joint.
In 90 % of the cases, hip fractures occur as a result of a simple fall, especially among elderly people . A number of studies have found a significant overlap in the bone mineral density (BMD) and bone mass (BM) in patients with hip fractures. Several research studies has demonstrated that there are other factors that strongly contributes to the risk of hip fracture events. These factors mainly include the size of the body, muscle strength, inactivity, unbalanced gait, chronic illnesses and drugs, vision issues, and antidepressants. Consequences of hip fractures are associated with mortality or morbidity and both impacts on the functioning and quality of life of the patients. In a year, the mortality risk of men who are 75 years old or older is approximately 20 percent. Diseases associated with hip fractures might result in serious problems, for example, Deep Venous Thrombosis (DVT), muscle atrophy, infections after the operation, pain, and rigidity of mobility. In a study, researchers assessed the quality of life of the patient’s post- surgery and reported that approximately, 50 percent of the patients could walk independently without support while rest were bed ridden or needed support post- hip fracture and surgery.
The main purpose of treating hip fractures and surgeries is the restoration of the patient’s quality of life and ability to their pre- fracture condition. The treatment options depend on the site of fracture and its type. Physical therapy has an important role in increasing the mobility, functioning, range of motion and prevention of furture fall risks.
2.3. Type of Hip Fractures
Hip fractures usually occur in the upper region of the femur, which is also known as the thigh bone. At any age, hip fractures are considered as a serious injury as conditions or consequences associated with it can be life- threatening. Hip fractures usually occur at the upper region of the femur bone, around the femoral head which articulates with the acetabulum (socket) in the pelvis. They generally occur at three major regions: femoral neck fracture, intertrochanteric fracture, and subtrochanteric fracture (Figure.1).
2.4. Femoral Neck Fractures
The femoral neck fractures appear in the narrow area of the upper femur region that is present in between the femoral head and the trochanters of the femur. Most femoral neck fractures appear in the capsule besiege the hip joint. The location and severity of the hip fracture can result in a number of complications such as osteonecrosis and loss of blood supply to the femoral head called avascular necrosis (AVN). Femoral head gets its blood supply from the arteries passing from femoral neck region (Figure. 2). Thus, fractures of the femoral neck can break the supply of blood to the femoral head, resulting in healing complications for example necrosis of the femoral head tissue.
Garden’s classification for femoral neck fracture :
Type 1= incomplete fracture femoral neck
Type 2= complete fracture but not displaced
Type 3= complete fracture with partial displaced
Type 4= Completely fracture with full displacement
2.5. Intertrochanteric Fractures
Intertrochanteric fractures occur laterally as compared to the femoral neck fractures, between the region of greater and lesser trochanters. Trochanters are points for muscle attachments. Intertrochanteric fractures occur outside of the capsule (Figure 1).
Intertrochanteric fractures in older patients are now becoming more common because of the increasing number of the elderly population. Unstable intertrochanteric fracture in elderly people has a high risk of mortality that accounts for approximately 20 percent during the first year after the fracture . These fractures are complicated by the hip muscles because the attachments of hip muscles are on trochanters. The muscles exert a lot of pressure on the greater and lesser trochanters, therefore there can be serious problems. The healing of intertrochanteric fractures is different than those of the femoral neck fractures. The length of the femur gets shorter and the position of bones are not stable for the union.
2.6. Subtrochanteric Fractures
Subtrochanteric fractures occur under the lesser trochanteric process at the proximal part of the femur. Subtrochanteric fractures are difficult to manage and one takes long to heal as well. The subtrochanteric area is 5 cm below the lesser trochanter. Peritrochanteric fracture is combined with the intertrochanteric and subtrochanteric fractures. Deep Venous Thrombosis (DVT) is one of the most common problem post- hip fractures. The mortality rate for the elderly people is 25 percent after their first post- operative year and avascular necrosis risk is approximately 65 percent to 85 percent among the elderly patients .
Three clinical complications occurs with subtrochanteric fracture, which is as follows:
Malunion
Delayed union
Non- union union
The non- union form of fracture is a delayed form of complication, where there is an absence of union. However, according to the definition, non- union fractures are when in the bone, the union does not happen even after the passage of ample of time, where otherwise union would have happened naturally. The fractures of the shaft in the long bone cannot be described as nonunion until six months of the injury; however, in contrast, the central fracture in the neck of the femur post 3- months can be described as a non- union. The malunion, on the other hand, refers to a union fracture in an abnormal position. This abnormal position can be either lengthened, shortened, rotated, or angled . It can occur due to cosmetically unacceptable limb and abnormal or insufficient functioning of the limb. This kind of fractures can result in alterations in the normal dynamics of the joint motion . This can occur even as a result of the loss of position or inappropriate initial reduction due to inadequate immobilization. Lastly, delayed union describes the fractures, where the injury does not heal completely within the expected interval of recovery for the fracture. However, as compared to others, if proper milieu is given in the case of delayed union, the fractures can heal totally .
2.7. Surgical Treatment
Internal fixation is used generally when the patient is young, is in good health condition and have the good bone quality to hold the implants in its place without re- displacing the fracture during the healing process. Although, screws are used for non- displaced fractures, however, the plate and screw combination can be also used. Arthroplasty is done in case of displaced femoral neck fractures in the elderly patients with poor bone quality. Two types of arthroplasty are now available: hemiarthroplasty and total hip arthroplasty (THA). Hemiarthroplasty is the replacement of the femoral head, where the patient’s acetabulum is kept intact. Whereas the total hip arthroplasty is a replacement of the femoral head and acetabulum in the pelvis. In the total hip arthroplasty, the femoral head is attached to the metallic rod, which is present in the middle region of femur such as hemiarthroplasty. The femoral head moves in the artificial socket, which allows normal hip movement after the healing process is complete. The dislocation occurs very rarely in the case of hemiarthroplasty. Pertrochanteric fractures are the one in which the subtrochanteric and intertrochanteric fractures are combined or united. These fractures are usually treated with the internal fixation. If there is no damage to the blood vessels that obstructs the supply of blood in the femoral head, the internal fixation surgery is the only option.
Usually, posterior or anterior hip dislocations are treated conservatively, where patients are either subjected to bed rest or are given traction and limited weight bearing on affected leg for around 12 weeks. Patient’s in such cases are advised to avoid external rotation and abduction of the hip, especially when there is an anterior dislocation. In the case of posterior dislocation, traction is good for prevention but abduction, flexion, and internal rotation should be avoided for redislocation.
2.2. Gait
The gait is a cycle that depends on the sex, age and on the body geometry. For example, if results from an old women patient are compared with young and physically stable men, then there will be a huge difference. Usually, upper body extremities and the trunk ids in achieving the faster speed, stability, balance and propulsion while the lower extremities along with the trunk and arms aids in achieving the normal walking speed. The legs play a major role as a greater range of motion is produced by the joints through higher muscle responses. The three major joints present in the pelvis and the lower body in the bipedal system works together as muscles and produce momentum to move the body forward. The efficiency is determined by the degree to which the center of gravity of the body moves at the time of forward translation. During gait, the center of the body moves bot up and down and side to side.
2.2.1. Gait Phases
The gait cycle is a repetitive pattern that consists of eight periods in two phases: in strides and steps. These periods are initial contact, loading response, mid- stance, terminal stance, pre- swing, initial swing, mid swing and terminal swing. 60% Stance phase and 40% Swing phase completes the gait cycle. It comprises a combination of close- and open- chain activities. The upper body moves forward and trunk twists on the vertical axis, shoulder and pelvis rotate to opposite sides. Arms swings with the legs step forward such that the right shoulder and right arm moves forward when the left foot steps forward. The hip flex and extend during gaiting. The flexion reaches to the highest point during middle swing phase and is kept flexed till the stance phase. There are two times when flexion and extension occur at the knee during the gait cycle. At the heel, the contact knee is fully extended and flexion begins at the stance phase, which is followed by extension again during the mid- stance followed by the flexion again. The ankle remains in the neutral position at heel contact with slight inversion. After the heel contact, the ankle plantar flexes the foot on the floor and then inversion begins and tibia is compelled to move forward, and on the other hand, the angle of ankle changes from plantarflexion to dorsoflexion. During this phase, the tibia also slightly rotates externally, which then moves the foot by the subtalar joint. At the heel, off angle of ankle changes, moving back to plantarflexion till the toes are at the ceiling .
2.2.2. The Effect of Total Hip Replacement on Gait
Total Hip Replacement (THR) is an elective surgery. The primary purpose of choosing this treatment is to provide patients with some pain relief. It is important to improve patients quality of life and their body functioning. Total hip replacement is performed in patients with a functional disability of the hip and pain. The Total Hip Replacement patients might have serious problems with an abnormal gait that is why the treatment chosen by the physiotherapists’ targets the correction of gait dysfunction. In the majority of the cases, it is expected that the patient will have normal gait pattern after the surgery. However, sometimes mechanical or biological failures results in a revision of the surgery. Overloading on the prosthesis is one of the causes of failure in young and obese patients. After surgery, patient mostly continues to show lurching gait pattern or limp and excessive lateral trunk movements on the operated leg. The abnormal gait is often associated with weak abductor muscles of hip .
3. Research Objective
Angel Heel Treadmill is a new measurement technique, which has been suggested by its makers and some researchers to be effective in treating patients with hip fractures. It has been suggested to be an effective method for educating patients to practice partial lower limb offload and monitoring. This rehabilitation technique that measures the load on both limbs aids the patient to put appropriate pressure on the operated limb and aids the physiotherapist to choose the right option for their patients. However, not many studies have been conducted on this group of patients. Based on the evidence on this particular technique, we hypothesized that implementation of this technique in the rehabilitation setting might aid in restoring the gaiting pattern quickly and efficiently among the hip fracture patients and can be reinstated as and when used with the conventional gait teaching.
Therefore, in this study, we aimed to determine the feasibility of the retention and recruitment of patients in the Angel Heel Treadmill intervention as a strategy to improve the ambulation among this group of patients independently who had volunteered to participate in the inpatient rehabilitation setting. We also assessed whether the gaitting speed and the step length also gained benefits after subjecting this group of patients to this intervention.
4. Methods
4.1. Target group of the study
A total of 16 patients with hip fracture were chosen for this study and were examined for 5 weeks. These participants had been in physical therapy department for 5 weeks. The group was randomly divided into 2 groups where eight were subjected to the control group and eight were kept in the experimental group. All participants were elderly patients between 70 to 90 years old, where the youngest was 71 years and the oldest was 90 years old. These patient had an average body weight of 75 ± 5 kgs. These patient who underwent hip surgery were moved to the department of hip and knee replacement surgery patient ward after approximately 14 days. The inclusion criteria set for the enrolled patients were: 1) All participants were operated without any problem, 2) Participants’ hips fractures were successfully fixed by hemiarthroplasty and total hip arthroplasty, 3) Participants did not have any other disease or suffered from neurological disorder which might affect the proper gaiting cycle, 4) passes the Mini- Mental State Examination (MMSE) test by obtained a minimum of 25 points, and 5) weighed minimum 50 kgs. The patients were excluded based on the exclusion criteria, which were: 1) patients weighed over 100 kgs cannot be included in the level of inspection and 2) if suffered from motion sickness. Each of these participants was subjected to physical therapy and to angel heel treadmill therapy at the 2 weeks post- operative stage. Informed consent was obtained from each patient in order to avoid future ethical issues.
The controlled group was subjected to physical therapy only while the experimental group was subjected to physical therapy along with 15 minutes of gait training on motorized supported treadmill. Each group member weas measured by specialized treadmill on the first day of exercise program.
4.2. Test Procedure
Educating the patients: partial load, correct gait, and weighing calibration
Fırst Step: The upper and lower limits were set for the range of load on the computer where the sound signals into the districts
Second Step: the alarm was turned off
The first step aided in obtaining patient data after the feedback was taken post the partial offload of traditional weighing. The next day, the sound was turned on to receive feedbacks and the ceiling sets in the load were lowered to enable the receiving of audio feedbacks from either bottom or top. The frequencies received differed and thus the system beeped differently when the patient is either top loaded or under loaded. The lower limit was set as the 50% of the upper sub- 15 kg load. During the next phase, the sound was turned off.
The statistical analysis was carried out with the angel heel treadmill laptop technology. After each session, results were extracted from the laptop using the program which is connected to the treadmill.
4.3. Introduction to Angel Heel Treadmill
Angel Heel Treadmill is a special motorized and supported treadmill (Figure 4). The treadmill can measure the length of the steps and loading separately. The running area is separated from the middle of the walking path in order to protect one leg colliding from the other one during gaiting. This allows the investigators to measure the weight load on the two lower limbs. The real time results appear on the screen to the doctors, therapists and to the patients. The loading of each leg is immediately visible on the screen to the patients by different audio and visual warnings. The treadmill contains two cameras, one in front and another one on the side. Patients can see the monitor and are thus assisted automatically by the system to practice proper gaiting. This is also known as Mirror learning. The floor or the running area consists of white lines at an interval of every 5 cm and 10 cm, which aids the investigators to measure the length of the patient’s each step by observing these lines. The treadmill also aids in correcting the limb loading and it further helps the patient to reach or gain a better rehabilitation stage. The treadmill also contains an armrest place, which is designed to prevent the patient from falling down . Additionally, the treadmill also comprises of a slinging strap, which is located at the top of the machine which can further aid in protecting the patient against any kind of mishap/ accident . During the physical training, a physiotherapist and physician are always present with the patient who takes care of everything around the patient i.e., acts as a support system in order to prevent any harm or injury to the patient. The machine also aids the patient to learn how to practice gait pattern in the right way .
4.4. Interventions
The first rehabilitation program was started in the third week itself after the surgery at the Kenezy Hospital. The rehabilitation lasted for 5 weeks where patients were subjected to interventions for 5 days per week. Therefore by the end of the intervention, the patients were subjected to a total of 25 sessions.
The rehabilitation stage were divided into 3 main parts:
Maximum Protection (1-3 weeks postoperative)
Moderate Protection (3-6 weeks postoperative )
Minimum Protection (6-8 weeks postoperative)
During the maximal protection phase, care was taken that the fractured part of the patient was properly protected. Once the pain and swelling were reduced, the patients were then subjected to isometric exercises, supported ROM, and limited weight bearing.
4.4.1 Breathing exercise
During each session, we started the rehabilitation in patients by making them first practice the breathing exercises first. Our aim was to increase the blood circulation of the patient in the beginning of the physical therapy or the intervention for both gorup. During the breathing exercise, we also enquired to the patient if they had any previous history of fractures, prosthesis, impingement or pain in the upper limb in order to prevent harm or injuries due to the intervention.
Patients were made to sit in the supine position, arms next to the body knees and the hips were slightly flexed. The physicians had already warned us to take care that the patients are not made to bend more than 90 degrees of the hip during the exercise. The head of each patient was supported with a pillow. Patients were made to raise their arms next to their ears and back to the body. This exercise was repeated six times, which included 3 sets per session. When patients were in a supine position, they were instructed to grab their elbows with their hands. This was followed by raising the elbows and the shoulders to 90 degrees.
4.4.2. Ankle pump
Ankle pump aids in increasing the blood circulation of the patient by contracting the calf muscles. It also aids in reducing the risks of edema and prevents patients against developing DVT.
Following this the patients were made to sit in supine position, arms next to the body and the legs were extended on the bed. The patients were asked to flex- bend their ankle towards their knee and relax. The patients were made to repeat this exercise for at least 6 times i.e., 3 sets per each session.
4.4.3. Isometric Quadriceps
The strength of the quadriceps plays a major role in the knee as it bears the shock and reduces the chances of injury during weight bearing activities. Quadriceps strengthening is an important process as it aids in the prevention of exertion of uncontrolled and excessive loading pressure on the joints.
Patients were made to sit in a supine position and a small pillow was placed under their knees. The arms were placed next to their body. Following this the patients were then asked to push down the knee and the ankle to the bed and keep the contraction for 3 to 4 seconds.
4.4.4. Gluteus Contraction
Patients were made to sit in the supine position and their arms were kept next to their body and hands were made to face the bed palmarly. Following this, the legs were extended. The patients were then made to contract their butt muscles and push towards floor with both hands and heels.
4.4.5. Hip Abduction
Patients were made to sit in supine position, their legs were straightened, and arms were then placed next to their body. Following this, the physiotherapists helped or assisted the patient to gently move their operated leg to the side and bend around 30 degrees. Toes were pointing towards the ceiling. The patients were then made to repeat this exercise with their healthy leg as well.
4.4.6. Hip Flexion Heel Slides
Patients were made to sit in the supine position and arms were placed next to their body. The non- operated knee was then kept in the bending position to feel comfortable. The operated leg was then extended on the bed. Following this, the patients were then asked to slide their feet towards their butt. The physiotherapists took care that there was a limited hip flexion i.e., no more than 90 degree flexion in order to prevent any dislocation and compression in the joint.
4.4.7. Hip Flexion with Extended Leg
Patients were made to sit in supine position and arms were placed next to their body. Both legs were then kept in the extended position. The patients were then asked to raise their leg. The pysiotherapists assisted them to raise it to face towards the ceiling and then slowly move it down to the bed. With both leg, the patients were made to repeat this exercise 6 times per leg.
4.4.8. Hip Flexion Pull Knee to Belly (90 Degree limited)
Patients were made to sit in the supine position and both legs were made to bend around 90 degrees. The hands were then kept on the posterior distal part of the femur. The patients were tend instructed to pull their leg towards their belly and then move it back to the initial position. By using their hands to hold the grip on the femur, the patients supported themselves.
4.4.9. Step forward and Backward on the bed
Patients were made to sit in the supine position, following which their knees are slightly flexed on the bed such that their feet were on the bed and arms were placed next to their body. The patients were then asked to step backward with their left leg and right leg. The hip flexion was then limited and the patients were warned and instructed to not to reach 90 degrees or over the hip flexion.
4.4.10 Leg Cycling on supine
Patients were made to sit in the supine position and then both their knees were bent such that both hands and foot were on the bed. The patients were then instructed by the physiotherapist to tighten their abdominal muscles and keep their back on the floor and then lift one of their legs towards the ceiling and then lift another one next to it. Following this, they were instructed to move the legs both forward and backward such as the bicycle movement for 10 seconds. The physiotherapists then carefully inspected and supported the operated leg. Care was taken by the experts to avoid the hip flexion to reach over 90 degrees in order to prevent dislocation or injury.
4.5 Angel Heel Rehabilitation Treadmill
4.5.1. How the Angel Heel System works
The main aim of this system is to help the patient to understand the amount of pressure or load they can place on each of their limbs. Therefore, in order to do so, it is essential to measure the unit with sufficient accuracy and then analyze the outcomes of the training by extracting the data from the Angel Heel System using a software. These results are usually stored in the system and can be downloaded at any point in time. This tool is easy to use and is effective from the medical point- of- view as these require low- maintenance, reliable and affordable .
The existing models to help the patient to recover system are the Smart Step and the Pedar Modart Andante, which are expensive, short- lived, has low battery discharge capacity, tech- capable, and has limited data storage as other leg amplified instruments are concerned. On the other hand, the Angel Heel System records the whole data and aids in full recovery . It also aids the patient in identifying the optimal load that he/ she can take and further garantees the possibility of making a correction as and when required by the physiotherapists or the physicians. This device was designed by the Metalelektro Measurement Technology Ltd.by keeping the cost- effectiveness of this device at every step in mind. This system supports the heels specifically where the first phase of reliability is most important as it aids in the surge in the development of the load curve, which is much more intensive.
4.5.2 Elements of the Angel Heel System
The balance control is done with the help of the physiotherapist and physicians, who sets the value of load to be improvised on the patient. During the physical training on the treadmill the system is connected to the laptop so that the data generated during the exercise is easily transferred to the laptop or the computer. This also aids the physiotherapists and the doctors to review the experiment outcomes and make changes immediately. The device is designed such that it can automatically detect the patient’s action on the treadmill and automatically determine the maximum load step and the pressure on individual limbs with the help of the software that is already embedded in the system. It also provides feedback to the patient during gait walking, thereby lightens the professional’s job. The device can store data indefinitely. The warning beep indicates the physiotherapist when to adjust the load to match the patient’s level.
The device allows the patient to view his/ her information on their own and the data are either encrypted or password protected. These information can be displayed graphically or can be logged, thereby allows to check the appropriate number of partial relief, and also allows one to check if there was an overload of the injured limb. Table 1 demonstrates the technical paramenters of the Angel Heel Treadmill system.
4.5.3 Subjecting patients to the Angel Heel System
Each participant was subjected to Angel Heel Rehabilitation for 5 days in a week for a total of 5 weeks. Each rehabilitation took two minutes per day. The physiotherapists placed the patient’s elbow on the armrest area in order to for prevent falls and any kind of injury or accident. This also aided in limiting the weight on the operated leg. Following this, the patients were protected by straps, which were strapped to the hip and the belly. The physiotherapist was always standing by the patient’s side in order to prevent the patient from falling or injury. Once the patient was placed on the treadmill in a comfortable position the physiotherapist started the treadmill and the speed was kept between 0.24 km/ hour to 3.6 km/hour. During this rehabilitation process, the minimum patient weight was kept as 50 kg for the machine while the maximum weight was limited to 150 kg (Szilágyiné Lakatos, 2015).
4.5.4 Gait speed
Patients were made to stand on the treadmill with elbows on the supporter pads. The pads were placed there to prevent the patient from falling down. Under the band, there were sensors, which is very sensitive and efficiently senses each step. Following this, both legs were measured during the gait pattern. The graphics of individual legs were visible on the screen of the Angel Heel Treadmill system. Following this one gait cycle for each leg was calculated.
4.5.4 Statistical analysis
All data were extracted from the system and were evaluated in the Microsoft Excel application. The mean ± standard deviation (SD) was also calculated. The equal variance and the normality of the data were tested prior to the test of significance. If in case, the normality and equal variance tests were successful, then the t- test was used for estimating the differences between both the groups. If the equal variance normality tests failed, then the Mann-Whitney Rank Sum Test will be used. The p- value of <0.05 for the outcomes was accepted as the level of significance.
5. Results
The Angel Heal Treadmill intervention aimed to promote optimal healing of the lower extremity of the patients’ post- hip fracture and its surgery. The outcomes of the measurement aid the physiotherapists and the physicians to continuously track and control the healing process. It also aids the patients to recover faster and understand the amount of load they can put on their legs. The load to be applied to the patient’s legs were determined by dividing the patient’s weight by 2 and subtracting it by 15. Based on this calculation the load on each leg was increased every 1 to 2 weeks depending on the patient’s physical condition and capacity. We found that the experimental group who were subjected to physical therapy along with fifteen minutes of gait training on motorized supported treadmill showed an increase in their speed at average load, load slope and maximum load. The curve shape of the shift and move had also showed improvement. The gaiting speed had significantly increased in the experimental group post- intervention. The gaiting speed that was recorded prior to the patients being subjected to the intervention was 0.5 to 1 km/ hour which increased to 1 – 2 km/ hour post- intervention. The results are demonstrated in Figure 6 and Figure 8. The stride length in both the legs of the patients in the experimental arm showed a significant increase in its value as compared to the control group. Additionally, the steps by both the legs were also observed to be symmetrical in the experimental group. The patients in the experimental group who practiced walking on the Angel Heel treadmill for five days for five weeks showed a significant increase in the average step length value as compared to the control group. Similarly, the length of each step prior to the intervention was noted as approximately 20 cm which post- rehabilitation had increased to 50 cm, approximately. The values and the increase in levels have been demonstrated in Figure 7 and Figure 9. Similar trend was observed in the case of the average load put on each limb. Prior to the intervention, the time noted in the patients while on their feet was 0.3 seconds which later increased to 0.7 seconds. The full cycle on each limb was noted to be 1.41 seconds before being subjected to the intervention which decreased to 1.18 seconds post rehabilitation because the speed had considerably increased (Figure 10).
6. Discussion
A number of studies and clinical trials have demonstrated that Angel Heel system is effective and easy to use to treat patients with hip fractures . Therefore, in this study, we used this system for assessing and evaluating the efficacy of this system in helping patients to recover post- hip surgery. Our findings highlight important insights in the ease of retention and recruitment of patients who were transferred to the inpatient rehabilitation setting post experiencing hip fracture and undergoing hip surgery. It also demonstrates the ease with which the angel heel treadmill intervention could be easily implemented in these patients in order to obtain positive outcomes with respect to their gaiting capability. Retaining patients with hip fracture in the rehabilitation settings is difficult and thus requires rigorous strategies to retain them and minimize the loss of patients during the follow-up.
All patients who had volunteered to participate in the Angel Heel Treadmill intervention sessions rarely declined their scheduled session. This trial was designed in order to aid the existing physiotherapists to understand the importance of this intervention so that they can implement this intervention during their clinical practice. Additionally, it allowed us to evaluate the feasibility of the system and the setting, where its would be implemented. Future trials that would test the efficacy of this system should hire dedicated research experts for implementing this intervention so that the adherence to the study protocol is enhanced. Sınce a limited number of participants were enrolled in this study and the participants were gaining benefits and relief from this intervention we did not have any loss of participants during the study. We conducted a non- randomized study and thus, we did not assess the baseline difference between the experimental and the control groups as the sample size was small. The participants in both the intervention and the control group obtained good scores in the MMSE test. The participants displayed satisfaction and felt that this technique was easy to use and learn. Additionally, the physiotherapists and the doctors were able to make changes in the program and the outputs as and when required. They could also determine the optimal load for individual patients .
In clinical trials, the Angel Heel system has gained considerable attention due to the outcomes in the gaiting speed and length among patients. Studies have proved the feasibility of using this technique to restore the lower extremities functioning in patients. Our outcomes proved that our hypothesis regarding the use of Angel Heel Treadmill intervention on the patient with hip surgery was correct as the participants showed quick and better outcomes in the experimental group in adapting to this technique and restore their gait pattern. The intervention significantly increased the speed of gaiting, the slope of the load, average load and the force among the experimental group. Additionally, the curve shift and shape had also significantly improved as patients in the intervention group showed faster recovery and gaiting pattern resembling the normal gaiting pattern. The stride length in the both the limbs of the patients had significantly increased. The moves were observed to have improved in both legs and symmetrical pattern of walking was observed in both legs. The relative change in the stride length, walking speed and step length was most striking. Additionally, the relative change in the load on the treadmill and in the area of curve also demonstrated a significant increase in the values as compared to the patients in the control group.
Although, the expected outcomes were obtained out of this study and our hypothesis was proved, yet the results obtained from this study is less spectacular because of the small sample size. Therefore, further studies are warranted with larger sample size in order to evaluate the effectiveness of this particular therapy among the patients with hip surgery. However, irrespective of the sample size, it is evident that this technique is quiet effective in patients with hip injuries as compared to other therapeutic treatments.
In conclusion, the outcomes of this study suggest that the patients with hip fractures, post- hip surgery can be subjected to the Angel Heel Treadmill intervention in during the rehabilitation phase. This is because the patients in the experimental arm showed a significant increase in the gait speed and they learned how much load they can put on their operated limbs. The patients could also learn that their healing will delay if the operated limb was overloaded and also insufficient load on the limbs could also delay the healing process. Therefore, Angel Heel Treadmill intervention should be recommended to the physiotherapists when treating patients with hip fracture. However, further studies are warranted to check the efficiency of this technique.
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